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The Public Option and Real Health Reform |
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If you haven’t already, read Atul Gawande’s piece on health reform in the New Yorker, largely centered around McAllen, Texas, the community in America with the highest health care costs. It’s hard to quote the heart of the article, because it’s so good, so I’ll just quote the conclusion:
Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.
In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”
As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.
And he’s right. If we don’t get health care costs down, health reform will not work. People will still go bankrupt, we will still ration care based on ability to pay, and we will still have a health care crisis. And when you get down to it, health care costs are about how much and what medicine your doctor orders for you.
Conservatives will accuse those in favor of health reform of taking the easiest way out, in a sense. Health care costs are up? Ok, let’s ration care and drive those costs down. But that’s not what we’re proposing. And, as Gawande so eloquently points out, driving down health care costs and increasing the quality of that care actually can be one and the same. So that’s some pretty good news.
One thing about this article leaves me puzzled, though. Gawande seems to set up a conflict between advocacy for a public health insurance option and what he apparently considers “real” health care reform, which is setting up incentives for doctors to provide better care, not just more care. Maybe he’s just reacting to the media coverage around health care reform, which has been largely centered around a public health insurance option. And maybe I’m biased, seeing as I’ve been working to shape that media battle. But I really don’t think it’s either/or. Actually, I think Gawande’s point makes the public health insurance option more critical.
I agree with Gawande that we could end up with a public health insurance option that doesn’t foster the right incentives to control costs, and that wouldn’t be a big victory. But while Gawande is proposing some kind of outside board to control these incentives, I wonder if the public health insurance option isn’t the place where these reforms are put into action.
Think about it: One advantage to a public health insurance option is that it is transparent. Private insurance doesn’t tell you what they pay for services, how often these services are used, and whether these services have improved patient outcomes. A public health insurance option could make that data available and work with it to improve care and control costs. This data would put the public health insurance option in the perfect position to figure out why some places in America cost so much more and why their outcomes aren’t any better, and how to fix that.
We must get costs down, that much is clear. We need the tools to do it. I’m pretty convinced the public health insurance option can be at least a crucial part of that toolset.
(also posted at the NOW! blog)
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As long as private profit is the primary motivating factor in our health care system, there can be no reform. Until public health and good quality care accessible to all are the dominant motivating factors, the system is never going to work, except as a cash machine for the rich and the corporations they hide behind. It’s the basic outlook, the underlying philosophy, the political economics of the thing that are wrong, and nothing will change until those things change.
It has already been demonstrated on a daily basis over many decades that the so-called free market cannot or will not provide good quality healthcare for all. I’m sure that major healthco’s all have a chart or a graph showing exactly where the lines are: Those above a certain income level, “A,” can afford the best coverage and provide the most profit, if the smallest volume of business. Those below that down to lower level, “B,” can afford some coverage, at less profit but higher volume. At the very bottom level, “C,” the government picks up the tab, but only up to a certain income and age level; but it can be finagled and boondoogled and shortchanged as long as there are no major audits or crackdowns, so it can be very profitable.
All those who fall into the gray area, “D,” between B and C simply are not a source of profit to the healthco’s, and will not be served. That’s where the breakdown really occurs: Those people get sick but don’t get treatment. They slow down or drop out at work, and make other people sick around them. They go to emergency rooms at the few remaining public hospitals as a last resort and receive the least effective care at the highest price, which they frequently fail to pay. The taxpayer ends up paying for himself as well as for the poor, the elderly, and the uninsured. Since our tax system has become more regressive, those who earn the most and can afford the best healthcare are the only ones really benefiting from this system, along with the healthco’s. In effect, we have a national healthcare plan now, funded by the taxpayers. It just doesn’t work for anyone, except the rich and the healthco’s.
So it’s us, the underserved, over-taxed and overcharged majority, against them, the inefficient, overfed, undertaxed minority. Politically, it would seem to be a no-brainer, if this were actually a democracy. But, as the Courts have rightly noted, corporations are people, in fact a higher class of people, and money is speech, the corporations’ speech. So the minority has outvoted the majority consistently for many years and we do not have a healthcare system that benefits everyone today, as a result. Nor are we ever likely to, until we get corporate money out of the system.
That isn’t going to happen until we get the corporate whores out of our government and our political Parties. Anybody who thinks that our mean old corporate Daddies are going to let us have just this ONE big lollipop, real universal single-payer national healthcare, or anything like it, is crazy. The corp’s have no reason to give in. They own the whole system. Until we change that, there will be no substantive positive change in any area.
What we are really just about to initiate here is the biggest government boondoggle since the permanent war began in 1941. The same kind of Treasury-milking blank check that “defense” has gotten for almost seventy years will now go to the big healthco’s. The result will not be free or affordable quality healthcare for all, but some scheme that commits us all to everlastingly ensure the profits of the healthco’s by requiring us all to become their customers and pay whatever they require, directly to them and/ or indirectly through the government. There will be no efficiencies enforced or economies of scale, any more than there have been in the defense industry. The “public-private” model will only mean public moneys going for private profits, with questionable benefit for the taxpaying healthcare consumer.
It doesn’t matter if single-payer or any other idea is on the table or not: As long as mixed-market democratic socialism is off the political table in this country, and as long as corporate money is on that same table, there will never ever be any real reform.
We’re going to lose this. And that’s a good thing. It will serve as a rallying point to re-take and restructure our political Parties and our political system. It will clearly identify those who are with us, the progressive majority of the American people, and those who are corporate whores. If our political system cannot do the job for us, then it will have to be changed. That will take time, and it will require a lot of effort by a lot of people. But if all those who are now working so hard to patch and prop up an unworkable system turned their attentions to remaking the system itself, there is a vast number of Americans who will be right behind them. That is a fight we CAN win.
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I’m not sure we’ll lose the health care fight, I mean, I do expect something like Obama’s plan to pass. However, winning that sets the stage for a lot of the deeper reforms you’re talking about. It’s a long fight, but yeah, we can win.
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Not until we get corporate money out of it. And that’s not going to happen until we reform our political parties. And that has barely begun. Any so-called healthcare reform we get now will just be one big corporate boondoggle, because the corp’s are calling the shots.
I attended one of candidate Obama’s open public Democratic Party platform meetings here in Honolulu just about a year ago. Everyone at the meeting was in favor of universal single-payer national healthcare. We were told back then that it was off the table: Our input would not even be submitted.
Whatever happens, I know I’ll be dead before it does. And that’ll be due to lack of health care. So all the temporizing and there-there’ing really doesn’t mean jack sh*t to me and millions like me. I will be actively working against anyone who fails to support single-payer, Democrat or Republican, liberal or conservative, win, lose or draw. This is a deal-breaker. I don’t care what they think. I didn’t hire them to think. I hired them to represent me, not the corporations. If they fail to represent me, they’re fired. I’m looking forward to 2010 & 2012. Healthcare is already dead.
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Calling single-payer the only solution to health care may be the right policy, but it’s not the right thing politically. If you’re looking for single payer, you’ll have to wait another hundred years, seeing as it’s been that long that Democrats have been working for such a system.
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By “working,” you mean arresting medical professionals instead of letting them speak in favor of single-payer at Congressional hearings, and then hearing only industry shills?
And by “politically,” or “Democrats,” you mean, not democracy, but corporate control of government? Democratically, this is what the people want, and the Democrats will find that out in 2010 & 2012.
Politics is not what the politicians or their corporate masters want. It’s what the voters want, and need. Get out of DC once in a while, Dems. That’s what you & your buddies will be doing after the next elections. For good.
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Cos,
Do you know what you are talking about? What familiarity do you have with a government run health care system? Corporate whores–Think you miss the point completely — its government whores taking your money for their own and making you think its for your good. Look at the fiascos in MEDICARE. Is this what you want? Take a trip to a government run hospital and then go to a corporately run hospital and see the difference. If you tell me you prefer the government hospital- smoke some crack. Make you feel better.
Hey, I’m not in favor of arresting medical professionals, I think they should speak up.
Democratically, people want change, but they also like their current health care. That is why we want to give people a choice. And it is really the individuals that should have that choice. Not insurance companies. Not people in Congress. Not you or me. If people want to choose a public health care plan, they should be able to. And if they don’t, they should be able to, as well.
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This asinine cant and deliberate prevarication about single-payer meaning no one can buy private insurance any more is just pure propaganda, and identifies the true allegiance of anyone who parrots it: Corporatists all.
Private insurance will NEVER be off the table, any more than it is for Medicare members now. They can always go to a private doctor that doesn’t take Medicare, and many of them bought “Medi-gap” insurance to cover what Medicare does not cover. Those who prefer private insurance will never be forced to switch, and everybody knows it: That’s all that’s on the table now.
What is off the table is putting EVERYONE who wants it under Medicare, or a similar program. The one REAL choice, the one most people would choose, is not even being allowed in the discussion: Universal single-payer national health care. Why are we being denied our freedom of choice on this?
The only reason for taking it off the table is to protect private profits, not people’s health or freedom of choice. There will be no way to choose single-payer if Congress doesn’t include it. Cut the bullsh*t, Blue Dogs. Or not. We still have elections in this country.
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COS,
I notice you didn%u2019t answer the question of what your familiarity with government run health care is. Believing that you can offer Medicare to all and leave the private insurance option on the table is naive. How does private industry compete against government? They can’t because government has the taxpayer backing them up and don’t have to worry about running efficiently. Look at the billions of dollars in fraud today with Medicare and other state run insurance scams. Don’t know what your beef is with corporations– they built America and enabled the highest standard of living ever achieved by mankind. Don%u2019t sound like whores to me. 90% chance you work for a corporation. By the by%u2014What doctors are you talking about that were arrested for speaking their minds? Please back that up with some facts.
This is actually very much on the table, in fact, it is basically the heart of the proposal. If people want government-run insurance, they should be able to choose it, and it should be a strong, Medicare-like program. That’s what I am advocating for. So I’m not sure if we have disagreement…
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Well, you haven’t been clear on that up to this point. I hope you’re making that point where it counts, with the “deciders.” Those Senate Finance Committee whores deliberately excluded single-payer advocates from their hearings, and had medical professionals arrested for trying to get a place at that all-corporate table. With no advocates allowed at the table, how in the Hell are we ever going to get any form of single-payer? Please explain.
As to the private options, I could care less. The Blue Dogs’ corporate masters can go right on along ripping off the rich and foolish, as long as the rest of us get our co-operative healthcare. While I advocate a more socialistic program of government, I do not advocate eliminating private enterprise. But if the corp’s can’t survive, tough luck. That’s capitalism, babe: You fail to offer what the high-holy Market demands, you go extinct. Rest In Peace along with Studebaker, Hudson and Tucker. Survival of the fittest applies to corp’s, not just workers.
What I do not advocate is making EVERYTHING else subservient to private profit. Why should my government, which I own and utilize for my own benefit, be required to guarantee the profitability of any private enterprise? That’s Fascism, my ignorant little Right-Wing nutty-buddies. It’s just the obverse of communism: Total Business ownership of the State, instead of Total State ownership of Business. They both leave the great majority of the people out of the equation. Equally unacceptable.
All these private Healthco concerns came into being under various government regimes. Most did not exist fifty or a hundred years ago, at least not in their present form. Many are in fact creations of government programs, and are already dependent upon them. I would think that a REAL conservative, or classic economic liberal would insist that the corp’s be cut loose from the public teat of favorable taxation, government expenditures and corporate/ political boondoggles.
Real conservatives should be working for real reform. Instead, they have become nothing but creatures of the corporations, which, BTW, only sprang up and took over after the great era of trust-busting, the last honest Republican Administrations. The corp’s certainly did not build America, and now they are destroying it. They’re not even American, and would move our jobs and our capital to Brazil or China in a heartbeat if it meant a penny’s more profit. In fact they’ve been doing that for the last 40 years under the Republicans & DINOs. Corporations are not “persons” or citizens of any country, and should not be treated as such, much less allowed to dominate.
I’m no revolutionary. I don’t believe in killing doctors or judges, destroying programs that just need some repairs or reform, or hurting Americans for the profit of corporations, which is all that “conservatives” do. The Republicans and their DINO buddies had power for forty years, and they did little or nothing that was positive in that time. Thanks to them, our country has been attacked without retaliating, our military is damaged, our standard of living is down, our industries are dying, homelessness is endemic, education is falling apart, transportation is in gridlock, and people are dying for lack of healthcare. Everything we need already exists under our present form of government. But we have to cut out the corporate parasites and their lackeys in government who are preventing our government from working for us.
If you’re working for universal single-payer healthcare as a part of the reform package, JR, mazel tov, a gezunt on you. Let us know what we can do to help. But Gawd help anyone in DC who stands in the way of this. Their days in politics are numbered: 2010 & 2012.
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What we’re working for is choice. If people want a government run, Medicare-like insurance plan, they should be able to choose it. Nobody should make that choice besides you and me - not Congress and not the insurance industry.
To help, join up at healthcareforamericanow.org, for starters.
No Jason — A choice does not work. If everyone opts for a government subsidized plan then it becomes bloated and mismanaged like every other government plan. If you believe that Medicare is a well run operation then you are very, very mistaken. It just keeps sucking taxpayer dollars in fraud and inefficiency that will bankrupt the tax payer. Again I ask what familiarity do you have with any government run health care system? Just wishing for something without knowing what you are wishing for is a fools game. That you would damn the current system while applauding a government run system demonstrates your naivety.
Can you back up your claims about Medicare with..I donno..facts? Sure, there is waste in the Medicare system, but it’s administrative costs are 10 times lower than private insurance, and its outcomes are as good if not better. Seniors love Medicare, just like Vets love the VA. In fact, government insurance universally polls well with everyone in America who has it.
Are you denying that there is a health care crisis in this country? Are you denying that private health care is part of that problem? Because if so, you’ll have to prove it. I think I’ve done my piece with all my writing on health care here.
http://www.nytimes.com/1997/08/01/opinion/fraud-and-waste-in-medicare. html
In recent weeks, Federal auditors have estimated that $23 billion in Medicare payments last year — about one dollar in every seven — was due to fraud or mistakes. In Medicare’s home-health program, which spends about $20 billion a year treating about four million elderly people, fraud and waste account for perhaps 40 percent of expenditures. At 125 teaching hospitals, a yearlong investigation is uncovering Medicare overpayments of hundreds of millions of dollars
President Obama last week proposed spending $311 million in fiscal 2010 to slow fraud and abuse in Medicare’s prescription drug and Medicare Advantage programs. He estimated it would save $2.7 billion.
Medicare, the federal program covering 38 million elderly and disabled Americans,
paid out almost 700 million claims worth $192 billion.
Legislators say that
Medicare fraud
in the US costs
$50 million per day.
If your point is that Medicare has fraud and waste, then I agree with you. But if your point is that this means Medicare is somehow more inefficient than private insurance, you’re wrong. Almost 1/3 of the money in private insurance goes to something other than health care. Only 3% of the money in Medicare does.
Not sure what you mean. Are you saying $2.7 billion is only 3%? Where do the figures of “1/3 of the money in private insurance goes to something other than health care.” come from?
Here’s a good discussion of Medicare overhead rates: http://institute.ourfuture.org/files/Jacob_Hacker_Public_Plan_Choice.p df
Jason– Good article! I can attest to the quality of the Federal Civil Service plan. However, that is still private medical insurance (Blue Cross). I can also attest to the lousy quality of pure government run health care in the military and VA. Terrible! My main fear about single payer and or socialized medicine is its stifling medical innovation and quality of care. I believe our taxes already are to high and to provide socialized medical care of the quality we have to day would be cost prohibitive. As far as drug programs go socialized drugs from not for profit companies fails. The R&D costs to develop and bring a drug to market are unbelievable. Add the cost of litigation and you see the issue. I certainly believe that bringing in tort reform to stop the ridiculous law suits will bring down the costs of drugs. An example would be the failure of U.S. drug manufactures foregoing making the flu vaccine here because of lawsuits. Hence we end up with Chinese and other manufacturing in 3rd world to make these products. (I don’t know if that holds true with the current swine flu). Here is an article, albeit a weak one on the other side.
http://blogs.wsj.com/health/2009/05/14/eli-lilly-ceo-makes-case-agains t-public-health-insurance-plan/
RE: the VA, nobody is talking about government owning the hospitals or employing the doctors, as the VA does. Even in the most liberal version of health reform, this isn’t happening. So I’m wondering if a lot of your concerns are somewhat unfounded.
As for taxes, we can’t afford not to do this. Health care spending takes up almost 1 in every 5 dollars we spend. It will bankrupt the federal government if we don’t bring down the basic costs, and that means competition and regulation. Taxes may go up a bit, though most likely only for those of us who can afford them, but costs will go way down, for us, for the government, and for business.
“Why should my government, which I own and utilize for my own benefit, be required to guarantee the profitability of any private enterprise”. What a naive and idiotic statement. Your government has to ensure the profitability of private enterprise so the government can collect taxes to pay for your benefits. Or do you advocate a complete abolishment of private enterprise in favor of government despite your apparent antpithy against communism?
Jason,
You and the Left continually amaze me. In your pursuit of a leftist political agenda you routinely lie, distort facts or completely ignore countervailing facts. You say to get corporate money out of health care which only leaves government money in its place. You can’t name one socialized medical country that has been as successful as the current U.S. medical system . Yet you conveniently ignore this and proselytize. Do you even know what your are talking about. Explain why 10,000 people per month from Canada and England come to this country for medical care. Are not they the utopia your looking for?
Defending our health care system? Nice. How do you explain the fact that we rank 37th in the world, right ahead of Slovenia?
http://www.photius.com/rankings/healthranks.html
Jason–The devil is in the details and how the WHO ranks and interprets the data most of which supports an agenda. Check out this link for a different perspective executivephysician.blogspot.com/2007/08/us-health-rankings-are-accurat e.html.
I assume you are supporting government run health care system. You only have to look at current government programs in and out of health care to see how that is fairing. Watch as the government starts to build cars. Health care- Look at the VA which I am very familiar with. If we are truly 37th (IAW WHO) how do you explain so many of the world coming here for their health care. How do you explain that disparity in medical breakthroughs in the U.S. vs the rest of the world.
Do we have a problem%u2014absolutely . Is the government the way to solve it–absolutely not.
How do you explain the million people going to MEXICO from California for health care? Seems like a lot more than 10,000 Canadians…
People go to Mexico because the Medical industry is unregualted and they offer a lot of treatments that are just plain quackery. However, when your dying and traditional medicine is not working Mexico is not a bad alternative as long as your conscience of the risks you are taking. Price is about 1/3 of costs here in the U.S., but the Mexican economy is a much cheaper 3rd world place to live– hence cheaper prices for major operations.
Well if the medical system is really that great. Explain to me this. I was traveling in Eastern Europe(Latvia and Estonia) and someone I was traveling with had to spend a night in a hospital in Riga, Latvia to get some tests down. He got a bunch of tests done, including EKG and blood work. He was an American, but total cost including a night in the hospital was around 500 bucks! He said the care was about the same that he would have received in the USA. Also, I am from Canada but I live in the USA. Canada has both private and public insurance. For those who can not afford private insurance(extra coverage) they have the public insurance. It’s fine for the smaller things(E.R visits, regular doc Apps, etc) sure you have to wait a while….I usually wait around 30 minutes, I’ve never waited longer then an hour. Many Canadians go across the border to the USA for some of the larger things that they can’t wait for in Canada. These people are usually the ones that can’t afford private insurance in the first place, so they become a burden to your system. It seems to me that if the American system is so much more superior then the rest of the Western world, why is it then that Americans usually live, on average, 3 to 4 years less then Canadians, Europeans(FYI the prinicpality of Andorra in Europe has the longest life expectancy on the planet at 85.5 years…and they are a tax haven), or Japanese?? You would think the best health care system in the world would actually make us live longer..but that is not the case.
You have missed Gawande’s point. His point is that medical behavior is, to a much greater degree than many other occupations, driven by the ethic expressed by senior members of the profession.
That’s why he compares it to another profession, biotechnology– the importance of “anchor tenants” to outcomes. Just as MIT is the “anchor tenant” to the Massachusetts biotechnology mall, the top doctors of a community are the “anchor tenants” to the medical community.
I happen to think Gawande is wrong, that we don’t have the time to reform the professional ethic before the system goes bust and that we will have to use the hammer of cost controls. But if this were 1980 or even 1990, I’d say give his plan a shot.