The Misunderstood Public Option

I was verbally jousting about health care on another blog recently when a commenter challenged my support for the Public Option. He charged that the PO would not reduce costs, that is unless I intended it to entail “rationing”. Surely, he said, I didn’t mean that. Ah, but I did – in a sense.

Health care costs way too much in this country, more than double what comparable or better results cost in socialized countries, but except for bemoaning the soaring national debt, most Americans don’t seem to care. If they have insurance, very few options are closed to them and their own pocketbooks are mostly unaffected regardless of what kind or how many tests or medicines they are given. Their doctors are likewise unconcerned about costs, unless that is, as often happens, the doctors themselves own part of a lab or testing facility or have accepted favors from pharmaceutical companies. Want a third MRI to confirm the other two? No problem. Want to try the latest anti-cholesterol drug you saw on TV last night instead of the generic, even though it costs 10 times as much? No problem.

Health care consumers generally fit into one of two categories – they either get their medical care through their employer or they simply ignore health insurance and rely on an Emergency Room when they (inevitably) need it. The latter method works just fine, except that it simply transfers the costs to those who are insured. How did this happen?

When hospitals began “dumping” non-paying patients for lack of ability to pay, society reacted in 1986 by letting Congress enact EMTALA and extorting hospitals into caring for the poor. But that simply transfers the cost to those who are insured and is a major contributing factor in the soaring costs. Should we repeal EMTALA? Any politician who advocated that would be toast in the voting booths. They might as well try to cancel Medicare and Medicaid, those two very socialist programs which are so immensely popular. This is why I have touted a return to considering the Public Option as the solution.

What is the Public Option? It has been referred to, among other things, as the “Medicare You Can Buy Into Act” and that means just what it sounds like. You would have to give up some autonomy. You would have to defer to government doctors who might tell you you don’t need a third opinion or a third MRI. You might have to take a generic instead of the latest twist on some big pharmaceutical company’s expiring patent. But the government doctor telling you those things would be working for a salary and not trying to grow his own business.

My blogging adversary accuses me of ignorance and claims that Medicare and Medicaid are “bankrupt” themselves. But, they aren’t. They can’t be because they are not for-profit programs. They are tax-supported social services.  If you take the position that such things should be self-supporting in the sense that tax receipts should match all services, then how would such a system cope with economic downturns like the Great Recession or the dot-com bubble of 2000?  Simply turn people away from medical care?  Then shall we now eliminate Social Security because its receipts are scheduled to fall behind outflow requirements?  That would be a Libertarian world, but it’s not the world I want.

If you are on Medicare or other government insurance you receive something called an EOB, which stands for “explanation of benefits”, a form that spells out what treatment you got from a provider, what the provider charged, and what the government decided was a fair price the provider did get. In almost all cases the actual amount paid is a mere fraction of what was sought. What’s the message? The government saved you a bundle of money.

Under the present laissez-faire system, many doctors do not follow the best or the most efficient practices. If you don’t believe that, consider this from a recent USA Today newspaper article. (emphasis is mine)

In one case, gynecologists in Sacramento are being trained to perform less-invasive hysterectomies or risk losing their patients to doctors who know how.
“A minimally invasive procedure, when appropriate, is much safer for the patient. There’s a much quicker return to work, less chance of infection, a shorter length of stay and it’s less costly,” says Rosaleen Derington of Hill Physicians Medical Group in Northern California.
Vast amounts of money are at stake. The Banner Health system, which has hospitals in seven states, has instructed doctors they can no longer use a certain product designed to prevent abnormal scarring during cesarean sections, saying it does not improve patient care. The effort has saved more than $1 million so far.

The idea behind the Public Option is not to put private insurance companies out of business but rather to give them meaningful competition so they will seek out cost-saving best practices similar to the above example. I don’t blame the insurance companies for fiercely lobbying against the notion of meaningful competition – life has been very good for them under the present system. But that system is bankrupting the country. Unless you are like my blogging adversary who sees government as mostly a bad thing and Medicare/Medicaid as socialist programs to be eliminated, and who apparently would relegate health care for the poor to the mercies of charity, I invite you to join me in supporting a fresh look at the Public Option.
Related article: A Poll on the Public Option

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About Jim Wheeler

U. S. Naval Academy, BS, Engineering, 1959; Naval line officer and submariner, 1959 -1981, Commander, USN; The George Washington U., MSA, Management Eng.; Aerospace Engineer, 1981-1999; Resident Gadfly, 1999 - present. Political affiliation: Independent, tending progressive as the GOP recedes from its Eisenhower roots.
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31 Responses to The Misunderstood Public Option

  1. PiedType says:

    Regardless of whether the health care reform legislation and individual mandate is declared unconstitutional, something needs to be done about the insurance companies — either a public option or a removal of their exemption from anti-trust laws. They must be made to compete.

    Worth noting: There’s a big difference between government-run insurance and government-run health care. Medicare, for example, is my insurance, not my medical care. Big difference. I’m not at all interested in government-run, bureaucratic health care. It’s bad enough just having bureaucrats pull the strings on my insurance. I don’t want to go to government doctors and hospitals.

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    • Jim Wheeler says:

      I get where you’re coming from, Pied, so long as Medicare marches on as it is. The problem is, it can’t. The nation can’t afford it like it is and something will have to give. Now we just have to decide what gives. Or wait until the financial system collapses and we become like Greece, Italy, Spain and Belgium.

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  2. John Erickson says:

    The biggest problem I have with the public option is a very personal one: no choice of doctor. (I may have misread the information on this, so please correct me if I’m wrong.) I went through several doctors around where I currently live in order to find a doctor who would prescribe me JUST the drugs that worked, without either falling back on trial-and-error, giving me every medication under the sun, or telling me I’m psycho-somatic and to go … well, have fun with myself. The problem is my condition is counter-intuitive to accepted practices for migraine/cluster headaches, especially since my reactions to medicines are almost 180 out from what they should be. (Opiate pain-relievers wire me, rather than making me sleep; the “triptan” family of migraine drugs, which are normally well-tolerated digestively, make me EPICALLY nauseous.)
    I would not want to lose my current doctor, but without work-provided health care (my wife doesn’t qualify at either of her jobs) I’ll have to fall under whatever “for the uninsured poor” plan comes along – or do as I do today, and pay out of my pocket. (Okay, the wife’s pocket! 🙂 )
    Then again, I am saving the insured folk tons of money, since I don’t have to argue with my doc NOT to do an infinite number of X-rays, MRIs, ultrasounds, CAT and CT scans that my Chicago doctor insisted upon almost MONTHLY! (You’re welcome, folks! 😀 )

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  3. ansonburlingame says:

    Jim,

    I nor many other conservatives do not MISUNDERStAND the Public Option or the single pay approach. And as you at least suggest it does involve rationing by someone other than the patient.

    NO DOCTOR (or auto mechanic) will voluntarily ration his fees. They are all “in it for the money” at least to some degree. So you call for “someone else” to ration their fees for them.

    I call for the age old solution to high costs, throughout history, to use competition to limit high costs. Someone willing to make “a little less” is always ready to step up to the cost plate in any industry if true competition prevails. That is not a political view it is one of human nature.

    PATIENTS, the receipents of medical care (or auto repairs) must be the instigators to control cost. And NO GOVERNMENT or private company can do so, effectively, for them. Thus forcing patients to have “their own skin in the game” for every visit, small or large, to any HC “factory” is needed.

    Your Public Option, single pay, Medicare, etc. does NOT force such patient choices.

    In my view we will never “get there” to control medical costs until patients themselves make the decisions to do so for themselves. INDIVIDUAL FREEDOM TO CHOOSE, has always been our bedrock incentive to control costs.

    So when I hear you call for putting patient “skin in the game” and THEN support Public Options, well, I don’t misunderstand what you are proposing. I just disagree.

    Now if you want to focus on intial ways to control medical costs TODAY go read Geoff’s comments on my blog. He has 20 years experience in the industry and seems to understand quite well his own approaches, long articulated. I agree with them, by and large and disagree still with “socialized medicine” or whatever “collective” way you choose to pay for HC.

    INDIVIDUAL PAYMENT and competition are the right way, in my view, again. But as well I can figure out a way for your illegal immigrant mother to be from giving birth on her own on the doorsteps of a hospital, for crying out loud.

    Anson

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  4. Jim, I mostly agree with you on this one. But in my opinion you don’t go far enough. That said, here is an excerpt from a post that I wrote in August 2009, which I never got around to publishing. This piece suggests, not too subtly, that the health care industry in this country be nationalized. (My apologies for the length.)

    “First, as I recommended to President Obama several months ago (via web mail to the White House), the legislation dealing with health care reform should be bifurcated; one part needs to deal with health “care” and the other with health “costs.” It’s really the “cost” part that is of most concern – to all the stakeholders. The term “health care reform” is therefore misleading because the primary focus is on medical expenditures, as distinct from medical treatment.

    “Opponents of health care reform argue that it should be run mostly by the private sector due to the efficiencies and competitiveness of a free market and because, well, the government is lousy at running anything. Of course, any benefits the private sector produce as the result of competition accrues mainly to insurance, pharmaceutical, and medical equipment and supply companies. Health care providers that have one-on-one contact with patients – doctors, nurses, hospitals, clinics, therapists, rehabilitation facilities – provide services that, by their nature, do not lend themselves to market-based pricing. There is little or no competition going on between the providers and, obviously from the record, there are no incentives to provide the best possible service at the lowest possible cost. You rarely see an ad from a doctor who offers a free appendectomy if you have your gall bladder removed.

    “Of course, those individuals who have private health insurance and who receive private sector health care services (as opposed to government-run health care like the Medicare and the VA) are not really patients; they are profit centers. I’ve worked for several large employers (with one thousand or more employees) and at no point was I given a list of health insurance companies to choose from or that wanted to compete for my business. I was just given a booklet describing what was covered, what the co-pays were and what the deductibles were; all as provided by the insurance company already selected by my employer. And, I could only choose those health service providers who were “in-network,” PPO, POS, HMO, etc., whereas if I incurred out-of-network medical services, then that was on my nickel.

    “According to The Kaiser Family Foundation/Health Research & Educational Trust’s “2008 Annual Employer Health Benefits Survey,” employer-sponsored health insurance covers about 158 million employees and their family members. The Survey also shows average premiums from 1999 to 2008, in total, and by employee and employer. Inflation of the total premiums, from $5,791 in 1999, to $12,680 in 2008, was 219%. If premiums had increased at the same rate as the Consumer Price Index, then the total premium would be $7,486, which is $5,194 less than it turned out to be. Of course, there are many reasons for this difference and they are unique to the health care industry. Whether such increases are justifiable or not is another matter.

    “In 2005, the state of Missouri enacted tort reform that put a cap of $350,000 on malpractice claims. In a free market, malpractice insurance premiums would go down, legal expenses would be substantially reduced, and the doctors would have passed these savings on to their patients. In fact, health costs in Missouri are the same as before the legislation. Thus, the “invisible hand” that guides the marketplace is conspicuously absent in health care services.

    “It should be an affront to morality and public decency that a human being’s health is used to turn a profit. Insurance companies that deny coverage to enrich themselves and doctors that subject patients to unnecessary treatments have no “business” in the health care business. Maybe it’s not too much of a stretch to compare that kind of income with the profits made off of slaves and sweatshop workers.

    “The way health care services are delivered, the “consumer” often receives treatment whether he or she agreed to them or not. Consider these two cases (assumes there is no insurance involved in either case):

    Case 1 – You return home from vacation and find a man standing in your driveway who tells you that he was driving by and noticed there were leaks in the roof, so he installed a new one while you were away. He then gives you a bill for $25,000.

    Case 2 – You’re in an car accident and, after having been out cold for a day or so, you wake up to find a man standing in your room. He tells you about the accident, that you were transported to the hospital, and that you were treated for your injuries. He then gives you a bill for $25,000.

    “In the free market system, transactions are carried out between a willing and lawful seller and a willing and lawful buyer. When the terms are mutually agreed to, then a contract is established, often just implicitly, and the parties are obligated to each other – by their honor if nothing else.

    “That said, in Case 1, you are not a willing buyer and had no opportunity to negotiate the terms of a contract. Therefore, all other things being equal, you are under no obligation to pay the roofer. Furthermore, the roofer took it upon himself to install the roof and thereby assumed the risk that he might not receive payment. (He’s probably facing a few criminal charges to boot.)

    “Case 2 is identical to Case 1, in that no agreement existed between you and hospital. However, in Case 2, all things are not equal. If you don’t pay the roofer, then the roof is on him. But, if you don’t pay the hospital, you will be sued and perhaps your wages will be garnished and maybe you’ll even end up bankrupt.

    “If the private sector health care providers want to operate under the illusion that they are part of a free market system, then they need to act that way. When a patient arrives for treatment, then that patient must be able to negotiate and agree to the terms of that service, including the cost. Absent those requirements, if the services are provided anyway, then, like the roofer, the health care provider’s only claim is for a medal celebrating its altruism and service to humanity.

    “Likewise, health care providers who what to be free market, for-profit enterprises need to behave the same way. Let’s say a guy goes to the ER with a burst appendix but has no insurance, The ER, which we assume for this example is under no statutory obligation, then has to decide the terms of the deal. If the ER opts to perform an emergency appendectomy, then that’s on them. They took the deal and now have no recourse against the guy. Otherwise, an aide needs to escort the guy out to the curb. If the guy dies, then the ER is off the hook because, well, where’s the profit in treating people who have no money? What do you tell the stockholders?

    “Part of the Code of Hammurabi includes this nugget: “The first duty of government is to protect the powerless against the powerful.” Health care, therefore, is not a right of the people. It is a duty of government.”

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    • Jim Wheeler says:

      Yours is an excellent commentary on the subject, Herb, and I appreciate your input. As I read it, what you are advocating is essentially the repeal of EMTALA, and for my own part I would be happy to see that done, but as a citizen I would not wish to see that done to my country. First of all, Americans are not savers, they are, unfortunately, borrowers by culture, so we would be seeing a lot of needed health care denied, and that includes children, maybe especially children. Secondly, I would not want to take the chance that vital health care might be denied me or my family because we weren’t conscious or lucid enough to negotiate terms with a provider. But, you give excellent examples for why health care services are not competitive. The same rationale applies to Social Security, which Bush 43 wanted to privatize. When you are in need, you want security, not something that depends on the vagaries of a yo-yo market. Similarly, with health care, when you need it, you often need it quickly and without time to shop or even check your account balance or your credit report. Therefore, you and I end up with the same conclusion, which you put so well. In a modern and enlightened society, health care should be something government government should provide.

      I was not finished with this post, by the way, and I was thinking it was going to take me some time to answer some of Geoff’s criticism, but I am mulling that over in my mind. Given his and Anson’s disdain for “links” and references, and Geoff’s disparaging belittlement, I hold no hope of changing their minds in any way, and sometimes for the regular reader an excess of emphasis and denigration can be overpowering. Trying to word-joust with unreceptive minds would just produce more of the same. Also, I am not sanguine about a Public Option ever being acceptable to the American public, unless and until the present system collapses completely (something I consider quite possible). The prejudice agains anything like “socialized medicine” is a meme deeply embedded in the American psyche and criticism would resonate effectively, even as medical errors proliferate and the costs continue to make the budget unworkable.

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  5. hlgaskins says:

    Anson

    “I nor many other conservatives do not MISUNDERStAND the Public Option or the single pay approach. And as you at least suggest it does involve rationing by someone other than the patient.”

    We already have the worst kinds of rationing. Those of us who have a health care plan are told who our doctors are, and more often than not, which services they’re allowed to provide. There’s no question that we need to deal with health care costs if America is to remain as a republic. Unfortunately for those of us on the receiving end, health insurers increase profits by limiting services, labs and technology providers (PET, CAT, MRI) through the increased provision of services, drug companies through the sale of of overpriced patented medications, while many doctors are caught in the web of one or more of those. Health care is not, and should not, be sold as a commodity.

    Link

    http://www.reuters.com/article/2011/11/30/lipitor-idUSN1E7AT06B20111130

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    • Jim Wheeler says:

      What an excellent link, HL!! The Lipitor case is a great example of how Big Pharma has become the most profitable industry in the world, done primarily through manipulation of the patent system, congressional lobbying, and advertising.

      Regarding the interesting distrust by many patients of generic drugs I am reminded of another news item of similar behavior by the consuming public. CocaCola I understand launched a very large campaign touting a brand-new can for its sweetened product. It was mainly white, with polar bears on it for Christmas spirit. It flopped, big-time. Samplings revealed that people didn’t trust it was the same product because it looked different (but it was). Some even swore it tasted different.

      No wonder P. T. Barnum was a genius success.

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  6. Jim,
    The Public Option would be preferable to what we have now, but why wait for the inevitable? Let’s just do away with private insurance (okay, let it survive as an option only for the rich) and have Medicare for all?
    That way, as you sort of suggest, the government can do what insurance companies now do: negotiate payment for services well under what is on the medical invoice.You are right, though, that even the public option is not a possibility right now. It will have to wait for a the inevitable change in demographics that will put hard-headed conservatives on the defensive.
    By the way, I don’t know if you have heard of the idea of hot-spotting, but imagine, as you read the following, if we could get the entire health care bureaucracy (under a single-payer system), to act in common-sense ways like this:

    Hot-spotting was originally used in criminal justice in New York City when William Bratton, the city’s former police commissioner, revolutionized urban policing by using data to map when and where crimes took place, and then sending extra officers to the areas where crimes were committed most often. By putting extra resources to areas with the highest crime rates, Bratton found it was possible to lower crime across New York.
    This is hot-spotting: a problem solving technique that targets the most expensive problems or in-need people by allocating resources to specific problem areas as revealed by data.
    Let’s take a health care example. Imagine if you could identify a small number of patients who end up eating up most health care dollars. Let’s say you could focus resources just on them, improve their health outcomes,while also cutting the overall amount of health care spending dramatically. This wouldn’t be a question of how much, but how. This isn’t fiction, it comes from Camden, New Jersey, one of the poorest cities in the country. And the technique is known as hotspotting, or targeting resources to needs.
    A remarkable physician, Dr. Jeffrey Brenner, is Founder and Executive Director of the Camden Coalition of Healthcare Providers. He figured out that the sickest patients in Camden were returning repeatedly to the emergency room, costing the health care system enormous sums of money. Because they were always seeing specialists or coming to the ER, they had no real advocate overseeing their health. The health care system was fragmented and passive, and so it failed to deliver care where it was needed even though it cost huge sums of money.
    “So one of the problems in lots of fields, whether it be education, in policing, or in healthcare, is that that we don’t strategically allocate resources, that when a patient begins to feel overwhelmed, when their illnesses are overwhelming them, they are scared, they are frightened, we have a really passive healthcare system,” Dr. Brenner explains. “Doctors don’t wake up every day and think, “Which of my patients are having a hard time today? How do I deploy staff out to find those patients and take good care of them?” We are very reactive. We prefer patients to come to us and often when they come to us, it’s sort of too late, or it’s pretty far down the trajectory,” says Dr. Brenner.
    Brenner told me of one older diabetic patient who kept getting sick. Brenner sent a community outreach team to his home to see what the problems were. As they asked the man to show them his his routine, the team realized he was sight impaired. So he would put a syringe into his bottle of insulin to draw medicine, but instead it would draw in 50 cc’s of air. That’s why he kept getting sick, there was no complicated medical issue here, he didn’t need to see another expensive specialist. The guy just needed glasses!
    This process, of sending a team to one sick patient’s home to see what was going on saved money for all of us and improved health outcomes.
    This is hotspotting.
    Dr. Brenner believes that this community-based healthcare is the way to go for fixing our medical system. To solve the catastrophe of our ever-increasing healthcare costs, he believes that “we are going to need to de-institutionalize medical care. We are going to need to take all of this money and resource that we’ve applied to intensive care units in hospitals, and build the system on the outpatient side in the community to begin taking care of people better, which is going to create all kinds of new jobs and its going to eliminate some old jobs. And we probably need fewer hospitals beds, fewer specialists, we are going to need some of that and the money that we are spending on those things are going to be spend out on the community for primary care providers, community health workers, patient navigators, for care assistance, and a whole different kind of delivery system.

    Duane

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    • Jim Wheeler says:

      The article you found helps me think about the issue, Duane. It highlights the nature of the present system compared to what a single managed system would be. Under the present system there is no single entity concerned about the overall system – it is a free-wheeling cloud of individuals and individual groups, but without the essential element of true competition, as Jennifer’s comment so eloquently describes. Therefore, it is very difficult for any part of such a system to be proactive, as in your article. On the other hand, a single not-for-profit system could be proactive, as described.

      The idea of sending out teams, as related in the article, seems outre’, but come to think of it, that’s what the unorthodox doctor in “House” often does in the popular TV drama. Very interesting, and thanks for your civil and constructive input.

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  7. Jim,

    Sorry about the formatting on that comment. I forgot that your blog and mine do not format the same way. My bad. If you can, please fix it.

    Duane

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  8. ansonburlingame says:

    Well, I now change the subject from HC to “openness”,

    I read all of what you write, Jim , and even at least “check out” most of your links. Invariably the “links” support that which you write.

    Why not try this as a test. Post a link AGAINST the Public option and then refute it in a blog, substansively? If I KNOW a link is going to support what you have already said, why bother is my view in many cases.

    Now I give you plenty of rebutal on a lot of topics. But now I am accused of being “closed minded” and not receptive to your ideas. I could be accused of such if I DID NOT read your blogs and just stuck to my own conservative views. Same with Duane. Why should I bother rebutting his blogs?

    Well it is because I care about the direction our country is going. You and Duane, particularly Duane want to drive it in a direction with which I disagee, stongly in some cases. I speak my piece on YOUR blogs and then…….?

    As for Herb’s response and his call for a nationaization of all HC, I am just astrounded at the thought. That one almost has me sputtering to coin a phrase. Just one question in that regard. Have government run every medical school, laboratory for research, pay every doctor, nurse, technicial, build every hospital, etc., etc. HOW MUCH WOULD THAT COST and where do you find the money to do so?

    As to the QUALITY of such care run only by government, are you kidding me. As well who do all the trial lawyers sue with nationalized HC when bad things are done by bad people? Remember how hard it is to fire any civil servant!!!

    NOW for a final and really BIG point, for me at least. I referenced a detailed counter written by Geoff and posted on my blog to your call for “socialized medicine”. He makes valid points based on 20 years working in the HC industry. Did you rebut him??? Nope.

    I also know for a fact that Geoff posted a comment to this particular blog. You have NOT POSTED HIS REBUTTAL herein. WHY NOT, I ask? It has been two or three days since he submitted it!

    We all know you screen comments on this blog before allowing them to be posted. I prefer to “let’r rip” and allow all comments to go directly to my blog, unscreened. That may just be a matter of “taste” or a lame attempt at “civility”. But when you DO NOT POST a substansive rebuttal to that upon which you opine, I must ask, again, WHY NOT?

    If Geoff or I are too “tough”, etc. your readers can figure that one out for themselves and don’t need your tender oversight to protect their “sensibilities”. You even went so far as to engage in a round of private emails including you know who, who ignored the whole thing.

    So I directly and unequivacally challenge your own “openness” to allow a free flow of opinion on anything your write publicly. That is about as American as you can get and Duane and now it seems you have violated that basic precept of free and unfettered speech, in my view.

    I look forward to your answer herein to justify CENSORSHIP with only your judgment being used to censor legimate debat using words and phrases that would pass muster on any public means of communication. No profanity, no threats, no nothing that passes for libel or “craziness” or irrational behavior. Nope it is all about expressing, strongly, deeply held political view.

    And now you seem to tend to exclude such views that counter your own or when you do post them you start calling people names yourself!!! Does the word HYPOCRITE strick your “sensibilities”?

    Anson

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  9. Jennifer Lockett says:

    Thanks again for your points here Jim. One other thing I think you should point out is that we do exercise rationing – it’s just that rationing is by the health insurance companies. Health insurance companies make the decisions of what they will/will not cover – not patients (unless they can afford the thousands or tens of thousands to cover the expense). How many of us have had an emergency procedure (perhaps stitches, a broken bone, etc) and have gotten a shocking bill because some element of the ER (the doctors, the MRI company, whatever,) was not ‘in network’? When people need emergency care, they don’t ‘shop around.’ I recently had a bout of walking pneumonia. My Doctor (my GP for the last 6 years) gave me some antibiotic injections as well as vitamin B. He submitted it to billing, just this month I got a bill from the company for $300 – my company had denied the claim. It’s even worse when you look at people in need of transplants (many insurance companies still categorize them as ‘experimental’), cancer treatments (it’s costlier to keep the patient alive 6 months), etc. So rationing does in fact go on – it’s just who should ration?
    I disagree with the notion that we should all be shopping for health care. Shopping around while you’re ill or in pain (if your tibia is poking out of your leg, should you be waiting on hold trying to get estimates on traction?). Right now, with the way our system is set up, it’s impossible. Have you ever asked a Doctor what they charge for something? The nurses? Heck, even the billing tech? Unlike countries like Germany, we do not have laws that costs should be readily available, clear, and posted. I had surgery about 5 years ago, I was given an “estimate” and told I should expect the price to be higher. They don’t have to tell you the price in advance and most of them will not (or cannot). If conservatives are serious about a ‘market driven’ health care model, then they need to somehow regulate the market – costs are clearly posted, and expenses explained upon request? I’m not just talking about experimental cancer treatment here, but just my annual ‘well-woman’s exam’ or a flu shot.
    Shopping for insurance? Likewise an impossibility. I have the best possible insurance I can get in my state for me right now because I get it through my employer – the only way I could get a better plan is if my employer elected to do so. Individual plans are pathetic, expensive, and do not cover things like gynecological services (under the guise that they’re not universal, but all individual plans cover prostate services – interesting…). We do not have a competitive coverage industry. You get what your employer offers. If your employer doesn’t offer insurance, then you hope you’re healthy enough and make enough money to buy your own mediocre and expensive coverage (too bad for diabetics, cancer survivors, rape survivors (as they are at higher risk for STDs and HIV)), or people with bad genetics) – if you can get coverage (in my state, you cannot), then expect a bill of $1,500-2,000/month with limited or no coverage (hopefully for only a limited time) for those ‘pre-existing conditions.’
    In terms of choice of doctor, many of us don’t have that now. Your standard HMO or PPO gives you a list of doctors ‘in network’ and that’s your choice. Same thing with going to a specialist (you must get a referral – costlier in bills as well as time off of work and child care). If you’re in a government system (Medicare, Medicaid, Military, etc), your providers are similarly limited.
    I’m not saying that I’m pro single payer, I think I’ve discussed before that I’m in favor of systems like we see in Germany and Switzerland – where doctors and insurance companies are private, but all insurance companies are non-profit (they can only make a profit by selling ‘platinum’ plans that include things like single rooms in hospitals, spa ‘de-stress’ treatments, etc). All prices for procedures are clearly posted (they do have a co-pay system to help prevent an abuse of the system, around $50 US for visiting the doctor), they do have a ‘safety net’ for the indigent. The cost in Germany in $750/family of 4 (about $225 for a single person) paid for by employers compared to $1,000/family of 4 a month in the US (and yes, people pay $1,000/month or more for health insurance premiums, for my employer me and one spouse would be $650/month, plus children $1,100/month). So, less expensive, 100% availability, patient choice, better outcomes, and the system has been sustainable.

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    • Jim Wheeler says:

      Jennifer, your contribution in this case just happens to fit with my own perceptions, but that’s not the most important thing. I know I can count on you for a thoughtful and intelligent response from you on an issue of interest, whether you agree with me or not, and this instance is no exception. It is a pleasure to correspond with you.

      I’m glad you provided examples from Germany and Switzerland – the rest of the EU is considerably less stable, financially, so valid criticism might be directed at the weaker members. But health care, while a vital component of any budget, is not the only factor. Retiring massive numbers of civil servants at age 52 or 55 might be another.

      Like

      • Jennifer Lockett says:

        Oh yes, I am not a proponent of the ‘savior of Europeans.’ Having lived and worked there off and on throughout my life, there are many, many problems… many **cough*** Greece **cough** But there are working, sustainable, and effective systems out there that I think we need to seriously look at. Perhaps aiming for the Swiss is a little over-shooting (who can be that organized?), but perhaps Germany is feasible…

        Like

  10. ansonburlingame says:

    Jennifer’s points are reasoned and “normal”. Essentially she says it is not possible for patients to “ration” care through cost competition and therefore we must fine others to do the rationing be it government, private insurance, etc.

    Well might I point out that such is NOT WORKING. Evidence, you ask, simply the skyrocketing cost of HC every year and the total number, oft now used, of $2.8 Trillion a year and rising at ?? % each and every year.

    So we all agree that what we have today cannot be sustained. SOMETHING else must be done to CONTROL COST.

    I pick only one example from Jennifer’s list, the difficulty and cost of keeping a cancer patient alive for 6 months. Is it really worth the pain and suffering for “6 more months” simply to “stay alive” for a while longer? That is a humanitarian question, not one of cost. But then add should “others” be forced to pay say $150,000 for such End of Life Care?

    What about the impoverished that show up at an ER drunk, destitute, etc. to get “fixed up” only to go right back out and start all over again? It happens all the time folks and I have seen it happen and results when “they” go “right back out again” to start all over. I know one guy personally that did it 27 times at some $20,000 per “time” all at the expense of “others” before he got his act together. Others don’t get back to the ER and simply die on their own. And they die as such from terrible personal choice, not lack of available HC.

    Now let’s go back to the cancer patient. IF the family HAD to pay for that extra 6 months, few would do so if they were not “millionaires”. They would make a different but not necessarily inhuman choice for hospice care, etc to allow the cancer patient to die in peace and comfort, pain free generally speaking.

    But NO GOVERNMENT can make such a choice for others. Government can only keep providing that required by law up to the point that the money, literally, runs out. LIberals will say the money can NEVER be allowed to run out for such needs. Great, now go figure out how to pay $2.8 Trillion a year and going up for the unpredictable future with no end in sight.

    It for sure is a Gordian Knot of huge proportions and we all agree we MUST FIND A WAY to untie it.

    Essentially to me it boils down to bigger government to bear the burden for …… or allow the traditional way to control cost through personal choices in purchasing anything. We have been trying your way of more and more government in HC since at least 1965 and look where we are today. I don’t like it and you don;t either, today.

    But some are literally disdainful of a conservative, let the people decide as individuals, in this matter and continue to persue the path that for now 45 years or so has led us to where we are today.

    And if you think that is bad today in America, look east at the choices that will be confronting Europe, big and small countires therein, in the coming months and few short years. Their DEBT is going to overwhelm them much sooner than ours will overwhelm us. But we continue to try to head in that direction despite the gale warnings all over the world.

    And if any consider history, when such actual gales reach hurricane like winds, war, violence, survival of the fittest will inevitably take precedence. And our “soft” conditions of today will look like a cake walk when we, Europe, etc reach that point of DEBT that simply overwhelms.

    And IF you and yours cannot find a way to really contain HC costs, well all the humanitarian concerns in the world will not keep those wolves of destitution away for ALL or most Americans. Then only the “fittest” really survive.

    Anson

    Like

  11. I think the health care issue is just another example of what’s plaguing most our institutions these days, public and private, which is this insidious obsession with wealth. Everybody agrees that, to borrow from James Carville, it’s all about the money, stupid. Money has become the be-all and end-all, the single most important measure of success, the driving force behind most of our decisions.

    Of course our brand of capitalism has given us the highest standard of living the world has ever seem. But at the same time it has corrupted our sense of values; we have effectively monetized morality. As I have written elsewhere, in our socioeconomic system Adam Smith has trumped Thomas Jefferson; today, American values are not based on life, liberty and the pursuit of happiness, but rather on property, profit, and the Dow Jones Industrial Average.

    You would think that the best Congress money can buy would know better than to put us on a course that clearly leads to financial disaster. But money has captured the political will and Congress will no doubt keep kicking the can down the road until they run out of road.

    The Right holds to the myth that lowering taxes will lead to more jobs even though history shows it never has. The Left wants an ever increasing safety net for the disenfranchised even though history shows that such programs only lead to more welfare and the demise of personal responsibility.

    We have yet to prosecute any executive in any commercial, investment, or mortgage bank for the fraud they committed upon borrowers. Perhaps, methinks, that may be because of their influence (read financial connections) with the politicians.

    Most of our foreign policy is grounded in monetary considerations (read oil) while the education of our children continues to lag behind the rest of the world because, well, there is no immediate financial gain.

    We have laws on the books that would help solve the illegal immigration problem, but most of these lay the burden on employers, who then threaten to relocate in another country, taking their tax revenues and their contribution to our GDP along with them.

    And that gets us back to health care. The Congressional Budget Office estimates that total spending on health care would rise from 16 percent of GDP in 2007 to 25 percent in 2025, 37 percent in 2050, and 49 percent in 2082. The GBO also projected federal spending on Medicare (net of beneficiaries’ premiums) and Medicaid would rise from 4 percent of GDP in 2007 to 7 percent in 2025, 12 percent in 2050, and 19 percent in 2082.

    Now we’re talking about some serious money. When you consider that the administrative cost for Medicare is 3%, and the admin cost for private health insurers is 15%, then anything that can close that gap would be a benefit to the purchaser of health care. On this basis alone, the private sector simply cannot compete with government. Now, if Obama would just grow a pair, maybe our health care woes could be minimized – starting with the public option.

    All of which reminds me of the British historian Arnold Toynbee’s famous caution: “History shows that great nations rise and great nations fall but the autopsy of history is that all great nations commit suicide.” Arg.

    Like

    • Jim Wheeler says:

      Herb, I agree with you about money being a principal cause of our political problems. Perhaps the appropriate word is avarice. The idea is redolent of Duane Graham’s comment on this same post, wherein he referenced an online article about “hot-spotting” in healthcare, and I specifically refer to the term, “greedy bastards”. Here is the germane excerpt:

      Is there a problem with the way we solve social problems in America? More often than not, our problems in government and society can be traced back to behavior we call “Greedy Bastardism” — decisions that seek to exploit lack of shared visibility and breach personal and group integrity to get what one group wants over what another group needs.

      Greedy bastard. Has quite a ring to it, doesn’t it? Emotive, provocative, contentious. It conveys a visceral emotion about possession of wealth. It conjures up images, images like welfare queens, drunken sots, tramps, prostitutes, lazy good-for-nothings, dirt-bags. Behind the term, I suggest, is deep resentment that the “haves” are being forced by government to contribute money to “have-nots” who don’t deserve it. It is a simple world-view of a world that isn’t simple, because such generalities have so many exceptions. I submit that one slob can ruin pity for a hundred people.

      I was struck by a recent comment made by none other than Newt Gingrich. He said something to the effect that children should work because it would teach them the value of both work and money. And you know what? I agree with him. The culture in America, and I think it started at the end of WW II, is to dote on and spoil children, following the meme that “our children should have a better life than we had”. And now, my impression is that we have raised several generations of spoiled brats, and it’s not a pretty sight.

      But, will Gingrich’s approach work? Would it help to loosen up child-labor laws? Maybe. It sure wouldn’t hurt a kid to have a responsible task to perform every day, perhaps half an hour or an hour, for which she would receive some pay, partly to be saved even. But surely not a return to full time work for kids. But I can not imagine the public accepting this, especially by government fiat. Discipline is the exclusive domain of the parent in our society, even if discipline is absent, and besides, such ideas run counter to conservatives constant call for more “freedom”. (He’s gonna pay dearly for that one, I predict.) Like I say, it sure ain’t simple.

      One final thought, Herb. When you mentioned the influence of money on Congress I couldn’t help but think of the recent decision they made recently about school nutrition. The administration had proposed new, tougher rules on what constituted healthy fare for kids and conservatives in Congress, under pressure from the fast-food industry’s lobbyists, nixed much of it. As far as they are concerned, french fries are just great and pizza is a vegetable too. And besides, think of all the medical business that obesity will bring in. They are already putting kids on cholesterol drugs.

      Thanks, as always, for your input, Herb.

      Like

  12. Pandionna says:

    Hi! Found my way over from PiedType. Just thought I’d share this: http://www.forbes.com/sites/rickungar/2011/12/02/the-bomb-buried-in-obamacare-explodes-today-halleluja/ It makes sense to me.

    Like

    • Jim Wheeler says:

      Thanks for the link, Pandionna. This is something I didn’t know.

      When Nancy Pelosi commented famously that people would like the ACA when they found out what was in it, conservatives crowed that anything so voluminous must be bad, and I admit that it gave me bureaucratic shivers too. But so far, I find much to like and your link just adds to that. Among the other positives I’ve found are electronic medical records, which should reduce medical errors. There are some growing pains with that, but eventually I see it as a very good thing, considering that more people have died of medical errors in pas years than in car accidents. Another benefit is proactive, preventive medicine in the form of “free” screenings and basic tests for heart conditions and diabetes. If the GOP is successful in the elections and then overturn the ACA, how will people feel to see those things vanish, not to mention seeing their medical insurance premiums soar. Again.

      I appreciate your contribution, Pandionna.

      Like

  13. ansonburlingame says:

    To all,

    Actually, in my view, it is NOT all about money. Money is only a symptom of the deeper problem, how humans can live and prosper to the extent possible in any society.

    I know “poor” people, very poor in terms of money available to them that live and prosper better than any of us writing on these pages. I have even blogged on two of them several years ago. They have little money, live in a “single wide” way out in the sticks, etc and God forbide you would drive their “cars” on an interstate highway. But happy, content, take care of themselves and their families without a dime from the public trough, you bet they do. They live within their means, work their asses off 12 hours a day to achieve some limited means and are the happiest and most contented people that I know.

    So the issue is NOT all about money. Millionaires can and frequently are “miserable” in terms of their “feelings” etc. I am sure the suicide rate for “millionaires” may well be about the same for “average Americans” as well but do not know for sure.

    The human spirti cannot be BOUGHT. And the best and only way that I know of for the human spirit to rise and prosper is through unfettered individual freedom. That was the founding principle of this country and we seem to forget that today in much of our political discourse.

    Anson

    Like

  14. Anson,

    In re your last comment here, I have a thought experiment for you. Take a town, any town, say, Joplin, and then remove all the stop signs, all the traffic lights, all the speed limit signs, all the traffic laws, and all the traffic cops. Then sit back and watch “unfettered individual freedom” work its magic.

    Herb

    Like

  15. hlgaskins says:

    Anson
    “Actually, in my view, it is NOT all about money. Money is only a symptom of the deeper problem, how humans can live and prosper to the extent possible in any society.”

    There’s nothing wrong with wanting to “prosper to the extent possible in any society” as long as it’s done in a fair and humane way, but that’s not what’s happening in America today. Many of those who’re among the wealthy elite aren’t content with prospering fairly. They’re not just looking for a fair share of the action, they want it all, including near absolute control of our republic, and they’re doing it through the purchase of our elected officials.

    “I know “poor” people, very poor in terms of money available to them that live and prosper better than any of us writing on these pages. I have even blogged on two of them several years ago. They have little money, live in a “single wide” way out in the sticks, etc and God forbide you would drive their “cars” on an interstate highway. But happy, content, take care of themselves and their families without a dime from the public trough, you bet they do.”
    What happens if one of their children is diagnosed with cancer, do they still take care of it themselves? At the offset of an illness I suspect they do try to take care of it themselves to the detriment of their children since it’s unlikely that they have a health care plan. If they have a child with cancer is there a chance that they could make the mistake of waiting too long before seeking medical services they’re unable to pay for? Late term illnesses are not only far more expensive to treat, but are also far more likely to result in a less than satisfactory outcome or even death.

    “They live within their means, work their asses off 12 hours a day to achieve some limited means and are the happiest and most contented people that I know.”

    If all of that is true then who’s benefitting from their labor? Anson, for every happily impoverished family that you cite, there are countless more who’re suffering. Wouldn’t it be great if no one ever got sick or hungry, and we could all live happily and carefree in a “single wide” in a field?

    “So the issue is NOT all about money. Millionaires can and frequently are “miserable” in terms of their “feelings” etc. I am sure the suicide rate for “millionaires” may well be about the same for “average Americans” as well but do not know for sure.”

    Once again you couldn’t be more wrong! I can post links to numerous studies that strong suggests that suicide increases with poverty but you won’t read them. In America today, it’s always about money!

    “CONCLUSIONS: Suicide risk is strongly associated with mental illness, unemployment, low income, marital status, and family history of suicide. The effect of most risk factors differs significantly by gender.”

    http://ajp.psychiatryonline.org/article.aspx?Volume=160&page=765&journalID=13

    “The human spirti cannot be BOUGHT. And the best and only way that I know of for the human spirit to rise and prosper is through unfettered individual freedom.”

    Nonsense! Exactly what are these unfettered individual freedoms that you’re referring to? Do we still have “one man one vote?”

    “ That was the founding principle of this country and we seem to forget that today in much of our political discourse.”

    Obviously you know little about our founders and their principles, and even worse is that you fail to realize that those principles were based on an entirely different time.

    Like

    • ansonburlingame says:

      Herb,

      You know me better than that. Of course government has a role to play in any society. Without government there is anarchy. It is where to draw the line that is the big deal today. And we have gone so far beyond the “boundaries of liberty” envisioned by our Founders of long ago I can only imagine most of them rolling in their graves.

      ansonj

      Like

  16. ansonburlingame says:

    HGL,

    Unlike Herb, a personal friend, you know me not at all nor do you have any idea what I have read and studied about almost anything, the Founders included.

    The man and wife of whom I spoke above had terrible HC problems including today battling (for now ten years) congestive heart failure, diabetes, etc. And they PAID, out of their own hard earned pockets about $25,000 per year for a HC policy with a $5,000 deductible each year!!!! That was PART of the 12 hour work day, six days a week with not much left over after paying for the HC policy. But complain or whine, no way. And that policy by the way as well covers their 50 year old son who works for them. He is a veteran with a terrible back problem and several surgeries, none of which were covered by VA even though he hurt his back inititally in the army and received a discharge as a result. The discharging physical however did not provide the basis for a VA claim later one. Care to referee that one???

    They have one small TV with no cable or satelite dish. For 20 years they had no running water or indoor toilet or bathing facilities. One cold water tap to the kitchen sink only with the “living room” (and kitchen and family room combined) heated by one wood burning stove in winter. NO AC in summer, just open windows and cool evening breezes, just like I had growing up.

    NO, they are not “soft” or coddled by welfare. My friend would throw it back into any face that sent him a check as well. He hates the idea of welfare for himself or any of his family.

    So come with me back to the hills of Kentucky and I will show you some real happiness in the midst of what most would consider abject poverty. Again, and only in my view, there is the best of the human spirit and God only knows we need more of it today in America.

    Anson

    Like

  17. hlgaskins says:

    “Unlike Herb, a personal friend, you know me not at all nor do you have any idea what I have read and studied about almost anything, the Founders included.”

    You’re right, I don’t know you outside of our debates online, but I do have an idea of what you’ve read and studied based your previous posts. Among the greatest concerns of our “Founders,” was that of unfair treatment of the poor by and unconcerned wealthy aristocracy.

    “History affords us many instances of the ruin of states, by the prosecution of measures ill suited to the temper and genius of their people. The ordaining of laws in favor of one part of the nation, to the prejudice and oppression of another, is certainly the most erroneous and mistaken policy. An equal dispensation of protection, rights, privileges, and advantages, is what every part is entitled to, and ought to enjoy… These measures never fail to create great and violent jealousies and animosities between the people favored and the people oppressed; whence a total separation of affections, interests, political obligations, and all manner of connections, by which the whole state is weakened.”

    “All the property that is necessary to a Man, for the Conservation of the Individual and the Propagation of the Species, is his natural Right, which none can justly deprive him of: But all Property superfluous to such purposes is the Property of the Publick, who, by their Laws, have created it, and who may therefore by other laws dispose of it, whenever the Welfare of the Publick shall demand such Disposition.” Benjamin Franklin

    James Madison during the framing of The Constitution:

    “At Philadelphia in 1787 Mason was one of the five most frequent speakers at the Constitutional Convention. He exerted great influence, but during the last 2 weeks of the convention he decided not to sign the document.

    Mason’s refusal prompts some surprise, especially since his name is so closely linked with constitutionalism. He explained his reasons at length, citing the absence of a declaration of rights as his primary concern. He then discussed the provisions of the Constitution point by point, beginning with the House of Representatives. The House he criticized as not truly representative of the nation, the Senate as too powerful. He also claimed that the power of the federal judiciary would destroy the state judiciaries, render justice unattainable, and enable the rich to oppress and ruin the poor. These fears led Mason to conclude that the new government was destined to either become a monarchy or fall into the hands of a corrupt, oppressive aristocracy.”

    He seems to have bee right on all accounts.

    Jefferson writing to Madison:

    “The property of this country is absolutely concentered in a very few hands, having revenues of from half a million of guineas a year downwards. These employ the flower of the country as servants, some of them having as many as 200 domestics, not labouring. They employ also a great number of manufacturers, and tradesmen, and lastly the class of labouring husbandmen. But after all these comes the most numerous of all the classes, that is, the poor who cannot find work. I asked myself what could be the reason that so many should be permitted to beg who are willing to work, in a country where there is a very considerable proportion of uncultivated lands? These lands are kept idle mostly for the aske of game. It should seem then that it must be because of the enormous wealth of the proprietors which places them above attention to the increase of their revenues by permitting these lands to be laboured. I am conscious that an equal division of property is impracticable. But the consequences of this enormous inequality producing so much misery to the bulk of mankind, legislators cannot invent too many devices for subdividing property, only taking care to let their subdivisions go hand in hand with the natural affections of the human mind. The descent of property of every kind therefore to all the children, or to all the brothers and sisters, or other relations in equal degree is a politic measure, and a practicable one. Another means of silently lessening the inequality of property is to exempt all from taxation below a certain point, and to tax the higher portions of property in geometrical progression as they rise. Whenever there is in any country, uncultivated lands and unemployed poor, it is clear that the laws of property have been so far extended as to violate natural right. The earth is given as a common stock for man to labour and live on. If, for the encouragement of industry we allow it to be appropriated, we must take care that other employment be furnished to those excluded from the appropriation. If we do not the fundamental right to labour the earth returns to the unemployed. It is too soon yet in our country to say that every man who cannot find employment but who can find uncultivated land, shall be at liberty to cultivate it, paying a moderate rent. But it is not too soon to provide by every possible means that as few as possible shall be without a little portion of land. The small landholders are the most precious part of a state.”

    I could fill this blog with quotes from some of America’s lesser known “Founders” as well, but would read them and verify the content? Or will you once again tell me that it’s too much and then as always supplant with personal conjecture?

    Like

    • Jim Wheeler says:

      This is an outstanding comment on the subject in my opinion, HL. The most salient part, IMO, is this (emphasis provided):

      Whenever there is in any country, uncultivated lands and unemployed poor, it is clear that the laws of property have been so far extended as to violate natural right. The earth is given as a com mon stock for man to labour and live on. If, for the encouragement of industry we allow it to be appropriated, we must take care that other employment be furnished to those excluded from the appropriation. If we do not the fundamental right to labour the earth returns to the unemployed. It is too soon yet in our country to say that every man who cannot find employment but who can find uncultivated land, shall be at liberty to cultivate it, paying a moderate rent. But it is not too soon to provide by every possible means that as few as possible shall be without a little portion of land. The small landholders are the most precious part of a state.”

      Now clearly this was written in the context of a natal nation in which mere land offered most men the opportunity to prosper by their own labor, but even that required a grubstake, a certain minimum of property such as animals and implements. The principle is that among a tribe (nation) of people with disparate talents and resources ought to be provided by government the means for all to prosper.

      Well done.

      Like

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