T.R. Reid: Can We Really Fix U.S. Health Care?

From the Commonwealth Club of California Podcast is here.

Friday, September 18, 2009, 12:34:52 PM


T.R. Reid, Correspondent, The Washington Post; Commentator, National Public Radio; Author, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

For 100 years, U.S. presidents have unsuccessfully strived to provide universal health coverage. When LBJ created Medicare in 1965, he thought the program would gradually be extended – to people over 60, then 55, then 45, etc., so that everybody would have government health insurance by 2000. Decades later, the Clinton plan failed. George W. Bush created Medicare Part D. Barack Obama says we have the best chance ever this year to fix our health-care system. Is he right? Reid weighs in and reveals what we can learn from health-care models across the globe.

This program was recorded in front of a live audience at The Commonwealth Club in San Francisco on September 14, 2009.

A very good listen. Excellent tid bits about health promotion in Britain, insights into the minds of Canadians and more!

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Health Reform Without a Public Plan: The German Model - Economix Blog - NYTimes.com

Health Reform Without a Public Plan: The German Model - Economix Blog - NYTimes.com:

"What if that [public option] plan were sacrificed on the altar of bipartisanship? Would it be the end of meaningful health reform?

"Not necessarily, if the health systems of the Netherlands, Germany and Switzerland are any guide.

"None of these countries uses a government-run, Medicare-like health insurance plan. They all rely on purely private, nonprofit or for-profit insurers that are goaded by tight regulation to work toward socially desired ends. And they do so at average per-capita health-care costs far below those of the United States — costs in Germany and the Netherlands are less than half of those here."

When I get in discussions of HC reform with my friends who are more committed to a single payer solution than I, I point out that most countries we look to as exemplars of excellent universal health care do not, in fact, use the single payer model, but use some hybridized form of the Bismarckian, or Social Health Insurance model, such as Germany. This may explain why the American College of Physicians made its policy recommendations in 2007: though single payer was recommended first, a hybrid system was neck and neck and felt to be more achievable.

Dr. Reinhardt explains the overview beautifully here, and I cannot improve upon it. He, as always, provides great framing to his points that can be appropriated for the discussions you have on the topic. For more details on the German system, go here.

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World Health Organization Report on Social Health Insurance Systems

in Western Europe.

It's 313 pages, so, no, I haven't read it yet, but I want the resources at our fingertips when the time comes...

From the introduction:

The concept of social health insurance (SHI) is deeply ingrained in the fabric of health care systems in western Europe. It provides the organizing principle and a reponderance of the funding in seven countries – Austria, Belgium, France, Germany, Luxembourg, the Netherlands and Switzerland. Since 1995, it has also become the legal basis for organizing health services in Israel. Previously, SHI models played an important role in a number of other countries that subsequently changed to predominantly tax-funded arrangements in the second half of the twentieth century – Denmark (1973), Italy (1978), Portugal (1979), Greece (1983) and Spain (1986). Moreover, there are segments of SHI-based health care funding arrangements still operating in predominantly tax-funded countries like Finland, Sweden and the United Kingdom, as well as in Greece and Portugal. In addition, a substantial number of central and eastern European (CEE) countries have introduced adapted SHI models since they regained control over national policy-making – among them Hungary (1989), Lithuania (1991), Czech Republic (1992), Estonia (1992), Latvia (1994), Slovakia (1994) and Poland (1999).

Also, I'm going to add a topic Tag of "Social Heath Insurance" and cross tag all my "Bismarckian" ones so that it becomes clear they are the same thing.

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Mayo Clinic Health Policy Center Recommendations

Mayo Clinic Health Policy Center Recommendations

IV. Provide Health Insurance for All

Provide guaranteed, portable health insurance for all individuals, giving them choice, control and peace of mind.

Requires action from: Insurers, employers, the government and individuals

• Require adults to purchase private health insurance for themselves and their families. Employers could continue to participate by buying insurance for their employees or giving them stipends to purchase it. However, the individual could own the insurance.
• Appoint an independent health board (similar to the Federal Reserve) to provide a simple coordinating mechanism for individuals to select a basic
  private insurance option. Allow people to purchase more services or insurance,
  if they choose.
• Provide sliding-scale government subsidies to help people with lower incomes
  buy insurance.
• Realign the health system toward improving health in addition to treating
  disease.

This is, more or less, a Bismarckian or "sickness fund" type system. I would argue against leaving the employers in the loop, as salaries/wages can easily be designed to provide appropriate compensation without including it as a benefit. Just makes it easier to administrate.

I'd further argue that a more strenuous effort needs to be made to make the benefits provide and the cost to consumers of a "standard" policy uniform accross the nation. The way other countries have done this is to stricly regulate the costs and benefits of the basic plan very rigidly, and then allow insurers to compete in the non-basic elements of a plan, such as optical, dental, wellness, etc.

I think this approach will win support from essentially all Democrats and more than a few Republicans. It seems to already be in the works.

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FRONTLINE: sick around the world: five countries: health care systems -- the four basic models | PBS

FRONTLINE: sick around the world: five countries: health care systems -- the four basic models PBS:

"These four models should be fairly easy for Americans to understand because we have elements of all of them in our fragmented national health care apparatus. When it comes to treating veterans, we're Britain or Cuba. For Americans over the age of 65 on Medicare, we're Canada. For working Americans who get insurance on the job, we're Germany.

For the 15 percent of the population who have no health insurance, the United States is Cambodia or Burkina Faso or rural India, with access to a doctor available if you can pay the bill out-of-pocket at the time of treatment or if you're sick enough to be admitted to the emergency ward at the public hospital.

The United States is unlike every other country because it maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody. This is much simpler than the U.S. system; it's fairer and cheaper, too."

From the truly terrific PBS/Frontline site for "Sick Around the World"

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Miles Mogulescu: Why Not Single Payer? Part 6: New "Health Care For America Now" Coalition May Reflect Divisions in the Movement for Universal Healthcare - Politics on The Huffington Post

Miles Mogulescu: Why Not Single Payer? Part 6: New "Health Care For America Now" Coalition May Reflect Divisions in the Movement for Universal Healthcare - Politics on The Huffington Post

We all saw sicko, but many of us also saw Frontline's Sick Around the World program : http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

Certainly Single payer can work and might be the best system possible, but I don't think the Bismarkian systems of Germany, Switzerland and others can be dismissed out of hand. If you go to the frontline website and watch the show, be sure to read the supplementary materials, especially he interview with Uwe Reinhardt. http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/interviews/reinhardt.html

I had not given Bismarkian systems much thought until I heard a representative from the Stark Raving Loonie Party (Sorry, that's Python - I meant the Fraser Institute of Canada) actually confess that he could see working with reform along the Bismarkian lines:http://cmhmd.blogspot.com/2008/03/single-payer-debate-at-duquesne-u-31008.html

Further, Sen. Ron Wyden and others have introduced a plan along these lines, so HR 676 isn't the only ball in play at the moment.
Wyden Press release: http://wyden.senate.gov/newsroom/record.cfm?id=297073&
Other commentary: http://www.blueoregon.com/2006/12/progressives_re.html

So I guess I'd say not to discount the Wyden plan out of hand as not being "pure" single payer. because we have examples of this system working as well as single payer can.

Cheers,

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Report boosts bipartisan health plan - Yahoo! News

Report boosts bipartisan health plan - Yahoo! News:

"Sen. Robert Bennett, R-Utah, the other sponsor of the legislation, said the report confirmed that the plan would not only cut health-care costs but actually save money in the long run.

'I am convinced we can reach our goal to improve coverage and provide affordable, private health insurance to every American,' Bennett said at a news conference with Wyden and other Senate supporters of the bill.

The so-called Healthy Americans Act would replace the current employer-based health insurance system with a system in which the government requires, subsidizes, and oversees a system of private health care plans that individuals select. The coverage would be guaranteed to be as good as that which federal employees receive, and the government would subsidize health care for people up to 400 percent of the poverty level.

The plan is paid for in part by changes to the tax code, including a new tax on employers of between 3 percent and 26 percent. Wyden labels the tax 'employer-shared responsibility payments' and notes that they would replace money employers now spend to provide private health insurance for their workers.
The employer payments are expected to generate up to $100 billion a year in federal revenue.

'Employers like this plan, and the reason they like it is because it cuts their current and future health care costs,' Wyden said."

Obviously, the torpedos are being loaded into the submarines already, but this may represent an opportunity for real reform and, although not single payer so much as Bismarkian/sickness fund style plan, I can live with it. And, more importantly, even many free marketeers can live with it, too.

Sen. Wyden's press release is here, and it lists current Senate co-sponsors.

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Six steps to bring about true health-care reform in Utah - Salt Lake Tribune

Six steps to bring about true health-care reform in Utah - Salt Lake Tribune:

Dr. Joe Jarvis of Utah has written a nice opinion piece for the Salt lake Tribune identifying six important areas to address in health care reform discussions. Some I have addressed here in the past, such as the Moral hazard myth. His number one is:

"Health underwriting: Every critically ill or injured person will be treated in our health system whether they have health insurance or not. Therefore, we should not waste resources trying to identify persons likely to have critical illness in order to exclude them by price or refusal from acquiring health financing. Community rating, guaranteed issue and risk-sharing will increase health system efficiency and eliminate the unfunded mandate that is cost-sharing."

After seeing the Frontline Sick Around the World Program and web site, and also after attending the Single Payer Debate at Duquesne University earlier this year, it may be that the path to reform in the US might have to be the path of Bismarckian universal healthcare. It seemed that even the far right Fraser Institute's spokesman at the debate was willing to grant that this might be a reasonable way to provide universal access in the US and not violating the hard charging laissez-faire types ideology too badly.

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Household Income, US Census Data

Household Income-2005--Part 1:
"Table HINC-05. Percent Distribution of Households, by Selected Characteristics Within Income Quintile and Top 5 Percent in 2006

[Source: U.S. Census Bureau, Current Population Survey, 2007 Annual Social and Economic Supplement. Numbers in thousands. ]



I always get confused when I hear people talking about middle income families/households, and it alwasy seems to me that if you are in the DC or other elite groups, $100K or even $200K puts you squarely in the middle class.

As you can see by the table (if you can't read it, follow the link to the Census Bureau), the true middle, is between $37K and $60K for the true middle quintile and between $20K and $97K for the 3/5 in the middle.

Now, just to follow up on something I heard McCain (and the usual propogandists agains National Health Insurance systems of any kind) say is that you'll be taxed to death. Now, if you are in the middle 3/5, and you are paying, for argument's sake, $12K for healthcare (either out of your wages or paying it yourself), how, again, do you lose by adopting a single payer or Bismarck style insurance plan?

And I guess I learned something from Frontline and Uwe Reinhardt: I have to add "Bismarckian Insurance Plan," to my categories/tags.

Cheers,

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Single Payer Debate at Duquesne U, 3/10/08

SEPP Organization - SEPP Events

(The link above takes you to the details of the event.)

I attended the debate last night among Dr. Scott Tyson and Gariel Silverman, arguing the single payer case, and Sue Blevins and Nameed Esmail, arguing against at Duquesne University last night. First, props to Duquesne: Great venue in the Power Center, easy parking, nice facility all around. And props to both groups for getting attendance to a surprisingly high level (over 200, I'd guess). Pro-single payer were in the majority, I'd guess, by a significant amount.

I'll cut to the chase: Jerry Bowyer, moderator, at the end of the evening, asked if the discussion had changed anyone from their pro or anti single payer or undecided camps, and only a handful of hands went up. Sigh. But, not, of course, unexpected.

To those of us who are familiar with the issues and arguments for and against single payer, and familiar with the players (esp. Mr. Esmail's Fraser Institute), there were not many surprises. My most pleasant surprise was Dr. Tyson's excellent performance. Powerful, personal and passionate, Dr. Tyson did a very good job of making the moral, practical and economic case.

As my bias is obvious, I won't pretend to disguise it. I found the same old arguments from the status quo/free market/every man for himself side very tiresome indeed. I'll just toss out a few "highlights."

Single Payer advocates see Canada as a Panacea solution for America's woes. I don't know of any, but it somehow forces single payer advocates into the silly position of defending Canada's system, even though it is not the one we would emulate. From now on, we should respond to the Canada graphics with ones comparing us to Germany, France, Belgium, Japan, or almost anyone, and leave Fraser to shit on their own country as they seem wont to do. Heaven forbid they offer constructive solutions. And by this, I mean ones that at least 30 or 40% of the Canadian population would at least consider.

Showing a spending chart showing Canada at the high end of spending on healthcare compared to the rest of the world, and omitting the US, cause we're so off the charts as to make the chart look laughable.

Arguing that taxation sufficient to pay for healthcare would strangle economic growth. This is just too brain-dead to answer, especially sitting in a country that spends 16.5% of its GDP on healthcare. And especially from an economist who said, specifically, that there is no "government money" only our money in government's hands.

Waiting times in Canada are intolerable and/or deadly. Please click here.

$32 Billion in Medicare fraud annually is an outrage and a scandal. I don't know the source or veracity of this figure, but the 2006 Medicare expenditures were $408 billion, meaning 92% of the money gets where it's supposed to, which needs work, but isn't awful. And the suggestion that I think Ms. Blevins made was that she preferred private insurer's solution: deny care first, and then sort out who was trying to scam you, rather than covering claims in good faith and then going after the perps. I'm all for getting the perps, but not until I've made sure the patients are taken care of first. Silly me.

Patients in Canada often have to wait 10 or 12 hours to get a hospital bed when admitted through the ER. Imagine our shock. (He did know Pittsburgh was in America, right?)

Veterans Administration hospitals are horrible places. Dr. Tyson did try to set Ms. Blevins right on this one, though I think she didn't believe him.

You cannot pay for treatment in Pennsylvania outside of your contract with your health insurer.
This one got my attention. I hope somebody will post a comment for me about it, because I'd never heard this before, and it seems exceedingly odd.

The usual "anecdote-off," for which I'll just refer you to our special section.

I was pleased to see Mr. Esmail's praise of other systems, particularly those of Switzerland, Japan, France, Sweden, Germany and some others. He rightly pointed out that the old PNHP proposal, from 1993, was fairly beholden to the Canadian model, but there are newer proposals from PNHP, and besides, they are not the only proposals out there. As has been often pointed out by our side, and always ignored by theirs, we need a uniquely American system, pulling from the best of all other extant systems. Though Mr. Esmail did seem gratified to sear Dr. Tyson say this, I doubt it was the first time he heard it. (You don't suppose he didn't watch Sicko, even as an academic exercise?) Oh, and Esmail even admitted we were rubbish for Mental Health care, too.

Oh, and a personal shout out to Scott Tyson for his wonderfully dismissive treatment of HSAs. Made me chuckle and even snort a bit!

OK, folks, that's all I can remember at this late hour, but please add your comments to remind me of things I forgot to mention....

Cheers,

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