the government we deserve

All I can say is that if we let these idiots sink health insurance, we'll have the government we deserve.  (tip to BitchPhD for the link)

T flips out every time we hear a news story about the crazy claims people are making about health insurance, because of the problem of source amnesia:  people who hear a story that says "scientists have conclusively debunked claims that the moon is made of green cheese" are as likely several weeks later to think the story said "the moon is made of green cheese" as what it really did say.  The White House has posted a whole "Reality Check" website, but it's not clear that the people who are susceptible to the misinformation that's out there will ever see it, or be swayed by it.

Over the weekend, the NY Times had some fascinating data on who is paying attention to the health care debate.  Interestingly, Republicans were far more likely to paying close attention.  My theory is that the Dems who really are passionate about health care are more likely to support single payer models, and so aren't getting as engaged in the debate.  That's a mistake.  I'd like to see single payer myself, but it's not happening, and while none of the proposals out there are perfect, they are a heck of a lot better than what we have now.

What I'm uncertain of is whether it's worth falling on our swords over a public option.  I think there should be one, but I really don't know enough about health insurance to know if it's truly essential.  And there are people I trust on both sides of the "is it essential?" debate.  From a purely political perspective, while it's looking less and less likely that there will be some sort of centrist agreement on a health care proposal, I think it would look really bad if there was one and the Dems killed it because it didn't have a public option. 

Certainly, if we're going to wind up passing health care without a single Republican vote (which is starting to seem possible), it had darned well better include a public option.

26 Responses to “the government we deserve”

  1. Jennifer Says:

    On Talk of the Nation today they’re talking about why people are so angry about health care reform. It’s an interesting question. People ARE really angry, ordinary people, not just the wackos at those town halls.
    My husband, who’s a Republican, gets apoplectic when discussing health care reform. I’ve been listening to him rant for a few weeks and I think what it comes down to is, he does not trust Congress. He does not believe that Congress can or even knows how to help the average American.
    I’m a contractor, so I don’t get company-provided insurance; he works for a company with fewer than 25 employees, which provides him and me and our kids with somewhat limited insurance. From what I understand, this reform is aimed squarely at people in situations like ours. That makes me nervous. I don’t think Congress has ever passed a law which affected me so immediately and essentially, and it makes me really, really nervous. I guess I don’t trust them to get it right, either.

  2. dave.s. Says:

    I think Rahm Emanuel’s ‘never waste a good crisis’ is proving one of the stupidest and most damaging things said in this Administration. Health care is not a crisis. It’s urgent, it’s non-optimal, there should be careful though given to the bad incentives there, everybody has a brother-in-law or a cousin or son who is not covered and we worry – but it’s not a crisis. AND most of us have decent coverage for ourselves, which it worries us to lose for something new-fangled. There are crises out there: the economic collapse. North Korean nukes. Iranian nukes. Swine Flue. Failure to remake the American health care system by August 1, or September 15, or whatever – that’s not one.
    The optics of trying to put a 2-ream bill which no one can have read and though through before the Congress, and to have tried to get them to pass it before the recess, are disastrous. So folks who mistrust the government have a pretty good basis for doing so. Obama has said in the past that he likes single-payer, now he is saying, ‘cant get there from here’.
    This has been, and is being, remarkably poorly handled by the Administration. I won’t be at all surprised if it fails.

  3. dave.s. Says:

    sorry, ‘thought’, not ‘though’

  4. urbanartiste Says:

    The healthcare discussion has been ongoing for decades, so why not finally get something done fast. Bush was able to get that prescription thing done within his term, which really was only affecting seniors. Unfortunately, healthcare will need to be a long term process and our government keeps fluctuating between those that want change and those who don’t. I have very low expectations for this passing at all, but I am more in support of single payer.
    Part of me feels that it is a crisis due to the fact that almost a third of our population will be on Medicare in the next decade. If private insurance is so great why do so many retirees jump to Medicare? People who have insurance are subsidizing everyone else, so it is baffling me as to why these people are so vocally against a cheaper public plan. It takes 5 healthy people to pay for one really sick person.
    Basic reforms could probably cut the cost within the system we have. Like Medicare managing their own care rather than letting private insurance make a profit off it administering it. Tort reform is a major area that could cut cost (with all the lawyers in government I am not holding my breath on this one.
    People need to be informed as to how much money healthcare costs right now. A person or family of a person sick should receive a printout of all the money it costs to take care of the sick person, even if the health insurance is paying it out. I think that will wake up a lot of these anti-public option protestors. People don’t want to really face the reality in health care- that it costs a lot of money and if people actually had to shell out the cash for some of these issues, perspectives would change.

  5. Amy P Says:

    “The healthcare discussion has been ongoing for decades, so why not finally get something done fast.”
    Because if it’s botched, the repercussions will go on for decades.
    Obama himself is responsible for a lot of public nervousness. He’s said a lot of odd things about medicine over the past few months, which is weird since his wife is a former high-paid hospital administrator. He ought to have picked up a lot of information via pillow talk and social interactions. Obama just doesn’t come across as having a good feel for the medical system. Perhaps the most damaging statements are the ones he’s made about unnecessary tonsillectomies (which was genuinely a problem–30 or 40 years ago) and his recent remarks about the incentive structure for amputations for diabetics vs. preventative care. I’ve sat in on almost literally dozens of endocrinology appointments over the years for a non-native English speaker friend who struggles with type 1 diabetes, and Obama couldn’t be more wrong. The focus of diabetes care is prevention and the endocrinology folk want nothing more than to save diabetics’ feet.
    We have insurance (Blue Cross/Blue Shield) and an HSA. Our insurance is a lot less generous than our old plan and we have more ongoing health expenses these days (various therapies for oldest daughter), but the level of expenses is predictable and the quality of care is excellent. I understand my family’s needs and I make sure that we get the most bang for our health care buck. Forgive me for not believing that the current administration understands my family’s needs as well as I do.

  6. liz Says:

    What you said about if it’s passed w/ no Republican votes. But, yeah, we do need a public option. Unless there are rules about how much an insurance co. can charge and rules that say they have to take everybody and bounce nobody.

  7. urbanartiste Says:

    I respect Michelle Obama’s experience, but she is a lawyer not a nurse, doctor, social worker, etc. However, I do agree she could have some input on the healthcare situation. It seems the Obama administration is excluding her on purpose as to not have a repete of the Hillary healthcare thing.
    The more I think about this issue the more aggravated I become. I keep hearing that the most expensive costs in healthcare arrise with seniors and end of life. Yet, this is where the government is paying and private health insurance is out of coverage except for supplemental. Couple this with a number of long-term diseases (kidney failure as an example) and it seems Medicare is covering non-seniors because private health insurance is allowed to drop the patient after a certain amount of time. Yet private health insurance is still pocketing 20% of reimbursement from medicare to “manage the care.” Something is not adding up here.

  8. dave.s. Says:

    I’m with you, uart, that the situation is not good now. I’m unhappy with process: I think these guys are blowing it (these guys: Nancy, Barack etc) with their attempt to shut people up rather than work their concerns. Harry Reid called the protesters ‘evil’ today – not a good way to address the concerns, clearly strongly felt, of a lot of voters.
    End-of-life care is a dreadful problem: my adored ma, born 1922, is clear that she wants a do-not-resuscitate order. I’ve seen others just as old consume tens of thousands of dollars in medical services and bounce back for three-four years of good life. Can’t tell in advance who you have.
    The Brits won’t do dialysis past a certain age, I’ve read. Nor for folks who did it to themselves with heavy drinking. This likely makes sense – but if it’s your aunt, it’s hard.

  9. jen Says:

    I have to disagree with Dave S. about health care not being in crisis. It is in total crisis and has been for a while. In what other sector would we accept twice the cost for lesser performance than other industrialized countries?
    I’ve said it before and I’ll say it again, all this stuff about who pays (single payer vs. public option etc.) is not the heart of the matter. The heart of it is the fee for service model: that is what needs changing, and it’s not being discussed enough. When people reference pulling cost out of the system and rewarding performance, that’s indirectly what we’re talking about. We need to make this not be an argument about how the insurance company doesn’t agree with your doctor. Instead we need to remove incentives for doctors to over-test and over-treat in the short term (including such things as patients demanding the overtreatment, something doctors currently sometimes cave in to in order to maintain their practices), and reward long-term effectiveness.
    We should all do some more reading about what’s happening currently in Massachusetts, as they try to reign in the cost of their MassCare program. http://massmed.typepad.com/each_patient_counts/2009/07/payment-commission-recommends-global-payments-mms-urges-cautious-and-careful-transition.html

  10. amy Says:

    It’s a marvelous technocratic plan studded with disingenuousness here and there. I just don’t think it’s going to work.
    I pay about $450/mo for star-quality medical and dental. And I suspect that what this plan will mean for me is that:
    1. My kid and her generation will pay a large chunk of my premium, plus interest, not that I ask them to;
    2. My coverage will not be so star-quality. Because the name of the game will be fitting inside the new federal ropes, which will cost money;
    3. Except in well-established areas like breast cancer, women’s medicine will fall off the table again, because the studies are not there to justify differential treatment, and it’ll be tougher for docs to experiment.
    Well, you don’t expect couture in a socialist state. But I’d rather be left alone, thanks. Though usually poor, and though I’ve had several chronic illnesses, I’ve always managed to get the coverage and drugs I’ve needed. And as I’ve mentioned here before, I was radically underwhelmed by S-CHIP, and won’t use it for my kid.
    The private insurance cost more than Medicare, incidentally, because Medicare chronically underpays. That’s why so many docs refuse to add Medicare patients. They lose money on them. What makes me more nervous than anything else in the proposal is the combo of the denial of this reality and Obama’s weird doctor-bashing. Most of the docs I know are well-paid, but also carry staggering school-loan burdens, work insane hours, and are ready to go to bat for their patients v. the insurance companies. While being, on the whole, nice. I’d be pretty pissed if I were a doc.

  11. Amy P Says:

    “In what other sector would we accept twice the cost for lesser performance than other industrialized countries?”
    How about education?
    “I’ve said it before and I’ll say it again, all this stuff about who pays (single payer vs. public option etc.) is not the heart of the matter.”
    I think who pays is the heart of the matter. If you are the one paying, you will be heard.
    “We need to make this not be an argument about how the insurance company doesn’t agree with your doctor. Instead we need to remove incentives for doctors to over-test and over-treat in the short term (including such things as patients demanding the overtreatment, something doctors currently sometimes cave in to in order to maintain their practices), and reward long-term effectiveness.”
    I think there really is a role for the Feds to help produce and publish information on effectiveness, so that if you suffer from a condition, you can log in to a single official website and see what percentage of fellow-sufferers actually benefited from a procedure or medication. It would also be nice to be able to look at a price list for medications, services and procedures for different parts of the countries under different modes of payment (private insurance, Medicare, Medicaid, cash patient, whatever).

  12. urbanartiste Says:

    Tort reform is the only way we will reign in overtesting. Doctors are practicing defensive medicine and rightfully so. Tort reform would allow the medical field to remove bad doctors without forcing doctors to view every patient as a potential lawsuit. Doctors are not god and health is no guaratee in life.
    As someone married to a doctor, I hear that they are more than happy to accept Medicare, but not Medicaid. Medicare actually reimburses pretty well and I suspect Medicare does not call doctors up like private health insurance does to tell them to release a patient from the hospital because it is too costly.
    With all that I have heard from family and friends in healthcare it is a miracle we have any doctors and nurses at all. I have heard of lawsuits where anyone who interacted with a patient (from doctor to nurse to aide) are named in lawsuits. My personal opinion is that doctors should be allowed to unionize. Maybe that would effect some change within insurance. There is a continuing myth that doctors have a lot of power and control in the healthcare industry. That was the 1950s, but it is not the reality of today. The way it is now, there are a lot of factors, insurance companies for one, malpractice insurance costs second, that are making it difficult for doctors to maintain private, independent practice.

  13. amy Says:

    urbanartiste, maybe Medicare reimbursements are swift and appropriate where you are and in your husband’s specialty, but around here and in many other parts of the country practices cap the number of Medicare patients they’ll take, because the reimbursements are low, the pay can be slow, and the administration is a headache. It’s not a new problem, either; see here: http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102275510.html
    For all they’re paid, the only overpaid docs I’ve met are a few bad docs and glorified specialists. Arrogant? Sure. Lots. But overpaid, no, particularly the younger ones. It’s unbelievable how much these people work, and what kind of stakes they accept on a daily basis.

  14. urbanartiste Says:

    I can only speak from what doctors I know tell me and they love Medicare over private insurance. According to them, private insurance pays 80% what Medicare reimburses and dictates every step of care, for example what facilities a patient can be referred to (everything from x-rays to lab work). Which is why it makes me laugh that people think a public option would be limiting. Private insurance is extremely limiting; it is a mirage that just because one can select from multiple insurance carriers that equals choice. One must be aware that all corporations are working together in their own interests. It seems insurance and pharmaceutical work together more than they are competing against eachother. This is why many are severely afraid of a public option. They would actually have to come up with a better product and take in less profit.

  15. Amy P Says:

    “It seems insurance and pharmaceutical work together more than they are competing against eachother.”
    Speaking of strange bedfellows, the Obama administration and Big Pharma has apparently just come to some sort of backroom agreement under which Big Pharma will spend $150 million on advertising to support Obama’s health policies.
    http://www.huffingtonpost.com/2009/08/13/internal-memo-confirms-bi_n_258285.html

  16. amy Says:

    UA, Medicare reimbursements vary substantially by state. If you’re in a state that’s regulated the hell out of private insurers and comes top of the Medicare formulas, then I don’t doubt that the docs prefer it. But I can tell you that’s not how it is all around, and that this has contributed to two big problems: Practices closing to seniors, and public hospitals going deep into the red.
    I’ve had some very complicated insurance issues, of my own and family, and I’ve been impressed both by the coverage I’ve had and the speed with which the insurance reps straighten things out. I cannot remember the last time I worried about whether or not something was covered, because it’s all there — gyn, MH, organ transplants, prescriptions, long hospital stays, outpatient, durable med equip. There is no number of maximum office visits per year. No cap for imaging services. I have no annual deductible, and my copays are relatively tiny. I believe my policy’s got a $5M lifetime max. I’m on COBRA post-divorce, and was worried about how I’d keep up this level of insurance after the 36 months — and then I looked at the insurer website and saw that I could get essentially the same coverage for slightly cheaper there. HIPAA takes care of the preexisting-condition problem.
    On the other hand, my experience with the public-option program (S-CHIP) that we’ve been eligible for left me backing away slowly, then sprinting away. It’s terrific if you’ve got nothing to lose. Otherwise, it’s potentially a very expensive plan.

  17. Amy P Says:

    amy,
    Could you elaborate on your experiences with S-CHIP? You may have talked about it earlier, but I missed it.
    UA,
    My grandpa had a hip replacement surgery last year. There were complications and it wound up being a 5 or 6 hour surgery. My dad had a look at the Medicare paperwork and the surgeon was getting about $500 for the job. As my dad put it, “that’s plumber’s wages.” (This was in Washington State.) In the discussions of foot amputations and tonsillectomies, similar surgeon’s rates have been cited.

  18. amy Says:

    Amy, here’s what happened:
    I pay half my daughter’s private insurance, which runs me $150/mo. My income’s low enough to qualify her for S-CHIP, but I’m not destitute outside my income — I’ve got investment property, her college fund, and my retirement to lose. So if I’m going to buy insurance, I want insurance that actually protects my assets and provides very good coverage. The S-CHIP site didn’t give a whole lot of info about what was covered — there was a list of maybe a dozen items, which is a far cry from the benefits certificate you get when you buy real insurance. So I figured there was a real certificate somewhere, and I set out to find it. I called the insurance co that does the coverage — the same one I buy our excellent private insurance from — and was told they couldn’t give me any info until I was already signed up.
    I didn’t like the sound of that, but I called all around my county’s human-services offices to find the S-CHIP rep (whose salary I’d helped fund as a county grants-board member). I knew she existed, but damned if I could find anyone else who did. After many, many calls locally and I established that she’d left and gone to work for the VA, and a new part-time person was supposed to be in maybe this week. Nobody knew her name or, more important, what a benefits certificate was. Essentially they had no idea what I was talking about. I called state DHS, and they couldn’t tell me anything, either, since these things are all administered county-by-county, with different insurance arrangements.
    So I went back to the private insurance rep, who took pity on me and offered to arrange a 3-way call with me, her, and a DHS rep, and I said thanks but no. If I was having that much trouble finding out what was covered, I didn’t want to know what would happen when my daughter was sick with something unusual under S-CHIP. I got the feeling that it’d come down to Bob and Mary, neither one a genius, batting it around in a county or DHS office, and finally giving me an answer — and then, three months later, finding that Mary’s boss had superseded the answer without quite understanding the issue, and now it was something else. I’m not rich enough for that kind of uncertainty about coverage, and I don’t have time to duke it out with a system like that if I don’t absolutely have to. In other words, S-CHIP looked potentially very expensive.
    So I continue to pay the $150/mo, and frankly I think it’s a good deal. The coverage is unbelievable. Happily, we hardly ever use it. But if we need it, my experience with that company is that they’re honest, they’re on top of things, they’re professional, and they’re fast. That’s worth the extra money. If she really got sick, insurance wouldn’t be one of the things I worried about.

  19. amy Says:

    Huh. You know, I think what it really comes down to is that I don’t want to buy insurance from amateurs, and I especially don’t want to buy health insurance from amateurs. It’s just too important for that. And I don’t want amateurs trying to run my insurance company from above. Things get messy and expensive that way, especially when the turf lines are not clear.
    I think in the end this will turn out to be an untenably expensive experiment, partly because of the expense of amateurs, and partly because we just plain expect too much from the healthcare system. Britain pulls the plug on Grandma when she hasn’t got the QALY rating to stay connected, and even so NHS takes on water.
    Ack. I don’t even want to think about the genius ideas that are going to spring up involving “personalized medicine” and preventive care.

  20. Elizabeth Says:

    My understanding is that HIPAA does not take care of the pre-existing condition problem. It says that you can’t be denied coverage because of a pre-existing condition, and that you as an individual member of a group plan can’t be charge higher rates. But it doesn’t say that as an individual you’ll be able to buy a plan at an affordable rate (the only guarantee is through the state high risk pools) and the insurer can raise the rates for everyone covered by your employer. Which means that not only can you wind up uninsurable if you get sick, you can wind up unemployable.
    I’m trying not to freak out too much over Obama backing off on a public plan. First, I think the House bill will include a public option. (See: http://www.democracyforamerica.com/activities/181) And second, per Krugman, if we wind up with a plan that looks something like Switzerland, that’s still a million times better than what we’ve got.

  21. amy Says:

    Elizabeth, if you come in from a group plan, HIPAA essentially waives the waiting period for pre-existing conditions so long as you make the jump within (as I recall) 60 days. That’s been so since Clinton signed the first bill into law, and I’ve used the provision twice since then. If you’re coming in from an individual plan, then no, HIPAA does not apply. I think most people with insurance are still on group plans, though, and I’ve been careful to keep access to a good range of group plans no matter what my circumstance. The only group plans I know of over which there was some question was student health insurance plans; I don’t remember how that one was resolved.

  22. amy Says:

    Sorry, Elizabeth, I missed part of your comment. HIPAA has nothing to do with premium prices; it’s only about access. “Affordable”, of course, depends on your circumstance. I find that I manage to afford my premiums on a household income in the $30K range (coincidentally, my health insurance costs, annually, about what my property taxes do, and I don’t hear anyone rushing to save me from those). Of all the policies I’ve had, I’d say this one comes second only to the one I had as a House of Reps employee. Just in case, I also carry a catastrophic policy that maxes at $20M, but it’s not the sort of thing you expect to use. I think I pay $200/yr for it.
    If someone had a genius idea for lowering the premiums while a) maintaining the quality of my insurance, b) not introducing the sort of amateur-night risk to my assets that I talked about above, and c) refraining from putting more debt on the public tab, I’d be all for it. What concerns me is that politics/agency-driven federal management of insurers will lead to Geico insurance — sure, the premium’s lower, but it lands me with more health and/or insurance risk. I buy insurance to shove the risk over to someone else. Risk is expensive, and, in my book, not terribly affordable.
    I think when all’s said and done we’ll find that the proportion of waste in the system is not as big as we’re assuming, and that where it exists it has to do with practice inefficiencies like “how many man-hours does it take to get food from the loading dock to the hospital cafeteria,” not greed and paper. And my guess is that if we want cheaper healthcare, in the end we’ll have to use less of it. I’m guessing that the plans on the table are effectively ways of shoving the lump around under the rug. Don’t forget that through the 90s we railed at HMOs, but they were going bust because healthcare turned out to be more expensive than they’d figured; Obama’s taking a whack at docs, but for what they do, how they train for it, and when they do it, their salaries don’t look that far out of line to me. Next up are the pharmas, but I think we’re going to find that drug development and QA are not things you can skimp on.

  23. jen Says:

    Amy, I’m surprised to hear you say that in the 80s HMOs were going bust. Everything I’ve heard about HMOs in the 80s is that they were actually very successful at holding down costs, but the patient/doctor choice they wrung out of the system led to serious pushback from both patients and doctors.
    I agree with Amy on one thing: if we’re going to save the scale of money that needs to be saved, we all need to use fewer services. (I would argue we should be using roughly the level of services used in other industrialized nations with good outcomes.)

  24. amy Says:

    In the 90s, Jen. The HMOs held out great promise for holding down healthcare costs, but instead we had double-digit healthcare inflation. There was quite a lot of criticism saying that this was because HMOs were for-profit, but the BC/BS remnants have also had a real struggle holding down costs, and they also have had to hike the premiums quite a lot. I seem to remember some BC/BS HMOs, but don’t hold me to that.
    There were good and bad HMOs, and much depended on how big the network was, the quality of the docs inside, and the rules for getting past the gatekeeper doc. I had two good ones, though the second was really hit-or-miss when it came to doc quality, and the whole operation went bust soon after I left it.

  25. amy Says:

    Incidentally, Elizabeth, I cannot help but find it ironic that here you are wanting to help children & poor people w/o employer coverage get health insurance & pushing for a public option to do it, and here I am — poor by the numbers and nearly always have been as an adult, a single mom, on-and-mostly-off with employer coverage — saying “no thanks” to both S-CHIP and public health insurance for myself. I find that the usual take when this sort of thing happens it to assume that the person saying “no thanks” is some toothless pappy with a shotgun who doesn’t know what’s good for him, or some poor frizzed-out Jesus-loving mom with slightly more education than a rock gets. But you know pretty well that I’m neither one. My ed, my ability to do math, 20 years’ experience in staying insured, and my sense of self-preservation all tell me: “Thanks, but I’ll pass. How about some ice cream? Let’s go get some ice cream.”

  26. jen Says:

    Really good piece in the Atlantic this month about why the public option doesn’t change anything: http://www.theatlantic.com/doc/200909/health-care.
    FWIW, I personally am extremely committed to universal coverage; I just don’t think the public option will really do that.

Leave a Reply