Insurance Adds Negative Value

Ezra Klein has a nice post beginning with the proposition that the health insurance industry adds negative value to health care -- that is, they make it worse. For those conservatives who go on about how competition always makes things better, he offers, "Competition among drug dealers does not aid the neighborhood, and currently, competition among insurers does not aid the ill. Indeed, their inattention to actual care is startling."

Bravo.

Barry Keene, a businessman who is vice-president of Health Care for All Colorado, often sounds sincerely sympathetic to the plight of the insurance industry -- something with which I can't quite empathize, although I understand the argument. Ezra puts it like this:

It is actually counterproductive for insurers to compete on giving us the best care. It's not simply that they're not doing it, but given the structure of the marketplace, they shouldn't do it. Imagine insurer X creates the best damn diabetes protocols in the country. And they begin advertising this fact. What happens on Day Two? Well, they're flooded with individuals suffering from diabetes, or individuals who fear they will one day be suffering from diabetes. These people, in the current system, are a bad deal. Not only is it near impossible to insure them at a profit, but pooling their costs (which is what insurers do, after all) raises premiums for all the insurer's other customers. When the average customer of an insurer gets sicker, prices go up for all their customers. So the healthy folks contracting with that insurer quit the pool, and go find a cheaper deal, which forces the insurer to raise premiums again, driving out more healthy folks, which forces them to raise premiums again, which drives out more healthy folks, and so on. It's what we call an insurance death spiral, and it ends with the collapse of the insurer.

Risk Equalization in Eire

For Americans, reading about "risk equalisation" in the Irish insurance market can only evoke a snort of disbelief. It's a concept so foreign I'm not even going to Americanize the spelling.

So what the bloody hell is "risk equalisation" you ask?

According to Medical News Today, risk equalisation is how competition in the health insurance market works to the benefit of all health insurance subscribers. It operates alongside community rating, open enrollment and lifetime cover. Here are the definitions:

• Open Enrollment entitles persons of all ages, irrespective of health status to avail of health insurance.
• Community Rating ensures that younger and older subscribers pay the same amount for similar health insurance cover and that subscribers pay the same amount for similar cover throughout their lives. This means that people can continue to afford health insurance right into those decades of their lives when they are most likely to need it.
• Risk equalisation payments involve transferring funds from insurance companies which have a disproportionate share of young, healthy subscribers to companies which have a disproportionate share of older people who are more prone to illness.

Crazy.

"This allows for an equitable market, enabling companies to compete on a equal basis, but also protecting customers through removing the incentive to engage in preferred risk selection," according to the story.

Crazy.

This would protect individuals and families at the cost of profit. It's nuts. Probably communist.

Most EU countries have supplemental insurance that a lot of people buy -- about 50 percent in Ireland. (And yes! Those private insurance costs are factored into the total costs you read about where the U.S. looks so bad.) Evidently the EU court doesn't want to model their insurance market on ours. Odd, eh? Ours is so robust. Very profitable industry.

No doubt the insurance industry will continue its assaults on the notion of protecting the consumer in this wild-eyed manner. Sooner or later, by hook or by crook, "risk equalisation" will be a boogey-man of the past.

Two Kinds of Health Reformers

Brad Warthen says this well:

We continue to concentrate on the wrong thing -- getting the uninsured into the present system -- when we talk about health care reform.

Increasingly, those of us who are privileged to be in the system find that we can't afford health care, either. The whole system is rotten, wasteful, too expensive and too inefficient. We pay more money to be sicker than folks in any other advanced nation.

There are a lot of problems with our system, but the biggest is the basic premise -- employer-based health care through for-profit (and we're talking for HUGE profits) private insurance companies.

If private health care coverage weren't so expensive for all of us, the 1 in 7 who remain uncovered would be in it. But it is, and will be, expensive by definition. A profit has to be made.

A single-payer system is the logical way to go.

So what kind of health reformer are you? The kind who is trying to get the uninsured into the system, or the kind that is trying to change the system? Mother Teresa or Archbishop Romero? Charity or justice?

My Next Life

Kevin Drum posts Friday cat pictures. Maybe I'll start posting Wednesday sailing pictures.

Denver Post vs. the Governor

What is it with the Denver Post and Colorado Governor Bill Ritter?

I'm even seeing this when I basically agree with the criticism. Today it's a good health care story about a 53-year-old guy with seizure disorder who can't get insurance. Me, basically, except I've managed to keep my coverage.

Cover Colorado said they'd insure the guy for $500 a month. Only $100 more than I pay. The one private insurer who agree to take him on had a plan that cost $650. Pretty standard, if you're talking about decent coverage for someone with pre-existing conditions. And how many of us reach 50 without a few?

Katy Human, their health care reporter, writes:

While some Coloradans can't afford health insurance and others have inadequate coverage, Sullivan falls into another problem group — people who are generally healthy and middle-class but can't easily get insurance because of pre-existing medical conditions.

Colorado lawmakers, who promised last year to make health reform a priority this session, are rapidly backing off health-reform ideas after realizing it would cost roughly $1 billion to get insurance to the state's 790,000 people without it.

She didn't mention the fact that Health Care for All Colorado's plan would save the state $1.4 billion annually, and that people like this guy with the seizure disorder would be covered -- but again: Pretty standard fare.

Then comes this quote that provides the pullquote and jump tag that the paper uses. It's from the guy's wife:

"When a government cannot respond to the needs of the people, then there is a real problem," Patty Sullivan said Tuesday. "Gov. Ritter is not our friend on this."

What? It's a great quote, and I agree with the basic premise -- politicians are not providing the leadership that they could on this. Ritter himself told me in front of a crowd that the time isn't right, that the pols need us to do more educating. Standard fare, fair enough. Probably even right by many measures.

So on the one hand, I agree that the governor, as the highest elected official in the state has a special responsibility to lead. On the other hand, the Post really viciously attacked Ritter for his support of unions. So I wonder.

Ritter has a press conference today on health care. He referenced cost-shifting the other night on a public television call-in show, a misleading diversion from real solutions. Reducing cost-shifting due to the uninsured has very little potential for saving money under health insurance mandate schemes. If Ritter goes in that direction it would be a great disappointment.

The last part of Human's article was great. It referenced the phased approach to single-payer that Rep. Claire Levy of Boulder hopes to introduce.

Sullivan said she's pinning hope on the few state lawmakers still interested in universal coverage, including Rep. Claire Levy, a Democrat representing parts of Clear Creek, Gilpin and Boulder counties.

Levy said she is looking to introduce a late bill to start building a universal health insurance system in the state by creating an agency to draw up a benefit package and calculate costs.

Eventually, a single-payer system would probably need voter approval.

Startup costs could be high, as much as $15 billion by one estimate, though a nonprofit insurance program would lead to savings for most Colorado families, businesses and health care providers, Levy said.

"I keep hearing people repeat as if it's a received truth that the voters won't pass it," Levy said. "But I hear the same people saying they support a single-payer system. And businesses — especially small businesses."

Imagine No Insurance Industry

It's easy if you try.

Kevin Drum has a fabulous post at Washington Post on living without the insurance industry. One of the reasons that both Kevin Drum and Ezra Klein are so great is the quality of the comments they inspire. Scroll down and admire how smart people are.

Drum links to an LA Times article on Blue Cross/Blue Shield sending a threatening letter to physicians, telling them they'd better tell all about their patients' conditions so that the insurer can deny treatment by any means possible.

He asks -- what good are insurance companies? "They cherry pick clients, add huge administrative costs to the system, and do nothing to drive innovation or bring down costs."

Next he muses on a column by right-winger Tyler Cohen, who thinks that all we need to do is set up a massive new federal bureaucracy forcing the insurance industry to be more accountable. Drum's responds,

But if it's price signals and competition you're after, why not cut out the middleman and have consumers pay doctors directly? For example, imagine a national healthcare plan that paid 75% of all medical expenses but required you to pay the other 25%. Your maximum out-of-pocket expense each year would be capped at, say, 5% of income at low income levels, 15% in the middle, 30% at the next level, and 50% for the rich. Or something like that. It covers everyone, it limits catastrophic medical expenses, and it eliminates insurance companies and their bloated administration costs. But the copay is high enough that it gives consumers an incentive to shop around and doctors an incentive to compete.

This kind of single-payer system obviously requires lots of government funding, but on the regulatory front would probably be more conducive to competition and innovation than desperately trying to bring down ever-bigger hammers on private insurance companies who are gaming the system. And since the government would basically just be in the check writing business, not the spending business, deadweight costs would be fairly low.

I didn't have to go far before finding a commenter pointing out that high deductibles are counter productive to preventive care.

The internet is a wonderful place. Thanks Al Gore.

Canadian urban legends and realities

Every single-payer supporter should take a look at the Urban Legends Reference page on an email that purports to be from a Canadian talking about the problems with the health care system there.

[from the inaccurate viral email]What they don't tell you is how much we pay in taxes to keep the health care system afloat. I am personally in the 55% tax bracket. Yes 55% of my earnings go to taxes.

[in reality...]The highest federal income tax rate in Canada is 29% (for persons with annual taxable income over $120,887), and the highest provincial income tax rate in British Columbia is 14.7% (for those with annual taxable incomes over over $95,909). The typical upper-income level Canadian taxpayer is not in a 55% tax bracket.

By way of comparison, a typical upper-income level American taxpayer residing in California pays a roughly equivalent share of his income in federal and state taxes, even though the U.S. has no national health insurance program.

On the other hand, the Canadian system is not perfect. There are waits, and in a recent Commonwealth Fund report, Canada scored fifth out of six nations in terms of overall system adequacy. (The U.S. came in sixth.)

And so people do have complaints. They rarely take into consideration what the alternative is to guaranteed health care for all, and they get some things just plain wrong, but we need to be aware that Canada is not a panacea. We're not selling snake oil. We're simply arguing for a better way.

U.S. Medicare is already better than Canadian Medicare. There's no reason an expanded U.S. Medicare couldn't also be better.

Mass Gov Looks to Single-Payer

The Berkshire Eagle reports that regarding Massachusetts' mandated insurance scheme, Governor Deval Patrick says:

"the rate of increase in premiums is a serious problem for the state system and for private individuals, families and businesses as well. . . and there's a view out there that as long as private insurance is a part of health-care reform, we're never really going to break the back of the pattern." He called for serious consideration of a single-payer universal health care solution by the next administration in Washington.

The paper cited a series from the Boston Globe outlining the state's problems with their new system, which forces people to buy private insurance. In particular, the Berkshire paper noted,

Patrick inherited inaccurate assumptions about the cost of state-subsidized health insurance from the Romney administration, which created the program along with Beacon Hill lawmakers. (It's laughable whenever the presidential flunk-out blasts "Hillary Care" as socialized medicine, since it's based largely on "Romney Care.") Patrick's budget proposal for the upcoming fiscal year includes $400 million in extra health care spending — taxpayers would be responsible for nearly half of that, with the federal government counted on to supply the rest.

With the Bush administration now seeking massive cuts in health-care and other non-military spending, the immediate prospect of relief from Washington looks bleak. A McCain presidency would amount to a Bush third term when it comes to domestic spending. A Clinton or Obama administration would produce a sea-change, but it's unlikely the federal government will be in a position to bail out Massachusetts if health care insurance spending spirals out of control.

#

The state program is run by the Commonwealth Connector, which hooks up uninsured residents with the appropriate coverage. Jon Kingsdale, head of the program, told The Globe in no uncertain terms: "This is not sustainable if we don't deal with affordability." Proposed solutions are vague or half-baked at this point, ranging from a $1-per-pack increase in the cigarette tax (a great idea anyway) to help fund the state's health program to plans by a pharmacy chain to put affordable clinics in its stores to deal with basic maladies (a highly-debatable idea). Down the road, tighter regulation of hospital fees and insurance rates may have to be considered.

To put it simply, unless and until the cost of health care — much of it administrative, tied to the bureaucratic jungle of dealing with private insurance carriers — is contained and reduced, the Massachusetts reform program is in jeopardy. And this would bode ill for any universal health care program, with or without mandates, nationwide.

Polish lobbyists call for private insurance

The Polish Insurance Chamber is calling for private insurance that would compete with their government programs. They say, "The PIU assumes the cost of the additional health insurance would be around zł.50 per month. Assuming a take-up of 15%, this would mean an extra zł.3.5 billion for the Polish healthcare system."

If the system is underfunded, wouldn't an increase in taxes do that more efficiently?

Already on Our Way

The libertarians are right about one thing -- we already are well on our well to universal health care. When you add up the veterans, active duty military, government employees, the elderly, the incarcerated, the poor on Medicaid, the disabled, etc., a large percentage of U.S. citizens do already receive health care paid for by the government.

This writer from an Oklahoma College paper thinks it's 60 percent. I think that figure actually is how much of the $2 trillion price tag is paid for by our tax dollars, not the percentage of people getting care. Remember that 80 percent of the cost is eaten up by the sickest 20 percent of the people -- many of whom are indeed already getting subsidized care.

What we're fighting over is whether the rest of us should not only have to pay for that, but pay through the nose to get substandard coverage for our own families through extortionary private for-profit health insurance.

The Oklahoman writer posits that this is a fiscal and moral crisis -- a good way to put it.

And the sad thing is that we're already paying for universal health care. We're just not getting it.

UAW President Calls for Single-Payer

Crains Cleveland Business reports that United Auto Workers President Ron Gettelfinger in a speech at the City Club of Cleveland urged the country to adopt a single-payer health care system.

Gettelfinger, president of the 640,000-member union since 2002, said the health care crisis, the lack of a national industrial policy and the need for improved trade agreements are at the top of his agenda.

“We believe health care should be a right, not a privilege for those who can afford it,” he said.

FL's Ben Graber & single-payer

Ben Graber, MD, is running a sleepy campaign against six-term Democratic Rep. Robert Wexler in Florida. Congressional Quarterly reports that Graber only raised $700 in the last quarter of 2007 -- unlikely to be enough to unseat an incumbent.

His lack as a candidate makes for bitter reading when compared to his good sense in health care reform. In an opinion piece in the Sun Sentinel, Graber writes, "A wise person once said, 'There is nothing as powerful as an idea whose time has come.' A single-payer health plan is that idea."

Here's are his talking points:

• Expand Medicare to include people 55 to 64 years old, veterans and the chronically ill.
• Eliminate the need for any HMO involvement in regular Medicare by stabilizing premiums. This is accomplished by providing a formula for a much expanded and reduced-risk population.
• Offer an affordable premium until age 74 and then freeze the premium at age 75 and beyond.
• Enhance the Medicare D program by eliminating the doughnut hole and negotiating with pharmaceutical companies worldwide for a bulk discount on medications.
• Remove research and development costs from the price determinator and offer independent U.S. research grants.
• Incorporate the Veterans Health Administration into Medicare and Medicaid.
• Fund Medicaid premiums for those below the poverty line — 75 percent by the federal government and 25 percent by the states.
• Develop Medicare and Medicaid buy-in programs to expand the single-payer system to all ages, including children.
• Place premiums for small businesses and individuals on a sliding scale based on the ability to pay.
• Change annually based on individual financial circumstances.
• Utilize existing infrastructure, saving billions in conversion costs.
• Allow insurers to participate, but in a new capacity as facilitators, product enhancers and recruiters.

This phased-in approach may have a better shot than HR676.

Vermont rallies - whoops

Single-payer supporters in Vermont seem to have lost it, according to the Rutland Herald. This is from a report on single-payer supporters meeting with legislators:

But as the crowd grew more raucous (some began interrupting lawmakers and insulting legislative staff), Rep. Patricia O'Donnell, R-Vernon, staged her own interruption as she came to the front of the room and asked people to treat their lawmakers with respect.

"If you want to be listened to, you have to be respectful," O'Donnell, a member of the House Health Care Committee, told the crowd before a chorus of people yelling "sit down" and "shut up" sent her out of the room, the door slamming behind her.

Maier told the crowd the criticism for legislative staff — who have researched aspects of the hospital plan for lawmakers — is off base. He added that while he doesn't "enjoy being yelled at, it is our job to listen and to ask the tough questions and to dig down."

"If we don't ask these kinds of questions we would be irresponsible," he said. "It's not our job to pass ideas and concepts."

Racine also told the crowd that their anger is misplaced and suggested that attention should also be focused on state and elected officials who do not support universal health care. He cited the new proposed budget from Gov. James Douglas, which he said underfunds Medicaid and will result in "$5 million in new co-pays and price increases" for Vermonters.

"I know the system is not sustainable. It's a national crisis," Racine said. "If some folks have ideas on how to make this work, I'm all ears."

On the opinion page,the editors opined:

In Vermont health care has taken on the feel of an ideological crusade among some supporters of universal care, partly because of the apparent simplicity of their proferred solution and because it is easy to vilify opponents as creatures of self-interest. So they are able to clothe themselves in the robes of virtue and lose sight of who is and isn't working to advance their cause.

Racine and Maier are working to advance their cause. But it is not simple. The bill that was up for discussion would place all hospital costs under the jurisdiction of the state in a step toward a single-payer system. The idea makes some sense, but there are many complications. If the tax hike supporting such a program were not offset by comparable cuts in health care premiums, what would happen? These are not questions to be dismissed lightly, and lawmakers are not less than dedicated to the cause for considering them.

The left is capable of blowing it this year. Self-righteous, ideological posturing is a turn-off to voters and does not encourage intelligent policymaking.

We should not make the mistake of the right-wing, who were so certain they were right they forgot the need to persuade the rest of us, who were pretty darn sure they were dead wrong.

Only about a quarter to a third of the country is pretty darn sure we're wrong. But we can increase that number if we're not careful.

Hell, even if we are careful that number's going to increase, because we've already awakened the giant.

Minnesota Health Plan

The Bemidji Pioneer reports that Sen. John Marty, a Minnesota state legislator, led a delegation of freshmen legislators to Bemidji to unveil the Minnesota Health Plan, a bill he introduced late last session and which he hopes will be heard this session.

It would create a single-payer system -- or, as the Legislators introducing the bill prefer, a single-administrator plan. A board, set up by the Legislature, would collect premiums from all Minnesotans -- based on ability to pay.

The plan obviously creates savings by centralized billing and by spreading premiums among all Minnesotans. They take pains to explain that the plan is not socialized medicine as providers such as doctors are still private.

Marty outlined the proposal as:

• Allowing people to go to the doctor, clinic or hospital of the patient’s choice.
• The plan covers all medical needs including prescriptions, mental health care, dental services, chiropractic.
• A patient cannot be rejected because of a pre-existing condition.
• No deductible or co-payments.
• Premiums on individuals and businesses are based on ability to pay.
• The plan is administered by a 15-member public board representing the public, not just insurance company executives.
• The plan focuses on preventive care and early intervention to keep people healthy and save money.

Marty expects it may take four or five years to make a full change.

Health insurance, he says, is not something we should be selling. It is rather something we should be making sure we all pay into and we all get the service, like we do with police and fire.

Well put.

Harry and Louise in 2008

Breaking news from the Newark Advocate:

In 1993... The insurance companies and pharmaceutical giants spent millions of dollars on the Harry and Louise ads. These ads featured a married couple discussing the negatives of that system. Think of Barry Bonds discussing the problems of steroids.

Regardless of your politics, I ask you to consider only candidates who want to solve the medical insurance problem in our country. It is the key issue of this campaign.

Oh yeah, it seems Harry suffered from several infirmities and died broke in a nursing facility. Louise was forced to sell all of the couple's assets after a debilitating stroke forced her into a Medicaid-paid care facility.

Mandates To Buy into a Sick System

Democracy Now has a transcript from their 8 February 2008 show with Juan Gonzalez and Robert Kuttner that includes a transcript from the Obama/Clinton debate that had the spontaneous audience applause for single-payer.

Kuttner makes excellent points on mandates -- "My point is that a mandate, in a situation where the whole system is sick, makes that sickness the problem of the individual. Instead of putting a gun to people’s heads, typically people who can’t afford good quality insurance, and saying to them, “You must, under penalty of law, or pay a tax or pay a fine, go out and find decent insurance,” it’s so much better policy to just have insurance for everybody. Then there’s no question of a mandate.

"I think it’s a very bad position for progressives to back into, because it signals that government is being coercive, rather than government being helpful. Now, we can split hairs and argue whether Obama is being principled or tactical, but I think his discomfort with the idea of a mandate is something that I applaud. I wish that both he and Clinton had gone all the way and said, let’s just to do this right and have national health insurance. I think they could have used this as a teachable moment. They could have bought public opinion around. Medicare is phenomenally popular. Medicare is national health insurance for seniors. Let’s have national health insurance for everybody."

Here's the transcript from the debate:

SEN. HILLARY CLINTON: We cannot get to universal healthcare, which I believe is both a core Democratic value and an imperative for our country, if we don’t do one of three things. Either you can have a single-payer system, or—which I know a lot of people favor, but for many reasons is difficult to achieve—or you can mandate employers—well, that’s also very controversial—or you can do what I am proposing, which is to have shared responsibility.

Now, in Barack’s plan, he very clearly says he will mandate that parents get health insurance for their children. So it’s not that he is against mandatory provisions; it’s that he doesn’t think it would be politically acceptable to require that for everyone. I just disagree with that. I think we, as Democrats, have to be willing to fight for universal healthcare.

SEN. BARACK OBAMA: What they’re struggling with is they can’t afford the healthcare. And so, I emphasize reducing costs. My belief is—is that if we make it affordable, if we provide subsidies to those who can’t afford it, they will buy it. Senator Clinton has a different approach. She believes that we have to force people who don’t have health insurance to buy it, otherwise there will be a lot of people who don’t get it. I don’t see those folks. And I think that it is important for us to recognize that if, in fact, you’re going to mandate the purchase of insurance and it’s not affordable, then there’s going to have to be some enforcement mechanism that the government uses. And they may charge people who already don’t have healthcare fines or have to take it out of their paychecks. And that, I don’t think, is helping those without health insurance. That is a genuine difference.

Amy Goodman points this out: "It’s interesting to note something Hillary Clinton says in that clip. When she mentions a single-payer system, the audience applauds and cheers, even though it’s an option rarely seriously discussed by politicians or the corporate media. And Hillary Clinton acknowledges the applause by saying, “I know a lot of people favor [it], but for many reasons [it’s] difficult to achieve.” She doesn’t explain why she thinks it’s difficult to achieve. And polls repeatedly show a majority of Americans favor it. An A.P. poll in December found nearly two-thirds of voters want universal healthcare, in which everyone’s covered in a Medicare-type program, while more than half of voters explicitly said they support single payer."

Kuttner replied that "one of the reasons that it’s difficult to achieve is the lack of leadership on the part of leaders like Hillary Clinton and, for that matter, Barack Obama. I mean, if you had Hillary Clinton and Barack Obama say, 'You know, this is an intramural debate that we should not be having, this debate about mandates; we should do this right: we should have national health insurance,' public opinion would turn around on a dime. And instead of it being this fringe idea, all of a sudden, just because the two of them had blessed it, it would become a mainstream idea, and we would be having a debate that we should have been having all along."

Amy Goodman is a national treasure.

Al Franken on Single-Payer

During a Minnesota Public Radio debate, Al Franken said that "states should pick which system works best -- maybe the Clinton plan would work in one state, but single-payer would work well in another."

Coloradoan single-payer - again!

Fort Collins' is the real deal. The progressive community likes to say that while other progressive places in Colorado (no names...) do a lot of talking, the progressives in Fort Collins actually get things done.

I gotta admit, I see proof of it on a daily basis. Here's yet another single-payer column in The Coloradoan, their paper -- this one by G. Richard Dunn. He writes:

The potential national savings has been confirmed recently at our own state level; the Colorado 208 Health Care Commission report is complete and confirms there could be a major savings in health-care costs for Coloradans. The stated charge to the commission was to make a recommendation of health care for all Coloradans and to reduce health-care costs. The good news is that one of the recommendations does exactly that! The bad news is several politicians have already responded that while it might save our residents money, we need to carefully study the issue because it might raise taxes.

The commission retained an independent cost expert and the expert confirmed that 100 percent of Coloradans, including the 800,000 presently uninsured, could be covered and still enjoy an annual savings of $1.4 billion. The commission has forwarded its findings to the Legislature.

If the Legislature and the governor will read carefully, they will find there was a great deal of public and professional support across the state during the hearings for the "Colorado Health Services Plan (single payer)."

True. The 208 Commission held hearings across the state, and they heard again and again from single-payer supporters. Some of the commissioners -- and Colorado pols -- thought that Health Care for All Colorado must have sabotaged the hearings, filling them with our members.

In fact, we'd never heard of most of the people who showed up. There's a groundswell of support for single-payer, not just in Colorado but across the country.

I'd say it's past time for the insurance industry to bring out their big guns, and start running ads on how horrible health care is outside the U.S. They seem to be counting on the Democratic politicians to bring about mandates for people to buy their crappy product. They may be reassessing that now that it's failed in California.

ABX 1 1 Favored Insurance Industry

California State Senator Leland Y. Yee, whose constituents live in San Francisco and San Mateo counties, wrote to the San Francisco Chronicle on why he didn't support Gov. Schwarzenegger's health reform bill -- which would have forced Californians to either buy health insurance or face the loss of their homes and the garnishing of their wages.

Now it's true that already happens to people once they get sick or injured in the United States, but this would have brought it on even sooner.

This bill was not a step in the right direction, but a huge jump backward for working families who lack health care. As a co-author of the true universal health care bill, Senate Bill 840, I opposed AB X1 1 because it would have required consumers to buy their policies regardless of the cost. Under AB X1 1, all Californians would have been required to buy insurance with no caps on premiums, no regulation of the costs of insurance or medical expenses, no maximum deductibles, and no clearly defined minimum coverage...

The most objectionable part of this proposal was that if an individual did not purchase insurance within 62 days of the enactment of this flawed legislation, then the Franchise Tax Board would have been authorized to collect premiums by garnishment of wages or mortgage liens on the property of working Californians...

Such an experiment is under way in the Commonwealth of Massachusetts with troubling results. Already the Commonwealth's budget is being strained by the unanticipated costs of the mandated insurance program. Over the next few years, Massachusetts lawmakers will be forced to divert hundreds of millions of dollars out of the general fund to subsidize a program that was supposed to pay for itself, taking scarce funds away from other critical programs. While this is happening, Massachusetts residents who have not or cannot comply with the mandate to buy costly insurance on the open market are being forced to pay hefty fines, further compromising their ability to meet the requirements of the law.

I hope Colorado legislators are taking note.

Mandates Do Not Equal Universal Coverage

There's a well reasoned piece by RJ Eskow at Huffington Post on mandates. He points out the maddening nature of Clinton claiming that Obama's health plan isn't universal because it doesn't include mandates.

A lot of good progressive people are fooled on this. Particularly galling was the woman who wrote in some place to express her dismay over not being able to vote for Obama because she was in favor of universal health care. Geez. Eskow points out that the Massachusetts' plan is more "mirage than miracle," and that "the plan will leave 20% of that state's uninsured without coverage, and the real number may be higher. Why? Because there is a wide band of people who would suffer financial hardship if compelled to pay the premiums, and it's financially infeasible to subsidize them all."

And look at what mandates might do to a family of four. While Clinton won't tell us the percentage of income she'd tie to mandates, many analysts have been using 10%. If premium assistance is provided up to 300% of the poverty level, a family of four trying to survive on $75,000 could be forced to pay $7,500 to insurance companies or in health copayments. The alternative could be tax penalties or garnished wages. That's profoundly unfair. I also believe it's a serious misread of American political culture to think that kind of mandate could ever get through the legislative process....

Adding 10% to struggling families' financial burdens is nothing more than a highly regressive tax to be paid to wealthy insurance companies, which is why insurance companies prefer the Clinton plan.

J. Jonik's view

This is one way to think about mandates. I love the smiley face on the wing.

Agreeing with the WSJ

This is a bit scary.

There is a part of me that is pretty sure that if the Wall Street Journal's certifiably malicious editorial page is against it, I'm for it.

On the other hand, I know for certain that it's wrong to garnish someone's wages or impose liens on their mortgage to force them to pay for private insurance.

The WSJ's article, misleadingly titled "Saying No to CoerciveCare" (that should be "Saying No to Coercive Private Insurance") noted that labor unions launched the last minute revolt against the mandates in California Gov. Schwarzenegger's plan and caused its downfall -- 7-1 in committee.

This defeat has national political implications. Hillary Clinton, for example, has denounced Barack Obama for refusing to include an individual mandate in his health-care plan. Yet many California unions argued that a mandate would force uninsured, middle-income working families to divert money from more pressing needs toward coverage whose price and quality they cannot control.

I'm no economist (but I'm married to one, something that leads to many, many conversations on true costs and the need for marketplace transparency, as well as mini-lectures on fixed vs. variable costs, and other truly boring matters) but the WSJ author seems to be making a leap to claim that health insurance costs have gone up in Massachusetts mandates because of heavy regulation and increased demand. Insurance costs are supposed to go down when you increase the risk pool, as supposedly happens with mandates. That's because suddenly all the healthy free riders who before had gambled that they weren't going to get sick are paying into the system. More money in the system, fewer claims per capita (because those folks are indeed healthy) and voila, costs per capita go down. Except they didn't.

The author instead seems to be suggesting that costs for health insurance would go up with increased demand in the same way that costs for a rare but suddenly popular dog breed would go up after everyone realized they wanted one.

No surprise to hear that regulations are also blamed. Those are the regulations that say that health insurers have to actually give some value for the money -- that they have to give a percentage of the value, for instance, that people in France get for their health dollars spent.

It's also no surprise that the private insurance industry cannot in fact give that kind of value for the dollars we pay them. Unless you're a shareholder or CEO. Good value received per share in that case.

The cost of health insurance went up 12 percent last year in Massachusetts -- twice the national average.

No one is escaping the financial sting. The state health-care bill for fiscal 2008-2009 is expected to touch $400 million -- 85% more than originally projected. Still the state won't be able to fully shield those it subsidizes from the premium increases. But uninsured folks who don't qualify for government help really get pounded. Before the hike, the cheapest plan for uninsured couples in their 50s cost $8,200 annually. Now, unless government bureaucrats hand them an exemption, they might well find it cheaper to pay the penalty -- up to half the price of a standard policy -- than purchase insurance. That is, pay to remain uninsured. This is legalized extortion: TonySopranoCare.

The government response to rising premiums is, unsurprisingly, price controls. The Commonwealth Health Insurance Connector Authority -- the bureaucracy created to oversee RomneyCare -- is considering prohibiting underwriters from raising premiums more than 5% for unsubsidized plans, meanwhile requiring them to cover 40-odd benefits from hair prostheses to chiropractic services. If companies can't scale back coverage, they'll have to compromise care; and the Connector is perfectly willing to assist.

As reported in the Boston Globe, the Connector is encouraging insurance companies to include only a limited network of cheaper physicians and facilities in some plans to hold down premiums. Patients who wish to see more expensive providers will have to dig into their own pockets. Dr. Steffie Wollhandler, a professor of medicine at Harvard University, worries that the Connector will revive Gov. Romney's original idea of enrolling poor people in plans that only offer access to neighborhood health centers ill-equipped to treat anything beyond routine ailments. Forcing people to buy substandard care they cannot afford is not universal care, she says. "It is a hoax." And so Massachusetts is marching toward a system of two-tiered medicine -- the alleged market inequity that universal care is supposed to cure.

Imagine that. Steffie Wollhandler approvingly quoted in the Wall Street Journal.

Greeley Tribune on single-payer

The Greeley Tribune has published a wonderful piece by Tom Linnell on single-payer. He begins,

I am starting to see why all of us -- liberals, conservatives, and independents -- might really like single-payer health insurance. Here are some principles that I believe most of us can agree on: 1) the least possible amount of government involvement in our lives, 2) efficient delivery of services and, 3) freedom of choice for individuals.

Bravo!

Clinton Won't Discuss Penalties

The NYTimes reports that in discussing her health care plan that includes forcing people to buy private health insurance:

When asked for a third time whether garnishing people’s wages was an option, Clinton told Stephanopoulos: "George, we will have an enforcement mechanism, whether it's that or it's some other mechanism through the tax system or automatic enrollments." She went on to say that enforcement of her mandate was less important than the fact that her plan requires all citizens to have coverage, while her rival, Senator Barack Obama of Illinois, would only require children to be covered, according to the article.

The issue of health care mandates has become a central topic in the Democratic primary contest because it represents "one of the few substantive differences" between Clinton and Obama, reports the Times. Clinton insists that the mandate is key to achieving universal coverage, while Obama argues that the "use of government subsidies to reduce the cost of insurance, would effectively guarantee coverage to anyone who wants it." Some Obama advisors pointed to Massachusetts, which recently implemented an insurance mandate, as an example of a state that has "failed to enroll nearly half of its uninsured despite imposing a modest first-year tax penalty of $219."

Get it in Writing!

The Boston Globe reports:

In New Haven on Monday, a fourth-year Yale medical student named Liza Goldman approached us excitedly to report on a conversation she had with the New York Senator on the rope line.

According to Goldman, she told Clinton, “I’m sure you know that single-payer would save billions of dollars and thousands of lives.”

Clinton, Goldman says, responded in agreement but said, “It’s not politically feasible.”

So Goldman offered her a hypothetical: “Would you sign it if it came across your desk?”

“She said yes, and shook my hand,” Goldman said.

A Clinton spokesman did not get back to us about whether Clinton remembers the conversation the same way.

Pharmaceutical Ads Since 1997

Amazing. The FDA only gave its blessings to "direct to consumer" ads for prescription drugs in 1997. Those ads now sponsor our nightly news and pay the production costs of our magazines. That was just 10 years ago -- who paid in 1996?

The LA Times has an opinion piece on how the ads have "fundamentally altered the doctor-patient relationship by forcing physicians to respond to people's demands for heavily touted drugs, rather than taking the initiative in suggesting treatments."

"DTC advertising increases people's awareness of diseases and available treatments," Pharmaceutical Research and Manufacturers of America, an industry group, says on its website. "Studies show DTC advertising brings patients into their doctor's office and starts important doctor-patient conversations about health that might otherwise not have happened."

For example, how many people would have thought to ask about "restless legs syndrome" until pharmaceutical giant GlaxoSmithKline launched a DTC campaign in 2003 to raise awareness of the problem.

Good point. It appears that the industry is now moving to tackle the problem of "excessive sleepiness." They've got something other than a cup of coffee in mind -- and it's not a recommendation to get more sleep...

Need for Vigilance Never Ends

Last summer I was in a meeting with leaders of Colorado health care organizations. I offered that one of the problems being discussed would not be a problem if the United States had true universal health care through a single-payer system. Actually, most of the problems under discussion weren't problems in most of our peer countries, where there's guaranteed affordable health care for all. A woman who heads a Colorado health care organization, a group nominally for helping people who aren't getting needed medical care, replied sarcastically, "Right, and we'd all be out of a job."

It's possible -- probable, in fact -- that she was joking, and that she simply has really bad timing and judgment.

The fact is that we should all be out of a job, and able to move on to other things. There's lots that needs fixing in this world, if that's our passion.

And in any case, as a story on Medical News Today points out, you can't ever fix anything once and for all, any more than you can clean the kitchen once and for all.

The center doesn't hold.

In "Bush Budget Cuts Will Cripple U.S. Teaching Hospitals And Erode Medical Progress," the news links to a press release from the Association of American Medical Colleges.

Cutting indirect medical education (IME) payments by more than 60 percent, combined with other Medicare cuts affecting all hospitals, will have devastating results. Millions of Medicare patients-as well as the uninsured, the disabled, and the severely ill-rely on teaching hospitals for health care and community services. Such unprecedented cuts to these institutions will endanger their ability to provide the full spectrum of patient care and treatment, erode their fragile trauma and emergency services, and impede the progress they have made in advancing the health of all Americans through education and medical research.

Bush has said that we have universal health care because, he says, people can always go to a hospital to be treated. Evidently he wants to put a stop to that.

In the earlier days of Bush, my husband used to ask the conservative business people with whom he worked to name something that Bush had done competently. The Bush supporters could never come up with anything.

(At this point, I suppose if you were set on judicial activism -- finding more judges who would elect illegitimate presidents, for instance, always side with corporate interests, not concern themselves with personal freedom, etc. -- a person might say that Bush has done a whiz bang job of appointing Supreme Court justices...)

In any case, because it's always easier to destroy than to build, there will always be the need for health care advocates. There were in Britain during and after Margaret Thatcher -- and now, because that country is facing a lobbying assault of privatizing interests.

Canada has groups to save their popular Medicare system.

We'll still need advocacy groups. Not to worry about your job.

Are Mormons Christian?

Are Mormons Christians?

I've heard my favorite literate priest explain how come not, in theological terms, but it seems pretty academic, doesn't it? After all, as far as I can tell, most Christians aren’t Christians. That's something that becomes even more clear once you begin advocating for guaranteed health care.

It's a cliche but worth repeating: How many Christians today would have anything to do with Christ? Some outcast figure who surrounded himself with poor people, prostitutes, and tax collectors? Some guy who argued against wealth creation, who told people to leave it all behind, and go follow him to some commune or something! The megachurch and born-agains think they’d know Jesus, but I have yet to be convinced.

The thing is, see, Jesus wouldn't have that halo -- the kind Bush sometimes wears. Karl Rove, the master, realized that if you put your guy in front of a circular, golden image, and then told the photogs where they could shoot from, you’d be sure to end up with a couple halo shots. Put that together with the fact that Bush himself believes that God fixed it so he could be president, and of course that chat between him and God about invading Iraq, and voila. You've got some pretty strong indications that someone more powerful than Florida voters wanted this man to be our decider.

I talked with a woman a month ago who was just back from missionary work in the Philippines. She believed that Bush was president because of divine providence. She thinks it might have been in order to make things so bad we'd all wake up.

Thanks, God. Back atcha.

Caucuses and Shame

I went to my precinct caucus tonight, resolution for single-payer in hand.

I walked away pondering how we can use people's unwillingness to be seen as uncaring to our advantage.

The caucus took place in the cafeteria of my old high school in southeast suburban Denver. Back then, I attended on Tuesdays, Thursdays, and every other Friday. Honestly. I never would have gotten that diploma had I faced the attendance requirements my children faced. Back when I was in school the administration had the option of graduating kids just to get 'em out.

Tonight a crunchy, dry snow covered the roads -- enough to provide a good excuse to anyone who hadn't really wanted to go. We got there about a quarter til, and the parking lots were already filled. It's a suburban school, so there are plenty of parking lots.

There were about 10 precincts, 600 - 700 people in the cafeteria. It was hot, crowded and noisy. At 40, we were one of the smaller precincts. I passed out copies of the resolution to the various tables, explaining that we'd be voting on it later.

We moved through the straw polling, delegate selection and other business, and some of the people melted away. I've been sick but did my best to shout out why we were pushing this resolution -- the only one considered by this somewhat apolitical crowd. I explained that single-payer was already part of the state platform, but not explicitly. I read the HCAC resolution --

"The current health care system in the United States has reached crisis point. The fragmented, administratively wasteful model of commercial health care costs and bureaucratic nightmares for health care providers, patients and employers. Therefore, as a matter of basic economics and the common good, the Denver County Party supports guaranteed, quality, affordable health care for all through a single-payer financed system..."

And so on. We voted -- first for it, then against.

No one raised their hand against it. No one.

But afterwards I learned that someone had muttered, "Right, and who'll pay for it?"

But they didn't openly vote against it.

What if it had been a curtained booth, though? How often do we vote against the common good when there's a curtain there? I did it once. I'm usually a reliable vote for increased taxes when it's for the cause of civilization, but on that election day, for some reason, I was feeling churlish. I still remember it. I wouldn't have done it if it had been visible. It felt like I'd slipped a five out of the church offering instead of putting one in. Or lit a bank of candles without giving an offering.

The trick is, once that curtain is pulled behind you, it's just between you and God -- or you and the thought of your grandchildren's future. What kind of country will we leave them?

Of course, fortunately, single-payer actually means it's less expensive. So it's a fairly easy concern to allay, if a person actually looks into it. But there will always be the folks who don't get the message. And aren't they the same people most tempted when the curtain's closed?