This is fun, in addition to being tough. I think that right now, health care is one if those areas where "only Nixon can go to China". I like your pro-business rationale for single payer, but I just think it is a bridge too far for the American people right now. 1993 really poisoned the well for single payer. Socialized medicine, another big government program, and truly massive tax increases -- the talking points for the right wing echo chamber are very well rehearsed and have a ready audience. There is no way to get this through on a bipartisan basis, it's way too easy for the Republicans to parody, and it is a giant risk for the Dems to take in an area that isn't a crisis in people's lives. It is probably the best solution, if designed correctly, and it could be a political winner for the GOP in 2008 or for the Dems in 2016, but I don't think it is for the Dems now. Politics (and this exercise) is the art of the possible, and I can't see the Dems being able to pass this.
But let me give you a chance. Tell me the legislative/political steps by which you think single payer could pass in the next 4 years. Convince me that it's possible. :)
BTW, I really like the MA plan. If the goal is 100% coverage, that is probably the most effective way to get it done that is broadly acceptable. BTW, I am very concerned about the law of unintended consequences. It's a practical reason to be very cautious about a wholesale reinvention of 15% of our economy. Those MA pols are pretty clever? Who was the gov. who did that?
Wednesday, August 29, 2007
Luddites unite (right after the anarchists)
The site totally messed up the format of my last post. I e-mailed it directly to Dave. If any one of our multitude of readers wants to see it, s/he can e-mail me directly. We'll continue the rest of the discussion on the blog.
Data Dump
Thanks for the compliment, and I'll take a longer read through your post for us to discuss. But to react to your first two paragraphs, reading poll results is as much art as science, so each of us can find different facts out there to support our reasoning. Below are some I just found. (One of them is quite old, but I believe that a more recent poll would should similar results.) Looking at the polls further, I still read this situation as similar to how I think people see education -- country in crisis, but I'm doing OK, thanks; and I think the country's ambivalence towards NCLB and federal involvement in local education would be reflected in a wellspring of opposition to any specific plan that would involve lack of personal choice due to more federal involvement in health care.But I was very surprised in the last three polls below by the extent to which people expressed support in general for more radical health care solutions. (In the 2nd to last poll in particular, I'd be interested to hear the results if the question was phrased in terms of "increased taxes" instead of "increased spending".) More to follow, but these provide some interesting food for thought.
28% Support Democrat strongly 11 Support Democrat, not so strongly 14 Support Republican, not so strongly 43 Support Republican strongly 2 Neither (Vol.) * Both (Vol.) 2 Don't know/Refused [Question ID: USGREEN.07DCJUL.R073] Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
24% Support Democrat strongly 13 Support Democrat, not so strongly 17 Support Republican, not so strongly 43 Support Republican strongly 2 Neither (Vol.) * Both (Vol.) 1 Don't know/Refused [Question ID: USGREEN.07DCJUL.R074] Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
19% Very satisfied 30 Somewhat satisfied 21 Somewhat dissatisfied 28 Very dissatisfied 2 Don't know/Refused [Question ID: USGREEN.07DCJUL.R048] Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
48% Very satisfied 33 Somewhat satisfied 9 Somewhat dissatisfied 9 Very dissatisfied 1 Don't know/Refused [Question ID: USGREEN.07DCJUL.R049] Data provided by The Roper Center for Public Opinion Research, University of Connecticut. "Overall, how confident are you that your health insurance for next year will meet the healthcare needs of you and your family?"Base: Will have employer-sponsored health insurance next year
Note: Percentages may not add up exactly to 100% due to rounding. Next, thinking about the campaign for the presidential election in 2008, which one of the following health care issues would you most like to hear the presidential candidates talk about and focus on in any health reform plan they may develop?...Expanding health insurance coverage for the uninsured, reducing health care costs, improving the Medicare prescription drug benefit for seniors, improving the quality of care and reducing medical errors, reducing spending on government health programs like Medicare and Medicaid Subpopulation/Note: Asked of Form 1 half sample |
32% Expanding health insurance coverage for the uninsured 31 Reducing health care costs 13 Improving the Medicare prescription drug benefit for seniors 11 Improving the quality of care and reducing medical errors 7 Reducing spending on government health programs like Medicare and Medicaid 2 None of these (Vol.) 1 Other issue (Vol.) 3 Don't know/Refused
| Survey by Henry J. Kaiser Family Foundation. Methodology: Conducted by Princeton Survey Research Associates International, May 31-June 5, 2007 and based on telephone interviews with a national adult sample of 1,203. [USPSRA.062007HTP.R03] Data provided by The Roper Center for Public Opinion Research, University of Connecticut. |
| (Now I'm going to read you some pairs of statements about health care reform for the country. After I read each pair, please tell me whether the first statement or the second statement comes closer to your own view, even if neither is exactly right.)...First statement: The best way to lower health care costs is through government intervention. Second statement: The best way to lower health care costs is through more choices and competition....(If First/Second statement, ask:) Do you feel that way strongly or not so strongly? Subpopulation/Note: Asked of Form A half sample |
27% First statement strongly
9 First statement not so strongly
13 Second statement not so strongly
45 Second statement strongly
1 Both (Vol.)
1 Neither (Vol.)
3 Don't know/Refused
| (Now I'm going to read you some pairs of statements about health care reform for the country. After I read each pair, please tell me whether the first statement or the second statement comes closer to your own view, even if neither is exactly right.)...First statement: Now is the time to establish a Canadian-style national health care system that provides affordable health care for all Americans. Second statement: We can improve our health care system through incremental steps without taking radical measures that will result in a government takeover....(If First/Second statement, ask:) Do you feel that way strongly or not so strongly? Subpopulation/Note: Asked of Form A half sample |
40% First statement strongly
13 First statement not so strongly
14 Second statement not so strongly
29 Second statement strongly
1 Neither (Vol.)
3 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R066]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| All Health-Related Questions from this Survey |
Democracy Corps Poll [May, 2007] Survey by Democracy Corps. Methodology: Conducted by Greenberg Quinlan Rosner Research, May 29-May 31, 2007 and based on telephone interviews with a national likely voters sample of 1,000. Likely voters are registered voters who voted in the 2004 election/weren't registered/ineligible/too young to vote and said they are probably or almost certain to vote in the 2008 election.
| (Now, I'd like to rate your feelings toward some people and organizations, with one hundred meaning a very warm, favorable feeling, zero meaning a very cold, unfavorable feeling, and fifty meaning not particularly warm or cold. You can use any number from zero to one hundred, the higher the number the more favorable your feelings are toward that person or organization. If you have no opinion or never heard of that person or organization, please say so.)...Single-payer health care system...Give...single-payer health care system a rating, with 100 meaning a very warm, favorable feeling, zero meaning a very cold, unfavorable feeling, and 50 meaning not particularly warm or cold. (If Don't know, ask;) Would you say you are unable to give an opinion of...single-payer health care system, or have you never heard of...single-payer health care system? Subpopulation/Note: Asked of Form A half sample Mean = 45.1 |
16% Warm 51-100
24 Cool 0-49
25 Not particularly warm or cold 50
35 Never heard of/Don't know/Refused
[Question ID: USGREEN.07DCJUL.R030]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| (Now, I'd like to rate your feelings toward some people and organizations, with one hundred meaning a very warm, favorable feeling, zero meaning a very cold, unfavorable feeling and fifty meaning not particularly warm or cold. You can use any number from zero to one hundred, the higher the number the more favorable your feelings are toward that person or organization. If you have no opinion or never heard of that person or organization, please say so.)...Canadian-style health care system...Give...Canadian-style health care system a rating, with 100 meaning a very warm, favorable feeling, zero meaning a very cold, unfavorable feeling, and 50 meaning not particularly warm or cold. (If Don't know, ask;) Would you say you are unable to give an opinion of...Canadian-style health care system, or have you never heard of...Canadian-style health care system? Subpopulation/Note: Asked of Form B half sample Mean = 48.9 |
34% Warm 51-100
32 Cool 0-49
14 Not particularly warm or cold 50
20 Never heard of/Don't know/Refused
[Question ID: USGREEN.07DCJUL.R031]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Thinking about the country as a whole, would you say you are satisfied or dissatisfied with the quality of health care in this country? (If Satisfied/Dissatisfied, ask:) (Is that very or somewhat?) Subpopulation/Note: Asked of Form C half sample |
19% Very satisfied
30 Somewhat satisfied
21 Somewhat dissatisfied
28 Very dissatisfied
2 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R048]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Thinking about your own situation and your own family, would you say you are satisfied or dissatisfied with the quality of health care you receive? (If Satisfied/Dissatisfied, ask:) (Is that very or somewhat?) Subpopulation/Note: Asked of Form C half sample |
48% Very satisfied
33 Somewhat satisfied
9 Somewhat dissatisfied
9 Very dissatisfied
1 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R049]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Thinking about the country as a whole, would you say you are satisfied or dissatisfied with the cost of health care in this country? (If Satisfied/Dissatisfied, ask:) (Is that very or somewhat?) Subpopulation/Note: Asked of Form D half sample |
5% Very satisfied
18 Somewhat satisfied
32 Somewhat dissatisfied
42 Very dissatisfied
3 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R050]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Thinking about your own situation and your own family, would you say you are satisfied or dissatisfied with the cost of health care? (If Satisfied/Dissatisfied, ask:) (Is that very or somewhat?) Subpopulation/Note: Asked of Form D half sample |
18% Very satisfied
25 Somewhat satisfied
24 Somewhat dissatisfied
32 Very dissatisfied
1 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R051]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Which of the following do you agree with most?...One: On the whole, the health care system in America works pretty well but some changes are necessary. Two: There are good things about the health system in America, but some major changes are needed. Three: America's health care system is so inadequate and has so many problems that we need to completely rebuild it. Subpopulation/Note: * = less than .5%. |
20% One: On the whole, the health care system
in America works pretty well but some changes
are necessary
55 Two: There are good things about the health
system in America, but some major changes are
needed
24 Three: American's health care system is so
inadequate and has so many problems that we
need to completely rebuild it
* Other (Vol.)
1 None (Vol.)
* Don't know
[Question ID: USGREEN.07DCJUL.R052]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Now I'm going to read you some pairs of statements about your own health care priorities. After I read each pair, please tell me whether the first statement or the second statement comes closer to your own view, even if neither is exactly right....First statement: Lowering health care costs is the more important thing to me. Second statement: Improving quality is the more important thing to me....(If First/Second statement, ask:) Do you feel that way strongly or not so strongly? Subpopulation/Note: Asked of Form C half sample |
32% First statement strongly
9 First statement not so strongly
14 Second statement not so strongly
38 Second statement strongly
4 Both (Vol.)
1 Neither (Vol.)
1 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R054]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
2
| (Now I'm going to read you some pairs of statements about health care reform for the country. After I read each pair, please tell me whether the first statement or the second statement comes closer to your own view, even if neither is exactly right.)...First statement: Now is the time to establish a Canadian-style national health care system that provides affordable health care for all Americans. Second statement: We can improve our health care system through incremental steps without taking radical measures that will result in a government takeover....(If First/Second statement, ask:) Do you feel that way strongly or not so strongly? Subpopulation/Note: Asked of Form A half sample |
40% First statement strongly
13 First statement not so strongly
14 Second statement not so strongly
29 Second statement strongly
1 Neither (Vol.)
3 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R066]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| (Now I'm going to read you some pairs of statements about health care reform for the country. After I read each pair, please tell me whether the first statement or the second statement comes closer to your own view, even if neither is exactly right.)...First statement: Now is the time for single payer health insurance that is funded and administered by the US (United States government. This Canadian-style system would guarantee affordable health care coverage for all Americans and reduce costs by streamlining the administration of health care. Second statement: We need to make changes to our health care system, but we cannot put it in the hands of the government. While health care accounts for 15 percent of our economy, a government takeover is a radical move that will reduce quality of care and eliminate a patient's choice of doctor....(If First/Second statement, ask:) Do you feel that way strongly or not so strongly? Subpopulation/Note: Asked of Form B half sample |
29% First statement strongly
17 First statement not so strongly
14 Second statement not so strongly
35 Second statement strongly
2 Neither (Vol.)
3 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R067]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Would you favor or oppose a proposal that provided every American with health insurance, even if it meant your taxes or health care premiums would increase as a result? (If Favor/Oppose, ask:) Do you feel that way strongly or only somewhat? Subpopulation/Note: Asked of Form A half sample |
27% Strongly favor
27 Somewhat favor
16 Somewhat oppose
27 Strongly oppose
4 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R068]
Data provided b
| Let me tell you about a proposal to reform the health care system in this country. This plan would use what some people call a single-payer health care plan. Under this plan, you still would be able to see your own doctor, just like under Medicare, but the federal government would pay the health care costs for all Americans. This would require a significant tax increase, but all of your current health care costs and insurance premiums would be covered by the government. Having heard this, do you favor or oppose this proposal? (If Favor/Oppose, ask:) Do you feel that way strongly or only somewhat? Subpopulation/Note: Asked of Form D half sample |
25% Strongly favor
29 Somewhat favor
12 Somewhat oppose
29 Strongly oppose
5 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R072]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
Health Care: A Much Different Answer
I am beginning to realize just why this little project I have gotten us into is, in fact, deeply challenging. You and I, two reasonably intelligent adults who share many common beliefs about the proper role of government and of what constitute our major problems of the day, still adopt fundamentally different approaches to one of those major problems. Usually, I tend to disguise my conclusions of an argument until the end so that I can build to it, but let me make an exception in this case and start at the end and then walk through the logic of my thinking-- to use the term liberally -- all while trying to address the points you raise in your post. So, here's the bottom line: I think the only adequate solution to the health care challenge is to move to a single-payer system. Now, let me explain why.
I'll start by challenging your starting point. You claim that most people are satisfied with their own health coverage, but complain that the system itself is broken. I actually think that most people believe the system is broken AND that their own coverage is both unsatisfactory (or at least frustrating) and -- to one degree or another -- at risk. (By the way, the one group for which the complaints about health care system are lowest is among the elderly who benefit from a single-payer system.) If one starts with this premise, it is a lot easier to argue that radical change (though I wouldn't use that term to sell the plan, of course) is needed. I totally agree that single-payer is easily parodied and has lots of interests arrayed against it, but I also think that the reasons why it is not so far fetched to consider is that (a) a majority of the public is already accepting of single-payer of one form or another and (b) the largest interest of all -- buisness -- is quickly coming to the conclusion that the current system where buisnesses are largely responsible for paying health care costs is unsustainable.
Taking these points in order, consider this poll from CBS, where two thirds say that they believe that there should be universally guaranteed health care and that only 8% want the whole system to stay the same and fully 36% want a total overhaul. I know that these type of polls are not totally reliable because they are conducted in a political vaccuum where people only imagine a best-case scenario without considering all the potential downsides, but still, it seems to me that the public is primed for a total re-thinking of the ways in which health care coverage is delivered in this country.
The second point, in my mind, is more important. You argue in your post that we need to avoid making this about covering the uninsured because -- by and large -- the uninsured don't vote. On this I agree, but rather than aiming to satisfy/appeal to the middle class, I think instead that the whole issue needs to be framed as one that supports business growth. This is an argument that has even broader appeal and, actually, is even more accurate. Until we figure out a way to enable buisnesses to get out from under the burden of rapidly rising health care premiums, economic growth is threatened. When compainies like GM, IBM and GE are paying billions every year in health benefits for their employees, they are looking to stop the bleeding. The best way to stop it is not to stem the rise of health care premiums, but to throw off the burden all together. I suppose these large companies could simply refuse to pay premiums any more and risk losing vast numbers of employees, but a much more reasonable solution is to get some other big entity to pay. Enter the U.S. government.
This argument, by the way, to me represents the true $800 screwdriver. When GM is about to enter contract negotiations with the UAW and the main issue on the table is how to cover the rising health premiums -- not wages, not work conditions, not retirement benefits -- then it seems that the general public will begin to appreciate the scope of the problem.
Now, as to how to implement. This, I grant you, is a bit tricky not so much because the idea is flawed, but because you can't very well propose a plan that -- as attractive as it might be to many -- wipes out an entire industry (HMOs). I was going to propose that we need an interim phase where coverage is universal and that the cost burdens are shifted from business to the government, but that preserves the role of HMOs to manage individual plans. I suppose this is the route that Massachusetts has taken. (Details here.) We'll have to see how this plays out. It will certainly help with one of the main issues -- coverage -- but I find it hard to believe that it is going to make much of a difference on business growth matter and, so, does not represent a long-term solution.
Instead, I think we need a plan that simply sets the goal of universal health care coverage by the U.S. government as a goal and builds in a phasing in period where essentially Medicare extends its coverage to ever-greater age range. Coverage should begin first with 0 - 18 and then, for example, could add people within five-year age range increments each year over the next several years. This phase-in period would then give time to (a) HMOs to adjust their services to supplemental coverage -- much as they do for the over-65 set now; (b) the government to build up the systems needed to vastly expand and, as you rightly suggest, streamline the coverage and delivery of health care in several ways (electronic record-keeping, standard-setting, etc.); and (c) buisness to adjust salary structures to accommodate the sloughing off of paying health care benefits. On this last point, I would suggest that any good plan also has to have some regulation built in for how businesses shift monies from paying health care premiums to increased salaries that is fair to both employer and employee.
As for the issue of choice, I've never understood this problem. If every doctor accepts the same payer, then presumably patients would have more -- not less -- choice than they do when some doctors now accept patients from some plans and not others. There would be less choice for doctors, I suppose, but I think it is possible to build in some safeguards to insure that payments are fair and that there is limited abuse. As for rationing of certain procedures, this may be a real problem, but think it will be relatively limited and, if we are able to spread health care dollars more equitably, then it will actually make other problems like better technology driving up costs less dramatic. We could also build in some incentives for getting more primary care doctors into practice to build in more gate keepers into the system
A final detail point about how we pay for all this. Coverage is paid for by an increase of taxes to both employers and employees/taxpayers, but these increases, I am assuming, will be lower overall than current taxes + health care premiums. Even if the total tax/health care burden is reduced by 10% overall, it seems a no brainer. My guess, though, is that there will be even more savings than that, however. I am not sure, but I would think that covering the uninsured will do much to drive down costs. After all, if the uninsured currently use expensive ERs as their primary form of care and do not take preventive health seriously then it just makes sense that they will spend less as individuals with access to regular health care and, so, costs for the whole system will fall, as well. I know that Massachusetts is counting on this phenomenon to kick in. Also, eliminating HMO bureaucracy from the mix is bound to reduce overall costs.
To wrap up, I am both optimistic and pessimistic. On the latter point first, considering you claim that a single-payer system is a non-starter in your view, I'm not sure you and I are going to come up with some consensus plan that satisfies both our perspectives and if we can't do it, then I fear that no one can. If we cannot reach some national compromise, we'll be stuck with some variation of the same mess we are in now. At the same time, I have become increasingly persuaded that we are approaching a crisis moment. As many are fond of saying, the Chinese word for crisis is a combination of the words "risk" and "opportunity". I believe that as the crisis looms larger, the U.S. will simply have to take a more risky, but opportunity-filled step of completely overhauling the health care system. With all due respect, anything else just tinkers around the edges and leaves us in the same sorry state we're in now.
One final -- and tangential -- point that I was going to include in a separate post, but may as well throw it in here since it stems directly from yours. Your notion that there should be a set of industry-based standards of care is, in theory, good, and should defintely be explored within the context of a single-payer system, but I also think that you both overestimate and gloss over the capacity of medicine to adhere to standards. On the one hand, medicine is as much art as science. There may be certain standards of care, but as I see up close, there is also a fair amount of guess work and gray areas that simply cannot be regulated from afar. There may be room for standards, I suppose, but doctors also operate on a case-by-case basis and make decisions with individual patients and so such standards may not be possible to implement absolutely in practice. On the other hand, doctors also can fall into the habit of operating by rote and misdiagnosis or mistreat some condition because they are looking at the problem in a particular way or with a particular set of experiences. Standards may act only to exacerbate such tendencies and may, in fact, make things worse, not better.
I guess that, ultimately, our debate will continue. I only wish that the debate in the wider public sphere would continue with even a modicum of the respect and earnestness we are trying to exhibit here.
I'll start by challenging your starting point. You claim that most people are satisfied with their own health coverage, but complain that the system itself is broken. I actually think that most people believe the system is broken AND that their own coverage is both unsatisfactory (or at least frustrating) and -- to one degree or another -- at risk. (By the way, the one group for which the complaints about health care system are lowest is among the elderly who benefit from a single-payer system.) If one starts with this premise, it is a lot easier to argue that radical change (though I wouldn't use that term to sell the plan, of course) is needed. I totally agree that single-payer is easily parodied and has lots of interests arrayed against it, but I also think that the reasons why it is not so far fetched to consider is that (a) a majority of the public is already accepting of single-payer of one form or another and (b) the largest interest of all -- buisness -- is quickly coming to the conclusion that the current system where buisnesses are largely responsible for paying health care costs is unsustainable.
Taking these points in order, consider this poll from CBS, where two thirds say that they believe that there should be universally guaranteed health care and that only 8% want the whole system to stay the same and fully 36% want a total overhaul. I know that these type of polls are not totally reliable because they are conducted in a political vaccuum where people only imagine a best-case scenario without considering all the potential downsides, but still, it seems to me that the public is primed for a total re-thinking of the ways in which health care coverage is delivered in this country.
The second point, in my mind, is more important. You argue in your post that we need to avoid making this about covering the uninsured because -- by and large -- the uninsured don't vote. On this I agree, but rather than aiming to satisfy/appeal to the middle class, I think instead that the whole issue needs to be framed as one that supports business growth. This is an argument that has even broader appeal and, actually, is even more accurate. Until we figure out a way to enable buisnesses to get out from under the burden of rapidly rising health care premiums, economic growth is threatened. When compainies like GM, IBM and GE are paying billions every year in health benefits for their employees, they are looking to stop the bleeding. The best way to stop it is not to stem the rise of health care premiums, but to throw off the burden all together. I suppose these large companies could simply refuse to pay premiums any more and risk losing vast numbers of employees, but a much more reasonable solution is to get some other big entity to pay. Enter the U.S. government.
This argument, by the way, to me represents the true $800 screwdriver. When GM is about to enter contract negotiations with the UAW and the main issue on the table is how to cover the rising health premiums -- not wages, not work conditions, not retirement benefits -- then it seems that the general public will begin to appreciate the scope of the problem.
Now, as to how to implement. This, I grant you, is a bit tricky not so much because the idea is flawed, but because you can't very well propose a plan that -- as attractive as it might be to many -- wipes out an entire industry (HMOs). I was going to propose that we need an interim phase where coverage is universal and that the cost burdens are shifted from business to the government, but that preserves the role of HMOs to manage individual plans. I suppose this is the route that Massachusetts has taken. (Details here.) We'll have to see how this plays out. It will certainly help with one of the main issues -- coverage -- but I find it hard to believe that it is going to make much of a difference on business growth matter and, so, does not represent a long-term solution.
Instead, I think we need a plan that simply sets the goal of universal health care coverage by the U.S. government as a goal and builds in a phasing in period where essentially Medicare extends its coverage to ever-greater age range. Coverage should begin first with 0 - 18 and then, for example, could add people within five-year age range increments each year over the next several years. This phase-in period would then give time to (a) HMOs to adjust their services to supplemental coverage -- much as they do for the over-65 set now; (b) the government to build up the systems needed to vastly expand and, as you rightly suggest, streamline the coverage and delivery of health care in several ways (electronic record-keeping, standard-setting, etc.); and (c) buisness to adjust salary structures to accommodate the sloughing off of paying health care benefits. On this last point, I would suggest that any good plan also has to have some regulation built in for how businesses shift monies from paying health care premiums to increased salaries that is fair to both employer and employee.
As for the issue of choice, I've never understood this problem. If every doctor accepts the same payer, then presumably patients would have more -- not less -- choice than they do when some doctors now accept patients from some plans and not others. There would be less choice for doctors, I suppose, but I think it is possible to build in some safeguards to insure that payments are fair and that there is limited abuse. As for rationing of certain procedures, this may be a real problem, but think it will be relatively limited and, if we are able to spread health care dollars more equitably, then it will actually make other problems like better technology driving up costs less dramatic. We could also build in some incentives for getting more primary care doctors into practice to build in more gate keepers into the system
A final detail point about how we pay for all this. Coverage is paid for by an increase of taxes to both employers and employees/taxpayers, but these increases, I am assuming, will be lower overall than current taxes + health care premiums. Even if the total tax/health care burden is reduced by 10% overall, it seems a no brainer. My guess, though, is that there will be even more savings than that, however. I am not sure, but I would think that covering the uninsured will do much to drive down costs. After all, if the uninsured currently use expensive ERs as their primary form of care and do not take preventive health seriously then it just makes sense that they will spend less as individuals with access to regular health care and, so, costs for the whole system will fall, as well. I know that Massachusetts is counting on this phenomenon to kick in. Also, eliminating HMO bureaucracy from the mix is bound to reduce overall costs.
To wrap up, I am both optimistic and pessimistic. On the latter point first, considering you claim that a single-payer system is a non-starter in your view, I'm not sure you and I are going to come up with some consensus plan that satisfies both our perspectives and if we can't do it, then I fear that no one can. If we cannot reach some national compromise, we'll be stuck with some variation of the same mess we are in now. At the same time, I have become increasingly persuaded that we are approaching a crisis moment. As many are fond of saying, the Chinese word for crisis is a combination of the words "risk" and "opportunity". I believe that as the crisis looms larger, the U.S. will simply have to take a more risky, but opportunity-filled step of completely overhauling the health care system. With all due respect, anything else just tinkers around the edges and leaves us in the same sorry state we're in now.
One final -- and tangential -- point that I was going to include in a separate post, but may as well throw it in here since it stems directly from yours. Your notion that there should be a set of industry-based standards of care is, in theory, good, and should defintely be explored within the context of a single-payer system, but I also think that you both overestimate and gloss over the capacity of medicine to adhere to standards. On the one hand, medicine is as much art as science. There may be certain standards of care, but as I see up close, there is also a fair amount of guess work and gray areas that simply cannot be regulated from afar. There may be room for standards, I suppose, but doctors also operate on a case-by-case basis and make decisions with individual patients and so such standards may not be possible to implement absolutely in practice. On the other hand, doctors also can fall into the habit of operating by rote and misdiagnosis or mistreat some condition because they are looking at the problem in a particular way or with a particular set of experiences. Standards may act only to exacerbate such tendencies and may, in fact, make things worse, not better.
I guess that, ultimately, our debate will continue. I only wish that the debate in the wider public sphere would continue with even a modicum of the respect and earnestness we are trying to exhibit here.
Monday, August 27, 2007
Equal Opportunity Reviewer Bashing
I am similarly displeased by this review from the left of another "What's the matter with the Democrats" book, "The Argument" by Matt Bai. A few points:
1) Michiko reviews far, far too many contemporary political books. And her "reviews" are rarely more than summaries of the key points from the books with a few illustrative quotes, followed by some like-minded piling on against the Bush Administration.
2) I'm very tired (as has previously been documented, as my friend Ted knows) of the self-serving reviews within the Times of books by NY Times writers or which have previously appeared in a different form in the Times. These books should appear in a "Noted for your Information" column, as the Times has shown no ability to conduct reviews for these books which are either fair or useful for their readers.
3) I haven't read Bai's book, but I've read almost all of his NY Times Magazine pieces, and this book is so clearly a compilation of the past 4 years of this reportage. Maybe Bai is hoping that no one has noticed, but the political world has changed just a bit since 2003. How can any serious reviewer can not point out how dated the book is? This is yesterday's first draft of history, which isn't too different from what is lining today's litter box.
BTW, the Salon review of the book includes this great quote.
One of my favorite stories in "The Argument" features Democratic Congressional Campaign chairman Rahm Emanuel, another ambiguous figure -- Bai seems to like him, even though he's a message-agnostic, win-at-any-cost pol from Chicago -- blowing up after having to sit through a work session on crafting a coherent Democratic appeal. Told that it's not enough to simply attack the Republican Congress (which is the whole point of Bai's book), Emanuel snarls: "I have my knee on their vertebrae, and I'm not going to let up on the pressure until I hear the vertebrae snap."
I don't know the date of this quote, but it could be anytime from 2006 until now. Emanuel is right and wrong at the same time. We'll find out in Nov. 2008 if he was more right than wrong. (It's a little bit like the difference between Hillary and Obama. BTW, I would love to sit in on the uncensored conversations that he and Obama have. Same city, same generation, and seemingly such a different approach to politics. Would be fascinating.)
1) Michiko reviews far, far too many contemporary political books. And her "reviews" are rarely more than summaries of the key points from the books with a few illustrative quotes, followed by some like-minded piling on against the Bush Administration.
2) I'm very tired (as has previously been documented, as my friend Ted knows) of the self-serving reviews within the Times of books by NY Times writers or which have previously appeared in a different form in the Times. These books should appear in a "Noted for your Information" column, as the Times has shown no ability to conduct reviews for these books which are either fair or useful for their readers.
3) I haven't read Bai's book, but I've read almost all of his NY Times Magazine pieces, and this book is so clearly a compilation of the past 4 years of this reportage. Maybe Bai is hoping that no one has noticed, but the political world has changed just a bit since 2003. How can any serious reviewer can not point out how dated the book is? This is yesterday's first draft of history, which isn't too different from what is lining today's litter box.
BTW, the Salon review of the book includes this great quote.
One of my favorite stories in "The Argument" features Democratic Congressional Campaign chairman Rahm Emanuel, another ambiguous figure -- Bai seems to like him, even though he's a message-agnostic, win-at-any-cost pol from Chicago -- blowing up after having to sit through a work session on crafting a coherent Democratic appeal. Told that it's not enough to simply attack the Republican Congress (which is the whole point of Bai's book), Emanuel snarls: "I have my knee on their vertebrae, and I'm not going to let up on the pressure until I hear the vertebrae snap."
I don't know the date of this quote, but it could be anytime from 2006 until now. Emanuel is right and wrong at the same time. We'll find out in Nov. 2008 if he was more right than wrong. (It's a little bit like the difference between Hillary and Obama. BTW, I would love to sit in on the uncensored conversations that he and Obama have. Same city, same generation, and seemingly such a different approach to politics. Would be fascinating.)
Friday, August 24, 2007
Attack of the smug
Though I appreciate the diversity that David Brooks brings to the NY Times Op-Ed page, and he frequently makes some interesting points (which are just as frequently expanded way out of proportion to his supportive evidence), this "review" is Exhibit 28 in why he infuriates me. And the editors thought he would write a fair (and meaningful) review of this book, Why?
Thursday, August 23, 2007
Go Team!
I didn't mean to leave you speechless, Dave. Well, good thing we have 15 months to go before we give these ideas to the next Democratic President. :)
While it's a pretty safe assumption that Dems will be less aggressive and strategic in responding to spurious claims than the right, I think that Drum is off-base here. Dems still have a winning hand on the Iraq issue. It's was a war of choice, George Bush's choice, it's going badly, 70%+ of Americans want it to end and for us to bring our troops home. Bush and the GOP have been dead wrong on every aspect of the war, from choosing to fight it to how they fought it to telling the American people for 4 years that it was going great. Bush is desperately grasping at anything he can to rebuild some support for the war, but Vietnam is a distraction. We should keep focus directly on this war, which is a disaster for everyone and is Bush's fault. (And I like your line. That kind of dismissal of this attempted sideshow is perfect.)
The problem we all have is that Colin Powell was right, and, to some extent, Bush was right. We broke it, we bought it. Maybe 2-3 years ago it was accurate to say that much of the violence in Iraq was spurred by the American presence, and therefore our departure may have been an improvement for Iraq. But now, with a full fledged, low-level civil war underway, it seems hard to argue that the Americans are not a stabilizing force in the country and that, at least in the short term, you'd see an upswing in violence were we to leave.
This is a very tough one. There's a reason why the objective function of the Baker-Hamilton report seemed to be an outcome that would have broad bi-partisan support among the U.S. public and preserve some of our dignity rather than one which would be the best for the Iraqi people.
Worst. Foreign. Policy. Debacle. Ever.
While it's a pretty safe assumption that Dems will be less aggressive and strategic in responding to spurious claims than the right, I think that Drum is off-base here. Dems still have a winning hand on the Iraq issue. It's was a war of choice, George Bush's choice, it's going badly, 70%+ of Americans want it to end and for us to bring our troops home. Bush and the GOP have been dead wrong on every aspect of the war, from choosing to fight it to how they fought it to telling the American people for 4 years that it was going great. Bush is desperately grasping at anything he can to rebuild some support for the war, but Vietnam is a distraction. We should keep focus directly on this war, which is a disaster for everyone and is Bush's fault. (And I like your line. That kind of dismissal of this attempted sideshow is perfect.)
The problem we all have is that Colin Powell was right, and, to some extent, Bush was right. We broke it, we bought it. Maybe 2-3 years ago it was accurate to say that much of the violence in Iraq was spurred by the American presence, and therefore our departure may have been an improvement for Iraq. But now, with a full fledged, low-level civil war underway, it seems hard to argue that the Americans are not a stabilizing force in the country and that, at least in the short term, you'd see an upswing in violence were we to leave.
This is a very tough one. There's a reason why the objective function of the Baker-Hamilton report seemed to be an outcome that would have broad bi-partisan support among the U.S. public and preserve some of our dignity rather than one which would be the best for the Iraqi people.
Worst. Foreign. Policy. Debacle. Ever.
We Interrupt This Discussion...
I know I have lamely shirked my responsibility to respond to your thoughtful post on health care. I promise that I will, but wanted to get your thoughts on this idea that Kevin Drum proposes.
What is the proper reaction to the president's latest salvo at undermining all that is good and noble about simple truth? Do we ignore the inanity of the claim that Vietnam could have been won and we are in the same situation now in Iraq so that we prove its inanity by ignoring it or do we actually try to counter the fantasy by bombarding the public with a dose of reality? I'm actually inclined to take the middle ground between the choices. How about dismissing the claim not with an argument, so much as with a snarky comment like, "If the president really wishes to associate his war with the ten years of failed military and political policy of Vietnam, that is his choice."? If Kevin really wants us to fight back against the right, then we need to sound as arrogant and cavalier as they do.
What say you? Talk truth, ignore fantasy or talk trash?
What is the proper reaction to the president's latest salvo at undermining all that is good and noble about simple truth? Do we ignore the inanity of the claim that Vietnam could have been won and we are in the same situation now in Iraq so that we prove its inanity by ignoring it or do we actually try to counter the fantasy by bombarding the public with a dose of reality? I'm actually inclined to take the middle ground between the choices. How about dismissing the claim not with an argument, so much as with a snarky comment like, "If the president really wishes to associate his war with the ten years of failed military and political policy of Vietnam, that is his choice."? If Kevin really wants us to fight back against the right, then we need to sound as arrogant and cavalier as they do.
What say you? Talk truth, ignore fantasy or talk trash?
Monday, August 13, 2007
Health Care - The Answer :!*)
OK. I’ve been thinking about your health care challenge over the last week or so. I definitely view this as a work in process, to be improved by our mutual contributions. Let me lay out a framework for how I’m thinking about this, then work up to a policy solution and a way to package it.
The landscape on this issue is not as politicized as some. To the extent that it is, the groundwork is laid along the usual lines of the Dems as the mommy/big government party - wanting to make sure that everyone is covered and healthier and eager to see the government expand deeper into all of our lives to accomplish this - and the GOP is the daddy/small government party - wanting to see people take responsibility for their own health, trusting the free enterprise system to solve social problems, and wanting a relaxation of the government's role in the sector.
Currently, I'd say most Americans feel about health care similarly to how they feel about education. Everyone says it’s a crisis, so it must be, but my school (or coverage) seems to be pretty good. To the extent that there is a problem, people would describe it differently. Some point to 50 million uninsured, some point to the hassles of those with insurance and the evils of HMOs, some point to the toll that health care spending is putting on American companies, some point to the wasteful spending, with primary subproblems within that being too little spent on prevention, too much spent on insurance and unnecessary procedures, too much spent on paperwork and processing, too much spent on pharma, too much spent on the last 3 months of life.
One issue with taking the lead in trying to solve health care is that no one can agree on what the problem is. So, first you've got to convince the majority of the American people that what you say is a problem is really an important problem, then you've got to deal with everyone trying to tear down your solution.
There are a few traps for the Democrats to avoid. First, they have to avoid single payer. The entrenched interests against it are too many, it’s too easy to parody as socialist (or worse, French) and there is not enough of a sense of crisis for people to support a revolution in our health care delivery and payment system. Second, you have to avoid anything that would restrict or ration care at the top end, for the same reason. Third, you have to avoidance making 'universal coverage' your rallying cry. The middle class doesn't care, many uncovered people could afford coverage but choose not to buy it, and the working poor are outnumbered and under-registered.
So, what do you do? First, you focus on the issues of the middle class and the economy. Then you focus on cost and quality. We’re not getting what we pay for. Increasing technology is decreasing costs in computing, home electronics and telecommunications. Why is it increasing costs in health care? And why aren’t we healthier when we are paying so much?
To step back, why do people buy insurance? Typically, it's to avoid risk. Maybe there is only a 1/1000 chance of your house burning down this year, but that outcome is so catastrophic that it is worth paying 1/500th of the value of your house each year for fire insurance. So, it's worth paying $5000/year for health insurance to avoid the 1% chance of having to pay $250,000 in health costs which would be bankrupting. For health insurance, there is another, somewhat paradoxical reason to buy it. Humans are notoriously poor at making trade-offs between the present and the future. Even while we know that eating fatty foods will clog our arteries in the future, we often don't pass up the KFC for the big salad. In terms of health, that means that people will put off that check-up at their doctor and stay home to watch Big Brother instead. So, it makes sense to have pre-paid insurance so the check-up is free and more people would go than if they paid the actual price. The downside of insurance is what's called moral hazard. If I know that I have collision insurance in my rental car, I may drive a bit more recklessly than if I knew I was liable for any scratches. (The health care world is filled with enough other economic inefficiencies to fill about a dozen PhD theses.)
So, here are some attractive principles to start with that make sense and would appeal to the American public. I’ll build my policy and packaging suggestions from these:
1) People need catastrophic insurance. They want it and need the security of knowing that they are not one illness away from bankruptcy
2) People need choices. You only can go to this one doctor and have to pay huge to go out of network is a non-starter
3) Squeezing cost out of the system is good, if it doesn't hurt quality or personal choice.
4) Americans like technology and they like progress. Any system has got to encourage technological advances
5) Health care should be affordable for the average American
6) Single payer is a non-starter
7) The focus of reform efforts should be on things that make life better for the middle class
8) There is lots of room for quality improvement in American health care
9) You shouldn’t have to pay a lot to get high quality. People get it with
So here are some components of a solution that should be sellable. I'll think about the packaging of this a little later.
1) Implement voluntary, industry based standards organizations with incentives to join. Government imposed standards are easy to attack. Industry driven standards work very well in the technology/telecommunications fields and are harder to criticize from the right. There should be standards of care for say the 10-20 most common/expensive complaints/procedures/ conditions. The AMA and hospital associations, etc. should get together to agree on these standards of care, convened by the government. Health care providers should be judged based on how well they meet these, and there should be a financial incentive (but no requirement) to do so.
2) Tort reform. This is an issue to take away from the GOP and it reinforces the message of controlling costs (even though it’s probably not a big component of that.) A couple of things I’d suggest. First, all MDs or HMOs should be exempt from liability when they follow the standard of care guidelines above. Second, there should be a declining, sliding scale for legal fees. Third, punitive damages above a certain amount go to a central fund not to the plaintive.
3) There should be differential Medicare reimbursement rates based on efficacy. Providers meeting the standards of care above should be reimbursed at a higher rate. New drug reimbursement rates should be keyed to how much of an improvement the drug is over the previous therapies. Perhaps MD’s or hospitals should receive some kind of incentive based on how often they prescribe generics when they are available.
4) Tax advantages should be available for companies and individuals that follow these “more effective” plans. This should help lift the burden on companies facing foreign competition and make it easier for uninsured Americans to buy plans.
5) There should be an industry based standard for electronic medical records. Not a standard software, but a standard dataset and flows. This is a huge savings opportunity and a great way to use standards to help a whole community. (It's like defining a standard rail track gauge in the olden days.)
6) Cover all kids. This is just a no brainer. (I'm not up on the details of the current proposals for this.)
7) Create attractive national policies for individuals not covered from work to buy into. These should be offered by private companies, and giving people a choice of different tiers. The baseline ones should be low cost, cover preventative care for free, give $ back for healthy behaviors, have high deductible but good catastrophic coverage.
In terms of messaging, I think these are the kind of messages we should use:
- Health care is becoming unaffordable for the average American
- We need to make sure health care is affordable for everyone
- We can get higher quality at lower cost
- We will use market based solutions to fix market failures
- American ingenuity will help us make sure that all Americans have the best health care in the world
Also, to drive the cost point home, we need to find our $800 screwdriver -- the sticky example of just how broken the system is. And we should make the point that these changes will be revenue neutral at all levels of government. The federal government will spend more on tax breaks for these “approved” plans, but it will reap savings in Medicare and Medicaid spending, and the state and local governments will save a lot in these two areas.
To wrap up this mega-post and return to its political possibilities, the left wouldn’t like this plan because it doesn’t provide universal coverage. The right wouldn’t like it because it will increase federal spending and also injects these standards organizations into the marketplace. The pharmas won’t like it because they will have to show greater efficacy for their drugs to get maximum reimbursement. I’m not sure how the AMA and hospital groups would react. Getting them inside the tent on the standards of care setting is key. (But that process will be hellacious.) Individual doctors may object, saying that the government is telling them how to practice medicine. (In reality, the government is just setting different reimbursement rates based on the scientific recommendations for standards of care.) Insurance companies should like the electronic medical records and the additional tax incentives, but may have issues with selected standards of care.
For middle class consumers, I think this issue is winnable in this presentation. They would be told that their own health care costs will start to decline and that the government is reining in costs overall. Not exactly the most powerful rallying cry, but I think it is still a compelling message for how they benefit and how the country benefits, which is what was missing in the compromise immigration bill.
Your thoughts?
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