The Bottom Line on Health Care

Slinkerwink at dkos and Jane Hamsher/MoveOn/ActBlue have all been making excellent progress in confronting Dems that haven't been on the right page. That's constructive, and I'm supporting those efforts.

I'm just not buying that OFA can turn us off and on like spigots.

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Can't agree.

Steny Hoyer is holding a town hall today in MD. There is a diary accusing him of "murder by spreadsheet" for $30K in donations and calling for packing the town hall.

It just lends creedence to the WH's "left of the left" descriptions, i.e., loonies. "Murder by spreadsheet" isn't going to play here. That these town halls are getting packed by screamers on both sides just paves the way for "sensible, bipartisan reform."

Howard Dean attended a town hall in VA last week and continued to mislead on the "public option" issue. Anyone who is interested in what is actually in Senate HELP can read here.

Leaders of the "public option" movement have an obligation to advertise the HELP Committee bill truthfully. It is not accurate to say the HELP Committee bill creates a "robust" or "strong" public option. It is not even accurate to say the HELP Committee bill creates one "option." The truth is the "option" is balkanized and very weak. In fact, HCAN, Andy Stern, Howard Dean and other "option" advocates who have praised the HELP Committee bill should do more than cease to praise it. They should tell Congress they oppose it.

I agree.

To the larger point of your diary -- I can't speak for OFA participants in your neighborhood, but in mine, the people who were bullish early on were attracted by the participatory nature -- they thought their opinions mattered. Now, not so much.

However, I would extend this to so-called progressive efforts in general. An example -- I know you don't have a Whole Foods unless you're in the greater Omaha area. So, there's a boycott going on of some sort, based on a WSJ op-ed by its CEO, John Mackey. He promoted the use of HSA/HRA insurance.

Mmmmmm-kay, well, I understand why he wrote the op-ed -- his insurance will triple under this "reform." Mackey and I have something in common: unlike our Dem WH/Dem majorities, we've  provided a living wage and health insurance for others.

I see a lot of hollering on blogs about how this only works if you're young/rich ... no ... what he described is what I've done for my employees. I buy a high-deductible package from the insurance company, however, the employee "sees" a low deductible. The difference gets put in a reimbursement account by me for the employee to draw on. If he/she doesn't use it, it rolls over to the next year. End result: less profit for the insurance companies since I've inserted myself into the process by absorbing some of the risk. I've even covered people in their early 50s this way. I purchase a $3000 deductible plan and dump $2600 into a reimbursement account.

Now, I don't believe that this can work as a nationwide model. I don't agree w/ Mackey's comments on health care not being a "right" (although I'd say our Congress is right in line with his thoughts). Nevertheless, I understand why he wrote the article -- HSA/HRA benefits are to be phased out under current "reform" in exchange for mandatory junk insurance that, according to my estimates locally, will triple my costs FOR LESS COVERAGE. I'll just have to employ fewer people.

So, if progressives want to boycott some business to ensure greater profits for the insurance industry, be my guest. However, if you're going to lecture people like me about the great benefits of a "public option," then at least know EXACTLY what you're fighting for. I started this as somebody willilng to pay more for the greater good. I'm finished with this as someone not willing to follow fluffy bunnies along a path of breadcrumbs to greater insurance company profits in the name of "fighting wingnuts." Tiresome. My life isn't perfectly D or R, and like most people, I have to deal with reality. Advocating for a public option placebo doesn't fit in with my plans.

If the final bill out of conference looks like the HELP bill, I don't think I can support it, and we would have to hope for the Progressive Block to vote it down.

If the final bill looks more like HR 3200, I think I can live with that compromise, but I would have to learn more about the details.

I still want to know what road map you or PNHP see for improving the status quo. If we wait until there's political will to pass single payer before doing anything, we'll be waiting forever.

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I'm curious -- is this what you tell people in your neighborhood while canvassing for DFA? What kind of reactions do you get?

Even if I believed in the above strategy, I wouldn't be able to sell it. This is just the old 'why buy the cow when you can get the milk for free' -- you're lending support w/o knowing up front what you're getting.

I still want to know what road map you or PNHP see for improving the status quo.

Well, we have a problem here, because I can't argue that X is better than Y, w/o knowing what Y is. We haven't even seen what comes out of Senate Finance yet.

Historically, Democrats have been against Medicare privatization because it would create a two-tier system -- the wealthy one, and the other one for people w/o political status. Pretty sound reasoning.

Democrats have also worked to prevent cuts in Medicare payments to doctors in the past. If Senate Finance hands over authority to an independent board, as is rumored, well, that's a pretty big piece of the puzzle, esp if the goal is to start enforcing unrealistic triggers.

So, I'm having trouble conceiving a two-tier system -- private + public, where private = 2x-64, except for Medicaid, and public= 65+, Medicaid, and some uninsurable + unattached workers, w/o imagining public getting the short end of the stick.

The only way the public option can be competitive is by paying Medicare rates or perhaps Medicare + 5% and allowing all in if they want. OTOH, we don't have a clear picture on what the future holds for Medicare rates, or if it even remains a meaningful concept given that the payment structure may change dramatically in the future. I've yet to see anything on paper that puts a meaningful nr in a public option, due to intentional limits, firewalling, and so on.

What is probably most frightening to me is that lack of honesty about what is costly, and what is causing the spiraling. The numbers:

Per 2001 Medical Expenditure Panel Survey:

- 74% of private health insurance spending is attributable to 45% of the privately-insured w/ chronic conditions.
- 83% of Medicaid spending is for the 40% w/ chronic conditions.
-96% to 98% of Medicare spending is for enrollees w/ chronic conditions.
-The uninsured actually clock in at 72% spending for chronic conditions.

The spiraling is due to patients that have more than one chronic condition, and of course, aging demographics doesn't help.

People w/ 2 or more chronic conditions account for 2/3 of prescriptions filled.

The prevalence of chronic illness is race- and location-dependent:

Health Outcomes Differ by Race and Location:

Other research has also pointed to the importance of location, and specifically the exposure to health risks associated with living in poor neighborhoods, as a factor in health disparities. A recent article in the journal Health Affairs highlighted the link between disadvantaged neighborhoods and detrimental health outcomes such as lower life expectancies. Roughly 76 percent of black children and 69 percent of Latino children living in large metropolitan areas live in neighborhoods that have higher poverty rates than those found in the neighborhoods of the worst-off white children. Many of the states with the highest poverty rates are also located in the South, contributing to the wide disparities in health outcomes seen across state lines.

Sorry, I'm sensing an ill wind. It is impossible to support a vague, unspecified plan with these factors at stake.

Yes, the r08 plan would look very different from what we're currently seeing. First, I believe that the health care cost crisis is integrated into the economy and thus very difficult to fix as certain regions have been either abandoned due to policy (like manufacturing/industry) or sheer neglect (New Orleans, MS, etc). We can only make this worse with payment packages designed to cut down on so-called high-frequency utilization. It lacks discrimination. Second, whether I like it or not, efforts have to be targeted to states like TX or cities like Miami. Control these areas and a major part of the crisis is fixed. It is very localized. Third, the walls need to come down between large group/small group/individual markets to create large pools of equal standing in states. Fourth, I think different states need different solutions.

Somebody did the work of analyzing McAllen properly and found that when adjusting for proportion of multiple chronic conditions and poverty, it is no longer an outlier. That's very bad news for the "greedy doctors" theory and for us, if  correct, which I suspect it is. I'd write it up as a diary, but I think progressives are so invested in Big Tonsil/Big Amputation and a public option saving the day that I'll just end it here.

And that was really my point above. Most people I know who were early OFA supporters really believed they had something to add due to experience or research or even common sense. They were motivated to solve problems, and this is getting thrown away. Their options are too push vapor, or something they're not entirely comfortable with, or to just be invisible.

And what you're saying is that either I have to support vapor until the bitter end when the rug gets pulled out, OR, I have to have to present a road map for improving the status quo? Nothing in the middle, eh? I can't just have good ideas? I need to fix the national health care problem if I don't go along with supporting some bad ideas?

Well, then, let me rush off to accuse Hoyer of SPREADSHEET MURDER, and after that's over, off to Silver Spring to boycott the Whole Foods.

The DFA/PCCC/Firedoglake/Open Left campaign has at least some chance of moving the bill in a better direction. There is no other way to do this besides encouraging House Progressives to draw lines in the sand and reject an AHIP bill. Obama needs to believe that he can't get a bill on his desk by letting Baucus/Grassley call all the shots. I admit that the Progressive Block is more likely to fail than succeed, but I don't see any other pressure point we have.

You may sense an ill wind, but many Progressive Caucus members who represent heavily black or Latino districts, where there is a high incidence of poverty, are among the strongest advocates of a public option. Maybe they are all misguided about what would be in the interest of their constituents, but I think they have valid reasons to believe care for their populations would improve.

I haven't read the alternative analysis of McAllen, but I have read other studies showing, for instance, that doctors prescribe way more CT-scans or MRIs after their offices purchase that equipment.

I also know that in the obstetrical field, OB-GYNs routinely push expensive interventions on laboring women without any medical necessity, and those interventions lead to other, costly interventions. We now have a national c-section rate of 30 percent, which is at least two times too high. At some hospitals the c-section rate approaches 50 percent, and no this is not just socioeconomic. Mason City and Fort Dodge are not that much different from Dubuque, where the c-section rate is much lower for various reasons, including access to midwifery care. OB-GYNS then refuse to allow women who have had one c-section to try for a vaginal delivery, which guarantees that all of their future births will be extremely expensive (and convenient for the doctor, since the c-sections are usually scheduled for normal office hours). So I am not willing to rule out "greedy doctors" as one among many causes of spiraling costs.

More preventive care should reduce costs for chronic conditions, but some of this stuff is unsolvable in the context of a health care reform bill. I don't think anyone has a good answer for how to tackle that. Our agriculture subsidies are one among many causes of the rising incidence of diabetes, and those aren't changing in the forseeable future.  

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which does nothing to stop the speeding train that is the Baucus/Grassley/AHIP dream plan

I happen to agree that Grassley is a useful tool to enable the dream AHIP plan and have always made that clear. Best thing that could happen is if he drops out, but WH-love seems to have no limits.

Quoting some of Taibbi's article.

It also left them scrambling to find other ways to pay for the plan, making it almost inevitable that they would step in political shit with seniors everywhere by trying to surreptitiously whittle down Medicare.
...
All that's left of health care reform is a collection of piece-of-shit, weakling proposals that are preposterously expensive and contain almost nothing meaningful -- and that set of proposals, meanwhile, is being negotiated down even further by the endlessly negotiating Group of Six. It's a fight to the finish now between Really Bad and Even Worse.

So I am not willing to rule out "greedy doctors" as one among many causes of spiraling costs.

You shouldn't. Of course we have greedy doctors, as well as saints and others in between. Fraud and waste should be purged. No argument there. The problem is that it is not the principle mechanism for spiraling costs and applying payment plans that discriminate against treatment frequency may deny care to those who need it most.

Good example w/ c-sections, but you must admit chronic care is the primary cost driver (see #s). Quick googling about ... VBACs are banned at many hospitals due to malpractice concerns (uterine rupture). Malpractice concerns are also cited in general, along with increased requests by first-time mothers (this appears to be a more controversial conclusion). Stats in 2005: 11% of first-time c-sections unnecessary and 65% unnecessary second-time. Hmm, do we file this under "greedy doctor" or "CYA doctor?" Malpractice insurance rates is one of those areas I haven't explored yet, though I suspect that effectiveness research may open the door to tort reform, so one of these days I will.

I don't see any other pressure point we have.

Frankly, if progressives stood firm against this "piece-of-shit," Democrats/Obama would have to go back and do better, much better.

You may sense an ill wind, but many

We seem to be talking past one another, so let's just let it go.

I've been commenting for months on what these bills were going to look like, long before there was even a hint of full blown RomneyCare and an official kicking to the curb of the public option. Did I ever sound uncertain? No. What I said is that I've been following the argument locally for some time. My opinion is that anyone in the area following the action should have seen this a mile away.

Yet, now we have a "speeding train," and you're telling me that I'm the problem, or PNHP, not flat-footed bloggers or the Democrats. Imagine that, I should have a national plan at the ready. I'm kind of amused, actually. Let's be honest: bloggers spent months in some sort of odd crouch examining emails or parsing speech for the occurrence of the phrase "public option." I give you full credit/kudos for not engaging in this hobby horse.

Best form of activism to date? Iowans hanging up the phone, bar none. Iowa is where Obama got his start. If he does a turnaround, I credit Iowans, not "murder by spreadsheet."

Second best? from a LTE/LA Times:

We did not vote for you to see if you could get Chuck Grassley or Michael Enzi to date you. The spectacle of you wooing them fills us with horror and even disgust. We recoil as from hot flame at each mention of your new friends. Believe me, I know exactly how painful this can be, how reminiscent of 7th-grade yearning to be popular, because I went through it myself this summer.

The progressive strategy, OTOH, is the same as its always been: set up a fall guy to blame if things don't work out.

I'll do some rooting around in Sept when this crap starts up again to see which way the winds are blowing.

I was thinking that it's too bad that you don't have BH t-shirts, b/c I'd go tonight to the town hall wearing it and shout "murder by spreadsheet" and "primary Hoyer!" just to entertain you guys. Of course, I'd have to wear a mask b/c I know long-time supporters and local pols who would wonder what was wrong with me.  

AFAIK. I'm not a member of the national org, but I'm aware of what local citizen-activists are involved with, and it's more along the lines of local/state efforts, esp preserving the rights of states to do something differently in the future.

*I realize this isn't fair to blood-sucking leeches. Blood-sucking leeches may be the only form of healthcare we get if "healthcare" corporations get their way.  

Health Care Reform is THE issue that pulled me into political activism and this article helped reaffirm what I already know. I do want to remain hopeful and optimistic, but at what cost?

Dem. Congress, which is still bought and paid for by lobbyists, STILL has no backbone and/or integrity and is about to botch it. Messaging and framing the argument were flawed out of the gate, almost as if they really didn't want reform or their communication peeps are incompetent.

I'm officially done fighting for these watered=dwpmn bills that will not help my situation in any way (since I cannot buy into the public option because my employer offers shitty, expensive health insurance)and will only support a policy and/or candidate that has the integrity and courage to stand behind a single-payer system. This debauchery points to the bigger problem: campaign finance refrom, which I hope folks will use to help push this forward when the dust settles on the operating room floor. Putting a dysfunctional and corrupt system in charge of fixing one that is equally dysfunctional and corrupt is compleely absurd.

Amen...

"For every political action, there is an equal but opposite satiric reaction." Political Fallout: http://www.political-fallout.blogspot.com/

As for the President, he has made some poor political choices...but so have the Democrats in charge of Congress.

Here's what they should have done.  Instead of having 5 different 1000-page bills in various Congressional committees, President Obama should have championed two simple reforms:

1.  Deal with the issue of purchasing health insurance across state lines (or lack thereof).

2.  Deal with the pre-existing condition issues with coverage (or lack thereof).

Why do these two things first?  Well, #1 would pass with huge Democratic and Republican support.  #2 would probably be a little less popular, but the bill would ultimately pass.  And then you have your first and second (easy) victories.  The bills would have passed in one month, been signed into law, and health care reform would have been on its way with one important difference than where we are today:  Barack Obama would have a political win notched in his belt.

This is not a "Go big or go home" situation.  I know I'm playing Monday morning quarterback, but it was a serious political miscalculation.

Congress should have started small and non-controversial, to get the ball rolling.  Instead they put all their eggs into the one basket of "all encompassing health reform in 2 months."

Mistake.

Anyway, they did this in a sense by expanding the State Children's Health Insurance Program in January.

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Again, I'm being a Monday morning quarterback, here.

I'm just saying, Democrats in Congress would be in a lot better position right now, had they done what I suggested.

Lumping in the uncontroversial things with the controversial things clearly isn't working.  Lumping everything together allows for the clouding of major issues (death panels, anyone?), and ultimately hinders any reform whatsoever.

I'm a firm believer in springboard politics, where passing successful legislation is a lot better than not passing legislation.  I argue that it is well worth passing the uncontroversial things early for several reasons:

1.  The boost given in polls is well worth it.
2.  The label of "the same old Washington" is avoided, mainly because something of substance has been achieved.  A big reason I think many people are upset is because nothing has been done, and there are several things that could be fixed VERY easily.
3.  In the realm of public opinion, you now have "capital" for lack of a better word...and you can use it...plus you might be on a higher road than the opposition, due to your success.

I guess I was too strong in faulting the Democrats for their strategy.  However, I still maintain that the way they handled things this summer was unfortunate, and that successful legislation can easily springboard to more successful legislation, while legislative failure (i.e. where we are right now) can more easily lead to legislative failures.

Running under a banner of hope is dandy, but running under the banner of (worthwhile, quality, and popular) success is superior.

Keep in mind, I'm not suggesting that success for Obama is compromising on key issues.  But I am suggesting that Obama could have important, quality, non-controversial, and widely popular reform under his belt already.  But at this time, he does not.  Which position is more desirable, where he is now, or where he would have been had he done what I outlined above?

is the lack of uniform regulatory standards across states -- something that this "health insurance reform" boondoggle is intentionally masking, IMO.

I get that you want to see this year's draft bills shot down. Then how do we get to where you want us to go next year?

Canada didn't pass single-payer all in one go either--they created a public plan that was expanded over a couple of decades. I'm not saying the current bills under consideration would lead us in that direction, but I want to hear how you would get us there.

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We have a chance at this after waiting for 16 years since the last attempt. People don't understand that the mandates are part of what makes the plan affordable for everyone. Besides, young people, who tend to feel immortal, do need some basic health insurance and don't quite get it as a rule.

We need leadership, and we need it pronto.

Educate yourself. Think for yourself. Be yourself. Act for others.