Wednesday, July 22, 2009

A Few Items on the Issue of Health Care Reform

President Obama is slated to give a televised press conference tonight on the topic of health care reform. The debate over this issue has been heating up over the last few weeks and I feel that it is necessary to address a few items prior to Obama's press conference.

First it important to remind everyone that the House did pass the America's Affordable Health Choices Act last week. While this bill did not include any aspect of single-payer coverage (this option has been said to be "off the table" for some time now) it did include a strong public option. This essentially means that if this bill were to pass as is, Americans would be afforded a choice in their health care. Citizens could either keep the coverage that they currently have or decide to go with a kind of plan that is more government based. Jonathan Cohn also pointed out some of elements within this bill:

Once fully implemented, this reform plan will accomplish most of the goals on my mental checklist:

- Generous subsidies, available to people making up to 400 percent of the poverty line
- Expansion of Medicaid to cover people making less than 133 percent of the poverty line
- Guarantees of solid benefits for everybody, with limits on out-of-pocket spending
- Strong regulation of insurers, including requirements that insurers provide insurance to people with pre-existing conditions without higher rates
- An individual mandate, so that everybody (or what passes for everybody in these discussions) gets into the system and assumes some financial responsibility
- A public plan, one that appears to be strong, although I'll reserve judgment on that until I hear from the experts
- Choice of public and private plan, at first just for individuals and small businesses, but later for larger businesses and--possibly--eventually for everybody
Efforts at payment reform, if not necessarily as strong as they could be
- Investment in primary care and prevention, which is not sexy but potentially important for general health .

The cost of this bill is estimated at around $1 trillion dollars which Paul Krugman calls a "bargain" in contrasting it with leaving the system alone. The Congressional Budget Office (CBO) also concluded that this bill would be "deficit neutral" over the 10 year budget window and would even produce a $6 billion surplus. It was also released today in a report by the Commonwealth Fund Commission on a High Performance Health System that a bill which includes a choice in public and private care could save the nation $265 billion dollars in administrative costs over the next ten years.

The Senate is currently working on their own version of a health care reform bill which will likely look vastly different than the House version. The bills will then be debated on in committee and some type of compromise will likely emerge for Congressional vote.

It is important to note that despite very vocal opposition of the Republicans and some of the Blue Dog Democrats, the Republicans have not put forth their own version of a health care reform bill or offered much constructive suggestions to the existing legislative process. Republicans have repeatedly gone on television and utilized many of the same arguments against reform that they used to quash the health care legislation in 1994. Republicans also continue to claim that Obama is simply trying to "ram through" health care reform without giving them ample time to consider the proposals.

In recent days however it has become clear that the basis for these scare tactics and for the strategy of delaying passage of reform is rooted in the Republican quest to bring down President Obama by any means necessary. Republican talking points on the issue of health care reform, were leaked the other day and confirmed that they view this as a political opportunity. Here were the talking points:

* President Obama and Democrats are conducting a grand experiment with our economy, our country, and now our health care.

* President Obama's massive spending experiments have created more debt than at any other time in our nation's history.

* The President experimented with a $780 billion dollar budget-busting stimulus plan and unemployment is still rising. The President experimented with banks and auto companies, and now we're on the hook for tens of billions of dollars with no exit plan.

* Now the President is proposing more debt and more risk through a trillion dollar experiment with our health care.

* Democrats are proposing a government controlled health insurance system, which will control care, treatments, medicines and even what doctors a patient may see.

* This health care experiment will have consequences for generations, but President Obama and Democrats want to ram this legislation through Congress in two months.

* President Obama's health care experiment is too much, too fast, too soon. Our country cannot afford to fix health care through a rushed experiment.

* Americans want health care reform that addresses, not increases, cost or debt.

* Government takeover is the wrong way to go -- health care decisions should remain between the doctor and the patient.

digby does a good job of taking on these talking points one by one, but the goal here is clear. Republicans are not contributing any constructive ideas to this debate and their primary goal is to defeat Obama which they feel they can do in this debate on health care reform.

Separate from the official Republican Party opposition to the proposed reforms, I have heard from a few different conservatives a reference to the health care reform that Massachusetts passed in 2006 under the leadership of then Gov. Mitt Romney (R). The argument that is being advanced is the claim that the Massachusetts model of "government run health care" does not work. I find this argument odd because the Massachusetts Health Reform Law of 2006 did not implement a single-payer "government run" system. According to a study done by three Harvard Medical School Professors entitled "Massachusetts' Plan: A Failed Model for Health Care Reform":

Under the reform, the state committed to providing subsidized medical coverage to an expanded set of eligible individuals through the Medicaid program (called MassHealth in Massachusetts)and through a new insurance program, Commonwealth Care. A unique feature of the reform is the statutory “individual mandate” that requires most non-poor adults to purchase private(unsubsidized) health insurance policies or pay a fine.

Massachusetts simply made it a requirement that individuals (whose income exceeded 300% of the poverty rate) buy private health insurance coverage and fined people if they didn't. Massachusetts gave exemptions to individuals who did not meet this 300% threshold (about 79,000 according to the report), but all that meant is that not only did these individuals not get fined, but it also left them uninsured. The Massachusetts plan did very little to bring down costs and actually made it harder for the poor to receive medical care by forcing them to pay previously non-existent premiums and co-pays. In addition the report sites the following shortcomings of this reform:

- The reform did not achieve universal coverage
- The reform was more expensive than anticipated and because of this money is now being drained from public hospitals and community clinics.
- While access to health insurance increased under this reform, access to affordable care actually decreased.
- The reform reinforced the power of insurance companies due to the mandate on individuals buying private insurance plans.

The report concludes:

The nation must not look to Massachusetts’ health reform as a model. If we truly want to provide comprehensive health care for all of us at a price we can afford, we must adopt a single-payer plan.

So why on Earth am I hearing the argument from some conservatives that the system in Massachusetts is evidence that single-payer, government health-care doesn't work? It doesn't make one bit of sense and completely misrepresents why the reforms in Massachusetts did fail.

Lastly, since we are on the topic of single-payer, it needs to be noted that this option was been labeled as "off the table" by the Obama Administration and most members of Congress from the very beginning of this debate. The public option that is contained in the House bill is not the same thing as a single-payer option, so when you hear people running around yelling about the "government taking over health care", it is simply inaccurate.

Now this is not to say that a single-payer option should not be seriously considered. There have been a couple of very good conversations on this topic on recent editions of the independent news program Democracy Now!. Host Amy Goodman and co-host Juan Gonzalez recently sat down for a conversation with Howard Dean on the topic of health care and they asked him about the single-payer option:

HOWARD DEAN: Yeah, look, I don’t position myself against single payer, but I position myself for giving the American people a choice. I think what the President understands is the country is a conservative country with a small “c.” That is, they want change, but like most human beings, they don’t want so much that they’re uncomfortable. And so, the genius of the Obama healthcare plan is it’s not the healthcare plan that an academic would write in the ivory tower, but it starts from where we are, not where we would have been.

The Europeans all have single payer, because essential their healthcare systems were destroyed during World War II. And they went to a single payer during the war as a necessity, and then it turned out they loved it and didn’t want to get away from it afterwards. Winston Churchill was the person who put in single payer, essentially, in Britain, who was a conservative prime minister.

In this country, we didn’t have—we had exactly the opposite. Not only was our healthcare system not destroyed, but it was driven towards a private sector system, because it was the only way that you could give your employees wage increase in the price control and anti-inflation atmosphere around World War II. So here we are.

and then today Amy Goodman spoke with President Obama's longtime personal doctor for the last 22 years who has come out in support for a single-payer option:

AMY GOODMAN: So, can you look—tell us about the plan that is presented by the House and whether or not you support it?

DR. DAVID SCHEINER: The problem, overwhelmingly, is the issue, in my mind, of the private insurance companies being a part of the program. Their record has been so abominable that to have them in the program just doesn’t make sense. The cost—Ezekiel Emanuel, Rahm’s brother, made a comment in the Journal of the AMA that just the administration costs of employers’ health is over $300 billion a year. And that money will still be wasted. There will probably be even more advertising. The huge CEO salaries will continue to be made. I think the head of Aetna makes $23 million a year.

Insurance companies repeatedly interfere with the care of patients. The opponents of health reform keep saying that if the government gets into medicine, you won’t have a choice of your doctor, you won’t have a choice of your hospital, your care will be restricted. I don’t know where they got that. Medicare, if anything, is too permissive. Medicare never gets in my way. But insurance companies—I have to use special labs. I have to—I can use certain hospitals for one person; I can’t use them for another. I’m repeatedly getting responses from the insurance company disallowing certain procedures, disallowing certain medications. The insurance company is in the room every time I see a patient. And somehow, the patients think they have free choice. Medicare gives them free choice. They will have their choice of doctor. They will have their choice of treatment. With private insurance, that will not be the case. It’s an extraordinary waste of money.

And the public—if I had a single point to make about what is going wrong with this health reform is that the public is so uniformed. They think somehow that they get the best care in the world. We know by health statistics we’re thirty-seventh. Even people with good health insurance don’t realize that the healthcare they get is often not appropriate. Sometimes they get unnecessary treatment. The whole issue, for example, of prostate cancer, which is an extraordinary industry today, and there’s no proof that doing anything is of any value. But, you know, if I have a patient with prostate cancer, there’s no way I would sit back, because I know the trial lawyer is also in the room watching me. That’s another issue, which—there’s no way you’re going to control costs, if you don’t get that under control also.

As President Obama prepares to give his press conference this evening and as the debates and discussions continue, it is going to be necessary to recognize all the different layers that are involved when speaking about health care reform. Criticisms of the public option as a "government takeover" or as an abolition of private coverage are just accurate. No one in Congress is arguing for this even though there are many (like Dr. Scheiner and even myself) who feel that this option deserves to be considered and discussed.

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