Note to Barack Obama: Choice is the Problem, Not the Fix in Health Insurance

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I hesitate to write about health care issues at this moment as a colleague of mine is embroiled in a controversy regarding his comments about health insurance policy ads being released by the Obama campaign.
I don’t want to go into the controversy or to try and speak on behalf of or defend my colleague other than to say that I very much disagree with the tenor and content of his reported comments on a Clinton campaign conference call. (Len Nichols does offer a statement here on this subject)
That said, I do want to raise an issue about the “choice” question that Senator Obama raised last night in the debate.
And like Senator Obama, I have an open mind on this as well as I don’t understand why he thinks that people who are not well off financially would be better off “choosing” not to have health care if in fact he, like Clinton, plans to subsidize the provision of that health insurance.
From my reading of the problem in comprehensive health insurance, “choice” is the problem — not the fix.
Someone on the road with him should ask Senator Obama if he thinks we should give the elderly the “choice” of being in Medicare.
I received a note this morning from an Obama foot soldier (this may be from a self-appointed follower of Obama rather than an official campaign representative — I’m not sure) that was sent to me and a good number of other publications and editors. This individual wrote:

Barack Obama’s Health Care is the Same Universal Health Care offered by Hillary and Edwards, but with one Major Difference: You Have the Option of Choice!
We as a nation have to decide, do we want to be forced to pay for universal medical insurance, like we are mandated to pay for auto insurance now? Or would we rather have the option of CHOICE — to be able to decide whether or not we want to buy our medical coverage when we think the time is right?
Barack Obama’s plan thoughtfully does not want to put another mandated cost, like auto insurance, on the backs of the people, especially the young, who already have college costs to contend with. However, the coverage is always there for you, if and when you need it. That is our decision and our choice!

This emphasis on choice by Obama and his followers seems misplaced to me. I don’t think he fuly understands why the American health care system is struggling today.
One of the reasons that the health insurance system is failing is that some healthy, young to middle-aged people with the resources to buy insurance are electing not to — or in your words, their “choice” is not to participate in any insurance at all.
This creates the problem. Choice means that many who are healthy and don’t have insurance don’t kick into a system that would help subsidize the less well-off economically and those who may be ill. Thus, insurers want to cherry-pick among those they want in their portfolios and want to avoid covering those at the lower end of the spectrum.
Including the non-participants in a comprehensive program would make everyone’s costs decline on average, but you need full participation.
Barack Obama is trying to do an honorable thing by putting a plan forward that would cover more Americans — but he needs to listen to his own words offered in last night’s debate. He said that he’s not always right and will listen to others. I think he may be wrong on this front — and his embrace of “choice’ may not only inhibit provision of health insurance for the poor but also for others in our society because his system would propogate adverse selection.
I may be wrong as well and have an open mind — and don’t feel as passionately about this as apparently others do. I’d welcome informed comment and thoughtful commentary below on both sides of this question — and personally, I feel regret for the unfortunate imagery that a colleague of mine used in this policy conversation — but I don’t want to speak for him. He’ll do that himself.
But just intellectually and practically on the subject of choice and health insurance, choice seems to me to be part of the problem, not the fix.
— Steve Clemons

Comments

36 comments on “Note to Barack Obama: Choice is the Problem, Not the Fix in Health Insurance

  1. DrSteveB says:

    Sorry to keep posting, but answering different questions here…
    Above was David N. To which I would just add that traditional supply-demand economics really don’t work with health care. Even pretty conservative economists acknowledge this. Classic example is ability of physicians to generate demand. If more of the same specialists move into an area, instead of prices going down, the number of patient/procedures/visits goes up. There is a group at Darmouth turning out studies about this for a while.
    Also, moral hazard does not work properly… keeps people who need care out of care; does not reduce total system cost.
    Large majority of care is by small number of patients with repeat chronic illness (we call it the 80% – 20% rule).
    Plurality cost and expensive care is last 6 months of life.
    To move on to Steve C’s question:
    Us single payer advocates, as a matter of both economics and nitty-gritty reality, don’t think it can be done with the private for-profits kept in the mix.
    1-One issue, is their excess overhead/profits… they run 15-20%, compared to Medicare at 4% (the other comparison would be to the Veterans (VAMC) which runs a relatively good quality (pre-Iraq) purely socialized (lol) system. This amounts to $350 billion per year which more then pays for the uninsured.
    2-We already pay more in JUST our public expenditures (federal such as medicare, medicaid/SCHIP, DoD, VA, etc.; and state medicaid, schip and local public hospitals and clinics) then do the other western industrialized countries that have real universal coverage. In other words, we already pay for universal coverage, we just don’t get.
    3-in the real world the private for-profits always find a way to game the system. Remember, their business and profit model is based on NOT providing care. When they do have to provide care they lose. They do everything they can to not insure sick people or people who might get sick. They then do everything they can to deny care or deny payment or deny reimbursement.
    Much more…
    I did a Health Care Thursdays serie on dKos in 2006 and 2007 on this, and after a break will be doing more. Meanwhile check out:
    http://www.pnhp.org/facts/single_payer_resources.php
    http://www.pnhp.org/news/quote_of_the_day.php
    http://www.pnhp.org/news/articles_of_interest.php
    Peace & Health

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  2. questions says:

    On the best health care in the world thing, I’ve often wondered if the statistics are skewed because we have very good health care for some and just about no health care for others. Infant mortality rates here may be high because of poverty. Do the wealthy have high infant mortality rates as well? Are some adverse numbers caused by older women’s high risk pregnancies? I never ever know how to read any stats that come out. So if the U.S. has a “great” health care system for SOME people, maybe that’s why there’s so much worry about changing it. If you’re healthy, wealthy and lucky, you do very well! If you get sick and you’re in an HMO, you’re out of luck. If you max out on benefits (recent report on hemophilia patients) then you’re in trouble. So the trick would seem to be to allow the lucky to keep the goods they have while encouraging them to share. My guess is that there needs to be a very large carrot to encourage a shift. A stick will just make the well-insured people vote against “change”. So “choice” is a feel-good term, “keeping your own doctor”, “no mandates” and so on are all there to make a shift politically feasible. I wish us all luck!

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  3. K Ols says:

    I’m late to the party, but will comment anyway.
    I would like to see single-payer medical care, but I’m not hopeful we will ever see it.
    First, You must have everyone in a single-payer or universal health coverage plan or it won’t work. Premiums have always been based on claims experience so if you only take sick people or those apt to get sick you won’t be able to pay for it because no one can afford it. Every person healthy or otherwise must be included with no pre-existing conditions excluded.
    Secondly, we need to look at countries with more success in medical care delivery than just England and Canada. France comes to mind.
    There are other things to consider like controlling the cost charged by medical providers. They charge too much, but other countries deliver the same or better results and their physicians still live quite confortably.
    The United States does NOT have the best health care in the world. I’m tired of hearing this lie from those who just can’t admit it. Just look at the WHO statistics and it is proven as a lie. The public has been fed this lie so long by mainly Republicans that we have to start admitting the truth.
    There is also the problem of what to do with all the many insurance companies that exist today. There would be massive unemployment if they stopped being profitable. They are going to fight single-payer or universal heatlh care to the death and we know where they spend their lobbying dollars.
    There is also the problem of people fearing their taxes will rise to pay for this. Those people haven’t been hit with a catastrophic loss yet or don’t pay as much in premiums as the rest of us. It will be hard to convince them that a tax increase to pay for medical care will work to their huge advantage in the long run if they should fall seriously ill or have an accident because they haven’t experienced that hardship yet. For them it is hard to understand that we’re all just one illness or accident away from bankruptcy sometimes even with insurance.
    Lastly, it is difficult to convince the general public that we need single-payer medical care because at any given time there is a fraction of the country suffering financial disaster with or without insurance at their disposal. I’ve been near bankruptcy over medical bills so I know what it is like and we had insurance. The deductible and co-pay will quickly ruin you financially if the illness doesn’t get you first. The only thing that saved us is the stop loss provision.
    By the way, we pay over $10,000 annually in premiums along. That is a huge chunk of our income.
    I could elaborate more, but I’ve said plenty to ponder above.

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  4. David N says:

    wb:
    My only response is that I’ve noticed far more RNC talking points coming out of the mouth of Clinton than of Obama.

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  5. wb says:

    The fiction of greater freedom of choice is the essential, habitual argument of the right wing, and always trotted out to scuttle health care/social security reform. It is depressingly characteristic of the great Obamaboozlelment that he would use such tactics, particularly against a solid effort by Hillary and Edwards to resolve the issue. Effective politics perhaps but hardly hopeful for a Democrat.

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  6. David N says:

    So, does a lot of this come down to:
    In a universal health care system, who pays for Brittney Spears treatment??
    A lot of the discussion is about the merits of one or another health insurance system. That misses the point that what some of us are arguing for is is a health care system. Mandates only cause problems for health insurance systems. There will be — there will always be — cheats and free riders in a universal health care system, but they will be far less expensive that the 30% overhead and profits that we sink into our so-called health care system today.
    Of course, given the entrenched interests who will scream the usual screams about ‘socialism,’ we who believe in rational argument know that talk of universal health care and paying attention the working models of European health care systems will never get anywhere.
    We ‘Murricens will never copy anything from them Eurpeens, don’chano?

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  7. questions says:

    ‘Tis I again! Another question! If there are mandates and subsidies for premiums, then of course at some income level, the subsidies end and you are required to pay your own premiums. Premiums for family coverage are somewhere around $13,000 per year, employers often do an 80/20 split on the premiums. Without the split, you pay a lot of money. What happens to the people who are just above the cut off and who have unusual expenses like caring for an elderly parent or some other high expense that doesn’t show up on tax forms? We may end up forcing a decent sized group of people to choose between somthing very basic (utilities) and insurance premiums. No one is required to have car insurance unless he or she drives, so that analogy isn’t perfect. Admittedly everyone’s having health insurance is better for all, and game theory has lots to say about free riders, but it seems possible that the mandate may cause more problems than it solves, or at least a whole new set of problems to be dealt with. Is Obama’s “no mandates” shtick just a rhetorical flourish, or is it sound economic reasoning? I still don’t know what to think. (And I just want to thank everyone for all the thought, time and effort going into this discussion!)

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  8. Glen says:

    I see a whole lot of people saying what CANNOT be done. Universal single payer health care cannot be done. I say BS.
    There’s all this discussion about choice. More BS. I have to pay taxes and I do not get to choose what I pay for. If you really believe in this “choice” BS then let’s start where the rubber hits the road – I want a line item veto like “choice” about what I pay taxes for and until I have that all this talk about “choice” is just a whole bunch of people trying to ram the current broken health care system down our throats. Enough BS, lets fix this mess.
    If we do not get enough of a mandate to fix this mess when we run the whole country then we will NEVER get it, and our country will eventually end up on the ash heap of history as a failed experiment in self governance.

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  9. Linda says:

    Carroll,
    You obviously didn’t read all the comments above or read and understand both Clinton’s and Obama’s health plans. They both try to be as universal as possible. They differ about mandates, and neither campaign’s advisors have any real life data to support their claims and won’t until a plan is in effect.
    Your example that got you angry is ridiculous as the young woman was getting health care and paying the bill herself. We and you don’t know any more about her. She may have funds to pay all her health care bills. And often consumers with health insurance get lots of care they don;t need and don’t check the bills closely because insurance is paying. You seemed to take offense that she had a big car and assumed she didn’t have car insurance that might include medical payments.
    You’ve revealed yourself to either be a blogger or some kind of journalist if you are in LA asking questions at Obama’s presser this morning. You have every right to comment here as an individual not representing your employer and to be angry. You at least have the sense not to identify where you work.
    Those of us who were interested went to the links and read all the stuff you quoted, formed our own opinions and had one of the more intelligent and reasoned discussions that I’ve seen on TWN for a while. I wondered how long it would last..probably time for Steve to close this thread.

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  10. Carroll says:

    If this is all there was to Nichol’s statement then everyone’s outrage is ridiculous.
    The outrage should be over Obama using the old Harry and Louise ad tactic. It’s pretty clear that Obama is courting his “students youth movement” by citing a “Student’s newpaper”.
    Pardon me if I don’t think students,who think they will never be sick just like all of us did when we were young, should be pandered to on the health care issue.
    And the nazi thing? So what. Wake me when George, the neo’s and the zionist and their pundits quit calling everyone and their brother a new Hitler.
    I am more interested in what using this kind of ad shows about how Obama is trying to keep his youth movement going by pandering to them on this issue. I am really begining not to like Obama’s feigned insult routines, he is as much a political hustler and opportunist as Hillary. As far as I am concerned his “opt out” negates his sincerity about a “universal” plan.
    As I remember it when I was a student I was covered by my parents insurance plan. I don’t remember ever giving insurance a thought between the time I was a student and I got married..I doubt many young and healthy do. But that doesn’t mean they shouldn’t. What you don’t want to happen is what I observed one day checking out of my doctors office. A mid to late twenty’s professional looking girl without insurance was questioning her bill at checkout. In the parking lot she got into a $40,000 SUV and drove away. If she gets in an accident the insured will be paying her emergency and hospital bills in higher insurance premiums and hospital bills because of her misplaced priorities. Obiviously she isn’t allowed to opt out of her car and uninsured motorist insurance, if she did she couldn’t drive. If the youth group in the Obama campaign really wants “change” and “hope” for a better society they need to get their priorities straight and get onboard with the crisis of our uninsured and health cares cost.
    “The Clinton campaign convened a conference call with health policy experts to denounce Obama’s new mailer, which attacks Clinton’s plan for “forcing” Americans to sign up for insurance, and which features a couple at a kitchen table that recalls, for some, the famous insurance-industry-financed “Harry and Louise” ads against the original Clinton plan.
    “I am personally outraged at the picture used in this mailing,” said Len Nichols of the New America Foundation, a leading supporter of mandatory insurance, who called it a “Harry and Louise evocation.”
    “It is as outrageous as having Nazis march through Skokie, Ill.,” Nichols said. “I just find it disgusting that this kind of imagery is being used to attack the only way to get to universal coverage.”
    [UPDATE: At the end of the call, Clinton aide Howard Wolfson disavowed the Nazi reference, saying the campaign didn’t think it was appropriate, though he acknowledged the passions the issue stirs.]
    Clinton adviser Neera Tanden called the mailer “politically dangerous.”
    I didn’t get my question about this in at Obama’s presser this morning, but Lynn Sweet and I cornered David Axelrod in a Los Angeles hotel afterward and asked him about it.
    He called the image “standard” and defended the argument against the plan. He also dismissed the suggestion that this mailing is similar to Clinton attacks that Obama has denounced.
    “Ours is based in fact, and theirs is based in fabrication,” he said.
    He also defended citing a student newspaper, the Daily Iowan, in the piece.
    “It’s a respected newspaper,” he said, noting that the objection has been voiced by “plenty of other sources.”

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  11. p.lukasiak says:

    What bothers me is the huge gap between Obama’s overall rhetoric (the Magical Unity Pony) and his health care proposal’s failure to cover everyone. There is an irony in the fact that the group least likely to buy health insurance are the same people with whom Obama’s Pony message resonates — young people. A leader who bases his appeal on being able to “bring the country together” in order to fight the special interests would, one assumes, be the person to inspire young Americans to accept universal care.
    (And while I don’t think that Obama’s appeal to younger voters is based on pandering to them on health care, one wonders to what extent this ‘it won’t cost young voters a cent — you can still make mom and dad pay until you’re 25!’ rhetoric factors into his support.)

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  12. PissedOffAmerican says:

    Do you people really think that health insurance is going to be an issue in the coming months, after these monsters in the Bush/Cheney camp hand us Act Two of “The Neo-Con Agenda and The Amazing Effect Of Widespread Terror”?

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  13. Steve Clemons says:

    PW — I’m sensitive to the point you raise, and can only say that none of us was pleased with what happened yesterday. But I hope you will know that Len Nichols feels badly for what he said and knows that he should not have been on that campaign call. His statement makes both of those points. He was not speaking on behalf of New America or on behalf of the Clinton campaign — but from his own visceral anger that Harry & Louise like ad-making was coming back again within the Democratic Party to sabotage prospects for universal health care coverage.
    I disavowed Len’s comments — but I understand his passion on the matter — and while his imagery was absolutely wrong, his anger about the ad was probably right.
    best, Steve

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  14. Linda says:

    Duncan,
    It just isn’t that simple. Spreading risk is important, but insuring more people increases demand. That can raise costs even with healthy lifestyles. The same question could be raised about Clinton’s mandated program. Do we deny health care to people who don’t buy mandated coverage?
    Do we cover abortions? And universal care will mean mental health parity? Do we deny care to addicts, alcoholics? To obsese people, smokers?
    Does everybody who thinks a bone marrow transplant will help them get one even if medical practice standards say they won’t help. And part of the trade-off might be having to wait for elective surgery like knee replacements?
    I surely don’t know all the answers,but I don’t think we let people die just because they have a problem like most of those above.

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  15. duncan king says:

    The definition of insurance is that you spread the risk among many. If you let people opt out of the system but still enjoy the benefits (is Obama going to deny people health care if they don’t have insurance) then you are defeating the whole purpose.
    Universal Health Care and enpowering people to pursue health lifestyles is how the US is going to lower the cost of health care.

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  16. Linda says:

    Interesting and good comments all though everyone has missed how much the nonprofit health care system has gone into the hands of for-profit corporations since Reaganomics took hold including the demise of Blue Cross-Blue Shields that were non-profit and community-rated. A large percentage of nonprofit hospitals including many university hospitals went from non-profit into ownership by corporations. HMOs aren’t really bad at all if one understands the entire history of them and again if they are non-profit.
    The more of these that are run by for-profit corporations, the more difficult it is to do single-payer or anything.
    Also Medicare is the part of entitlements that is in the most financial trouble–not just Part D that never should have passed. It is not inexpensive coverage at all with premiums that run close to $100 a month and then several hundred a month for supplemental coverage. Lots of things need fixing there. Many people who continue to work after age 65 prefer to keep employer-based coverage instead. And United Health has a deal with AARP that should be stopped as it gives them a marketing advantage.
    Also hospital staffs have been cut so much to the bare bones that many people who can afford it hire extra private duty nurses or nurses aides around the clock—and no insurance covers that.
    Willem above adds some history that is worth mentioning, i.e., U.S. Social Security passed in 1935 was based on models from Bismarck’s Old Age and Disability Insurance Act of 1889. Nobody in US had any kind of pension plan then. People worked all their lives. Part of the motivation for doing this program was not only to allow people to retire but also to get older people out of the workforce and make more jobs available to the younger people with no jobs.
    They considered also doing health insurance, but there wasn’t much cost to health care then–not even antibiotics that didn’t come along until 1940s. People, especially older people, died of pneumonia, etc. Also physicians made house calls and treated patients for free. So they didn’t do health care reform during the Depression. It happened to have been the first of many social programs Bismarck put in place with the Health Insurance Bill of 1883. This was way before the Nazis, but the U.S. social insurance programs developed during the Depression were all based on Bismarck’s plans from Germany including unemployment insurance and workers’ comp too.
    So everybody above has made excellent points. I worked in health care all my career, studied all the systems, and I personally am skeptical of all the plans. The public has been sold sound bites by all the politicians. I think we may have to go through one of the options on the table and have it fail before we get to single-payer.
    Obama is right about one thing more important than mandates or not, i.e., there is going to need to be a lot of open public debate and education so that people will understand the complexity and options, trade-offs, costs, etc. Public demand for change and solutions is high, but it will be difficult even with a Democratic president and veto-proof majority in Congress. Clinton concerns me because she is so sure she has designed the best plan and cares so much and will fight for them. That does sound like “old politics” of promising to get elected and then not being able to deliver. Obama sees the need to involve and educate the public. And I think that shows more respect for the electorate.

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  17. Scott says:

    Can we stop being such Democrats about this? I’m a specialist in health policy who spent much of his career in the UK, and so can happily endorse single payer as the most rational health finance system. And I initially thought that not endorsing universal coverage was a killer argument against Obama. But I have changed my mind.
    1. Single payer might be obviously the most rational option, but it is highly unlikely to pass. The Constitution is designed to make highly unlikely, but rational ideas, impossible to pass, and unfortunately that is one of the few things it does as planned.
    2. So the next question is: what combination of existing things produces universal health coverage? In other words, who has the best plan? Per the comments above. This is where Democrats, wonks, and my students tend to settle.
    3. But can we please not be Democrats for a moment and try thinking strategically? If you create a plan as attractive as the federal employees plan and let anybody join, it will
    a. cost a fortune (but be less wasteful than the present system)
    b. crowd out all sorts of bad and inefficient health care plans
    c. avoid looking like the IRS is imposing a health tax (how else do you plan to do it?)
    d. force a choice late in the first term in which we either go for the right to buy health insurance with federal subsidy, or lower taxes. Risky, but only because the capacity of American political elites to go against overwhelming public opinion on this point is well documented.
    That leaves two genuinely good questions for Obama- which might also, unfortunately, be asked of Clinton:
    a. In most other health systems you show your card and get treated, or just walk in. Obama (and Clinton) both leave the rigamarole of insurance and some little **** trying to draw you away for a conversation about insurance while your loved on is wheeled away on an ER gurney. Bad, but everybody is equally bad because of their shared committment to the insurance companies Americans are thought to love so. How do you plan to get an inspiring plan without getting the cashiers out of the way of health care? No Democrat can answer that. Perhaps America can’t establish a program that simple and attractive.
    b. Financial question: how much paying-in would the people who choose to avoid Obamacare do? In other words: drop the generalities about riskl pooling and ask what the uninsured (probably 20-something Latinos from all we know about uninsurance) would contribute. Not enough to matter, frankly. The blow is not financial; it is to solidarity.

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  18. David N says:

    There have been a lot of really intelligent, well-thought-out, and reasonable points made in this discussion.
    Who’d a thunk it.
    I just want to interject one point based on Linda’s post. What bothers me about the Democratic proposals on health care is that they aren’t.
    None of the Democratic proposals are about universal health care. They are all about universal, mandated or not, hearth insurance. The difference is exactly what Linda is talking about, with the MA plan’s difficulties pointing out that insurance is not care.
    Willem, you make an excellent point, as well. I suppose the only thing we can say is that the difference between the different European models is invisible to Americans because our system is so radically different. I am reminded of a discussion between Thom Hartmann and the editor of some liberatalian magazine. Hartmann had just finished talking about living in England, with small children, and how well the health care system there worked. Then the libertarian described the English system as “a disaster.” No reason be ideology.
    In America today, mere evidence, mere facts, mean nothing. As so many others have said, all that counts is power. Even the wealthy would be better off in Bedford Falls than Potterville, but they refuse to believe it.

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  19. Whskyjack says:

    A sad fact for 6months of the Iraq war we could buy the basic blue cross blue sheild insurance policy for every uninsured person in America.
    Jack

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  20. Dan Kervick says:

    Thanks for linking to the report Willem. It’s good to see a comparison based on actual experience, rather than projections.

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  21. PW says:

    Steve: I don’t in the least disagree that single payer is where we want to go (this being America, probably with some intermediate steps, frustrating though that is. But I have to say that my respect for NAF took a serious punch in the gut today. That was bad, bad, bad.

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  22. Willem van Oranje says:

    I’m Dutch and I’d like to enter the following point in this discussion. The advocates for universal healthcare in the US all point to Canada and the Uk as examples of what they would like to see for the US: single payer systems. These systems are known here as Beveridge models of health insurance.
    You might be interested to learn that this system is not rated all that well in European studies. The countries that Europeans rate as the most consumer-friendly and cost-effective are Austria, Netherlands, Germany and France. Their universal healthcare system is based on the Bismarck-model.
    Read this report: http://www.healthpowerhouse.com/files/ECHCI_2008_Full_Report_final.pdf
    I’m not much of an specialist about these issues so I’m afraid I can’t add much to this debate. Just that I believe that given the political climate in the US, I’m afraid that single-payer systems will be dead-on-arrival in the US. And that such a thing might be even for the better.

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  23. Carroll says:

    Well I am with Dr.Steve all the way.
    And Edwards is gone but of the three I liked his plan best….which was a universal medicare plan..and then let the privates compete with it..if they can.
    If they can’t..too bad.

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  24. dan s says:

    I think Dan K’s take is exactly correct.
    “A whole bunch of interested parties, whose real motivations for trying to kill health care reform have nothing to do with their love of “choice”, will nevertheless find in the mandate proposal a highly convenient wedge to drive between reformers and a lot of ordinary Americans, whose liberty-luvin’ ethos unfortunately recoils at the idea of the government forcing them to do *anything*.”
    I live in Ma and here in the “liberal Blue” I have heard these exact sentiments over and over again. Obamas plan, regardless of the detials and whether or not it will work, has the best chance of not being torpedoed out of the water on the first pass. As others have said there are many assumptions and projections with all the plans, only time will tell if they will work out. First though the door must be cracked open with some kind of action, the proverbial camel”s nose.

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  25. Linda says:

    Steve,
    Please link to the statement I sent you earlier today signed by a lot of prominent health policy people about how little difference there is between either Clinton’s or Obama’s plans.
    I agree that single payer is better, but politically it isn’t going to happen.
    All the estimates are just that. Both plans to work in the long run have to institute a lot of programs to cut costs including electronic medical records, improve prevention, and provide better quality and coordination of care for chronic illness (BTW, everybody including the Republicans recommend those reforms.) Even when implemented, those will take time to take effect and lower costs. If you mandate before that happens, then what happened in MA after one year of Romney’s plan will happen, i.e., premiums the second year are going up 10-15%. The fine for not buying insurance is $210–a month’s premium. So what do you do with those who choose not to buy mandated insurance? Raise the fines until they are as much as the cost of premiums? Deny them emergency room care and let them bleed to death? And how do you enforce mandates and check on who is insured and who isn’t? That creates a big bureaucracy.
    BTW, there is a very good example of what happens when insurance is mandated with auto insurance. We all still have to carry uninsured motorist coverage because even with all the mechanisms in place to check when cars are registered, tickets are issued, accidents happen, there still are those who choose not to be covered.
    Clinton’s line is to claim that she wants everybody to have high quality health care and implies that Obama doesn’t want people to have that. BTW, I think McCain, Romney, and Huckabee want that too as an ideal,but they just don’t have plans that will do that. Actually, I think none of the Republicans want women to have high quality care available for their choice to terminate pregnancy.
    It’s a complex issue and this all is about one small part of a very big one. BTW, you and New America appear to be for Clinton because both New America’s Health Policy Directors worked in the Clinton Administration on Clinton’s health care reform. Nichols was out of line on his statements because of that. You have a right to say whatever you want on TWN; however, you mainly have heard Clinton’s ideas.
    If you had called in all the Democratic candidates health advisors when there were more in the race, you’d have heard different ideas entirely from Kuchinich. Actually I think it would be a good idea to do that with Clinton’s and Obama’s health policy people. And give them time to explain all the wonky options in detail as well as how figures about how many won’t be covered by which plan are just wild guesstimates.

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  26. Dan Kervick says:

    [I posted about this topic earlier on another blog, and a portion of the following comments are repeated from that post.]
    Steve,
    I don’t really think Obama is out to make any grand philosophical point here about “choice”, despite the apparent libertarian enthusiasms of the self-appointed Obama “foot soldier” who sent you the letter this morning. After all, Obama has said that if he could build a health care system from scratch, it would be a single payer system. So he’s clearly not out to defend libertarian principles of individual choice. The issue here is just a question of political reality and political strategy.
    Passing any one of the health care plans – Obama’s, Clinton’s or Edwards’s – is going to be an extremely tall order. All of them are very ambitious and pose challenges to large numbers of vested economic interests who will be fighting tooth and nail to hold onto their portion of the healthbucks pie.
    An individual mandate adds another area of political vulnerability to Democratic health care proposals. Clinton has been skating so far on the issue of just what she will do to enforce the adult mandate. But she will not be able to skate on this question in the general election. And once she does start talking about enforcement, all of the heavy shelling will start to rain down on her about Big Brother, the Heavy Hand of Washington bureaucracy, a return to the era of Big Government, etc. A whole bunch of interested parties, whose real motivations for trying to kill health care reform have nothing to do with their love of “choice”, will nevertheless find in the mandate proposal a highly convenient wedge to drive between reformers and a lot of ordinary Americans, whose liberty-luvin’ ethos unfortunately recoils at the idea of the government forcing them to do *anything*.
    In addition, the mandate proposal is going to be tied in the public mind to Massachusetts, and the mess they are having with their own mandate program. Now I lived in Massachusetts for ten years, and I liked it there quite a bit. But I recognize that nationwide it is not exactly the most popular state in the union. It is widely associated with a messy combination of wasteful and incompetently managed boondoggles, exorbitant taxes, ultra-liberal social experimentation, ivory tower head-up-the-ass impracticality, and Eastern city corruption and palm-greasing. And Hillarycare II is probably going to be known as the Massachusetts Plan.
    I think Obama’s strategy for getting health reform done, which depends crucially on his proposals for broadcasting public deliberations and getting citizens to do more to participate and take ownership of the debate, is sounder than Clinton’s. For all of Clinton’s talk about the lessons she supposedly learned in the failed health care initiative of the 90’s, she still doesn’t get it when it comes to the political logistics of moving this kind of ambitious legislation to passage through the political and corporate minefield. Clinton still seems to think the way to get a health plan done is to get all the parties together in a room, make some trades, bang some heads together, twist some arms, break some balls, hammer out a package, and then deliver the goods through the sheer force of presidential oomph. The only difference between now and the nineties is the nature of the plan – but not the approach.
    Well that’s what we did last time, and it failed spectacularly. The Clintonian paradigm of secrecy and back room deal-making among the most powerful insiders didn’t work then, and it’s not going to work now. You think you have agreement behind closed doors, and then your negotiating partners march right out in public and start ripping the agreement down, directly or through proxies, piece by piece. Since your negotiations were private, you can’t come out and argue that your partners are breaking their bargains, because not enough people were there to say what the deal actually was; and anyway it is embarrassing to talk publicly about what particular horses you traded when people weren’t watching. And since most members of the public have just been bystanders to the process, rather than participants, they are less well-informed and easily victimized by demagoguery.
    What you need to do is get the big players to make their arguments in public, and to face public questioning from both elected representatives and their antagonists on the issues. If corporate insurance poobahs, for example, make commitments to their interlocutors, those commitments should be made on the record and in public. If on the other hand, they want to argue the more selfish case for private gain and profit, force them to play the Scrooge role with the cameras rolling. This Obama proposal isn’t just about feel-good theatrics; it’s about winning tactics.
    Once again I worry Democrats are deluding themselves about the uphill nature of the fight to come, just because they are in a primary campaign where they are mainly only talking to other Democrats – people who already by and large agree with them. I have been frustrated for weeks that the discussion of these health care proposals takes place in a political vaccuum, as though it is all a question of who has the best policy, as viewed purely on the public policy merits by health care economists. But the problem is that the health care struggle is going to take place in the political context of an American society in which there is massive built-in structural resistance to making serious changes. Health care reform is not going to take place on some economist’s blackboard, whether Paul Krugman’s blackboard or Austin Goolsbee’s blackboard. It will happen – if it happens at all – in a highly politicized arena.
    Most Democrats would like single payer. I know I would. But it’s not going to happen. Not in America; not in 2009. We are dealing here, as always, with the art of the possible.

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  27. Steve says:

    I think I disagree with some of Dr. Steve B’s quality reporting.
    Hillary Clinton’s proposal includes three broad categories of choices:
    1. Keep the coverage you currently have.
    2. Enroll in the federal employee benefit system, which allows a choice among many private insurers.
    3. Enroll in a new public plan that will be similar to Medicare.
    In addition, there will be subsidies and a cap on what fraction of your income can be required to pay for health care. There are also a lot of new restrictions on insurance companies–they can no longer discriminate based on pre-existing conditions, etc.
    So it doesn’t force people to pay for unaffordable private plans (because of the public plan, and because of the subsidies).
    The above part I’m fairly certain about. Below is more speculative on my part:
    I think Clinton’s belief (and Edwards, too) is that the new public plan will have a big competitive advantage, since it will have drastically lower administrative costs (as Medicare does) and not be run for profit. Thus private insurers will either have to lower their premiums or lose market share. Ideally, the new public plan would gain enough market share to make the switch to a single payer system easier.
    Also, as for the argument that anything will be changed unrecognizably by Congress, this is true only to a point. If Democrats control both chambers of Congress, the president will have a lot of control over what happens (as Bush did with his tax cuts). But more importantly, there is almost no chance that Congress will come up with something that is MORE ambitious than what the president offers. Only someone who proposes universal health care will get universal health care. Clinton may not get Congress to go along with her plan, but Obama has already written off any chance of that.

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  28. lina says:

    Healthcare reform ultimately will not look anything like either the Clinton, Obama, or Edwards campaign policy positions. It has to get through Congress, remember? The Dems are going to need a 60 vote majority to get it through. Ted Kennedy’s fingerprints will be all over whatever gets introduced. How it ends up is anybody’s sausage.

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  29. Jason says:

    I think health care experts are going to have to come to a stronger consensus before Obama or any politician changes his or her mind. There are already significant political and psychological roadblocks to changing one’s mind. The strongest catalyst for changing one’s mind in spite of these roadblocks is an over-abundance of evidence for the other side, and even then some people can be slow to convince, such as was the case with global warming.
    Dr. Steve B and others make me lean towards thinking that a mandatory single payer system is the best system, but it’s hard for me to fault Obama yet when I haven’t seen a majority of health care experts coalesce around a particular solution, or even penetrate policy-friendly places like the blogosphere too deeply.
    My point is that now that Obama has committed himself to a proposal, there needs to be a certain amount of evidence and consensus before we can argue that he should change his mind. Are we at that point yet? Maybe, but in my eyes, I think the debate needs to advance forward for another few months before we get to this point.

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  30. DrSteveB says:

    Sorry to keep posting, but answering different questions here…
    Above was David N. To which I would just add that traditional supply-demand economics really don’t work with health care. Even pretty conservative economists acknowledge this. Classic example is ability of physicians to generate demand. If more of the same specialists move into an area, instead of prices going down, the number of patient/procedures/visits goes up. There is a group at Darmouth turning out studies about this for a while.
    Also, moral hazard does not work properly… keeps people who need care out of care; does not reduce total system cost.
    Large majority of care is by small number of patients with repeat chronic illness (we call it the 80% – 20% rule).
    Plurality cost and expensive care is last 6 months of life.
    To move on to Steve C’s question:
    Us single payer advocates, as a matter of both economics and nitty-gritty reality, don’t think it can be done with the private for-profits kept in the mix.
    1-One issue, is their excess overhead/profits… they run 15-20%, compared to Medicare at 4% (the other comparison would be to the Veterans (VAMC) which runs a relatively good quality (pre-Iraq) purely socialized (lol) system. This amounts to $350 billion per year which more then pays for the uninsured.
    2-We already pay more in JUST our public expenditures (federal such as medicare, medicaid/SCHIP, DoD, VA, etc.; and state medicaid, schip and local public hospitals and clinics) then do the other western industrialized countries that have real universal coverage. In other words, we already pay for universal coverage, we just don’t get.
    3-in the real world the private for-profits always find a way to game the system. Remember, their business and profit model is based on NOT providing care. When they do have to provide care they lose. They do everything they can to not insure sick people or people who might get sick. They then do everything they can to deny care or deny payment or deny reimbursement.
    Much more…
    I did a Health Care Thursdays serie on dKos in 2006 and 2007 on this, and after a break will be doing more. Meanwhile check out:
    http://www.pnhp.org/facts/single_payer_resources.php
    http://www.pnhp.org/news/quote_of_the_day.php
    http://www.pnhp.org/news/articles_of_interest.php
    Peace & Health

    Reply

  31. DonS says:

    Dr Steve explains it nice and clearly in the first paragrah above. Its one of those miracles of obfuscation why the rationale for health care as a shared public expense benefitting the entire society remains lost on politicians.
    Oh wait, I forgot who owns that segment of politicians compartmentalized brains. And the perpetuation of the great lie that somehow the American way of health care must be superior , a subset of the fictitious American dream, is wearing thinner all the time.
    As I close in on 65 by the day, the 80 – 20 Medicare split isn’t looking too user friendly either.
    Forgive the rant.

    Reply

  32. DrSteveB says:

    Medicare for All: Basically everybody pays, has to pay, for it via taxes. Everybody is eligible for the services it provides. Everybody-in and Nobody-out. Just like we pay for other government services, whether we use or like them, via taxes. Same as for national security, social security, roads, police, fire, interest on the debt, etc.
    This being America, of course folks who want to and can afford to, can buy extra. There is an issue about being able to buy your way to the front of line, but details of regulation cand deal with that. Analogy to paying extra for single room in hospital vs. shared room covered by insurance (if you have insurance).
    Best place to learn all about this is:
    http://www.pnhp.org/facts/single_payer_resources.php
    I am on the board at my chapter of this nationwide group.
    Peace & Health

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  33. questions says:

    Do the madates generate so much extra money from premiums that they make a difference in the amount of money available to cover people? Is there some way to “sneak” coverage in by starting with a gov’t program to cover major medical/catastrophic and super expensive chronic problems and take the last and most expensive few months of life coverage out of the system at some level? (Don’t states usually have car insurance for the uninsurable?)This way perhaps insurance companies can have the profitable stuff and we socialize the losses. Should insurance cover the first dollar expenses or only kick in after we’ve spent some of our own money? Co-pays, it’s reported, are stopping some women from getting mammograms….I’m not a health economist and I can’t figure my way through what really matters and how best to spend limited money, and how to keep costs down enough so that insurance is reasonable. I kind of think that a layer of profit taking is problematic and that forming co-ops that are non-profit might be a middle ground, but I’m really at sea about all of this. Could we just develp a parallel system and let the major insurance companies wither slowly? Thanks for reading my ramble….Any thoughts anyone??

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  34. David N says:

    DrSteveB:
    Would appreciate your comments on my own idea. Since Steve seems to be stuck with the notion that there are 2.0 sides to this or any other question, he can read along and learn from you along with the rest of us.
    My own thought would be: Modified single-payer.
    That is, there would be a single, universal health system, similar to the Canadian, French, English model. But there would also be the option for the wealthy to use private facilities. Since the universal system would be tax-funded, there would be no “opting out” and refusing to pay into the system, so it’s affordable and workable. Why corporations are against this idea, and want to continue to pay into the current expensive system, is beyond me. Narrow-mindedness is a true growth industry these days, but greed is not the only basis of an economy.
    It would be like what the educational system should be. Some people can afford to and think there is a benefit to sending their children to public schools. That does not mean they don’t pay their taxes, and don’t pay for the universal public educational system that we all benefit from, even those without children in any system. Because the real benefit of universal education is that the entire economy and society are more stable, secure, and prosperous.
    Health should be treated like any network system that benefits the entire economy: roads, infrastructure, water, law, public transportation (think of the investment and growth Metro has promoted in our area), and education. Actual users can’t afford them as individuals, but they more than earn back their investment in general economic growth and tax revenue.
    Network economics, people. Learn about it.

    Reply

  35. Steve Clemons says:

    Dr Steve — thanks for your note. From your point of view, is there a way to get to comprehensive coverage, private sector provision backbone, some sort of cost controls (would love to know more about this, and mandate? would be good to hear more from you on this.
    best, steve clemons

    Reply

  36. DrSteveB says:

    Well, gee, I tried to give everybody a heads up about why both Clinton and Obama are both right and both wrong on the mandated health insurance schema in a do your homework before the debate diary on Kos yesterday:
    http://www.dailykos.com/story/2008/1/31/123659/474/505/446985
    Short version:
    Obama is right that it will wind up as unaffordable subsidy to for profit health insurance industry. He is wrong that his plan is better, insofar as it is equally unaffordable and just insures less people as its solution to unaffordability.
    Clinton is wrong insofar as it it is a forced subsidy to the private for profits. She is right, that once you have made the mistake of leaving the private for profits in place, that her plan will get more people insured and that without mandates less people get covered and the folks who are betting they are healthy and stay healthy will opt out making it more expensive for everybody else.
    Which is why we need single payer, the only way to get to Universal coverage (everybody), Comprhensive coverage (covers everything needed) and Cost-control (affordable for individual and country).
    Still supporting HR-676!

    Reply

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