Note to Self: Brainstorming: A Health Care Symposium?

What would I most like to see in a quick health care symposium this fall/winter for The Economists' Voice?

(A) Ask representatives of the three major Democratic campaigns to comment on the excellences of the other campaigns' plans:

• Obama rep. on the excellences of Clinton and Edwards
• Clinton rep. on the excellences of Edwards and Obama
• Edwards rep. on the excellences of Obama and Clinton

(B) Ask people who know the legislative politics to explain:

• What significant improvements are impossible because the pharmaceutical lobbyists will block them?
• What significant improvements are impossible because the insurance lobbyists will block them?
• What significant improvements are impossible because the doctor lobbyists will to block them?

(C) Taking a broader view:

• What's wrong with all three plans: the view from the right?
• What's wrong with all three plans: the view from the left?

(D) Taking a broadest view:

• What public-policy mediated changes in health care financing, delivery, education, and information would produce the biggest improvements in Americans' health status, and why?

Comments

[SamChevre]

I'd add:

What marginal fixes would be of most benefit? How possible are they? What pre-conditions do they have?

Who loses from your plan, answered by each campaign.

[Denis Drew]

A syllogism:
a) Hillary's (and Edward's) plan can work only with a mandate.
b) A mandate is likely unworkable (see below) and is almost certainly unacceptable to Americans who don't like be told what to do (who like it less than Canadians and Europeans in any case). And, guess what: Hillary herself says she does not forsee any penalty to enforce the necessary mandate -- has so far, as far as I know, only come up with some "Brave New World" speculation about a future in which we may be forced to show proof of health insurance to get a job.
c) Ergo, Hillary's (and Edward's) plan cannot work.
*************
Quoted from:
The Gaping Holes in Massachuesetts' Health Care Plan
Mass Failure
By Dr. STEFFIE WOOLHANDLER
and Dr. DAVID HIMMELSTEIN
http://www.counterpunch.org/woolhandler09212007.html

And 244,000 of Massachusetts uninsured get zero assistance--just a stiff fine if they don't buy coverage. A couple in their late 50s faces a minimum premium of $8,638 annually, for a policy with no drug coverage at all and a $2,000 deductible per person before insurance even kicks in. Such skimpy yet costly coverage is, in many cases, worse than no coverage at all. Illness will still bring crippling medical bills--but the $8,638 annual premium will empty their bank accounts even before the bills start arriving. Little wonder that barely 2 percent of those required to buy such coverage have thus far signed up.

[Denis Drew]

(Let me try to sort this out.)

Our Dem heroes got licked last time out (1993) because the Republicans could get away with calling PRIVATE based health coverage "socialism".

But this time out our Dem heroes are afraid to propose PUBLIC based Medicare-for-all -- which ironically is the only plan Repubs CANNOT GET AWAY WITH calling "socialism" because everybody knows what Medicare is -- because our Dem heros are now that the "very industry" that (together with Repubs) knocked out private-based universal care the last time will oppose Medicare this time.

(Am I making any sense?)
***********************
Medicare is ready to go now -- no need for years of phasing in.

Medicare is almost too easy to sell to the American public.

Medicare may need to take over from Medicade -- the difference in fee payout can be so exaggerated (as much as 8X lower in N.Y. state) that it defeats LBJs original purpose which was to get care to the poor -- which is where we supposedly came into this movie. (Between Medicade's partial erasure and the 1968 minimum wage -- $9.50/hr adjusted CPI-U -- diving almost in half by the time average income doubled, LBJ must be spinning up a storm.) http://www.nytimes.com/2005/10/17/nyregion/nyregionspecial4/17clinic.html

Next to last gasp on Medicare-for-all:
Leaving universal coverage in the private hands leaves our industries competing with foreign counterparts who don't have to include -- ever more unaffordable -- employee medical coverage in their price structures.

Last gasp:
It would shore up the funding of Medicare if the great mass of patients -- who pay its regressive taxes -- were not so badly underpaid in these days of deunionized America, low low minimum wage (2009 version will be at least .50/hr short of 1956 minimum wage in equal purchasing power), etc. The rich don't have more livers and teeth to fix so support for doctor's incomes has to come from the incomes of the great majority.

Last gasp on private medical insurance:
If unnecessary paperwork constitutes 30% of private insurance costs (20% on the part of the insurer, 10% on the part of doctors trying to get paid -- and to not get treatment denied -- by dozens of varied insurance plans), that means that (rounded to the nearest 5%) private insurance ADDS 45% to health insurance prices -- 30% down equal 45% up in 8th grade math.

[David Lloyd-Jones]

.

Note that improvement in health is not the only reason for nationalizing health insurance.

The provision of health care on the taxpayers' tab has major redistributive effects, exactly as the Republican right fear and predict.

People have to step up to the plate and boldly state that this is one of the major virtues of socialized health insurance.

Note, also, that I am emphasising nationalization of the insurance function, not of health care delivery itself. One of the major problems with American health care is that its delivery has been brutally centralized by the insurance companies and the profit-oriented hospital chains, to the detriment of health care professionals and of the health of the people.

American health would probably be improved by the adoption of a Canadian style of health care system, where we have things like family doctors, community clinics, and very great authority in the hands of county and regional medical associations.

Such associations of course exist in the US, but they seem to spend so much of their time on the delivery of right-wing political propaganda that they have no time to take back the administration of health care from the insurance companies and the commercially operated HMOs.

[wood turtle]

I would be interested in seeing your summary and comparison/criticism of the three health care plans, since you worked so hard on the failed health care plan of the early 90's. You probably know more about it than you want to know.

I have doubts that a single payer plan like there is in more socialistic countries will pan out for the U.S. Whatever plan is finalized though, it will have to include some provision for the government to be the insurer of last resort, as it is for Medicare patients.

[Joel]

Is health insurance is an unalloyed good when its main effect is redistributive?

One of the simplest heath care reforms would make the cost of health insurance visible.

Instead of employers giving health insurance as a benefit, give the employees the health-insurance money in payroll, making it taxable. Employees could then buy individual private health insurance, _if_ they wanted it.

The insurance companies wouldn't like this free-market solution, but if health insurance is so attractive that employers feel they need to offer it, why wouldn't individuals buy it?

Is government afraid that most employed people would rather have the money, and is unwilling to change the tax law to make this solution, individual choice, viable?

The tax revenue on additional employee income, from receiving what were formerly employer-paid health insurance premiums, would be used by the government to provide some minimal insurance for the unemployed, that is, everyone not employed; or only for children.

Opting out of health insurance is not an option for people who have employer-paid insurance. Now there are proposals for compulsory insurance. Why are we afraid of individual choice? because Big Brother (employers! government!) knows better than ourselves what to do with our money?

[anne]

http://www.boston.com/news/globe/editorial_opinion/oped/articles/2007/09/17/health_reform_failure?mode=PF

September 17, 2007

Health Reform Failure
By Steffie Woolhandler and David U. Himmelstein - Boston Globe

IN 1966 - just before Medicare and Medicaid were launched - 47 million Americans were uninsured. By 1975, the United States had reached an all time low of 21 million without coverage. Now, according to the Census Bureau's latest figures, we're back where we started, with 47 million uninsured in 2006 - up 2.2 million since 2005. But this time, most of the uninsured are neither poor nor elderly.

The middle class is being priced out of healthcare. Virtually all of this year's increase was among families with incomes above $50,000; in fact, two-thirds of the newly uncovered were in the above-$75,000 group. And full-time workers accounted for 56 percent of the increase, with their children making up much of the rest.

The new Census numbers are particularly disheartening for anyone hoping for a Massachusetts miracle. In the Commonwealth, 651,000 residents are uninsured, 65 percent more than the figure used by state leaders in planning for health reform. Their numbers came from a telephone survey done in English and Spanish. But that misses people who lack a land-line phone - 43.9 percent of phoneless adults are uninsured, according to other studies.

It also skips over the 523,000 non-English speakers in Massachusetts whose native language isn't Spanish (e.g. Portuguese, Chinese, or Haitian-Creole), another group with a high uninsurance rate. In contrast, the Census Bureau goes door-to-door for its survey and has translators for almost every language. It gets a more complete picture.

In sum, Massachusetts health reform planners have been wishing away a quarter of a million uninsured people. Recent Patrick administration claims that health reform is succeeding are based on cooked books. According to the state's figures, almost half of the previously uninsured gained coverage under the health reform bill by July 1. But according to the Census Bureau, the new sign-ups amount to less than one-quarter of the uninsured. Moreover, it's likely that much of that gain has already been wiped out by shrinking job-based coverage - a longstanding and nationwide trend.

Why has progress been so meager? Because most of the promised new coverage is of the "buy it yourself" variety, with scant help offered to the struggling middle class. According to the Census Bureau, only 28 percent of Massachusetts uninsured have incomes low enough to qualify for free coverage. Thirty-four percent more can get partial subsidies - but the premiums and co-payments remain a barrier for many in this near-poor group.

And 244,000 of Massachusetts uninsured get zero assistance - just a stiff fine if they don't buy coverage. A couple in their late 50s faces a minimum premium of $8,638 annually, for a policy with no drug coverage at all and a $2,000 deductible per person before insurance even kicks in. Such skimpy yet costly coverage is, in many cases, worse than no coverage at all. Illness will still bring crippling medical bills - but the $8,638 annual premium will empty their bank accounts even before the bills start arriving. Little wonder that barely 2 percent of those required to buy such coverage have thus far signed up.

While the middle class sinks, the health reform law has buoyed our state's wealthiest health institutions. Hospitals like Massachusetts General are reporting record profits and enjoying rate increases tucked into the reform package. Blue Cross and other insurers that lobbied hard for the law stand to gain billions from the reform, which shrinks their contribution to the state's free care pool and will force hundreds of thousands to purchase their defective products. Meanwhile, new rules for the free care pool will drastically cut funding for the hundreds of thousands who remain uninsured, and for the safety-net hospitals and clinics that care for them....

[anne]

"Is health insurance is an unalloyed good when its main effect is redistributive?"

Duh, that's what is insurance is about. Say what?

[JonF]

Re: Instead of employers giving health insurance as a benefit, give the employees the health-insurance money in payroll, making it taxable.

The problem here (if this were followed literally) is that it eliminates group-rate insurance which renders insurance a lot less affordable to everyone over 40 and anyone younger with any sort of medical condition.

Re: Opting out of health insurance is not an option for people who have employer-paid insurance.

Most jobs will allow you to opt out. Some may require proof of other inmsurance (e.g., through a spouse). Very few will give you anything extra in your pay for opting out though.

Re: Why are we afraid of individual choice?

Same reason we have speed limits, sanitation laws etc: too many people make the wrong choices and in effect impose their costs on others.

[Denis Drew]

Just an idea:
Assuming Medicare-for-all became reality (except for employers/employees who opt for private plans -- and out of "for-all" taxes?)...
...then, a firm like GM could conceivably use Medicare as the base for employee coverage to take advantage of the 30% paperwork savings we are always hearing about -- and supply its employees with a company supplemental plan to cover the 20% of medical bills that Medicare presently doesn't pay. Don't know how much of a problem for GM workers the likely spit tax might be (6% for employer and employee?). Just a hybrid concoction.

[Joel]

>> "Is health insurance is an unalloyed good when its main effect is redistributive?"

> Duh, that's what is insurance is about. Say what?
> Posted by: anne

Insurance distributes risk, it isn't supposed to redistribute income. 90% of health expenses are incurred in the last 30 days of life. That means that young healthy poor people are mostly paying for the care of rich old unhealthy people. For young people, health insurance should be cheap, it isn't. My guess is that most young people would opt out of employer-paid health insurance if they could have the money instead.
- http://govtwork.home.att.net/

[Denis Drew]

>>My guess is that most young people would opt out of employer-paid health insurance if they could have the money instead.

Joel,
Read the book "The Two Income Trap" by Elizabeth Warren if you really want to know why you are wrong -- not the kind of book that repeats itself over and over after the first couple of chapters, keeps up the good stuff throughout.

You have something going there about spending too much to keep terminal patients with nothing really to live for alive -- seen a couple of cases of that permanently. I don't think either one would have asked their friends and neighbors to take up a collection for $100,000 to keep shoring up one system after another to keep them alive one more miserable year. With costs skyrocketing we ought to move a little bit in the direction of England on that.