Practice Makes Perfect!

....to say nothing about American dental care.

Barack Obama's amazingly consistent smile from Eric Spiegelman on Vimeo.

Beware the Pig in the Poke

The Baucus health care bill (will this this become the president's ???) is looking more and more like a pig in a poke. When the senator introduced the bill on the Senate floor this morning, he reportedly acknowledged its chief criterion was to be acceptable to any 60 senators who are needed for passage (short of the nuclear option).

Republican Senator Olympia Snowe (ME) announced her own criterion: no money added to the deficit. And there are some 584 amendments already proposed to the legislation.

All this makes me wonder...what happened to "reforming" health care? Why aren't senators concerned with ensuring the quality of our present system while expanding it to include those who are left out for reasons of income or pre-existing condition? Shouldn't the issue be resolving current problems in the most practical way possible rather than creating a grossly patchworked pig?

And to make matters worse, this morning Humana, the insurance company that provides Medicare Advantage plans that increase coverage for elderly purchasers, was told (on penalty of lawsuit) to stop sending letters to its customers informing them of the effect cutting Medicare funding will have on their premiums.

Say what? Is the pig also gobbling free speech rights? No wonder seniors are angry, and anyone with a knowledge of and appreciation for our Constitution should be also. This administration bumbles along with a heavy foot, whether through ignorance or intent.

The New English

It's hard to tell which came first, the chicken or the egg, but Senate Finance Committee Chairman Max Baucus (D. Montana) certainly tried to decipher the president's health care reform criteria: Not a dime added to the deficit....unless "spending cuts" are made if "savings" don't materialize. Of course Baucus could find "savings" only or almost exclusively in added costs and fees for consumers and providers of health care. The result is those with insurance will pay more for less to cover those without. That will save the government money. Meanwhile, those presently without health insurance will be forced to pony up some of their cash (and some of the taxpayers') to receive services many of them would not voluntarily have deemed worth their penny.

And all of us are left wondering what this has to do with health care "reform," although it certainly falls into the definition of "change" for one-fifth of our national economy.

Two areas of traditional savings have been identified by the administration: 1. electronic record keeping and 2. a $500 billion cut in Medicare (at the expense of seniors' popular Medicare Advantage supplement insurance programs). Writing in The American Thinker (http://tinyurl.com/lcb2wh), Dr. Gerald T. Reiss, a neurologist, finds the savings from eliminating paperwork will be negligible, but says electronic health records will save money "by using computer algorithms to override the medical decisions of doctors in favor of less expensive alternatives." And does that also mean "less effective" alternatives? The government will decide. As to Medicare Advantage, sorry, old folks.

Writing in Real Clear Markets (http://tinyurl.com/kkamxn), Diana Furchgott-Roth of the Manhattan Institute said the increase in health insurance premiums under the Baucus plan will be "a major cost...to the American public," and along the way wondered if this is "a major violation of President Obama's promise not to raise taxes on those making under $250,000 annually." Well, hey, is a government mandated "increased cost" synonymous with a tax raise? The administration will decide.

But there are a few pluses: The Baucus plan will cover most of those who don't already have coverage even if it's by threatening to impose fines of from $750 to $3,800 on those who don't comply...and by charging businesses a $400 fee per employee for not providing coverage. The Baucus plan will subsidize, on a sliding scale, insurance for those with incomes up to 300% of the federal poverty level by placing a 35% tax on high end plans (guaranteeing that they will become either more costly or less generous) and charge burdensome additional fees on both insurance providers and providers of medical devices (and that's not just scooter chairs, but knee and hip replacements and stents). Isn't it a bitch, being sick and getting old?

Doctors have been promised more reasonable Medicare reimbursement, but this is not included in the Baucus plan and would, naturally, add to its cost...possibly bumping it over "the not one dime added to the deficit" rule and thus requiring additional cost to consumers or a much to be regretted "sorry, Charley" notice to physicians.

One group that won't be affected by traumatic changes in health care provision are trial lawyers. Oh sure, the president made a curtsey to the concept of "tort reform" in his speech before the joint session of Congress. He'll look into a couple of isolated pilot projects to be conducted under the auspices of Health and Welfare Secretary Kathleen Sebelius, eight years head of the Kansas State Trial Lawyers Association... although The Wall Street Journal's Kimberly Strassel claims the dollar "savings" with tort reform are estimated at from $65 to $200 billion dollars annually (http://tinyurl.com/lhnj7w). Do you wonder how politicians missed that saving? Well, Strassel points as one example to Rhode Island Senator Sheldon Whitehouse, who rhapsodized about the virtues of the tort bar without mentioning the "nearly $900,000" it contributed to his reelection campaigns. But let's not be cynics.

Did we really expect a free lunch? And won't we feel the warm fuzzies of caring for our less fortunate citizens? ...well, perhaps citizens, perhaps residents. We'll see how that shakes out five or six or eight years down the road. We'll be able to decide then when it's change we can hardly believe happened.

More Conversation With a Liberal

(...a conversation begun earlier today and recorded below)

It should be noted that Hussein gassed thousands of his own people with gas that we (America) sold him and with our tacit approval. Secondly, it is against international law to attack a sovereign nation without provocation. Iraq was in no way involved in 911. Most of the terrorists on those flights were Saudis. Why didn’t we attack Saudi Arabia?

You are the umpteenth conservative that has said there are better ways to solve the health care crisis but none have forwarded a proposal that does so.

I am one of the millions of people that is essentially without health care and I am anything but indigent. I am self employed and in an industry that has been hammered by the economic mess created by the conservatives. I can’t afford health insurance for my family with a deductable of anything less than $10,000. So, the hernia surgery and the skin cancer surgery that I had in the last three years came out of my pocket. The health care system is designed to do one thing well, make money for insurance companies. I have had better health care in Mexico, New Zealand and Chile while on assignments for National Geographic and Sports Illustrated. I, a tourist, was covered by their national system. I couldn’t have paid if I wanted to, I was seen, the problem taken care of quickly and efficiently and I went on my way. America is the only non-third world country without a universal health care system. The scare tactics used by the insurance companies and their friends in congress are lies. Yes certain coverage is denied some people in some cases in those systems but I have news for you: ALL coverage is DENIED to MILLIONS of Americans due to lack of or insufficient health insurance because the costs have gotten out of hand.

Mark Gamba

www.markgamba.com

Well, Mark, can you please document that Saddam Hussein had "the tacit approval" of the US in gassing thousands of his citizens? Or do you mean, we did nothing to prevent or punish it, which, I'm afraid, fits your definition of deferring to a sovereign state.

As to reforming health care insurance...many sensible proposals to do so have been widely circulated on the internet, even popping into the main stream press occasionally. Here's a few:

1. Allow individuals to receive the same tax credit for the cost of individually purchased health care as businesses receive for employer provided care, thus severing health care insurance from employment and solving the "portability" problem.

2. Allow individuals to purchase the policy they want across state lines (at present individuals are limited to purchasing plans that may be inefficient or not what the individual wants because he must purchase health care in state).

3. Expand the number of plans available so that individuals are not required to purchase services that they do not want (perhaps, for example, IVF treatments or breast implants).

4. Work on the problem of "pre-existing conditions" so that an uninsured individual has options for covering a sudden diagnosis of, say, cancer. I'm not sure if this should be accomplished by requiring everyone to carry at least some health insurance (thus lowering the risk factor for insurance companies) or by creating state pools for such individuals.

5. Provide vouchers to the genuinely indigent to purchase insurance.

6. Initiate tort reform to limit rewards to actual damage in order to reduce the practice of "defensive medicine" and the cost of malpractice insurance that has become prohibitive for many doctors.


Now, I don't know the particulars of your situation, although you do not sound indigent. However, there are many millions of Americans who choose not to purchase health insurance because they are young and healthy; they take their chances. Others, I'm sure, face a definite budget strain when confronting the cost of health care, but their decision nevertheless involves choice. Personally, my husband and I spend almost 10 percent of our income on the cost of our share of the health insurance we carry.

I have no personal experience with health care in other countries. However, my son, who lives in London, has been shocked by brief contacts with the NHS there. His wait time for an antibiotic prescription was 6 weeks. His wife, who is Spanish, purchases private insurance from her employer. Nevertheless, when admitted for day surgery for a cyst, she was sent to a recovery room in which there were at least 40 others lying, separated by curtains. She has also lived in Denmark, where, she reports, satisfaction with public care is higher (but Denmark is a very small country).

I have a brother-in-law who has lived in China on a number of occasions, during one of which he had surgery (I believe for a hernia). He was delighted to be charged only the equivalent of some 90 dollars. However, at the time, 90 dollars was about three months' salary for the average Chinese.

I might point out also that emergency room treatment in the US is available to everyone; I imagine many problems are taken care of there "quickly and efficiently." Overall, satisfaction with the quality of care received in this country is very high. It's that quality which conservatives want to protect, and we believe this is possible while extending private coverage to the most needy.

Terri

Here is my issue with all of this, both your suggestions and the current plans wending their way through congress: Why not create a system by which we all pay one entity (the government for example) exactly what we pay for our health insurance (in your case 10% of your income) and that entity provides health care for everyone - period. No enormous profits for soulless corporations (insurance companies, hospitals etc). The profits made off of health care in this country are massive. That money could easily cover (the now reduced) costs of providing health care to all Americans. Simple, logical and workable.

I can answer that question easily: Because some very rich people want to continue getting richer.

Mark

Hi Mark,

I'm not sure how your system would work. Honestly, were my income to increase, would I want to continue to spend 10% on health care? If I were indigent and receiving care, would I want to contribute anything at all should I acquire assets? I think the fact is that most everyone is interested in becoming richer. We're not frozen in our circumstances.

And then, about that one entity... imagine its power. I realize you believe government is benign, but that's hard to support given any historical knowledge. You, yourself, obviously have greatly mistrusted the administration of George Bush. It's not inappropriate here to recall the words of Lord Acton: "Power tends to corrupt, and absolute power corrupts absolutely." This is a lesson played out again and again throughout history.

The advantage of power in the hands of corporations, soulless or not, is their plurality and consequently the competition between them. I've read that health insurance companies reap an average profit of 3 percent. This hardly seems outrageous even though, considering the sums involved, that must be a very large absolute figure. Were there only one health insurer, I suspect profit would be a great deal higher. And there would be little incentive to improve service beyond the goodness of the corporation's soulless heart. (Please note here that a non-profit is equally soulless except its excess is paid out more exclusively in executive salaries rather than stockholder dividends.)

I don't think there is an easy answer to solving problems in health care, and this is all the more reason to proceed cautiously and responsively (i.e. with fiscal restraint) rather than rush in pell mell with good intentions lacking sound judgment and ladened with hubris. Health care is after all a life and death proposition.

Terri

Profits are easy to disguise, anyone who has ever done their own taxes will attest to that, the facts on the ground are this: the current US Insurance industry estimates that 18% of every dollar paid by the insured is used towards “administration”, In France the health care system there spends about 6%, Germany – even less. So there is another 12% (at least) of the money available towards actual care of our health. 10% does seem high when you say it that way, but I spend more than that for insurance and don’t really get anything for it. At least if I was part of a system where all my health care was covered I would be getting something.

I do not believe that governments are benign but I also believe that most of the evil they do is at the bequest of corporations. Had not the tobacco industry spent millions and millions through their lobbyists for the reelection of certain congressmen I doubt the government would choose to subsidize the tobacco industry.

I know that you conservatives hate and fear Michael Moore and he is (like all good showmen) over the top, but he is none the less relatively accurate and his portrayal of the health care system in foreign countries is very similar to my own experiences. I would suggest that you have a glass of wine and sit down and try to watch Sicko even with a grain of salt, he makes it very clear that we do not have a health care system befitting the status of our country. Indeed most people from even decently developed countries enjoy better health care than most Americans do.

It’s a very broken system now and the rest of the world is aware of that. China is watching how and whether we deal with it and whether they continue to loan us money or call in their loans may well depend on our decision.

Best,

Mark

Hi Mark,

Let's take a look at this piece by piece:

1. "Profits are easy to disguise." I'll agree with you here with the caveat that it may not be all that easy for corporations that face much closer regulatory scrutiny than, say, the average small business. However, what this exposes, I think, is the total chaos, or if you prefer, corruption of our tax system that allows Congress to provide sticks and carrots according to the pleasure and often self-interest of particular members of Congress, their constituents, or whichever lobbyists grab their ears. This is certainly an argument for the reform of the IRS tax code, which the Obama administration has not made. In fact, we have a secretary of the treasury who successfully avoided paying his own tax bill until discovered to have done so in the confirmation process.

2. I'll accept the figure of 18% of health insurance benefits going toward administration. I'd even up your figure and say I suspect that a doctor might say that more than 18% of his staff time goes to complying with various insurance regulations (including federal or state Medicare and Medicaid regulations). I don't find the 18% figure totally outrageous. For example, have you ever investigated a charity to which you consider contributing? There's ratings for these. One group that rates is the American Institute of Philanthropy, and here's what it says on its website about its criteria: the "percent spent on charitable purpose" is "the portion of total expenses that is spent on charitable programs. In AIP's view, 60 % or greater is reasonable for most charities. The remaining percentage is spent on fundraising and general administration. Note: A 60% program percentage typically indicates a 'satisfactory' or 'C range' rating. Most highly efficient charities are able to spend 75% or more on programs."

Now, honestly, I'd rather not contribute to a charity that spends more than 15% on administration, but that's my choice.

As far as the lower administration expenses of government medical service in France and Germany, I think it is worth considering that funding is fungible and health services may benefit from sharing administrative costs with other government agencies... say accounting services. The charge has been made that in this country Medicare benefits in this way to achieve a supposed superior administrative efficiency over private health insurance.

3. I agree: a pox on government subsidy for tobacco, corn, ethanol, organic agriculture, etc.

4. This conservative neither hates nor fears Michael Moore; I look at him as a buffoon. However, I have not watched Sicko, but I am willing to submit myself to this agony... fortified perhaps not by a glass of wine, but a good shot of single malt scotch.

5. As to health care in "decently developed" countries, this concept is hard to categorize. I imagine many countries have adequate health care for the reasonably healthy. The U.S. has far superior healthcare for those who are seriously ill. We have five times the survival rate for cancer, for example, than does the U.K., which is a great deal more than "decently developed." On the other hand, the growing phenomenon of "medical tourism" indicates that very good health care is available more inexpensively than in the U.S. in some surprising places. I'm guessing that many of the techniques used were developed here. And this is a factor to consider when judging our health system: its innovation in creating new treatments... which, of course, is a costly proposition. Factoring it out is not quite cricket.

6. Finally, you betcha China is watching, but China is watching our fiscal integrity which is plummeting. It's no wonder China doesn't want to loan us any more money when we are heading to a 9 trillion dollar deficit (without adding a costly remake of health care). We are hell bent on pairing our first world health care with third world financing.

Best,

Terri

Parsing the NY Times on Health Care

One of my sisters graciously forwarded two articles from Sunday's NY Times, and here's my take on these:

The article entitled "A Basis is Seen for Some Health Plan Fears Among the Elderly" (http://tiny.cc/MlOig) certainly illustrates that fears among the elderly are a great deal more than "not entirely irrational" as the author puts it. Let's begin with "Bills now in Congress would squeeze savings out of Medicare, a lifeline for the elderly, on the assumption that doctors and hospitals can be more efficient"....right on, but begging the question, by the way, of any thought that the government can be more efficient than either.

The article says that "the House version of the legislation [and doesn't having different versions cause questions about trial balloons and the lack of seriousness in drawing up the legislation?] would help older Americans with their drug costs." Now wasn't this done under the Bush administration....to general satisfaction????

One, apparently pro- Obama plan individual is quoted saying the elderly are responding to "fear of the unknown." Of course, such fear on questions of their health care would not seem unfounded, but the article goes on to diss the elderly, "62 percent [of those over 45] said they were confused by the debate in Washington, compared with 43 percent of those under 65." I'd suggest that the 57% of those under 65, or most of them, have not followed the debate and know nothing beyond platitudes of the discussion, in other words they know not enough to be confused.

Finally, what do doctors think: "In effect Mr. Obama says he can cut bloated Medicare payments to inefficient health care providers without adversely affecting any beneficiaries. Many doctors are dubious." And..."Cardiologists will be especially hard hit...'Cuts of this magnitude could cripple cardiology practices and threaten access to services for millions of patients,' said Dr. John C. Lewin, chief executive of the American College of Cardiology."

Please bear in mind that the people who are proposing this massive change in an existing system with which most people are happy (note polls) have never run anything in their lives. How can they, honestly, make the claims they do to produce a successful, if volcanic, change in something as vital as American's health care?

The second article on the San Francisco public health plan ("A Public Option that Works" http://tinyurl.com/nuqvy4) is interesting, and I am not opposed to differing plans being tried locally or within states. However, this article leaves many questions unanswered and fails to mention that the San Francisco plan is being challenged before the U.S. Supreme Court (The court will decide on Oct. 5 whether or not to review the case)...but the suit, which is supported by the U.S. Chamber of Commerce and the National Association of Manufacturers, gives an indication that the response of the business world is not as approving as the opinion piece indicates. According to the San Francisco Chronicle (http://tinyurl.com/njo9v9 July 20), "More than 80 percent of the $200 million annual cost will come from state and local taxes and payment from patients, based on their incomes. The restaurant association's lawsuit challenges the city's authority to require large and midsize companies [over 19 employees] to pay the rest of the bill."

The Times' authors offer a 4 percent surcharge instituted at 25 percent of restaurants as a mitigating factor... acknowledging also that costs are passed on to employees in the form of lower or delayed pay raises. This does seem regressive to me, as would the restaurant association's desire to pay for the plan through a quarter percent increase in the sales tax.

Under the San Francisco plan, employers with between 19 and 100 employees must add $1.85 per hour cost per employee for "pay or play" ($1.23 for those with over 100 employees). This is a substantial employment cost, and despite the assurances of the authors (offered without statistical backup) that employment in San Francisco has not suffered, it is a cost that would make most small business owners shudder.

There's nothing in this article that informs on satisfaction with the plan among users. It has the advantage that a national plan would not have of not affecting the health care of those satisfied with their current coverage (about 87% of Americans, I believe). The article mentions that Massachusetts has a public health plan without offering any details, and this is as well since the Massachusetts plan is rapidly heading for insolvency.

A Conversation With a Liberal

I had an interesting exchange of emails with a liberal this morning:

I'm fascinated that a person who loves the english language would prefer Bush to Obama or has my quick read of your site misrepresented you? I was looking for a description of plum duff on a whim and found you. I think that the current administration is at least in touch with reality whereas the previous one was not even on speaking terms. Not to mention the fact that Obama is a damn decent orator in this day and age and bush could barely string a coherent sentence together. And all this is mere superficiality. Bush got us into two wars neither of which was well reasoned and he put the final nail in the coffin of our economy. He also ignored all of science during a critical juncture in history. How can any thinking person still hold their head up and say "I'm a conservative"? The last eight years has caused conservativisim to equal having your head in the sand or worse.

best,

Mark Gamba

www.markgamba.com

Hi Mark,

I'm glad you stumbled upon my site and were fascinated. I must say that having just visited your site, I am astounded by the excitement and beauty of your photography.

However, I must confess to being conservative; therefore, although I am impressed by Obama's rhetorical skills in delivering a speech, I must judge him by his policies with which I largely disagree. Also, when he is speaking without a teleprompter, I find the president's rhetoric merely mediocre. He doesn't measure up at all to JFK or for that matter Ronald Reagan in his performance at press conferences, and he employs the most tone-deaf press secretary that we've seen in ages.

Of course how something is said is important, but nevertheless not the message. And in addition, should you read much of the political commentary of the day, I think you may find that conservative writers have better skills and employ logical thinking much more so than liberal commentators (even allowing for a wide range of exception in both categories).

So we must agree to disagree on politics, but I thank you for responding and giving me an opportunity to enjoy your work.

Terri Choate

Conservative writers may be better writers because spin is their biggest ally. The liberals count on truth and reality, both of those are given short shrift these days. Reagan spoke well, indeed. I would not agree that he speaks any better than Obama. I would also point out that Reagan was often lying or mistaken in order in ramp up his hyperbole. Again, the truth is never as glamourous as fiction.

Mark Gamba

Hi Mark,

I can agree that the truth is never as glamourous as fiction...but here's the rub: how can you assume that the Obama administration is speaking the "Truth"? For example, how can this administration claim it can reduce the cost of a Medicare program that already faces insolvency while adding millions of additional recipients and not reducing services? The president has no practical experience in administration (along with most politicians) and cannot honestly make this claim. I also question your faith that liberals, as opposed to conservatives, count on truth and reality. This is an enormous oversimplification.

I respect your concern about truth but believe you need to investigate further...and rely on individual instances.
Best,
Terri

Weapons of mass destruction for example? If Obama gets us out of Iraq, the money not spent there will easily cover the deficit in health care spending.

Mark Gamba

Hi Mark,

Well, weapons of mass destruction are rather old stuff. Like George Bush, and many others, I did believe Saddam Hussein harbored weapons of mass destruction: He certainly gassed thousands of his own population. I also believe that Hussein's repressive administration equaled genocide, reason enough to remove the bastard. I realize, however, this is a slippery slope and can appreciate that you consider internal abuses less than grounds for war (would you feel the same way about fighting Hitler in WWII?). I must admit I am dismayed that liberals show such little regard for human rights in oppressive Muslim countries...while they push for extreme niceties in Western nations.

And I dispute that ending US spending in Iraq (which is happening) will fund public health care for many months...to say nothing of the question of Afghanistan, where at least for the moment, Obama supports a war. I do agree he should; I suspect you do not.

I cover health care quite a bit on my blog. I believe there are many better solutions to health insurance reform than a monumental, necessarily exploding public option. As far as I am concerned it would be easier, more practical, and more affordable to issue vouchers to the truly indigent to buy health insurance without interfering with the coverage of everyone else.

Terri

Democrats Stoop To Censorship

From Saturday's Washington Post:

GOP: Democrats Censoring Mail on Health Care

House Republicans have been prohibited from mailing out this diagram of Democrats' health-care reform plan.

By Ben Pershing
The partisan debate over health-care reform has trickled down into one of the more arcane corners of the House -- the committee on free mail, otherwise known as the Franking Commission.

One of the perks of being a member of Congress is that each lawmaker is allowed to send "franked" -- or free -- mail, as long as it is related to official business. Members use that ability to send newsletters and legislative updates to their constituents. To ensure that privilege is not used inappropriately, a majority of the bipartisan six-member Franking Commission must approve each piece to ensure it meets some basic guidelines. Mail is blocked only on rare occasions.

But now the commission has gotten involved in the health-care fight, prohibiting several Republican lawmakers from mailing out reproductions of a colorful, labyrinthine chart that purports to diagram Democrats' reform plan. The controversy was first reported by Roll Call.

The chart was produced by the Republican staff of the Joint Economic Committee and has become a popular visual aide on the minority side of the aisle, as the GOP attempts to convince the public that the majority's plan will be a confusing disaster. But Democrats have argued that the chart is an inaccurate representation of their health-care efforts, and for that reason, the three Democrats on the Franking Commission say the GOP can't use it in official mail. House guidelinessay that in franked mail, "Comments critical of policy or legislation should not be partisan, politicized or personalized." But what about information that's inaccurate, or -- arguably -- just misleading?

"We have never before censored anybody's presentation of facts this way," Rep. Dan Lungren (R-Calif.) complained in an interview Friday.

Lungren, the top Republican on both the Franking Commission and the House Administration Committee, said the commission has never traditionally played a fact-checking role. He pointed out that Democrats this year have sent out numerous pieces of franked mail touting the number of jobs created by the economic stimulus package, and while Republicans might disagree with those numbers, they've never moved to block the mail from being sent out.

"We let those things go by, even though we don't think it's true," Lungren said, adding that he knows of at least 15 Republicans who have asked to mail out copies of the health-care chart in question. (For some context, Rep. Kevin Brady (R-Texas) explains the chart's purpose here. Ezra Klein mocked the chart here, and includes a chart of Republicans' own health-care "plan." )

The controversy extends beyond the colorful chart. Salley Collins, a spokeswoman for House Administration panel Republicans, said GOP members were also being told by the Franking Commission that they could not refer to "government-run health care" in their mailings, and had to dub it "the public option" instead.

Democrats, led by Franking Commission Chairwoman Susan Davis(Calif.), say they are trying in good faith to negotiate a compromise with Republicans on this subject. If the impasse isn't resolved, watch for the GOP to turn up the volume on the controversy next week.

By Ben Pershing | July 24, 2009; 3:06 PM ET
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