28 proposals to the 208 Commission

A smart healthcare provider in Boulder, Colorado, has summarized all 28 of the healthcare proposals that the Colorado Blue Ribbon Commission for Health Care Reform is considering.

The fact that there are 28 proposals is in itself amazing. At one of the early commission meetings a staff person reported on similar commissions in other states. Illinois got nine proposals, so did California. Washington got more, but they weren't calling for comprehensive proposals, as is the Colorado commission.

You can find the 28 proposals submitted to the 208 Commission here.

This woman works with one of the proposers, but notes that these are her own impressions — and she says that they may not be fair, since she's working from descriptions of the plans, rather than reading each and every plan. She shares her biases up front: "I think of 'premium assistance' to individuals or small businesses r the 'uninsurable').

"Many mentioned the desirability of “medical homes” of some sort, which would serve to coordinate care for patients.

"Many would increase reimbursements to Medicaid and/or Medicare providers to address the problems of inadequate access to providers. Also mentioned frequently were incentives for healthy choices, and some pay-for performance suggestions. A couple of proposals suggested limiting profits that insurance companies make."

So, cribbing from her notes, here are the 28, organized, as she organized them.

Types of Proposals
Predominately Single-Payer
Colorado Health Services, submitted by Health Care for All Colorado and signed on to by the Colorado Nurses Association, OWL, and the Physicians for a National Health Program. Publicly owned, not-for-profit insurance company, administered and governed as public utility. Negotiated provider fees, no co-pays to begin with. Private coverage will be a choice above standard benefits.

Comprehensive Health Advancement Plan for Colorado, submitted by retired University of Colorado professor Edwin McConkey. This is a modified single-payer with emphasis on health advancement rather than insurance. There are financial incentives for healthy lifestyles and training of professionals in high needs areas. It creates a new agency with state wide governance, public funds, set fees for providers.

Colorado Complete Healthcare Reform, submitted by PULSE. Expands Medicaid to all residents in a program called MediColo but allows insurance companies to operate in Colorado for up to five years. There would be a no-fault system that separates compensation from accountability which would reduce malpractice costs. Its medical home is a team of MD, nurse, social worker or counselor and advocate.

Colorado Comprehensive Care Coverage, submitted by Savant Solutions. Its state-run, paperless, profitless, models are Medicaid, VA, Kaiser and European countries. It would begin with a pilot project with four phases. An oversight group such as Savant, would serve as a procurement team requesting RFPs, getting bids, selecting them.

Colorado All Care, submitted by Nathan Wilkes. Healthcare delivery remains the same but funding would be through taxes. Reimbursement rates to providers would be set; there would be no co-pay or deductibles; all prescription, dental, vision, mental health, and long term care would be covered.

Universal Capitation Plan, submitted by Stuart Zisman. This single-payer plan is similar to HCAC proposal except that it's run by elected providers and consumers, with local assessments of needs and consumer choice of fee-for-service or a capitated-rate (recommended) plan.

Single-Payer with market component
Colorado Balanced Choice Health Care Reform, submitted by Balanced Choice Health Care, Inc. Ivan Miller's plan offers universal coverage, public funding, single-payer with a constant option of interchanging a two-plan system that allows for providers to set their own fees and for consumers to have cost conscious treatment choices. Spending on the two plans would be regulated by a mandatory funding split that adapts to market forces to ensure enough resources go to the standard plan to maintain quality care. There would be a focus on transparency, automatic enrollment (with opt-out possibilities if they have equivalent or better health insurance) so all residents are covered regardless of employment or income status, simplified paperwork and procedures, and relief for employers. Financial assistance for low income or catastrophic health expenses.

Predominately Subsidizing Private Insurance
A Comprehensive Health Care Plan for All Colorado Residents, submitted by Barry Bode. This comprehensive reform proposal would subsidize health, disability and life insurance.

Comprehensive Health Care Plan, submitted by Club 20. This plan mandates individual purchase of basic “Tier I” coverage as in Massachusetts. It uses value ranking procedures as in Oregon, which is a transparent way of limiting or rationing treatment. The plan states that the healthcare “...solution is less about need for new ideas and more about need to accept reality.”

A Plan for Covering Coloradans, submitted by the Committee for Colorado Health Care Solutions. This plan creates the Colorado Health Insurance Purchasing Authority, a quasi-governmental agency to standardize six to ten insurance benefit packages, assist with purchases of insurance, manage the insurance “pool” with community ratings and guarantee issue. The proposer believes that national policy is necessary. This plan has aspects of single-payer and expanding public coverage but remains a broker/ regulatory agency to oversee private insurance.

Solutions for Healthy Colorado, submitted by the Colorado State Association of Health Underwriters. This proposal would institute state-sponsored outreach for those eligible but not enrolled in public programs; insurance companies must guarantee issue “Core Limited Benefit Plan” with sliding scale premium subsidies; and mandated individual purchase to address the “voluntarily uninsured.” Plan lacks details.

Better Health Care for Colorado, submitted by the Service Employees Union (SEIU) and the Colorado Association of Public Employees. This plan would bring Medicaid-funded premium subsidies to purchase insurance; establish a clearinghouse to help small business purchase health insurance and offer private insurance products rather than mandating insurance. It would create a “culture of insurance” and extend coverage to 96 percent of residents. Recipients would have choice of managed care plans. It does provide long-term care plans and urges improved access to affordable housing so long-term care consumers can live independently.

Individual Based Insurance System Combining Free market Principles with Appropriate Role for Government, submitted by the South Metro Denver Chamber of Commerce. This plan mandates individual purchase of “maintenance tier” insurance not tied to employer. There would be a Massachusetts-style health connector portal and search engine that provides healthcare purchasing consultants. There would be group pools for catastrophic insurance that is re-insurance funded by contributions from the maintenance policies. The free market moves responsibility from managed care to the individual and eliminates inefficiencies. There is a heavy emphasis on HIT and incentives. A statewide system of clinics funded by the state, business gifts, and non-profit donations would serve the uninsured/minimally insured.

Universal Colorado Health Insurance Plan, submitted by Joseph Roddy and William Yancey. This plan would “fine tune the industry with regulation to... serve the entire population...” It puts people into groups of 10,000 with identical demographics so that the premium price is the same for everyone. Insurance companies decide how many groups to compete in. Providers are exempt from malpractice claims.

Combination of Expanded Public and Subsidizing Private
Uninsured Action Plan, submitted by Anthem BC/BS (Wellpoint). This plan expands CHP+ and Medicaid; subsidizes private insurance; increases managed-care; and “minimizes administrative costs by building on existing systems.”

Connecting Care and Health for Colorado, submitted by Colorado Consumer Health Initiative (CCHI), also signed by Health Care Policy and Finance, Division of Insurance, Department of Public Health and Dept. of Human Services. This government-run plan limits the profits insurance companies can make. It standardize benefit packages in both public and private markets and mandates individual purchase with limits of 5 percent of income for out-of-pocket costs. It builds on employer-sponsored plans with subsidies and/or reinsurance and consumer protections.

Healthy Colorado Now, submitted by the Coalition for the Medically Underserved. CCMU builds on our existing system but develops a new insurance plan for the working uninsured, funded by employer-paid payroll fees, which does provide premium assistance if necessary. This may be private insurance.

Community of Caring, submitted by the Colorado Community Health Network, Colorado Children’s Campaign, Colorado Access, and Colorado Behavioral Health Council. This plan calls for mandated individual insurance purchase with subsidies for individual and small business insurance purchases. A “quasi-governmental” entity creates a public-private partnership to purchase coverage for all Coloradans (except ERISA) and it expands public programs. They propose a “Safety Net Stabilization Program” which provides enhanced reimbursements to providers certified to meet needs of distinct populations.

Phased Approach to Universal Coverage, submitted by Kaiser Permanente. This plan expands public programs as funds permit, and creates policy and administrative infrastructures.

Additional but not Comprehensive Proposals
Improving Our Health Care and Condition, submitted by the Colorado Foundation for Medical Care. This plan would provides foundational elements essential to quality and functioning of health care systems.

System to Ensure Medical Home—Health Outcomes Measurement and Evaluation Consortium, submitted by Health TransPharmacy Care Fund. This proposal provides information on available resources, access to pharmacy savings program and subsidies.

Neighborhood Nurse Practitioner Clinics Mandating private health insurance “is absolutely the wrong approach [it] is the problem, not the solution” so neighborhood groups of 500 households would join a clinic for $25/month and receive unlimited free office visits with nurse practitioners. The $25/month would pay for a NP, part-time office staff and overhead, which is low because it operates out of a residence. Insurance would cover catastrophic care.

Free-market, Affordability and Individual Rights, submitted by Brian Schwartz. The fault for unaffordable healthcare lies in third party payments that delete personal responsibility

A Simple Health Care Solution, submitted by Monte Uyemura, MD. This proposal would make it illegal to sue providers and would eliminate physician shortage. In exchange providers could not refuse to see patients for inability to pay. It calls for major medical and HSAs to reduce paperwork.

Colorado Health Coverage and Jobs Solution, has no name on the submission. It requires insurance firms having government contracts to offer a plan comparable in price and benefits to Federal Employees Health Benefit Plan.

Telemedicine and Data management Systems for Improvement of HC Coverage Costs, submitted byEnigami Systems. This patent-pending protocol is a plan in which consumers' symptoms are telephonically assessed on a daily basis using interactive voice response system that can be viewed graphically on the web-site by the consumer. This addresses inadequate accountability; allows provider to change treatment plan and allows insurer to do utilization reviews and provider rating scales

The Option to Die in Peace, submitted by Bart Windrum. This proposes expanded hospice-type education and care for at-home deaths.

208 Commission in the Post

Jim Spencer, news columnist for the Denver Post, wrote a great column today about Colorado's (208) Blue Ribbon Commission for Health Care Reform's task of finding the best three to five of 28 proposals for comprehensive reform that they've received.

None of the proposals assumes people are not entitled to treatment if they cannot pay retail. The hardest question the commission must answer is the private/public mix in the provision of health care. Still, no one argues for the status quo.

Spencer interviewed Service Employees International Union's Colorado point man for health care and Dr. Rocky White, an Alamosa physician, conservative rancher, and Health Care for All Colorado board member. Both SEIU and Health Care for All Colorado submitted proposals to the commission. Rocky was lead author for HCAC's proposal. Spencer described Rocky's proposal as being, "the simplest, most progressive and most controversial of the commission's proposals."

Spencer got right to the heart of the problem when he quoted an advisor to SEIU, who said that what is easiest to administrate — single-payer — may be hardest to approve politically.

This advisor helped Mitt Romney come up with the Massachusetts scheme, which is ticking away — before it even begins — with costs overruns and inadequate plans that people will be forced to buy. "Republicans support the subsidized purchase of private health insurance," he told Spencer.

That is such a mystery to me — but it must be related to what our friend Jack Long says: People are either scared of the wealthy or of the government.

So they'd rather go with inefficiencies that is on course to bankrupt individual families and the government as well, all in the name of free markets. Except if the government is subsidizing private insurance, they're not free markets. Bush's Health and Human Services secretary, Mike Leavitt, recently said that government's role in healthcare should be to "manage markets." If that's the case, why not manage them right, and take private insurance out of the game?

Walking the talk

An angry woman not long ago demanded to know if Health Care for All Colorado's president, Dr. Elinor Christiansen, was a Medicare recipient, since Dr. Christiansen believes in a government solution to the U.S. healthcare crisis — as in so many other industrialized countries.

Of course, said Dr. Christiansen.

The exchange struck me as odd -- that this woman thought she was likely to score a point here, that she thought a 70-something retired physician wouldn't be signed up with Medicare.

Are there really a lot of seniors who decline Medicare? Even well-off seniors?

The other side of this coin comes in a letter to the editor today to Seacoast Online. Responding to someone who is against single-payer, Rich DiPentima writes, "Lastly, I assume since Mr. Brighton is so scared about putting his health care choices in the hands of a federal bureaucrat, that when he turns 65 he will decline Medicare and keep his ability to make his own choices with his private insurance overseer. Good luck and most importantly, good health."

Now that is a good question.

One size does fit all

We now know part of the health insurance industry's talking points regarding what's the matter with U.S. healthcare: It's that one size doesn't fit all when it comes to health insurance.

What a crock.

How does one size not fit all? Which one of us doesn't want care when we're sick or injured? This was the answer that the journalist bought in the New York Magazine article on "the young invincibles" and here's a reporter for the Indy Star giving a platform to Wellpoint to make the same point.

Jude Thompson, president of individual markets for WellPoint, the nation's largest health insurer, said the traditional one-size-fits-all approach to marketing insurance no longer works.
"That's one of the big reasons why we're where we are today with the uninsured," he said. "Companies need to change the way they are talking about insurance and offer different products with different price points. We need products that resonate with the different age and income groups and hit the mark with people who can and want to purchase insurance."

What Jude is talking about, of course, is actually "the choice" to pay less for a higher deductible and catastrophic coverage only — which hardly makes insurance more cost effective. It's still "playing the odds," just as people without insurance do. It still essentially takes people out of the risk pool, meaning that someone with a chronic condition who needs care will certainly be left in a market where that care is unaffordable — unless the government picks it up.

And that is OF COURSE the end game for the health insurance industry. They'll insure all the healthy people, and the government can take care of all the sick people. What a deal.

Don McCanne, former president of Physicians for a National Health Program, had a good post on this today. Sign up for those posts through this link from the PNHP website.

Paul's birthday

I've been being an aunt in California. Babies are wonderful and exhausting. I have wanted to be with the baby and Sarah every moment.

Paul's birthday was 21 April, and we went to the "Self-Realization Fellowship Lake Shrine," in Pacific Palisades. It's a lovely place, dedicated by Paramahansa Yogananda in 1950. Paul and his friend Robin had gone there together several times. The baby was entranced by the water. Not really the sight of the swans or the many turtles or enormous koi, but just the sight of the water. She fussed when Sarah left the water's side.

Some of Gandhi's ashes are here.

Kick the bums out

This would be why Sen. Chris Dodd should not have a chance at the White House. He shamelessly pandered on the insurance industry's behalf for cash and cheap political points at the time of the Clinton reform attempt. We've got to grow longer memories so that politicians can't get away with crap like that.

Single-Payer: Go for it!

Roger Hickey, co-director of the Campaign for America's Future, "an organization launched by 100 prominent Americans to expand the national debate about America's economic future," has a terrific post at TPMCafe on healthcare reform.

He makes the excellent point that even if you believe that single-payer isn't realistic, we should still go for it. That tactic puts the insurance companies on the defensive, where they'll be more amenable to a modicum of justice, less arrogantly certain that greed should be unlimited when it comes to their own profits.

Hickey quotes Clinton, saying it sounds to him as though she's figured out that the American public is outraged by the health insurance industry, and that she won't suffer politically by going after them (except, of course, in the all-important race for cash). "Now this kind of populist rhetoric is also useful if she is planning to go for a wimpy and dangerous Wyden-style plan that essentially gives all our public subsidies to the insurance companies – while pretending to regulate them," he cautions.

Hickey likes Jacob Hacker's plan, which takes us to single-payer in stages, as I understand it. I haven't read the plan, but I have read The Great Risk Shift, an important book worth the time.

Hickey also quotes Matthew Holt, from an earlier post on the discussion at TPMCafe:

My essential fear though, is that we’ll only get to some kind of compromised quasi-universal coverage system that doesn't really cover everybody, keeps a role for a private insurance industry operating under the wrong incentives, and looks like welfare for the poor. In that case this whole cycle will start again, and in about 15-20 years when we go into a more violent collapse—then we will end up with Soviet-style rather than Danish style socialized medicine. And we ought to be able to do much better than that.

Well said.

There are a number of posts on healthcare reform through the TPMCafe's book club discussion on Jonathan Cohn's new book, Sick.

One of the best is a comment to Cohn's post, "Un-compromising Positions." Cohn also praises Hacker's plan, although he caveats, "One risk in embracing such a compromise plan is that it will let stand a wasteful, poorly designed system that will keep generating unnecessarily high costs. But I’m not sure that, politically speaking, we can cover everybody and deal with the system’s inefficiencies all at once."

Which is probably why I haven't read the plan. I keep hearing it's a compromise, and if we begin with a compromise we'll be compromised.

Here's much of that great comment to Cohn's post:

... if you went car shopping and found...

Volkswagon Jetta - $20,000
Toyota Camry - $15,500
Volvo S40 - $18,250
Chevy Impala - $44,800

...you would say 'What a rip-off for the Chevy Impala!' and look on the invoice and laugh at all the comically overpriced features and poor relative performance and choose ANY of the others - even though the others are very different.

Now substitute OECD per capita health care costs (2003).

Germany - $2,938
Japan - $2,249
Sweden - $2,745
United States - $6,711

That's the same price spread the cars. The US has fewer doctors, fewer nurses, fewer hospital beds, higher infant mortality, lower life expectancy, and more uninsured people than Germany, Japan, and Sweden and we spend more than twice as much.

There are so many other good posts and comments to this discussion that it's hard to read them all — or find them all. Don McCanne had a good one last week that I wanted to link to, and now I can't find it. If TPMCafe has all the connected stories in one place, it's a place I don't know about.

Blackout on the truth

The National Education Association supports single-payer, universal healthcare. Who knew?

And that's the point. We didn't know. The media has effected such an effective blackout on single-payer that it seems like a silly, socialist, pie-in-the-sky idea. Then you dig in a bit and find out that the former head of Caterpillar has said single-payer's what we need, it's the only thing that makes sense; you find out that Ford Motors' former CEO has said much the same thing; that the nurses associations are for it and that the NEA backs single-payer.

But common wisdom still would have it that anyone who thinks single-payer is the solution to our healthcare Catch-22s is unrealistic — when in fact it's unrealistic to think that anything other than single-payer will contain costs and provide healthcare justice.

That doesn't mean that rich people don't get more healthcare under single-payer systems. That's just life. Rich people will always get more. As it turns out, however, more isn't always better. Too bad for them. No doubt when they figure out how to stay young for 50 extra years it won't be covered. That's fine — we're just looking for a normal life-span, like not dying at age 45.

I talked with a woman (we'll call her Julie) from Pueblo, Colorado, tonight. Julie's worried sick about her mother's health. Her dad gets health insurance through the government because he's disabled. He makes $7 and some change an hour. Julie says her mother's salary always supported the family, and that her mom has always gotten her own healthcare through a clinic for the indigent. Now Julie doesn't know what to do, because her mother is sick. Julie herself is a single parent, a junior in college on a scholarship that doesn't pay for her mother's healthcare.

Julie says that politicians keep talking about covering the kids. Good, she says, but it's not enough. "What are people supposed to do between the ages of 18 and 65?"

Julie says that she's heard the horror stories about people having to wait for surgery in countries that have healthcare justice, but that she's talked with people from Britain and elsewhere, who tell her it's not like that at all. "They say it's us that have the crazy system."

Tom Tomorrow in a bad mood

If you believe that a free-market health insurance system makes sense...

Ezra on patient incentives

Maggie Mahar wrote yesterday on perverse incentives for physicians that drive up costs; Ezra Klein writes today in American Prospect about perverse incentives for patients.

This again offers Bush & co. an opportunity to take real facts and twist them so they'll become ammunition for their class warfare against the middle class. C'est la vie, I suppose. Iron can be used for good — plowshares, say — as well as being potential death dealers as swords. We shouldn't turn our backs on the stuff.

Klein writes that RAND's 15-year study showed that "gold-plated" healthcare coverage that gave 40 percent more care than basic coverage offered no better outcomes.

This is actually an argument in favor of single-payer. Denver Dave of HC Talk has mused that the average person, when thinking about single-payer, pictures U.S. healthcare being a finite entity that he or she has a part of through his or her insurance. If we split the pie differently in order to give some of that healthcare to people who have none now, that seems to mean that he or she would have less.

The RAND study shows that less can be better. What's more, the study also showed this: "The only exception was for the poor, whose health outcomes were hurt by cost-sharing and improved by more generous plans."

Further showing that denying healthcare to the poor (and increasingly to the middle class) is foolish, Klein links to this:

The New England Journal of Medicine... compared Medicare patients who faced heavy cost-sharing for pharmaceuticals with those who had nearly unlimited benefits. The seniors with cost-sharing cut back on pharmaceutical spending (and thus, use) by about 31 percent. The results? More visits to the emergency room, more hospitalizations, and higher rates of death. And the upshot of all this is that the costs incurred by the deterioration in health completely erased the savings from the cost-sharing.

Klein agrees with cost-sharing by patients except for chronic conditions where generous care has been proven to pay for itself and more.

"One-size-fits-all high deductible policies associated with Health Savings Accounts (HSAs) require costly tax breaks for the most affluent while unnecessarily increasing financial and health risks for low- and moderate-income families," Klein writes. He instead likes a plan from his favorite economist, Jason Furman at the Hamilton Project, who has come up with a system that he claims could save 30 percent immediately by charging co-pays adjusted by income.

Of course the only realistic way to do that would be through a single-payer system.

TPMCafe with more single-payer

Maggie Mahar's post at TPMCafe kept me up until 1 in the morning last night, reading it and all its links.

I decided to buy her book on the spot — Money-Driven Medicine is a great deal for $8 at Amazon. Here's how she begins the TPM piece:

I understand why some believe that radical reform is politically impossible. But they remind me of those who said that we could never pass Medicare. Eventually, the pain became too great. Too many seniors could not afford care, and popular support trumped the then-powerful AMA. In 1962, Gallup polls showed public support at 69% and President Kennedy called for Medicare in front of crowd of 20,000 in Madison Square Garden.

Still, it wasn’t easy.

After Kennedy’s speech, the Medicare bill was defeated 52-48. This did not stop the Democrats—they understood what was at stake. They knew that the opposition would be fierce, but they also understood that this was like civil rights. It was not a time for caution. It was a time for politicians who cared about issues....

Great stuff.

Mahar seems to say, however, that even if we did institute a single-payer system that costs could still be out of control unless we fixed provider reimbursement: "The most honest physicians admit that in our system, over-treatment is driving healthcare inflation."

This sounds like the conservative argument that overuse is the problem, but in fact overtreatment and overuse are different creatures — although they're both created by the perverse incentives of our current system's for-profit market structure. Both would be most easily rectified via a single-payer system.

She criticizes fee-for-service — which seems to be a sacrosanct part of the single-payer deal for many physicians who support reform.

To support her position, Mahar links to a wonderful piece she did for Dartmouth Medicine Online about their research on costs.

In study after study, the Dartmouth team has shown that Medicare spends twice as much, per patient, in some regions of the country than in others--for reasons that have absolutely nothing to do with medical science, the severity of the patient’s illness, or even his or her preferences.

What’s driving the higher costs? Supply.

“Build the beds and they will come.”

Based on their research, the Dartmouth team estimates that one out of three of our health care dollars are squandered on redundant tests, unnecessary hospitalizations, unproven bleeding-edge procedures and over-priced new drugs and devices that are no better than the products that they have replaced.

Some hospitals spend two-and-a-half times what others do, without better outcomes. In fact, outcomes are worse.

Both pieces are thought-provoking. Single-payer will only be part of reining in costs. If we have single-payer and continue pharmaceutical advertising, or single-payer Plan D, shackling government's ability to negotiate for better costs, or single-payer with physicians still over-utilizing questionable pharmaceuticals, lab tests, technology, etc. — we'll still have problems. Other countries are so far ahead of us on all of this.

Lack of health insurance = more strokes

A study out of Beth Israel Hospital, Harvard, and several other facilities has found that people without health insurance don't get routine physical exams and have increased rates of stroke and death. The researchers reported their findings in the April issue of the Journal of General Internal Medicine.

Imagine that. Wasn't it just last week that a couple of Cato anti-single-payer "experts" wrote in the LA Times that there was no connection between people's health and insurance? In which case, why buy insurance? Especially since, in the America that anti-single-payer folks live in, we already have universal healthcare. And black is white, peace is war, up is down, there were weapons of mass destruction, and Bush is our greatest president.

Who was it who said that everyone's entitled to their own opinion, but that no one is entitled to their own facts?

Assault begins

This Tom Tomorrow cartoon is from the 1990s, but when it comes to healthcare, he may simply be able to pull out his old strips and run them again.
That's what the insurance industry has in mind. It worked then, should work again. Working against them is the fact that more middle-class people are hurting now, business is realizing how our system is hurting them, and all the data from other countries that show the relatively good news there. Is it the best? Nope. Is it better — far better? Yep.

'Sick' author Cohn at TPMCafe

Jonathan Cohn's new book, Sick, is this week's book club item over at TPMCafe. Jacob Hacker, Ezra Klein, Matthew Holt, Robin Podolsky, Don McCanne, Roger Hickey, Maggie Mahar and Joseph Paduda will debate Cohn on the options: single-payer, hybrid, or social Darwinism.

Cohn writes, "One of the most striking things about the hybrid crowd is how many of them actually believe, in their hearts, that single-payer is better. For these people, endorsing a hybrid is all about political calculation: Single-payer won't pass, so it's better to get behind a workable compromise."

He thinks that's a mistake: "For one thing, a discussion about changing public policy ought to start with a discussion about which policy would actually work best, whatever the politics."

Cohn refers to his NYT Magazine interview with Safeway CEO Steve Burd, who joined with Andy Stern of SEIU and Sen. Ron Wyden (D-OR) to call for universal healthcare. Burd didn't want to look to government. First he pushed personal responsibility in the form of forcing employees to cover more of their own costs, and then he pushed personal responsibility in the form of employees adopting healthy habits. But it's not enough, is it?

In conversations around the Bay Area, [Burd] heard over and over from hospital administrators about the financial burden the uninsured were placing on their facilities — a burden that eventually rippled through the insurance system and showed up on Safeway’s bottom line as inflated health premiums.

Burd’s first effort to trim costs and keep Safeway competitive involved cutting back on health benefits. Then he tried encouraging his workers to be healthier. Could nationwide universal health care simply be the next step? As long as there were large numbers of uninsured, Burd reasoned, there would be no solution to his company’s — or the country’s — problems with affordable care. And that, he says, is when it finally dawned on him: Maybe this was a problem the company couldn’t solve on its own. If he wanted relief from employee health costs, the government would have to help.

It was not an idea that came easily to Burd, a self-described conservative and Republican...

It's striking how many of the comments to Cohn's TPM piece push the free market mantra. Of course it can push down costs...

Well then why hasn't it? Or more to the point, why has single-payer kept costs down wherever it exists? As it covers everyone? Why hasn't "moral hazard" shot their costs out of the ballpark? Why have their outcomes remained as good or better than ours? For half the cost?

Lastly, how is the health insurance market different than a protection racket? Wouldn't it be better, in the long run, to set up a police department rather than relying on the Sopranos?

Study in contrasts

Dennis Kucinich, campaigning in New Hampshire, "was most passionate about his plan for universal health care, which would create a nonprofit single-payer system designed to keep the insurance companies from interfering with national policy, he said. The plan would put more control in the hands of doctors and help re-establish the doctor-patient relationship, he added."

Sen. Max Baucus (D-Mont) thinks that the U.S. health care system is on the "verge of collapse," and that it's "exciting and fun" to work on preventing that. Oh — and he doesn't consider single-payer a possibility. Baucus says he's pragmatic — that's probably why he brokered the the Bush tax cuts of 2001 and the Medicare prescription drug plan. Thanks Max.

Businesses think about national healthcare

This story on businesses speaking out for government involvement in healthcare ran in a dozen or more Southern papers, leading with: "Many executives of large companies are starting to call for a national approach to fixing health care, warning that an employer-subsidized health system is unsustainable."

“Five years from now this problem will have to be cured, or the competitiveness of the United States will be dramatically affected,” said J. Randall MacDonald, senior vice president for human resources at I.B.M. He called for a national debate on such topics as maintaining existing employer-subsidized health care, with “some level of umbrella coverage over that, some level of a single payer system.”

“A lot of positioning is going on now,” he said. “The reality is that changes are inevitable, I think sooner rather than later.”

..."“The way it’s going, there will be 75 million uninsured in another 10 years,” said James D. Sinegal, chief executive of Costco Wholesale, which subsidizes health care for 81,000 of its 100,000 workers in the United States. “The federal government has to lend some assistance.”

...“The system is going to break,” warned Carl T. Camden, president and chief executive of Kelly Services. “You can only put so many uninsured people through the emergency rooms before employers stop offering coverage.”

...Economists say that employers would raise wages if they did not have to pay for employee health care. The Treasury would stand to gain $140 billion a year in personal income taxes if the benefits were treated as wages, said Len Burman, director of the nonpartisan Tax Policy Center in Washington. There would be about $70 billion more in additional payroll taxes due on those wages, he said.

The story does a good job of delineating the differences between business sectors — including those who don't want more government involvement: "Craig R. Barrett, the chairman of Intel, another participant in the Better Health Care Together campaign, is skeptical about a new government role. He said the private sector could do the best job at improving efficiency in the system."

Plus a reason some small businesses might not want single-payer: "Another set of issues divides large companies from small businesses, which employ 50 percent of working Americans. Their owners worry that in some states they may be forced to spend for coverage of young workers with little interest in health coverage."

Right. All those young workers who don't want it. Until they need it.

In the meantime, UAW President Ron Gettelfinger called for "single-payer, universal, comprehensive national health care" at the union's bargaining convention last week in Detroit.

People's Weekly World Newspaper quoted Local 900 delegate Dwayne Walker, who said health care “was an issue that should have been dealt with a long time ago — we need national health care. We are all part of a community and the union looks out not only for its members but for the rest of the county too.”

Obama & single-payer

Barack Obama in New Hampshire has mostly been in huge venues — but Ron Brownstein of the LA Times writes that Obama "heard impassioned and sometimes wrenching pleas for a single-payer health care system at a forum limited to 100 people in Portsmouth on Tuesday afternoon."

Dozens of papers ran stories on Obama in Iowa, and his reluctance to spell out his position on healthcare reform. In Iowa, he told an audience that "We shouldn't just put more money into a system that isn't efficient." At another event he said,

Money saved by converting health record keeping into an electronic rather than paper process, early detection of chronic illnesses, and child wellness programs could help finance coverage for the uninsured, he said.

"We can save huge amounts of money and put that money into providing basic health insurance or subsidies to purchase health insurance for those who don't have it," Obama told about 400 supporters and Democratic activists in Fort Dodge. "We can create universal health care in this country."

... Obama has said he is open to raising income tax rates on wealthier Americans to pay for domestic priorities, including transportation, education and health care.

... Obama hinted during his later stops Thursday that his plan would likely include government assistance for some uninsured to enroll in insurance programs such as those offered to federal employees.

In another story, Obama was quoted as saying "if he was starting from zero, he would likely support a single-payer system, similar to the government-run program in Canada. But he's leery of taking such a step because the United States already has a complex and established system of employer-based health coverage."

State single-payer news

California State Sen. Sheila Kuehl's single-payer measure, SB 840, is supported by the California Nurses Association, California Federation of Teachers, SEIU, California Association of Retired Americans, League of Women Voters, Friends Committee on Legislation and many more labor, community and faith-based organizations.

At BeyondChron Peter Lauterborn writes in favor of S.B.840, the California single-payer plan. He calls out John R. Graham, director of Health Care Studies at the Pacific Research Institute, who has been busy penning anti-single-payer editorials for papers around the country.

Graham sounds like he doesn’t even see the need to cover the uninsured. “Eighty percent of the uninsured report good, very good, or excellent health,” he proudly boasts....

He writes that the fiscal burden of supporting these individuals is “caused by uninsured patients who apparently have nothing better to do than sit around emergency rooms consuming treatment for which the rest of us pay.”

Yikes.

Illinois State Senator David Koehler told Chicago Public Radio that adopting the Illinois' governor's proposal to "significantly increase affordable health insurance" is a last ditch effort. "Let's face it folks. This is kind of the last hurrah in terms of a public and private partnership for healthcare. If we don't do it at this point in time, then the next step is for us to look at a national single-payer system." And that would be a bad thing?

Pennsylvania Democratic Gov. Ed Rendell stopped by a public health forum to tout his multi-payer plan for the state.

Rendell defended his multipayer plan, even while conceding a single-payer model might be better. He listed Pennsylvania's powerful health-insurance lobbies and lack of support on the national level for universal health care as hurdles preventing him from proposing a single-payer plan....

That plan would guarantee 85 percent of every dollar invested in health care would be spent on treatment, not administrative costs. His plan also allows the state's insurance commissioner to set rates, as the commissioner does for car insurance.

National single-payer news

High-deductible health insurance plans favored by many employers often wind up being an unfair burden to women, Steffie Woolhandler's study on high-deductible health plans shows, largely because women need many routine medical exams that quickly add up. "The median expense for men under 45 in these plans was less than $500, but for women it was more than $1,200, according to a study by Harvard Medical School researchers."

A real hurrah goes to ACT UP. These are people who know how to stage a good demonstration, and they're now committed to single-payer. At a Manhattan demonstration where 27 activists were arrested, "David Golden of the New York City AIDS Housing Network called for the extension of the housing and social benefits provided by the H.I.V./ AIDS Services Administration (HASA) to people living with H.I.V. The group is pushing for 'HASA for all.' He asked, 'Why should you have to get gravely sick before receiving benefits?'... Fifty body bags were scattered around the bull 'to symbolize the 50 people a day who die from lack of insurance in this country,' said ACT UP’s Ann Northrop."

“We’ll show you what activists are capable of,” ACT UP founder Larry Kramer told the crowd before the march left the Federal Building at Broadway and Worth Street. “This is the beginning of a demonstration to take the country to task,” Kramer said. “It’s appalling that our country doesn’t have universal health care — we’re the wealthiest country in the world.”

The NY Times ran an op-ed on the U.S. safety-net's disappearance, focusing on those Circuit City employees laid off because they earned too much. "If companies aren’t going to provide health insurance, the government will need to. It can do so directly, through a single-payer system similar to those in other countries, or indirectly, by pooling together the uninsured and helping them buy coverage, as Massachusetts is now planning." Except that second choice locks in the inefficiencies and will bankrupt us. Except for that one detail.

Creative destruction for the rest of us: "Conservation programs and universal health care aren’t the problem; they are the solution. Environmental rules save resources. Universal health care saves lives. And both create jobs."

In North Carolina the News Observer gives kudos to Republican U.S. Rep. Walter Jones of that state.

Jones is expressing justifiable outrage at the way drug manufacturers pushed the Medicare prescription drug plan through Congress, including the night when the House leadership (then, in 2003, under Republican control) kept the vote open for hours while leaders and pharmaceutical reps worked the halls for votes.

The industry was especially fond of one provision in the plan -- barring the federal government from using its clout to negotiate lower prices for the drugs used by millions of elderly Americans. This was a blatant bow to the companies from the Bush administration, which wanted to protect its political allies and contributors even if it put a hit on elderly folks. It worked, too.

The Akron Beacon Journal reported on a healthcare meeting sponsored by Single-Payer Action Network Ohio."The closest the United States has come to a single-payer system is Medicare, the national health-insurance program for people age 65 or older and some younger disabled Americans. Just as the federal government does under Medicare, a state-run single-payer system would set the reimbursement rates for doctors, hospitals and other health-care providers."

The San Antonio Express gave space for a single-payer op-ed that nicely describes the Massachusetts' plan:

...a 56-year-old making $30,000 annually will have to spend $7,164 in premium and deductible payments before insurance kicks in and still pony up 20 percent of hospital costs after that, according to Physicians for A National Health Program, or PNHP. Such coverage is health insurance in name only.

The author, a pediatrician member of PNHP, argues that HR 676 is the way to go. Bravo.

Right resorts to lies

A couple of Cato Institute directors have resorted to half-truths and lies in an op-ed piece for the LA Times. The piece is titled "Universal health care's dirty little secrets" — those "secrets" evidently being foremost that preventive care doesn't make for healthier populations.

Ezra Klein does a good job of rebutting this, saying that the Cato guys distorted the study that supposedly proved this — and ignored the many studies that show positive correlations between preventive care and better health.

The other "dirty secrets" are similarly deceitful — beginning with the "fact" that the uninsured in the U.S. do get care in emergency room hospitals and via docs, who don't turn away patients just because they're uninsured. And there are physicians who take on an uninsured friend. But those instances hardly make for a "medical home" for a county's uninsured — especially for the uninsured with chronic conditions.

The Cato guys, of course, fell back on the right's frantic claim that there are waiting lists for elective surgery in countries with universal care. The right screams this so often that it's hardly a secret. They never mention the fact, of course, that there are also waits here in the U.S. — and that waits are hardly a secret in Canada. It's a public system that was underfunded and is now doing far better. Their problems are far more publicized than ours are, because it's public. People got mad about it, and they're fixing it. This is a "secret" only in the upside-down world of libertarians.

So will the Canadian system then be perfect — after they work out the waits? Give me a break. What system is perfect? The point is that the U.S. can do much, much better — and that Canada, Great Britain, Sweden and all the others already do much better. Unless you think that paying more and getting less is better. They have better outcomes for less money in a more transparent (and therefore amenable to improvement) system than ours.

Are we really such idiots that we can't do that too? Are we really so wedded to an inefficient, unjust, and uneven system just because it makes some people a lot of money? And employs — at the expense of lives — thousands of clerks, administrators, and marketing managers? Whatever happened to the joy of creative destruction that the right loves so much when it comes to outsourcing factory jobs? Whatever happened to the concept of retraining people whose skills become obsolete in a new, fast-moving economy that supposedly has to be as efficient as possible in order to compete globally?

Is that true in every sector except healthcare?

At least Amy Ridenour has come up with something new in her never-ending quest to ignore our own crisis and instead focus on the problems of others. Kind of like someone in the Philippines ignoring the hillsides of people living in squatter settlements made of cardboard an discarded mattress springs, saying that these folks are sheltered, after all — but look at the problems in Paris! Where so many people don't have air-conditioning!

Ridenour has dug up a nasty op-ed from the London Times about "mixed-sex wards," that makes it sound as though the British regularly share hospital rooms with sex fiends of the opposite sex. It is a scary story, but hardly, as Ridenour says, the one story you should read about single-payer, if you read nothing else this year. And in fact, a more balanced story from the BBC points out that most "mixed-sex wards" are actually emergency rooms. And I can tell you from recent experience that ours are mixed sex too — and that there is the occasional view of an octogenarian's butt. Big deal.

More recently, the scandal in the British papers about their hospital care is that the telephone charges have been increased. Evidently, it's now possible to spend 60 pence on a call before you're even connected. "It's outrageous!" thundered one letter writer. Indeed. I wonder if Ridenour is aware of that one.

Young invincibles don't need Wellpoint

Infuriating article in New York Magazine on New York's "young invincibles," which is the health insurance industry's term for 20-somethings who make the very rational choice not to buy health insurance to cover themselves and line the pockets of a very profitable industry.

It was a painful article to read, as it opened and closed with the story of Andrew Ondrejcak's bout with appendicitis. He survived.

Paul should have survived too. Would have, if there hadn't been an entire series of screw-ups and wrong judgments at the hospital.

"We trusted them," Sarah told me afterwards. "We trusted them."

Paul had evidently been on some kind of campaign to convince her to be more trusting of people — to assume the best of others. That is the kind of guy he was.

The New York Magazine article is infuriating because it draws absolutely the wrong conclusion about what to do about all the uninsured 20-somethings out there.

The common assumption is that the exorbitant rates are schemed up by the politically influential executives governing the trillion-dollar insurance industry. But if insurers could target cheaper plans at younger New Yorkers, they would: Every business thrives by exploiting untapped markets. State law, however, requires insurers to follow a “community rating” system that throws everyone—young, old, sick, healthy—into one risk pool. “The whole point of insurance is that you’re pooling the risk to spread out the costs for everyone,” explains Cunningham. “If you target healthier groups with favorable policies, you’re likely going to make it more expensive for the older, less-healthy populations who need regular care.” Of course, if the young and healthy don’t buy policies at all, who’s balancing the costs? Recognizing this Catch-22, some states have adopted a more flexible “age banding” system, allowing insurers to customize packages based on age. WellPoint recently created a youth-centric program called Tonik, with plans as low as $67 a month, but it’s currently only available in eight states.

So things are fine in those eight states.

Wrong. In those states there's still a third of U.S. healthcare dollars not going to healthcare, but instead to duplicated administration, obscene CEO salaries, profits, and marketing. People in those states still pay, per capita, twice as much for healthcare as do people in other countries, and there are just as many left uninsured or with crappy insurance packages. I haven't googled "Tonik," but would bet that it's a junk policy, with a high deductible, lots of co-payments, and a fat premium increase if it turns out you have anything wrong with you. In other words, if you might need care.

Wish I could write like this

Mark Morford of SFGate despises Starbucks. Hilariously:

Of course, their early, scrappycool coffee-culture vibe (circa, say, 1996) is long dead. It is not news that Starbucks' coffee is now invariably horrible, the overall quality shot to hell at the expense of absurd, outrageous growth, all made cruelly plain to me yet again by way of the last few times I was forced to purchase a coffee-like drink from them, each time in desperation when driving numbly up/down Interstate 5 and having no other options and each time hoping it might be different, merely praying for a passable soy mocha and every time taking two or three sips and gagging and pouring the thing out on the sidewalk, thus wasting upward of $49 and wishing Peet's was a more ubiquitous chain but also understanding that were Peet's to expand the way Starbucks has they would become exactly as atrocious and tasteless and cheesy and dumbed down and tacky and useless and annoying and forgettable and loathsome and tired and depressing as Starbucks. And no one wants that.

Morford manages to make me laugh, feel nostalgic for driving I-5, think about Portland's amazing local coffee shops, and feel defensive about Starbucks all at the same time.

I remember the Starbucks at SE 37th and Hawthorne back in the early '90s, before it expanded. The crew there really did know everyone by what we drank, and they seemed to believe that entertaining the people in line was part of their job.

Morford should try leaving I-5 to head west through Oregon's Coast Range towards the Pacific — where the only option is coffee from a bait shop in some gorgeous, green, run-down and rainy place like Hebo, Beaver, or Grande Ronde, where the locals think coffee is supposed to taste like boiled shoes. With synthetic creamer if you like. Now that's unforgettable. When you're truly far from civilization, Starbucks is a relief. Even the Starbucks at that truck stop on the endless reach of I-70 just west of Kansas, where the barrista looks confused by the idea of half-caf, and she hands you your coffee surrounded by the ambiance of hot dogs on a stick, gasoline, cigarettes, Twinkies, and trinkets for the kids.

I just wish I hadn't let my broker talk me into selling my Starbucks stock lo so many years ago. 11,000 stores today. With healthcare for their employees. And reliably good coffee. Yes it is.

Commonweal pro-single-payer

Commonweal, the smart and progressive Catholic journal has a thoughtful and persuasive editorial in favor of single-payer in its most recent issue. You can read it online.

Beginning with the news that some companies are paying for all their employees meds — preventive medicine saves money and lives — the writer moves on to the fact that by 2010 only half of adult workers will be covered by insurance through their employers and that insurance is becoming unaffordable.

Americans now spend roughly $2 trillion annually for health care, about twice as much per person as other developed countries, and with less to show for it....

John Edwards has outlined a mandatory federal system to cover all Americans, based on higher taxes for the wealthy and “Health Markets” to control costs. Such insurance pools, modeled after Medicare but separate from it, would allow negotiators to bargain with providers for lower prices and improved services. Edwards says his model might eventually evolve into a single-payer system, once the public saw the advantages such an option offers.

Under the present system, private insurers spend up to half their revenue on administration, advertising, and stockholder reimbursement, rather than on actual medical services. Health markets would deliver greater bargaining power in dealing with hospitals and drug companies, just as the Veterans Affairs Administration and the Canadian health-care system do today.

The writer describes Americans' changing attitudes well — our attitudes are "maturing." Latest poll numbers show that 64 percent of Americans are in favor of universal coverage, and would be willing to pay more in taxes to get it.

A single-payer system would not prevent individuals from buying added insurance. But the larger insurance pools would spread out the liability risk and allow the system to cover those who are now excluded. It would also facilitate preventive care.

In the past, Americans have said no to a national health system out of fear that it would lead to long lines and restrict choice in services. An evolving single-payer system like the one proposed by Edwards could allay those fears by providing greater efficiency, lower costs, and ample choice. The challenge will be to convince enough voters that the higher taxes required for such a program really would lead to better-and cheaper-health care.

Sex at TJ

Andrew Sullivan has this great link to a study of a year's worth of sexual hook-ups at "Thomas Jefferson" High — my own HS!

This "Jefferson High" was almost all white, in a mid-sized city an hour from the nearest big metro area. A few more than half the kids had had sex — 573.

This study has implications for how to stop sexually transmitted disease. In adult populations, there are "hubs," or key individuals who spread disease. At Jefferson, there weren't — although more than half of the kids who had had sex were part of a huge chain of potential infection:

The most striking feature of the network was a single component that connected 52 percent (288) of the romantically involved students at Jefferson. This means student A had relations with student B, who had relations with student C and so on, connecting all 288 of these students.

This is getting old

I’ve been hobbling around with a broken right ankle for more than a month now. I’ve got another three weeks to go before I can even think about a walking cast. My left leg has lost its flab. My right leg is melting away. If you’ve ever broken a limb and had to have a cast for any length of time, you know that it takes forever afterwards to get back that bulk and muscle.

I’ve been feeling sorry for my right leg. It was only this morning that I realized how wretchedly resentful my left leg has become.

I can’t tell whether it has been listening to too many rage-filled talk show hosts or what. The damn limb has no sense of noblesse oblige, that’s for sure. The complaining has been nonstop about how it has to do all the work, while the broken leg does nothing.

“Aren’t you glad you can work?” I ask.

“Not all the work,” it replies churlishly, resonating from my hip, I think.

“Look, this is ridiculous,” I say. “Work is good for you. You’re stronger than you’ve been in years. It’s the broken leg that fading to nothing — because it can’t do any work. You think it’s happy just dragging around?”

“But I’m supposed to be happy, doing all the work?”

“Look, we’re in this together,” I say. “From each according to his ability, to each according to his needs. Right now, rightie needs you to do all the work.”

At this point, my right leg accuses me of being a communist, claiming that was some kind of Leninist motto. “As far as I’m concerned, she’s on her own. I got to where I am through hard work, she can do the same.”

“Gimme a break,” I say.

“Very funny,” says leftie.

One risk pool needed

Saul Friedman at Newsday has written a great piece on single-payer. He quotes Robert Gumbiner, evidently one of the people behind the managed care movement. Gumbiner writes:

"I am proposing the federal government as the single payer of health care in this country. Only the federal government has the ability to fund one large risk pool through a payroll deduction. As the single payer, the federal government could negotiate hospital and physician payments even more effectively than it does now with Medicare.



"A single pool of funds, collected and administered by the government, would expand Medicare and replace Medicaid, SCHIP (State Children's Health Insurance Program), the VA health-care system, and private health insurance, including the health care aspect of Worker's Compensation. ... Also eliminated would be the tax credit - or subsidy - given to companies for providing health insurance to their employees. In other words, the current, inefficient patchwork of payment systems would disappear, to be replaced by one nationwide program available to every citizen."



Friedman writes he found the piece at the PNHP website.

Friedman invites letters on your ideas on universal care: Saul Friedman, Newsday, 235 Pinelawn Rd., Melville, NY, 11747-4250, or saulfriedman@comcast.net.