White House Chronicle

News Analysis With a Sense of Humor

Good Reason to Look at Health Care Anew

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Nothing is ever done until everyone is convinced that it ought to be done, and has been convinced for so long that it is now time to do something else. — F.M. Cornford

There are no simple solutions to complex problems — unless they’ve become so complex that only a simple solution will do. Welcome to health care and insurance in all of their complexity.

Engineers like to say that if a new machine of structure has too many parts, it’s not ready. Not a bad idea to keep in mind when creating a societal structure like health care. One should know where one wants to go; knowing what one doesn’t want isn’t a starting point.

I submit that the goal of health policy, stripped of its advocates, denigrators and rentiers, should be to get everyone insured for the minimum amount of money and best care result. Simple, eh?

Some aspects:

  • There ought to be enough money for the United States to have universal health care, not a patchwork — a crazy quilt with holes and weak seams. We spend 19 percent of our GDP on health care, but Germany and the Netherlands spend just under 12 percent of theirs on hybrid public/private, comprehensive systems.
  • Insurance is a probability game, ergo it’s not unreasonable to ask the able-bodied to pay for the sick.
  • Mandates are not alien to us. We are mandated to pay taxes, drive with licenses and even wear clothes.
  • The more people covered by insurance, the lower the cost to all.
  • There seems to be no good explanation in the public record as to why medicine is so expensive in the United States — so much more expensive than elsewhere on earth, under wildly different systems.
  • The United States is the only country that leans on employers to provide health insurance to employees and to administer the policy and deal with issues that arrive with disputes.
  • The cost of the service patients receive is opaque once a third-party payer is responsible: the insurer. The basis of a hospital charge is hidden from the patients and policymakers. The patient has little idea what a procedure costs and who benefits from the expenditure, including doctors who own imaging companies, testing labs and even operating theaters. At the time of delivery, as Norman Macrae noted in The Economist years ago, neither the doctor nor the patients has an interest in the cost.
  • Hospitals are burdened with emergency rooms that can’t refuse the uninsured and hide this cost by overcharging elsewhere.

For more than 30 years I operated a publishing business and provided health care for my employees. It cost. It cost in time. It cost in premiums. It cost in employee well-being because as the premiums (well before Obamacare) rose by 15 percent to 25 percent, I was forced to shop for providers — which meant, in many cases, new doctors for my employees every year.

After salaries, health care was the big expenditure. I thought I was in the publishing business, but I was also, reluctantly, in the health care business.

I was keen that people have the security that goes with not having to be frightened of getting sick or falling off a bicycle. Some of my employees were on a spouse’s policy as well as mine and didn’t tell me. One man, a printer, said he didn’t like to fill in forms, so he, his wife and three children just told the hospital emergency room that the family had no money. He wanted me to give him what I was paying the insurer so he could spend it.

None of the proposals now before Congress, nor those codified in Obamacare, address the fact that as a nation we backed into health care and created complex set of stakeholders — some of whom should leave the field.

For someone who has wrestled with health care as a provider, as in other things, I believe that if the purpose is not defined, you’ll get the wrong result no matter how hard you try.

The big questions Congress should be asking of the House Republican health care plan, backed by President Donald Trump, are: Will it save money? Will everyone be covered adequately? From my point of view, Congress is proposing to replace a monster with a monstrosity.

That’s no prescription for a healthy nation, free from fear of accident or illness. Time to grab a clean sheet of paper and start again, maybe check on what works around the world, if that isn’t too damaging to our self-esteem.

For InsideSources

Universal Health Care — It’s Addictive

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Opponents of President Obama's health care legislation were wise to attack it preemptively in the courts on constitutional grounds.

If they hadn't attacked now, they would've learned that universal health care systems – sometimes a hybrid of public and private and sometimes single-payer national systems – are wildly popular in other countries.

So popular that politicians can do no more than fiddle at the edges, as they have done in Britain recently and are about to do in France. No leader, not even that incontrovertible defender of private enterprise, Margaret Thatcher, dared or even thought, to privatize health care.

In the industrial democracies, from Canada to Japan, people complain about their health care systems and would defend them to the death. Once universal health care is introduced and people are relieved of the fear of illness, leading to financial ruin, it is unrepealable.

The opponents of Obamacare must know this, or they wouldn't have been so anxious to test it in court on the grounds of the constitutionality of the individual mandate. Kill it before people love it was an imperative.

Now it's widely believed, after three days of hearings, in which conservative justices sounded more like they were conducting a congressional hearing than a judicial one, that Obamacare will be thrown out before it has ever been sampled by the public, which wouldn't come until 2014. It's been a bit like the Chinese and democracy: Don't let them try it, they might like it.

So how is it the Republicans have been able to so demonize Obamacare? Partly, it's because the administration has done an appalling job of selling its own program. It's almost as though it's ashamed of its offspring because it isn't the child they really wanted: a simpler bill with a public option and such goodies as interstate insurance sales.

The administration is frequently bad at trumpeting its achievements. As health care reform is its defining domestic issue, the fact that Obama and his cabinet have not extolled the virtues of the bill amounts to a curious dereliction, a sin of omission.

Most people have been persuaded, if they know anything about the bill at all, that it's socialized medicine (it is not); that it will double expenditures on health care (it won't); that it's an enormous new dictatorial intrusion into individual liberty (it's not).

It's not a great bill, but a good start.

We in the United States spend about twice as much as other countries on health care – about 18 percent of our gross domestic product.

Why? Everyone knows there's excessive testing and waste. The quick answer is to defend against lawsuits. Another answer is that doctors have no incentive to save money and through their investments in testing companies, often they have an incentive to order up the tests.

Mostly, I suspect it's just indifference; the medical equivalent of not turning the lights off.

I don't like Obamacare because it only does half the job and I'm uneasy about the individual mandate. Just two cheers from me.

The uninsured should be assigned an insurer and the premium collected through the tax system. That way the insurers would compete for the most desirable prospects, young adults, and a real pool would operate.

Another question that isn't asked: As new technology usually brings down costs, why does this not apply in health care? Why are CAT scans and MRIs not getting cheaper, as they would if they were in a different framework?

Why not use the Republican idea of health vouchers as an incentive to keep patients from frivolous use of services – not as the substitute for insurance, but rather as an incentive mechanism. Pay them to stay healthy.

We suffer from a failure of imagination in health care.

There are good reasons to be ambivalent about Obamacare, but it's a start, a building block. Our medicine is without peer, but our concepts of care are quite sickly. – For the Hearst-New York Times Syndicate

New to Protesting? Enjoy

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One can only be glad that so many white middle-class conservatives are fairly late in life learning the joy of protest, the feeling the thrill of the barricades, and experiencing the carthartic wonders of getting involved.

 

Let’s face it, public protest is exhilarating. To see so many otherwise stodgy people on an adrenalin high as they shout down their elected representatives and lay siege to the very idea of a town-hall meeting as a forum for ideas, is to take one back to civil rights marches, anti-nuclear demonstrations, picket lines and construction protests.

 

You’ve not lived until you’ve yelled your heart out in public. Protest–even misguided protest–is good for the soul.

 

Day after day we see really nice respectable people giving voice to their dislike of the Obama administration, their sense that the America that has been so generous to them is changing; that it may not be as generous to their grandchildren.

 

Righteous anger is as good as a whole slew of martinis, and there are no calories and no hangover.

 

After all, this all about heat not light. You’re out there yelling in public for one of two reasons: (1)You’ve missed doing it since the days of Vietnam War, protests, or (2) It’s something you’ve never done because the beastly liberals were doing it.

 

These protesters want to take back America. But first, they want to wrest the joy of public protesting from the liberals. For too long these crypto-socialists have had all the fun, from free love to smoking exotic cheroots and pouring into the streets to protest every conservative initiative, social policy or war. Just think of Victor Hugo.

 

Begone liberals. You can’t have all the fun because now we have some of it. And if any of those crackpot, socialistic, inconveniently elected Congress types try and sell their Dr. Government health care schemes by town hall meeting, we’ll be there, golf shirts and pants with a touch of spandex freshly laundered. Protesting is no longer for the unwashed; people with Brooks Brothers suits in the closet can now head to the barricades to fight for the right.

 

These town hall meetings are the gift that keeps on giving. There’s really no impediment to the joy of protest for the aging guys and gals who find

retirement a yawn. Public policy activism is the tonic these people need. Get out there and let Obamacare take it on the chin. Tell them that old people are left to die in England, that rationing dominates in Canada, that the French are forced to guzzle wine in lieu of medication, and that the Japanese are falling like flies.

 

Isn’t this a great country in which even conservatives can have a go at hitting the bricks?

 

You’re the rebels now, at the baracades, standing strong against the forces of the evil reformers. Compare socialized medicine with the post office. Beat on those bureaucrats, who you claim are going to be making health care decisions instead of doctors.

 

Here is a quick guide for the neophyte protester:

 

Don’t use an out-of-state car. Don’t wear too many diamonds. Journalists don’t understand; besides they’re in the tank for Obama. Try to look like a liberal: shabby. Don’t mention daddy’s fortune, your Palm Beach pied-a-terre, or the place in France. Go forth and shout for America.

 

Just one more thing: Whatever you do, don’t let it out that you are on Medicare. Sadly, it’s one of the most popular government programs ever.  –For the Hearst-New York Times Syndicate

Obama Diagnosis, Won’t Prescribe

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President Barack Obama starts from a pretty compelling argument: In the rich industrialized nations, the rich and the poor should be able to afford to get sick. They surely will. Disease does not means test.

 

But after that, the health care argument gets away from the president. In fact, he hasn’t made his own argument.

 

This week Obama has argued passionately for reform, as he did in his prime-time news conference Wednesday night. But we have yet to hear his personal view of what an American health care system should look like. One suspects that it is the solution that dare not speak its name: a single-payer system, a government system. Yes, a–dread word–socialist system.

 

The empirical evidence from Australia to Ireland, Canada to Norway is that this is the way to go. Every country with a national health service pays less for health care per capita than does the United States. And not one has contemplated canceling their system.

 

Yet it is a concept that may be too radical for Americans. It also may be too late in the evolution of the health care industry to nationalize the system.

 

Canada had the most difficulty nationalizing health care of any major country, and is still groaning. Canada did not plunge in; it waded into a state system, and put it all together in an age of sophisticated medicine. But it is not without problems: for example, Canada failed to comprehend that if everyone who needs to see a doctor sees one, more doctors will be needed. There is a chronic shortage of doctors in Canada.

 

Britain, by contrast, nationalized its health system after World War II, when medicine was simpler and the process was easier. It was also a time of post-war idealism. Today, like most state systems, it functions well enough but not perfectly. Well enough for Britons living abroad, including in the United States, to fly home for major surgery.

 

The world of single-payer does allow for private insurance, and it is flourishing in countries like Ireland. This provides a second tier for those who feel the basic system is too rudimentary. Under this arrangement if you want a procedure for a non-life-threatening ailment, which would require a long wait in the state system, you visit the specialist–called a consultant in the British Isles–and the insurance company picks up the tab. The idea is that the well-off get what they want, and the rest get what they want.

 

Obama’s problem is that he can diagnose the problem but has failed to prescribe a solution that he appears to believe in. He is waiting for Congress to produce something that he can sign onto, called reform, and that will not expand the budget. Where European and some Pacific countries have allowed private systems to piggyback on state systems, Congress is struggling with the reverse and the president is going along. Congress is planning to have the state piggyback on the employer-paid system.

 

The idea that employers should carry the health care burden probably goes back to the 19th century when railroads, coal mines and ships found it best to employ a doctor to keep workers on the job. Today, it is an incongrous burden on American firms in an age of globalization.

 

The three principal schemes for a new day in health care seek to preserve private insurance as primary, mandate portability, demand that commercial insurers do not reject pre-existing conditions, and provide some kind of safety net from the government. And, yes, the whole new edifice will be revenue-neutral.

 

At his press conference, Obama was ebullient, funny at times–the very picture of a man about to get what he wants. By contrast, in the halls of Congress, the lawmakers who are supposed to deliver this package are despondent. They do not know what the president will accept and are not persuaded that huge federal spending will not result. There is real political fear on Capitol Hill. Wednesday night did not allay it.

 


 

 

 

 

Now Meet Those Too Big To Be Denied

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We have all heard about “too big to fail.” How about “too big to be denied?”

Step forward two commercial sectors that are certain to get in the way of President Barack Obama’s reform plans: the nation’s health insurers and its defense contractors.

 

The former are bound and determined to hold their lucrative position in any extension of health coverage to the uninsured. In this way, a new health agenda will be designed as much to accommodate the insurers as the patients and providers.

 

Likewise as Defense Secretary Robert Gates struggles to reform defense procurement and to cancel some weapons systems, he has to deal with the massive power of the defense giants. In defense, the customer is always wrong; and the vendors, through their congressional sponsors, overwhelm the department and get what they want, not what field commanders need or the national interest cries out for.

 

Ironically the Clinton administration strengthened the defense lobby, and its ability to push around the Pentagon, by orchestrating the consolidation of defense contractors into a few behemoths, as part of the downsizing of the military in the 1990s. Norman Augustine, chairman and CEO of Lockheed Martin from 1995-97, told me that during his tenure, Lockheed Martin had absorbed 19 small contractors.

 

The big contractors of today–Boeing, Lockheed Martin, General Dynamics, Raytheon, Northrup Grumman, BAE and the European wannabe EADS—have conscientiously scattered their manufacturing among many states. One program has components made in 44 states. That means jobs, and jobs mean political clout.

 

The health insurers, who succeeded in sinking the Clinton health care reform effort, are ready for some concessions, but only enough to insure their dominance. The health insurers and their conservative allies are expert in predicting the arrival of creeping socialism, unless the private insurers retain their supremacy in financing and profiting from the health care system. Ironically, they claim any larger government role in health care will lead to rationing. Yet it is the insurers who ration health care now; and if you are in an HMO they ration it severely, cruelly and sometimes lethally.

 

A favorite argument is that health care reform will substitute the judgment of doctors for the judgment of bureaucrats. One of the more appalling aspects of the current situation is that the insurance companies day to day substitute the judgment of clerks for that of doctors.

 

The health insurers will not be denied, but they feel it is reasonable to deny the evidence against them. When health care was in the operating theater in the l990s, and Hillary Clinton was poised to plunge in the scalpel, the insurers rose up against anyone who had evidence that the system was serving the companies, not medicine and not patients. They succeeded in banning from the debate what they dismissed as “anecdotal evidence.” They wanted the debate discussed on a level where they could dismiss reports of their own shortcomings, and conduct the debate in terms of capitalism versus socialism.

 

It is only now, with business crying out for reform, that the issue is being aired again.

 

My anecdotal evidence is this: I have lived under government-run medicine in England. It works well enough. The young are favored over the old there, whereas here the old are favored over the young here. Now I am on Medicare,which is remarkably like being on the National Health Service in Britain, except I am being favored over the young.

 

For 33 years, I ran my own publishing company in Washington. After payroll, the biggest expense was health care. To keep the cost down we changed the carrier frequently, to everyone’s inconvenience and a lack of continuity. When one employee had a rare and painful cancer, the insurance company paid for radiation and chemotherapy but denied payment for painkillers.

 

For years, ATT ran the telephone system and ordained that plugging in a phone could not be performed by a customer and black instruments were all that should be offered. They were, they thought, too big to be denied.

 

Robert Gates has shown guts in trying to deny the oligarchs of defense. Congress will need bravery in denying rent-takers in health care. Meanwhile, those who are too-big-to-be-denied are pumping dollars into Washington’s K Street, where the lobbyists carry their water.