Is the House Health Care Bill Better than Nothing?

What to make of the health care bill passed late in the night on 11/7?

Below are two (long) commentaries by writers I greatly respect.  Marcia Angell is the iconic former editor of the New England Journal of Medicine and a stalwart single payer advocate.  Maggie Mahar is a thoughtful non-single-payer healthcare writer, the author of Money Driven Medicine, and someone I admire although don’t always agree with.  It’s worth the time to read both of these as we figure out where we should go from here.

– Rob

Is the House Health Care Bill Better than Nothing?

By Marcia Angell, M.D.Physician, Author, Senior Lecturer, Harvard Medical School  November 8, 2009 08:02 PM

Conservative rhetoric notwithstanding, the House bill is not a “government takeover.” I wish it were. Instead, it enshrines and subsidizes the “takeover” by the investor-owned insurance industry that occurred after the failure of the Clinton reform effort in 1994. To be sure, the bill has a few good provisions (expansion of Medicaid, for example), but they are marginal. It also provides for some regulation of the industry (no denial of coverage because of pre-existing conditions, for example), but since it doesn’t regulate premiums, the industry can respond to any regulation that threatens its profits by simply raising its rates. The bill also does very little to curb the perverse incentives that lead doctors to over-treat the well-insured. And quite apart from its content, the bill is so complicated and convoluted that it would take a staggering apparatus to administer it and try to enforce its regulations.

What does the insurance industry get out of it? Tens of millions of new customers, courtesy of the mandate and taxpayer subsidies. And not just any kind of customer, but the youngest, healthiest customers — those least likely to use their insurance. The bill permits insurers to charge twice as much for older people as for younger ones. So older under-65’s will be more likely to go without insurance, even if they have to pay fines. That’s OK with the industry, since these would be among their sickest customers. (Shouldn’t age be considered a pre-existing condition?)

Insurers also won’t have to cover those younger people most likely to get sick, because they will tend to use the public option (which is not an “option” at all, but a program projected to cover only 6 million uninsured Americans). So instead of the public option providing competition for the insurance industry, as originally envisioned, it’s been turned into a dumping ground for a small number of people whom private insurers would rather not have to cover anyway.

If a similar bill emerges from the Senate and the reconciliation process, and is ultimately passed, what will happen?

First, health costs will continue to skyrocket, even faster than they are now, as taxpayer dollars are pumped into the private sector. The response of payers — government and employers — will be to shrink benefits and increase deductibles and co-payments. Yes, more people will have insurance, but it will cover less and less, and be more expensive to use.

But, you say, the Congressional Budget Office has said the House bill will be a little better than budget-neutral over ten years. That may be, although the assumptions are arguable. Note, though, that the CBO is not concerned with total health costs, only with costs to the government. And it is particularly concerned with Medicare, the biggest contributor to federal deficits. The House bill would take money out of Medicare, and divert it to the private sector and, to some extent, to Medicaid. The remaining costs of the legislation would be paid for by taxes on the wealthy. But although the bill might pay for itself, it does nothing to solve the problem of runaway inflation in the system as a whole. It’s a shell game in which money is moved from one part of our fragmented system to another.

Here is my program for real reform:

Recommendation #1: Drop the Medicare eligibility age from 65 to 55. This should be an expansion of traditional Medicare, not a new program. Gradually, over several years, drop the age decade by decade, until everyone is covered by Medicare. Costs: Obviously, this would increase Medicare costs, but it would help decrease costs to the health system as a whole, because Medicare is so much more efficient (overhead of about 3% vs. 20% for private insurance). And it’s a better program, because it ensures that everyone has access to a uniform package of benefits.

Recommendation #2: Increase Medicare fees for primary care doctors and reduce them for procedure-oriented specialists. Specialists such as cardiologists and gastroenterologists are now excessively rewarded for doing tests and procedures, many of which, in the opinion of experts, are not medically indicated. Not surprisingly, we have too many specialists, and they perform too many tests and procedures. Costs: This would greatly reduce costs to Medicare, and the reform would almost certainly be adopted throughout the wider health system.

Recommendation #3: Medicare should monitor doctors’ practice patterns for evidence of excess, and gradually reduce fees of doctors who habitually order significantly more tests and procedures than the average for the specialty. Costs: Again, this would greatly reduce costs, and probably be widely adopted.

Recommendation #4: Provide generous subsidies to medical students entering primary care, with higher subsidies for those who practice in underserved areas of the country for at least two years. Costs: This initial, rather modest investment in ending our shortage of primary care doctors would have long-term benefits, in terms of both costs and quality of care.

Recommendation #5: Repeal the provision of the Medicare drug benefit that prohibits Medicare from negotiating with drug companies for lower prices. (The House bill calls for this.) That prohibition has been a bonanza for the pharmaceutical industry. For negotiations to be meaningful, there must be a list (formulary) of drugs deemed cost-effective. This is how the Veterans Affairs System obtains some of the lowest drug prices of any insurer in the country. Costs: If Medicare paid the same prices as the Veterans Affairs System, its expenditures on brand-name drugs would be a small fraction of what they are now.

Is the House bill better than nothing? I don’t think so. It simply throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and it augments the central role of the investor-owned insurance industry. The danger is that as costs continue to rise and coverage becomes less comprehensive, people will conclude that we’ve tried health reform and it didn’t work. But the real problem will be that we didn’t really try it. I would rather see us do nothing now, and have a better chance of trying again later and then doing it right.


Why Congress’ Health Care Bills Are Better Than You Think

By Maggie Mahar, Health Beat. Posted November 6, 2009.

Many progressives are expressing deep disappointment with the health reform legislation now moving through Congress.

Some suggest that some legislators made deals with lobbyists and let them write the bills. Others complain that both the subsidies and the penalties are too low. Still others don’t like the fact that states can “opt out” of the public insurance option and decide not to offer “Medicare E” — Medicare for everybody.

Finally, many ask: “Why can’t everyone sign on for the public plan in 2013? Why do we have to wait until 2013? Why can’t they roll out universal coverage next year?”

Normally, I would be among the first to critique the bills. By temperament and training, I’m both a skeptic and a critic.

But in this case, I think it is important to recognize that we cannot expect this first piece of health reform legislation to be anything but wildly imperfect. In fact, I’m impressed by the progress Washington has made in just 10 months.

I’ve been watching the struggle for health care reform since the early 1970s, and compared to what has happened over the past 39 years, this is mind-boggling.

I also believe that those who favor overhauling our health care system should send a strong signal to legislators: We support you for having come this far. We realize that you have three years to strengthen, change and refine the plan before rolling it out in 2013.

What Has Been Accomplished So Far: Affordability

What is astounding is that this Congress has made as much progress as it has. We may have a new administration in the White House, but we do not have a brand-new group on the Hill.

The majority of our legislators are moderates; many are conservatives. Nevertheless, a sufficient number have found the will to stand up and back changes that would make health care affordable for millions of poor, working-class and middle-class Americans.

For example, under the House bill, a family of three making $32,000 a year would pay $1,360 in annual premiums for good, comprehensive coverage; under the Senate Finance Committee bill, that family would be asked to lay out $2,013. Today, without reform, if that family tried to buy insurance, it would find that the average plan costs $13,500. For this household, the current legislation makes all the difference.

Too often, the press suggests that such a family would be expected to pay $10,000 out of pocket to cover co-pays and deductibles. That just isn’t true.

Even if the entire family were in an auto accident and racked up $200,000 in medical bills, at their income level, the House bill caps out-of-pocket expenses at $2,000 a year. Under the Senate Finance bill, the family would have to pay $4,000.

Moreover, under both bills, there are no co-pays for primary care. Even private insurers cannot put a $25 barrier between a family and preventive care.

Moving up the income ladder, a median-income household earning roughly $55,000 would pay premiums of $4,300 to $6,500 — depending on whether the Senate Finance bill or the more generous House bill sets the terms.

Without legislation, they too would face a $13,500 price tag — and that is if they could get a group rate. If they are buying insurance on their own, coverage could easily cost $16,000.

For self-employed workers, early retirees and those who work for (or own) a small business, the legislation offers major savings.They will be able to buy coverage on the Insurance Exchange, where they would suddenly become part of a group — which makes their premiums much lower.

Whether rich or poor, this is great news for anyone who works for himself, retired early (voluntarily or involuntarily) or is part of a small firm.

Granted, the legislation now on the table still doesn’t make insurance affordable for many Americans at the upper edges of the middle class — or the upper class. They don’t qualify for subsidies. But, as I discuss below, the legislation does point the way to lowering their premiums.

Before reform becomes a reality in 2013, I am convinced that this will happen, in part because it must. We can no longer ignore the waste, inefficiency and pure fraud in our health care system. There is absolutely no reason why we should pay so much more for health care than any other nation in the developed world.

And at least the current legislation protects these more affluent households from medical bankruptcy. No matter how much a family earns, they cannot be asked to pay more than $10,000, out of pocket, in a given year. For households that have savings and property to protect, this means that they don’t have to worry about being wiped out by a medical disaster.

Even if you and your family are in that car accident that leads to $200,000 in doctors’ and hospitals bills, you will owe only $10,000. In that situation, doctors and hospitals will let you pay off your bills over time, because they know you can. You won’t be forced into bankruptcy court. This represents an enormous step forward.

In addition, under reform, private insurers will not be able to put a cap on how much they will pay out to you and your family, over the course of a year or over a lifetime. If tragedy strikes and a child needs six or seven years of cancer treatments, your insurance will not “run out.”

For some families, this one provision will mean the difference between being able to care for their child and financial ruin (coupled with the suspicion that, if they had just had more coverage, they might have been able to save their child).

Moreover, in the very first year of reform, the public plan will offer less expensive, higher-quality coverage to uninsured Americans, the employees and owners of small firms, and those who now buy their own insurance in the private sector.

Congressional Budget Office Director Douglas Elmendorf has been spreading misinformation about the government plan, asserting that only 20 percent of those who are eligible for the Exchange will choose it. His offers no evidence for this claim — just a string of “probablies.”

He then argues that despite the fact that its administrative costs will be far lower than those of private insurers, the public plan will cost more than comprehensive private insurance. This theory is based on the unfounded assumption that only one-fifth of Exchange shoppers will pick the government option, coupled with speculation that those running the public plan will make no effort to control costs and utilization.

For peculiar reasons that I don’t fully understand, progressives have been listening to Elmendorf’s numbers. They seem to forget his past: He was mentored by Martin Feldstein, known as the dean of conservative economists. Elmendorf first made his mark in Washington by helping to quash the Clintons’ hopes for health care reform.

Coverage Denial Is Forbidden

Finally, under the House and Senate reform bills, insurers will no longer be able to deny coverage, or charge a customer more, because of a pre-existing condition.

If you’ve begun to take that idea for granted, keep in mind that the Republican’s recent 11th-hour proposal for reform “gives the insurance industry more leeway” as the Wall Street Journal put it yesterday. (Media Matters points out that this WSJ story disappeared from the paper’s Web site sometime last night.) Under the Republican proposal, insurers would be able to take pre-existing conditions into consideration.

House Speaker Nancy Pelosi’s health care reform fact sheet offers two outrageous examples of just how easy it is for insurers to deny coverage today:

Peggy Robertson: The Colorado mother of two was denied health coverage because she had a C-section in 2006. The insurance company told her if she got “sterilized” she would be eligible for coverage.

Christina Turner: After being sexually assaulted in Florida, Turner followed her doctor’s orders and took a month’s worth of anti-AIDS medication as a precautionary measure. She never developed an HIV infection. Months later, when shopping for new health insurance coverage, Turner was repeatedly denied coverage because of the precautionary anti-HIV treatment she received after being raped.

Today, in most states, this could happen to anyone. (I am fortunate to live in New York, where we have community rating, so I don’t have to worry about pre-existing conditions. My employer provides excellent insurance, with no annual or lifetime caps, so the current reform legislation would probably have no immediate effect on my life.) We all should recognize that the bills on the table would change the lives of millions of Americans, giving them the security they don’t have today.

Progressives cannot let this opportunity slip through our fingers because we are so busy critiquing the legislation — and arguing with each other. The Wall Street Journal Online reports that Senate Majority Leader Harry Reid has begun to warn that the Senate may not be able to complete the legislation by the end of this year.

Given all of the criticism he has faced, Reid could be losing heart. After all, conservatives continue to argue that legislators like Reid will be punished at the polls. Congressmen who have been pushing for reform need our encouragement. Progressives should continue to make it clear that the majority of Americans want reform — and a public option — even if the legislation is far from perfect.

Next year, the 2010 election campaigns will be in full swing. Fearful of losing, some members of Congress will begin to back away from change, so it is critical that broad reform legislation is passed this year.

Over the next three years, it can be amended as the crucial details are fleshed out. Anyone who thought that Congress would be able to overhaul a $2.6 trillion industry with just one bill was, I submit, terribly naïve.

What Remains To Be Done In the Next Three Years

There is so much to be done to lay the groundwork for a reformed system — this is one reason reform cannot be implemented until 2013:

Congress must figure out how to regulate the private insurance industry. This will require enormous cunning.

Reformers will have to find a way to stiffen the penalties for those who choose not to buy insurance, without alienating young, healthy voters. This is a job for a charismatic president.

Legislators must map out how the Insurance Exchange will work.

They also will need to come up with a formula that will adjust for risk if one plan winds up with a larger share of poor and sick customers. (Some fear that this will happen to the public plan, so this, too, is a crucial detail.)

Finally, and perhaps most importantly, Medicare needs time to begin eliminating waste in the system — saving billions of health care dollars while simultaneously lifting the quality of care. In fact, while all eyes are focused on the legislation, Medicare already has begun putting its own house in order.

What the Current Proposed Public Plan Offers

What many reformers don’t seem to understand is that when the public plan begins to negotiate fees with providers in 2013, Medicare fees for some very expensive services will be significantly lower than they are today, while reimbursements to primary care doctors will be substantially higher.

Medicare already has announced plans to cut fees for CT scans and MRIs by as much as one-third and has proposed trimming fees to cardiologists by 6 percent next year. Meanwhile, it would hike fees for primary care physicians by 4 percent.

Congress has 60 days to respond, or the changes take effect Jan. 1. Over the next three years, we can expect more changes in the fee schedule. And private insurers will follow Medicare’s lead. As their representatives explained to the Medicare Payment Advisory Commission (MedPAC), they just want Medicare’s actions to provide political cover for their own.

In other words, the public plan will be negotiating fees with providers in a very different, less expensive and more rational context.

This is another reason why public-plan premiums will be significantly lower than the CBO’s Elmendorf suggests.

Over the next three years, Medicare will be realigning financial incentives to reward preventive care and management of chronic diseases, while reducing payments for overly aggressive tests and treatments that have no proven benefit — and penalizing hospitals that don’t pay enough attention to medical errors. In the process, Medicare will be conserving health care dollars while protecting patients from needless risks.

As President Barack Obama has promised, Medicare cuts can make health care safer and more affordable for everyone — including the upper middle class. Because most private insurers will mime Medicare’s efforts to reduce overpayment, the cost of care will come down for everyone.

The public health insurance plan will incorporate Medicare’s reforms, and it will have clout. Seven percent of Americans now buy their own insurance in the private sector market. Most are neither poor nor sick. (If they were, they wouldn’t be able to purchase insurance.) More than half earn over $55,000. They will be able to go into the Exchange and sign up for the public plan.

Other middle-class self-employed Americans who cannot afford to buy individual insurance will join them in the Exchange, where they will automatically become part of a group. In addition, a large share of relatively young Americans (age 25-34) are uninsured. Most are relatively healthy. No one knows how many will choose the public plan, but since it will have much lower administrative costs than private-sector plans, it will be less expensive. This should make it attractive to younger Americans.

Finally, even if the Senate’s opt-out provision for states remains in the final health care reform bill, states will not opt out. It would be too difficult for politicians to try to explain to voters why they cannot have access to a government plan that will be able to offer comprehensive insurance for less than what they pay for private insurance.

The Enemy of the Good

If there ever was a time to avoid the traps of perfectionism, it’s now. As the old saying goes, don’t let the perfect be the enemy of the good.

And there’s a lot that’s good in the bills coming out of the House and Senate. No, they’re not perfect, but they offer a path to even better reform in the future while improving the lives and health care outcomes for millions of Americans. And that is all to the good.


Time to Play the Single Payer Card

Rob Stone MD  March 30,2009

“First they ignore you, then they ridicule you, then they fight you, then you win.”  – Ghandi

A health care reform bill out of Congress by the end of the summer?  An end to our national nightmare within five months?  The health insurance industry is banking on an Obama-Kennedy-Baucus bailout – “universal” health care, with taxpayer subsidies for those who can’t afford the unaffordable premiums.

Right now the insurance gang is controlling the debate, with big headlines about how they will give up a few of their most egregious behaviors and accept a modicum more government oversight as long as we mandate that everyone become their customer.  And, most importantly, don’t let the Socialists have their way and allow a Medicare-like “public option.”  They cry that it would be unfair competition to ask the for-profit insurance companies to go up against a government run plan. 

If they think the government can do so much better than they can, why don’t we listen to them?  Let’s go ahead and put everyone in a government plan!

The strategy from the industry and their Republican allies is obvious – appear to offer a series of compromises, but draw the line to prevent any government plan.  Wrap it all up in a big package and proclaim that we’ve got a uniquely American solution to our problem: a huge system of taxpayer subsidies to the insurance industry, with no mechanism to control costs, because there are too many big money interests who don’t want to see real cost control.  They are happy to expand access to insurance because it makes good business sense to create more customers.

The strategy of Obama, the Democrats, many labor leaders, and “progressive” groups like Healthcare For America Now is equally clear.  Let’s offer a compromise plan with many complex features, all of which need to be clarified and debated, and hope that we can get the whole thing through Congress intact, including the public option.  This is a strategy for failure.  The public option will be the part that gets compromised out.

Many prominent progressives like Paul Krugman and Jacob Hacker have argued that the public option is the key to the whole reform process.  The public option will constrain the rapacious insurance companies.  The public option will be popular and efficient.  The public option will be, at its best, a slippery slope to a single payer plan.  Never mind that critics have pointed out that if the public plan is enacted, the insurance companies will find ways to game the system again.  Never mind that the Right has recognized the slippery slope argument, and that is why they are so adamantly against it.

This calls for an obvious change in the Democrats’ strategy.  Up to now they have tried hard to keep the voices for single payer out of the debate. They have reassured the Republicans that single payer isn’t even “on the table.”  If they want to have a chance to get the public option through Congress, it‘s time for a new strategy.  Time to play the single payer card. 

Purely from a strategic perspective, the President should put single payer back on the table and start explaining to the people all the advantages of Medicare for All.  Then, when the going gets tough in the trenches of Congress, they can compromise and  settle for the public option, and a muscular enough public option that it could serve as a model (a slippery slope) for an eventual single payer system. 

Of course, maybe once the single payer cat is out of the bag, the weight of logic and public support will just push the insurance gang right out of the way.


National Call-in Day February 12


The National Single Payer Alliance

National Call-in Day for HR 676
February 12, 2009     Lincoln’s Birthday

Dear Friend,
The Leadership Conference for Guaranteed Healthcare is encouraging everyone to participate in the next National Call-in Day for HR 676. Mark your calendars.
February 12, 2009: Call Congress – Congressional switchboard: 202-224-3121 – ask for your representative’s office, and the President – 202-456-1414
If your member is a current co-sponsor,  thank your rep. and ask him or her to stand firm for HR 676 and actively seek additional co-sponsors.
If your member was a co-sponsor in the last Congress, ask him or her to sign on immediately as a co-sponsor in this Congress.
If your member has yet to co-sponsor HR 676, ask him or her to please become a co-sponsor, select one or two talking points here.

In a letter to Col. William F. Elkins written November 21, 1864, Lincoln wrote: “I see in the near future a crisis approaching that unnerves me and causes me to tremble for the safety of my country. . . . corporations have been enthroned and an era of corruption in high places will follow, and the money power of the country will endeavor to prolong its reign by working upon the prejudices of the people until all wealth is aggregated in a few hands and the Republic is destroyed.”
In celebration of Abraham Lincoln’s birthday, remind your member of Congress to honor his words and heed his warning as we look to reform his precious nation’s healthcare system. 

Quentin D. Young, MD
National Coordinator
Phyisicans for a National Health Program

Donna Smith
Community Organizer
California Nurses Association
National Nurses Organizing Committee

PDA National Healthcare NOT Warfare Co-Chair

Tim Carpenter
Executive Director
Progressive Democrats of America

Katie Robbins
Assistant National Coordinator

P.S. Don’t forget to call (202-456-1414) or fax (202-456-2461) the White House to make sure our current President recalls how very troubled another young lawyer from Illinois was as he viewed the future of the nation under the control of the monied and corporate interests just like those swirling in the for-profit health insurance industry.


Is Daschle part of the problem or part of the solution?

Published on Saturday, January 31, 2009 by Politico
Health Care Groups Paid Daschle $220k

by Kenneth P. Vogel

Tom Daschle, tapped to be President Obama’s health czar, was paid more than $200,000 by the health-care industry in the past two years, according to documents obtained by Politico.

[US President Barack Obama’s pick for secretary of health and human services, Tom Daschle, seen January 8, paid over 100,000 dollars in back taxes in January after failing to report services from a wealthy friend, US media reported Friday. (AFP/Getty Images/File/Mark Wilson)]US President Barack Obama’s pick for secretary of health and human services, Tom Daschle, seen January 8, paid over 100,000 dollars in back taxes in January after failing to report services from a wealthy friend, US media reported Friday. (AFP/Getty Images/File/Mark Wilson)
The former Senate majority leader, who gave speeches to firms and groups with a vested-interest in the administration’s upcoming health reform, collected the checks as part of a $5 million windfall after he lost reelection to his South Dakota seat.

This weekend, Daschle’s nomination to be secretary of Health and Human Services became embroiled in controversy over the last-minute revelation that he had only recently paid long-overdue taxes.

Daschle made nearly $5.3 million in the last two years, records released Friday show, including $220,000 he received for giving speeches, many of them to outfits that stand to gain or lose millions of dollars from the work he would do once confirmed as secretary of Health and Human Services.

For instance, the Health Industry Distributors Association plunked down $14,000 to land the former Senate Democratic leader in March 2008. The association, which represents medical products distributors, boasts on its website that Daschle met with it after he was nominated to discuss “the impact an Obama administration will have on the industry.”

This week, the group began openly lobbying him, sending him a letter urging him to rescind a rule requiring competitive bidding of Medicare contracts.

Another organization, America’s Health Insurance Plans, paid $20,000 for a Daschle speaking appearance in February 2007. It represents health insurance companies, which under Obama’s plan would be barred from denying coverage on the basis of health or age.

There was a $12,000 talk to GE Healthcare in August, a $20,000 lecture in January to Premier, Inc., a health care consulting firm, and a pair of $18,000 speeches this year to different hospital systems, among other paid appearances before health care groups.

The speaking fees were detailed in a financial disclosure statement released Friday, which showed that Daschle pulled down a total of more than $500,000 from the speaking circuit in the last two years, and $5.3 million in overall income.

That includes more than $2 million in consulting fees from InterMedia Advisors, a private equity firm.

Daschle, who represented South Dakota in the Senate for three terms, initially failed to pay taxes on the free use of a car and driver that had been provided to him by InterMedia’s founder, high-rolling Democratic donor Leo Hindery Jr., according to the New York Times. It reported that Daschle this month paid more than $100,000 in back taxes and filed amended tax returns.

Daschle reported $182,520.26 of “company provided transportation” on the disclosure form, which also indicates he owns a stake in the company worth between $200,000 and $500,000, as well as a “5 % limited partner profit sharing interest.”

But he reported that only about half of his interest is vested, and he indicates that “upon confirmation, I will divest all my vested shares and unvested shares and relinquish any benefit to which I may otherwise be entitled.”

Daschle reported that he has been a consultant and chair of the company’s advisory board since January 2005, the same month he left the Senate after being upset in his reelection bid by Republican John Thune.

He also became an adviser to the law and lobbying firm Alston & Bird, which paid him $2.1 million in wages last year and also provided him a 401k and profit sharing plan worth between $100,000 and $250,000, according to the report.

In his three years at the firm, it’s earned more than $16 million lobbying on behalf of some of the health care industry’s most powerful interests before the department he’s in line to lead. Though Daschle himself did not register to lobby for the firm, he has advised the firm’s clients on health care issues, according to the firm’s website.

His disclosure indicates he provided “policy advice” to such clients as United Health, AT&T and the politically connected consulting shop Glover Park Group.

After leaving the Senate, Daschle also landed a host of lucrative board spots, including with the energy giant BP Corporation, which paid him $250,000 in fees, developer CB Richard Ellis, which paid $121,000, and ethanol processor Mascoma Corporation, which paid him $75,000, according to the disclosure.

It shows that Daschle has hundreds of thousands of dollars in stocks and options from CB Richard Ellis and Mascoma, though he indicated he forfeited his unvested stock options and wrote that “if confirmed, I will divest my vested stock options with CB Richard Ellis.”

He reported owning homes worth as much as $250,000 each in Aberdeen, S.D., and Altus, Okla., with his wife, a high-powered lobbyist for Baker, Donelson, Bearman, Caldwell & Berkowitz.

Daschle wasn’t required to disclose her income, but did report that her retirement plans through the firm were worth more than $260,000.

Chris Frates contributed to this report.

For the New York Times 1/31 on Daschle see

Atul Gawande in The New Yorker 1/26/09

Some of you have seen this week’s New Yorker and the piece on healthcare reform by Dr Atul Gawande. He is a good writer, but it is unfortunate that his hi profile piece is an apology for the for profit insurance industry and a call for incremental reform. Here is my reply to him:

Dear Dr Gawande,

“Getting There From Here” is a wonderfully written piece full of good analyses of how broken our healthcare “system” is and how we got into this mess.
Your central hypothesis is that we can use the idea of “path dependence” to understand how other countries achieved universal or national health insurance, and thus chart a route forward here in the US. Of course, path dependence is much better at explaining why things happened than it is at predicting what will be, or, as you put it, “With path-dependent processes, the outcome is unpredictable at the start.”
Your first example, the formation of the National Health System (NHS) in England after WW II, points out the temptation to choose facts to fit the hypothesis. You note that Churchill’s government never intended to coin a national health service, but you skipped over the British electorate turning out the Tories and installing a Labour government in 1945. The birth of the NHS required both political will on the part of the new government and a powerful economic incentive to use the implementation of the system as part of the economic recovery of the post war economy. When you frame the birth of the NHS this way, suddenly the path dependence implications for the US today take on a different hue.

You state that no other major country has adopted the British system, but that is only true if you don’t consider Spain a “major country.” The Spanish did borrow from England when they formed their system in 1986. The next “major” country to change to a universal system after Spain was Taiwan in 1995. Like Spain, they looked at systems all over the world, and they decided to model their new system on the US. Not our system of for-profit private insurance that you seem to be so fond of, but on our universal (single payer) system for seniors, Medicare. Learning from the experience of other countries is perhaps another way to consider path dependency.

Path dependence is one way to explain how history unfolds and systems change. Political courage and leadership are sometimes a better explanation. When Canadians were asked to choose “The Greatest Canadian” a few years ago, the overwhelming winner was Tommy Douglas, the father of Canada’s national health system. Starting in his home province of Saskatchewan, Douglas lead the charge that resulted in the Canadian system which was instituted in the mid-Sixties, right around the same time we launched Medicare and Medicaid in the US.

Finally, you use the example of Medicare Part D and its much maligned drug coverage as an example of the dangers of over-reaching reform that ignores the lessons of path dependence at its peril. Another interpretation of this fiasco is that Part D was an example of a different path, a Republican Congress running amok, a piece of legislation written by lobbyists, passed in the dead of the night, with debate suppressed, and the longstanding rules of House and Senate bent if not broken. There are many lessons to be learned from that debacle, but not that the idea of Medicare helping seniors purchase their medicines is somehow too ambitious a project for our government to tackle.

In fact, Medicare Part D should have been written to have traditional Medicare administer the plan, instead of creating a plan run by the for-profit insurance industry, with a built in subsidy to the pharmaceutical industry. If one reads from sources like the Heritage Foundation, it becomes clear that the goal of the far-right conservatives is to destroy Medicare by privatizing it. They don’t want Medicare to continue as such an appealing path toward healthcare reform.

Is it reasonable to conflate Medicare for all (single payer) with the total free-market crazies, to cast both as being extreme, radical positions that should be dismissed out of hand as impractical?

I think our 40+ year experience with Medicare has been pretty good. We already take care of the sickest, most expensive part of our population, everyone over age 65. The government (taxpayers) already pays for 60-65% of all healthcare spending. Medicare is the financial mechanism for healthcare for the elderly, but the care is delivered privately. After I see a Medicare patient in the ER, I send a bill, just the same as I do if they have private insurance or no insurance.

Let’s embrace path dependence from a different angle: the safest, simplest, most commonsense way to reform our broken healthcare system is to expand Medicare to cover everyone, and continue to deliver healthcare privately as we do now. The logical next step, Medicare Part E – E for Everyone!

‘_Medicare Advantage_ a misnomer | The Journal Gazette

Taxpayers foot bill for private insurance to inadequately cover seniors’ health care

Jonathan D. Walker

America has a split personality when it comes to health care. There is recognition that the government has to provide care for the people, but there is a conflicting sense that private industry has to be involved because it can somehow be more efficient. Medicare Advantage is the upshot of this thinking – but the result has been a lot of taxpayer dollars wasted on windfall payouts to private insurance companies.

With Medicare Advantage, the government is basically paying private insurance companies more money to do what Medicare could be doing more cheaply and more efficiently in the first place – if we as citizens asked it to. A lot of this extra money is not used to help the people Medicare is supposed to be helping.

via ‘_Medicare Advantage_ a misnomer | The Journal Gazette.

Hoosiers for a Commonsense Health Plan

Hoosiers for a Commonsense Health Plan.

The employer-based health care system is failing and is adversely affecting the public health, as well as the financial wellbeing of private industry and the nation’s position as a global economic superpower. Health care policy and public health experts are increasingly calling for major health care reform and an end to the incremental changes in the for-profit, market-driven sector of our health care economy.

Largely because of health care costs, businesses large and small are experiencing such severe financial difficulties that they are both discontinuing or minimizing benefits and outsourcing or changing the nature of their labor forces toward either minimum wage or part-time employment. Simultaneously, wages have stagnated and personal private health insurance is unaffordable for most. Indeed, half of our nation’s uninsured are employed full time, and the number of uninsured now exceeds forty-five million. More than eight hundred thousand Hoosiers lack coverage.

The nation now spends close to fifteen percent of its GDP on health care and spends twice as much per capita as any other nation. Despite our high rate of spending, measures of public health indicate that our health is worse than health in other industrialized countries. Administrative costs in health care simply to handle private insurance divert hundreds of billions of dollars annually from the direct provision of health care. The private health insurance industry routinely experiences inflation of three to four times the general rate, enjoys huge profit margins, discriminates against the sick and minorities, and adds no value to the health care sector. Economists agree that these trends are unsustainable. We concur and maintain that, in the absence of major federal reform, Indiana must seriously examine alternatives.