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.

California Mandate Plan Goes Down

It was good news regarding ABX1 going down in California. Here's from the LA Times:

Senators said it was too risky a financial commitment when California faces a $14.5-billion budget gap that could force them to cut existing healthcare programs. Schwarzenegger has proposed $2.9 billion in healthcare cuts over the next 18 months.

"It doesn't matter if there are these good things in the bill if there isn't the money to pay for them," said Sen. Sheila Kuehl (D-Santa Monica), who chairs the health panel and has proposed that the state take over the role of providing medical insurance. "We can't simply say to the people of California, 'Go buy insurance.' "

The defeat may be a poor omen for national efforts to overhaul the country's healthcare system. The three leading Democratic presidential candidates -- Hillary Clinton, Barack Obama and John Edwards -- all have proposed similar programs aimed at expanding private insurance while allowing people who have coverage they like to keep it.

The NYT also had a story on this, with this great quote:

“I just came to the conclusion that the working people are going to end up paying for it,” said Senator Leland Yee, Democrat of San Francisco, who announced his opposition before a committee meeting last Wednesday. “There’s control for everybody else — the employers are protected and the insurance industry. The only group that’s vulnerable is the working people.”

I understand that good people believe that mandates can work. Good, smart people, in fact, who've been at this far longer than I have. But that's part of the problem. These good folks are still shell shocked from the last battle. We can't fight the last war. Conditions are different now. More people have been hurt, the insurance industry has very little credibility. It may well be that we have to do this incrementally. But forcing people to buy private health insurance policies from for-profit companies is a deal killer.

Daily Kos on Obama & single-payer

There's a wonderful essay by a serious healthcare reformer, a professor of Health Policy; Director, Center for Health and Public Policy Studies, UC Berkeley. She writes about Barack Obama and Hillary Clinton (and Hillary's nasty clip accusing Barack of lying about single-payer):

Both of these candidates are very smart people. They both understand that single payer is THE best system for affordable, comprehensive, equitable, secure, efficient health care for all Americans. This is good news.

But the realities of our current system and how it has evolved over time, make it difficult, if not impossible, to move from where we are now to 100% single payer system over night.

I actually proposed this idea of giving Americans the choice of a single payer plan that competes along side the existing system in 2002. I first developed the idea for the state of California as part of the State's HRSA grant for Health Care Options. I will provide links below to both the original proposal as it was developed for California and the a link to the ESRI report (funded by RWJ) on Covering America, which includes the federal model I developed for CHOICE as a plan that would voluntarily transition the entire US health cares system to a single payer system, with private plan options for those who do not want single payer.

Interesting. Here's the link to her site about CHOICE OPTION for California and her federal plan as well -- about which she writes,

The federal plan speaks specifically to the point of having a single payer plan compete with the existing system and allow people to choose which they want. And guess what? Our current inefficient, inequitable, ineffective system cannot compete with a single payer plan. The Lewin Group, using their Health Benefits Simulation Model, modeled the CHOICE proposal and found that within one year of adoption a plan with the option of single payer, 70% of Californians would chose to enroll in the single payer plan and 94.4% of the Californians have health insurance coverage, all without a mandate.

For the sake of the health of the American people let's agree to agree. The goal of health care reform for the Democrats is universal coverage and they all support a plan that will enable the US to voluntarily transition to a single payer system.

San Franciscans covered for now

USA Today's headline reads "Businesses fight plans to ensure health care" -- the worst possible head for advancing health care.

That's because the polls show that small business is the key icon for Americans, held in higher esteem even than moms and apple pie. If small business is against it, so is America.

But consider this. It's true that a couple San Francisco businesses sued so they wouldn't have to pay more for health insurance for their employees -- and a lower court agreed with them, that the Employees Retirement Insurance Security Act forbade the state to require employers to insure their employees. But there's always going to be some businesses against minimum wage, health insurance, child labor laws, whatever.

At issue in the restaurant association's lawsuit is a 1974 federal law, the Employee Retirement Income and Security Act. It bars states from requiring employers to offer health insurance or regulating the benefits they do offer to protect companies from varying laws. Congress gave only one state, Hawaii, an exemption from the law in 1975. It is the only state that requires employers to provide health insurance.

Last week, a three-judge panel of the 9th U.S. Circuit Court of Appeals said business owners such as Scherotter will have to comply with the law, at least until the full court can review the lawsuit later this year. A lower court sided with business owners.

More important were the poll last year that showed that California businesses are in favor of universal health care:"Despite High Cost, Small Business Says It Supports Universal Health Care -- 80 Percent Say Employees Deserve Health Coverage" from the San Diego Business Journal:

About 500 small businesses across the state were randomly surveyed by phone and e-mail; many were in support of a 1 cent sales tax solution, while favor for a single-payer system was split, with the majority of business owners who don’t provide health care voting for the single-payer system, according to survey results.

Another article, this one from the Sacramento Bee covered that same poll. Some key findings:

• 57% regard health care financing as a shared responsibility among individuals, employers and government – three times as many as do not (19%).
• 55% were in favor of paying into a statewide pool that would enable their employees to obtain coverage at favorable rates – over three times greater than those opposed (17%).
• A substantial plurality (near-majority) said that they favored two leading California healthcare reform proposals, with a small plurality supporting a single-payer plan:
• Governor’s proposal -- 47% in favor; 31% opposed
• AB 8 (legislative leaders’ proposal) -- 47% in favor; 33% opposed
• SB 840 (single-payer) -- 42% in favor; 40% opposed

CA single-payer urges support for ABX 1 1

Stephen Schear gives a paragraph of his credentials as a single-payer supporter before urging Californians to reconsider and support the Schwartzenegger mandate plan, ABX1 1. (Why the name that sounds like a Reagan era star wars weapon?) His credentials are good. His support of ABX1 1 is unconvincing.

Schear's reasoning is that the Schwartzenegger plan will ease the transition to single-payer.

"Repeated polling, focus groups and experience have demonstrated that fear is the emotion that keeps most voters from supporting proposals for universal health care, including single payer."

Schear thinks that somehow forcing more people into private insurance will make them less afraid of single-payer, and ease the way to its eventual enactment. I read this article wanting to see his point — but it's not congealing. He writes:

"...The mandate for private health insurance is relatively meaningless, especially since ABX1 1 includes a provision that people can be excused from the mandate if buying health insurance would constitute a financial hardship. The government is not going to prosecute individuals for a lack of health insurance. The other “problems” with ABx1 1 are only problems if you compare ABX1 1 with single payer. Although there is not much in the way of cost control in ABX1 1, at least it requires insurers to spend 85% of their premiums on health care, a small advance in limiting private insurance waste. ABX1 1 will not achieve universal coverage, but it expands coverage far more than any legislation since Congress passed Medicaid and Medicare in 1965."

How can a mandate, further strengthening the key malignant element in our system, be meaningless?

ERISA Strikes in California

A federal judge on Wednesday ruled against San Francisco's brave program to guarantee health care to all.

Merry Christmas.

At issue is the federal Employee Retirement Income Security Act [ERISA] that White concluded in his ruling prohibits the city from regulating employee benefits.

Frank Furtek, chief counsel for the state's Health and Human Services Agency, said his office is studying the ruling and was not ready to comment on its import to the state's health care program. He added, however, that he believed the ruling was overly broad.

It sounds as though Gov. Schwarzenegger's staff is now working on figuring out how to keep that ruling from being applied to AB1X, a healthcare bill that's been worked out between the governor and the Democratic leadership.

The bill is based on the hope that once everyone has access to a doctor and preventive care, the cost of care will go down. All employers will provide insurance for their workers or else pay a tax of 1 percent to 6.5 percent, based on payroll. That's the part that "may provide biggest obstacle to passage in light of White's ruling, which San Francisco intends to appeal."

But there are other issues that could spell trouble for the bill in a hearing set for Jan. 16 before the Senate's health committee, which is chaired by Sen. Sheila Kuehl, D-Santa Monica, a longtime advocate of a single-payer health system that would eliminate private insurance.

Kuehl pointed out that AB1X provides a cap on how much employers would be required to pay into the state purchasing pool. But there's no similar protection included for worker costs in co-pays and deductibles.

She said there's no clear protection that the kinds of policies that employers could offer in the state pool would provide good medical coverage.

ERISA was intended to protect people, not insurance companies. It is, however, always invoked by those who are against health care reform. There's a good round-up of its incomprehensible provisions at the National Academy for State Health Policy. The policy brief there (on the Maryland ruling against that state forcing Walmart to insure its employees) says that a universal health reform that didn't target one particular business would be less likely to trigger a successful ERISA suit. Evidently Judge White saw it differently. Here's the skinny from the NASHP:

Congress enacted ERISA (the Employee Retirement Income Security Act of 1974) to establish uniform federal standards to protect private employee pension plans from fraud and mismanagement. But the federal statute also covers most other types of employee benefits plans, including health plans, and has a potential negative impact on state health care legislation, including health insurance regulation.

Several of ERISA's provisions preempt state laws and complicate state efforts to make health care coverage more broadly available. Among the state approaches that raise ERISA preemption issues: employer mandates, individual mandates, government-operated programs, and state approaches to finance health care for uninsured perople with low incomes or medical conditions that make them uninsurable.

Another resource: There's a discussion of federal and state reform proposals at the International Foundation of Employee Benefit Plans.

California Dems cave

Don McCanne has a good column at the California Progress Report on the foolishness of turning in your best cards before you even sit down at the negotiating table. In A Nunez-Schwarzenegger Compromise or Single Payer for California?, he writes,

in a classic example of political irony, Democrats are abandoning their preferred option, single payer reform, in order to reach a compromise with the Republicans and the private insurance industry. They have crafted a model that they believe does not repeat the mistake of the Massachusetts reform program. California Democrats proudly proclaim that they will not require individuals who cannot afford private insurance to be covered by a program that is being inappropriately characterized as universal.

It's sad stuff, in part because it's exactly the same — as 1993. It's like Groundhog Day for healthcare reform.

Not one Republican voted for this compromise, and Blue Cross of California is spending a couple million dollars in an advertising campaign opposing reform. So much for compromise. The Democrats have violated the first rule of negotiation. Before they even seriously sit down with the governor, they have removed from the table the most important polices that would bring comprehensive, affordable, high quality care to everyone.

McCanne notes that underinsurance is the fastest growing problem in U.S. healthcare. It's key in a brilliantly crafted scheme that the health insurance industry has put together. See, you don't usually know you're underinsured until you need your insurance. That happens to less than 10 percent of the insured in any given year. And so most people can be convinced that it was their own foolishness or bad luck, not part of a carefully designed plan in which their health is nothing more than collateral damage in the quest to create wealth for others.

Three talking points

David Welch of Chico wrote such a good letter to the editor of the Chico Enterprise-Record that you don't really need to see the piece he's reacting to. His three points are great talking points:

Sandra Pooley's attack on Michael Moore, single-payer health care and the California Nurses Association shares a notable common feature with all right-wing attacks of single payer in that it's completely fact free.

Anyone who examines actual facts, as opposed to slogans, innuendo and rumors, has to conclude that single payer is the only solution for fixing the failed American system.

Single-payer systems around the world vary quite a lot — different financing mechanisms, different administrative structures, larger or smaller roles for the private sector. Despite that variation, they all have three things in common:

1. They cover everyone in their country. You'll never see anyone in Canada, France or Britain holding a yard sale to cover someone's medical costs.

2. They achieve population health results and specific health care outcomes comparable to the U.S. or a bit better — sometimes a lot better.

3. They do it for about half what the U.S. currently spends, or less — often a lot less.

Of course the right-wing strategy for dealing with those facts is not to confront them but to just pretend they don't exist.

Business Week magazine — a rather conservative business journal — has a new article in their July 9 issue on the French system. I would recommend it to anyone who still imagines that the U.S. has "the best health care in the world."

— David Welch, Chico

Kuehl's single-payer bill passes in CA

This is big news. Senator Sheila Kuehl's single-payer bill, SB840, for California passed the California Legislature on June 6. The vote was 22 to 14, with only Democratic votes in support and 13 Republicans plus Democratic State Senator Lou Correa voting against the measure. This story from KPBS gives positive but brief and balanced coverage:

The State Senate has approved a measure that would create a single-payer, universal healthcare system in California. Critics call it socialized medicine, but supporters say it’s the gold standard for healthcare reform. KPBS reporter Kenny Goldberg has more.

Under the single-payer system, all private and public money currently spent on health insurance would be pooled. The state would use that money to run one healthcare plan for all Californians.

Donna Gerber is with the California Nurses Association. She says a single-payer system would be run like Medicare.

Gerber: It leaves the private hospital and doctor and other providers in place -- it simply takes the insurance industry out, which also in the process saves 30 percent of every healthcare dollar.

Governor Schwarzenegger doesn’t like the idea. He vetoed a similar measure last year, and says he’ll do the same thing if the bill hits his desk again.

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.

Celebs for single-payer

Ed Asner has always been one of the good guys. It figures that he'd be for single-payer.

Sen. Sheila Kuehl: patron saint of California healthcare

California State Sen. Sheila Kuehl reintroduced Senate Bill 840 yesterday — that's the same bill with the same number that Gov. Schwarzenegger vetoed last year. This time around it's got 38 authors. There's a rally planned for the steps of the California statehouse on Tuesday. One Care Now, the California organization advocating for the bill, has a page on Tuesday's events.

One Care has a three-minute version of their video explaining single-payer and Sen. Kuehl's bill up on YouTube:



Elsewhere in California, Anthony Wright, executive director of Health Access California, has written a great synopsis of a panel discussion with the Little Hoover Commission — a California state-sponsored group looking at how to make California government more efficient, beginning with healthcare.

Some of the other panelists (Wright himself was one):
• Peter Harbage, senior program associate for the Health Policy Program for the New America Foundation.
• Gerald F. Kominski, Associate Director of the UCLA Center for Health Policy Research
• Glenn Melnick, Professor and Blue Cross of California Chair in Health Care Finance; School of Policy Planning and Development at the University of Southern California

Kominski quoted the Lewin report on what California could expect if the Kuehl bill passed. Initial costs would go up by $25 billion for medical services, but efficiencies (including the use of price controls, reduced fraud, bulk purchasing and $20 billion less spent on private insurance company administration and profit) would save the state $33 billion.

[Commissioner Mitch] Mitchell asked what the minimum basic benefit package should be – and what did panelists think of the $5,000 deductible minimum plan the governor proposed, for those who would not qualify for subsidized coverage.

Kominski laid it out. Such a plan would cost a family about $200 a month -- $5,000 a year.[?] On top of that, the families would still have to pay $5,000 deductible. That’s $10,000 before they even see a dime of coverage. “If these policies were so desirable, why don’t we all have them?’’ he asked.

I said such policies caused families to have to “pay to be uninsured," paying premiums but still facing worse health outcomes and the possibility of medical debt and financial ruin. The other danger of high-deductible plans, he said, is cost-conscious consumers would have to decide which procedures were “necessary’’ and which were not. Half the time, they guessed wrong and forgo preventive treatments that end up making them sicker and costing more money to treat. Some may not also have the cash necessary to pay up front for doctor’s visits.

Mitchell asked why it would not be sufficient to have a high-deductible plan that also covered preventive services. While some high-deductible plans do allow for preventive services, they’re limited, I said. And if a consumer has a chronic disease, such as diabetes, asthma, heart disease, which require regular doctors visits and medications, such a plan would not work for them. Chronic diseases are also the largest cost drivers in health care, and to exclude such coverage would just make matters worse, experts said.

I read this and also Wright's group's blog on the commission, and they sure sound similar to the 208 commission in Colorado.

They're a bunch of bright people doing their best to get around the fact that the solution to the healthcare crisis is blindingly obvious yet somehow off limits.

Actually, maybe the California commissioners aren't all that bright. Commissioner Daniel Hancock suggested that Medi-Cal patients be “timed out" of their entitlement benefits — as welfare recipients were put on a five-year lifetime limit during the 1996 welfare reform.

Now there's a plan. Just because millions of Medi-Cal enrollees are seniors or people with disabilities – on respirators, wheelchairs — doesn't mean they can't get work. Let them join the rest of the working poor. Wheelchair-bound or not, they could all pay $11,000 plus annually for health insurance if they stopped squandering their money. The back of a Buick is a fine place to raise a family — or come home to in those golden years after a hard day's work at Burger King.

We love California nurses

Wish they were in charge.

Starr's dialectics

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Pipes rails on Arnold

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

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

Arnoldcare debate continues

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Krugman on Arnold's plan

Paul Krugman's column on Schwarzenegger's plan is at Smirking Chimp. He writes that he’s glad to see another Republican governor speaking out with a real plan to get more people covered, but that state projects should be pilots and we should have a federal system. Also, he compares the governor’s bill (to its detriment) with Senator Sheila Kuehl’s bill from last year — which she’s reintroducing this year, same number: SB840.

“There are three main reasons why many Americans lack health insurance,” Krugman writes. “Some healthy people decide to save money and take their chances (and end up being treated in emergency rooms, at the public’s expense, if their luck runs out); some people are too poor to afford coverage; some people can’t get coverage, at least without paying exorbitant rates, because of pre-existing conditions.”

Because Schwarzenegger's plan forces people to buy insurance, provides aid to those who can’t afford insurance, and forces insurance companies to adopt strictures on their business model, it "requires a much more intrusive government role than a single-payer system. Instead of reducing paperwork, the plan adds three new bureaucracies: one to police individuals to make sure they buy insurance, one to determine if they’re poor enough to receive aid, and one to police insurers to make sure they don’t discriminate against the unwell.”

RJ Eskow is slightly more positive about the proposal but writes that it's flawed in that it requires people to “buy insurance from private providers only, as with most ‘mandated coverage’ proposals. This leaves insurers with no incentive to perform better as an industry. The way to address that is by allowing people to buy into Medicare, then challenging private insurers to do better.”

Response: Arnold's plan

There's a great post over at Fixin' Healthcare about how you can't really call what we have a system, since it's actually systems within systems with no intelligent design. That being the case, reforming this "system" — rather than instituting single-payer — will actually exacerbate the dysfunction. "And, insurance has proven to be notoriously unreliable as an instrument for reform."

Matthew Holt, at the Health Care Blog, directs readers to Spot-On for his reaction to Governor Schwarzenegger's proposal for healthcare reform via mandated insurance.

Holt also likes Cohn's reaction (see below), and Lief Wellington Haase, of the Century Foundation.

Just how did we get to a place where Republican governors were proposing universal healthcare plans? (Albeit Republican, inefficient, catering-to-big-business ones...)
Haase offers a good round-up.

• Medical costs have kept going up, and employers and workers are feeling the pinch.
• Employers have run out of alternatives.
• States have taken the lead.
• Perceptions of U.S. medical care have changed.
• Health care costs are becoming a middle-class worry.
• Washington is finally paying attention.

Holt also links to Don McCanne, M.D., who has a response to Governor Schwarzenegger's proposal for healthcare reform through mandated insurance over at the Physicians for a National Health Plan's website. As to why Schwarzenegger's plan can't ultimately succeed in holding down costs or provide sustainable access, McCanne writes:

"The current administrative waste is due to our fragmented system of financing health care, and he would do nothing to bring about the structural reform required. It will be very difficult to reduce the 31% spent on administration without an efficient system such as single payer. He recommends health savings accounts, which, if they do reduce spending, would do so by making beneficial health services unaffordable for many individuals with unfunded or depleted accounts."

California or bust

Ezra Klein claims he was fighting lions barehanded, and so couldn't post his take on the Schwarzenegger universal healthcare proposal until this morning. His summary of the plan, which would mandate individuals buy health insurance and employers provide it (or else face a 4 percent "fee") is a good one to begin with.

The 10-page proposal itself is at the California governor's Stay Healthy California site. (Does that sound like 'Cal-ee-forn-eea' to you, or is it just me?)

A google news search this morning turns up almost 700 news articles on Schwarzenegger's universal healthcare proposal via individual mandates and employers, and a few of them shed some light on what's been a mystery for me:

Why are the insurance companies against this plan? It sure seems to benefit them, mandating coverage that may or may not be good enough to really be called coverage. After all, there's insurance and then there's insurance — some of of us face the Arctic covered with a -30 degree F sleeping bag while others have a holey sheet.

Reuters reported yesterday that Wellpoint shares dropped nearly 3 percent on Tuesday, "on worries a proposal by California's governor to boost health insurance coverage could eat into industry margins."

Wellpoint, which insures about 34 million Americans, would have to change its business model under Schwarzenegger's plan, because it's currently the Wall Street health insurance leader in spending the least on medical care — having the lowest "medical-loss ratio" in California.

Schwarzenegger's plan would require companies to spend at least 85 percent of every dollar in premiums on healthcare. The Reuters story notes that there's still plenty of time to correct this: the plan "must pass muster with the California legislature and lobbying interests."

Wellpoint Financial Officer David Colby told Reuters that the plan wasn’t necessarily all bad for Wellpoint.

"The fact of the matter is we are looking at putting a lot more dollars into the health-care system ... significant dollars into the system will provide significant opportunity for us," Colby said

Well, yeah. $12 billion dollars more.

And there's another mystery. Why have so few of the stories, none on TV, mentioned state Senator Sheila Kuehl's (D-Santa Monica) Senate Bill 840, which Schwarzenegger vetoed just last autumn? It was a single-payer plan that wasn't going to cost $12 billion more, but rather cover everyone with the same dollars now spent on healthcare.

Larry Mitchell of the Chico Enterprise Record quotes Georgie Summers of Chico and the Butte County Healthcare Coalition, a single-payer advocacy group, with an answer. Schwarzenegger took millions of dollars in campaign contributions from the insurance industry.

Kuehl reintroduces SB840 this year.

The LA Times yesterday ran a piece from Kuehl about healthcare reform in California. In "A second, third and fourth opinion on healthcare" she describes four healthcare proposals now before the legislature, including Schwarzenegger's. All but SB840, she writes, fall far short of providing comprehensive coverage and affordability. Schwarzenegger's plan "can at best provide high-cost, low-benefit plans for many Californians; it limits what employers pay but not what individuals must pay or what insurance companies can charge."

Kuehl also notes that Schwarzenegger's plan also adopts the worst possible option, Bush's individual health savings accounts.

The LA Times Lisa Girion, who wrote that great piece on the California insurers denying coverage to entire professions — like firefighters — and folks who take some of the most popular drugs — like Celebrex — covered Schwarzenegger's plan in yesterday's Times. "Plan to ensure health coverage could raise costs" led with the fact that the plan would end those practices of denying coverage. She quoted Cindy Ehnes, director of the Department of Managed Health Care, which oversees health plans, who said the proposal would "eliminate that long-standing barrier to access to individual coverage, which is if you need it, you can't get it."

Girion wrote that Blue Shield of California (one of the companies that currently excludes entire categories of workers) supports universal coverage according to Girion, and praised the plan; Kaiser was also largely favorable. A Wellpoint spokesperson said that the individual mandates would be tough to enforce, saying that a quarter of California drivers don't have the mandated auto coverage.

"'The bottom line is that healthy, uninsured individuals are not likely to respond to a government mandate.' In addition, she said, in New Jersey, where everyone is guaranteed access to health coverage, premiums for individual insurance are three times higher than in California.

Times letter writers weighed in, mostly cogently. Ronald Wolff says insurance shouldn't be part of healthcare. "The purpose of insurance is to prevent rare and unforeseeable events from causing catastrophic financial losses. Healthcare doesn't fit the definition — everyone needs it."

Michael Dressel writes, "It is amazing how there is a wrong solution to every problem. This particular solution is a blend of the worst features of socialism and capitalism. It comes down to forcing us by law to buy an inferior product without impeding the profiteering that makes it such, and is incompatible with the concept of insurance as a way to share risk."

Victoria Colliver of the San Francisco Chronicle quoted Art Pulaski, executive secretary-treasurer of the California Labor Federation, who called the proposal "a boon to insurance companies, but a bust for most workers."

"This plan requires all Californians to buy health insurance with no guarantee that it will be affordable or that coverage will be adequate," he said in a statement. "We are concerned that the plan creates an incentive for employers who currently provide health care to drop coverage and instead pay only a minimal tax."

Culver notes that Schwarzenegger's plan relies on the feds to pick up almost half its estimated costs — $5.5 billion out of the $12. That's because California would raise the rates that doctors and hospitals are reimbursed through California's Medicaid program, MediCal, and because more people will qualify for MediCal. Right now MediCal pays providers only 40 percent to 50 percent of Medicare levels. Schwarzenegger would raise that to 80 to 100 percent.

She gets a great quote from businessman Sammy Seo that provides insight into the business community's view. He told her that at worst Schwarzenegger's plan would be the same as what now exists. "And if we didn't have to deal with insurance, paperwork and hassle of administering this ... I'd be open to it.""

Deborah Burger, president of the California Nurses Association, writes "Healthcare packages all inferior, except for one" for the Ventura County Star today. The one, of course, is Kuehl's single-payer proposal. The others "continue to rely on a wasteful insurance industry whose focus is on making money by denying care to those who need it the most and other market-based mechanisms that created the current mess."

She then lists 10 points in favor of single-payer, beginning with
1. Everybody in, nobody out
2. Portability
3. Uniform benefits
4. Prevention
5. Choice of physician

Burger told the PRNewswire that the sum of this proposal may be "little more than a fresh coat of paint on a collapsing house."

She thinks it likely that "many Californians will end up with cut-rate plans that discourage people from using their health coverage, have huge out-of-pocket costs, and expose them to financial ruin in the event of a serious illness or accident."

She also told PRNewswire that Schwarzenegger's plan doesn't address price gouging by the pharmaceutical companies.

Lastly, Jonathan Cohn has an analysis of the Schwarzenegger plan at National Review. He describes it a bold and authentic, and says that its most radical element is regulating those medical-loss ratios.

"Not surprisingly, the insurers that provide the best, most cost-effective care have traditionally been the ones with the highest loss ratios, since they're putting the most money into patient care. But thanks to the dysfunctions of the health-care market, those same companies often end up at a competitive disadvantage, because they are the ones that attract sicker beneficiaries--on whom it's more difficult to make money....

"That feature goes a long way toward explaining why Bruce Bodaken, president of Blue Shield of California, has come out in favor of the program: Blue Shield, a non-profit that is generally well-regarded, and which has a high medical-loss ratio, would likely benefit if its competitors had to play by the same rules."

Cohn notes that one immediate effect of universal healthcare would be identifying all kinds of conditions that people had put off seeing a doctor about because they couldn't. All that preventive care all at once could burden the system.

He reports that "California liberals" don't think the employer requirements add up: either cover employees or pay a 4 percent fee. Actually, wasn't that the CEO of Safeway who first pointed that out? Is he some kind of famous California liberal, hanging out with Barbara Streisand?

Cohn also notes that because special interests are going to get a shot at this and its various elements, it's probably actually as difficult to pass as it would be to pass a single-payer proposal. Just as special interests defeated the Clinton health plan, which had quite a bit in common with Schwarzeneger's plan, they might very well tank this one.

Cohn concludes that Schwarzenegger's plan nevertheless moves the ball forward, simply because he's a Republican who has "put his imprimatur on the same policy principles--heavy regulation of insurers, mandates on employers, and higher taxes to pay for subsidies--that many Democrats propose to use in their health-care proposals. That will make these notions, and the idea of universal health care generally, a great deal more difficult to demonize."

Today's health blog news

Kevin Drum comments, without enthusiasm, on Gov. Schwarzenegger plan for California healthcare reform. Drum admits his bias against any plan that cobbles together reforms but keeps the health insurance industry underpinning the system.

Here's his description of the plan:

"Basically, it's an individual mandate (i.e., everyone is required to buy health insurance, the same way everyone who drives is required to buy auto insurance) with state subsidies for those too poor to afford coverage. There's a new tax on doctors and hospitals, and small employers are required to either provide insurance for their employees or else pay a 4% payroll tax. Insurance companies, for their part, are required to offer insurance to everyone, regardless of medical history, age, or occupation (aka "community rating," meaning everyone in a particular community gets the same rate.)"

Drum says that Safeway execs have said it would be cheaper to pay the 4 percent payroll tax than to continue to pay the 7 percent that health insurance costs them.

This is exactly why keeping the insurance industry in the game won't fly. They're too expensive a price to pay just to satisfy ideology.

Read the whole post regarding Schwwarzenegger's plan.

Ezra Klein links to Over My Med Body, which has a list today of 50 conditions that can cause insurers to reject you. Including allergies, bed wetting, breast implants, impotence, working with chemicals, roofing, lumber work, window-washing and war reporting. How does that serve our economy, not to insure those folks?

Klein also has an post about mandated insurance, such as Schwarzenegger proposed for California yesterday. Klein says he's heard criticism that such a system "criminalizes the uninsured," evidently from single-payer advocates, and he notes that single-payer is also mandated insurance. His criticism seems to be that single-payer advocates are complaining about government coercion when single-payer would also coerce: force people to have health insurance via their taxes.

Klein seems to think that as long as government subsidizes the private, for-profit system — up to 400 percent of poverty with Sen. Wyden's proposed plan and up to 300 percent in Massachusetts, that such a system would be fine. The Schwarzenegger proposal only subsidizes up to 250 percent; not enough in Klein's view.

This entire avenue of reform proposes wasting our dollars in order to continue a wasteful system. The problem with mandated insurance as in Massachusetts or Schwarzenegger's proposal isn't the mandate, it's what it's for: subsidizing an inefficient system with poor quality built in because of its fragmented structure. It's going to continue to be a drag on our economy as a whole and on our individual households. But yes, better than what we have now.

Andrew Sullivan provides a great link to Psychology Today Magazine and an article on ideology and fear:

"We tend to believe our political views have evolved by a process of rational thought, as we consider arguments, weigh evidence, and draw conclusions... Among the most potent motivators, it turns out, is fear... The fear of death alone is surprisingly effective in shaping our political decisions—more powerful, often, than thought itself."

This is potent. The powerful pharmaceutical/health insurance/for-profit medical industry counts on it. We on the side of the angels need to do a better job of understanding it.

Health Affairs blog reminds us that New York's Elliot Spitzer also is moving to reform that state's healthcare system. Or not — maybe he's just going to tinker with it, as in Massachusetts and along the lines of Schwarzenegger.

The top 25 articles from 2006 are available online free at Health Affairs until January 19. Go to the blog for that link.

Health Care Renewal has a post from Sunday about MBA-think screwing up all kinds of businesses, with the idea that every business is basically the same.

There's been a lot of news about Home Depot's CEO retiring after six years with a $210 million golden parachute, but Health Care Renewal points out that Pfizer's CEO got an even bigger package after being forced out after Pfizer's stock took an even bigger hit than Home Depots.

"So we see hospitals with fewer nurses, primary care physicians over-worked, under-paid, demoralized, and threatened with replacement by nurses and physicians' assistants, and the hiring of drug representatives not with pharmacology doctorates, but with experience as cheer-leaders. (Meanwhile, we see hospital, managed care, and pharmaceutical executives, many with little previous experience in actually providing health care, clinical research, or making pharmaceuticals, hauling in ever higher compensation.)"