Opinion: UPMC’s costly divorce from Highmark - Pittsburgh Post-Gazette

On Jan. 1, UPMC will achieve its long-sought divorce from Highmark. The separation will undoubtedly disrupt care, add untold stress and potentially harm thousands. UPMC, in refusing even to negotiate a renewed contract, has plainly driven the breakup.
UPMC’s grounds for divorcing Highmark are tenuous. In testimony to the Legislature, UPMC complained that Highmark threatens to injure UPMC by “steering” patients to the “now-struggling” Allegheny Health Network, which Highmark has supported to serve as competitive foil to UPMC.
UPMC further explained, “Western Pennsylvania simply has too many hospital beds, and any gain in admissions at one hospital must come at the expense of other hospitals.”
In brief, UPMC believes competition against Highmark is good, but competition against UPMC is bad. UPMC touts creation of the UPMC Health Plan as “a competitive thorn in Highmark’s side,” but derides its own competitors as malevolent meddlers. As once explained by its CEO, UPMC’s goal is to create a “benevolent monopoly.” Unfortunately, monopolies are rarely benevolent, and there is nothing suggesting that UPMC would forgo (untaxed) profits for the public good.

Op Ed Columns - Pittsburgh Post-Gazette

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Adventures in ‘Prior Authorization’ - NYTimes.com

 

DEAR Doctor,” the letter from the insurance company began. “We are writing to inform you that a prior authorization is required for the medication you prescribed.”

That’s usually where I stop reading. Thousands of these letters arrive daily in doctors’ offices across the country. They are attempts by insurance companies to prod doctors away from more expensive treatments and toward less expensive alternatives. To use the pricier option, you need to provide a compelling clinical reason.

In theory, this is a reasonable way to control costs by making it harder to prescribe costlier medications. In practice, it is a wasteful administrative nightmare, a cavalcade of recurring paperwork, lengthy phone calls and bureaucratic battles.

One study estimated that on average, prior authorization requests consumed about 20 hours a week per medical practice: one hour of the doctor’s time, nearly six hours of clerical time, plus 13 hours of nurses’ time. Other studies have suggested that prior authorizations could cost individual practices tens of thousands of dollars a year.

Adventures in ‘Prior Authorization’ - NYTimes.com

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Insurers Once on the Fence Plan to Join Health Exchanges in ’15 - NYTimes.com

 

In a sign of the growing potential under the federal health care law, several insurers that have been sitting on the sidelines say they will sell policies on the new exchanges in the coming year, and others plan to expand their offerings to more states.

“Insurers continue to see this as a good business opportunity,” said Larry Levitt, a health policy expert at the Kaiser Family Foundation. “They see it as an attractive market, with enrollment expected to ramp up in the second year.” Eight million people have signed up for coverage in 2014, and estimates put next year’s enrollment around 13 million.

In New Hampshire, for example, where Anthem Blue Cross is the only insurer offering individual coverage on the state exchange, two other plans, both from Massachusetts, say they intend to offer policies next year. Harvard Pilgrim Health Care, a nonprofit insurer with 1.2 million members, said it expected to participate in the exchanges in both New Hampshire and Maine for the first time and to add Connecticut to the mix in 2016.

Insurers Once on the Fence Plan to Join Health Exchanges in ’15 - NYTimes.com

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Opinion: Cancer survivor: Obamacare got me covered - CNN.com

 In January, for the first time since my diagnosis 36 years ago, I will have an individual health plan that offers quality coverage for me and my family. I will save $628 every month on premiums. Best of all -- I wasn't even asked if I've ever had cancer.

Opinion: Cancer survivor: Obamacare got me covered - CNN.com

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'Premium Shock' and 'Premium Joy' Under the Affordable Care Act - NYTimes.com Uwe Reinhardt

Community Rating Under the Affordable Care Act
Under the law, an individual health plan selling policies in the small-group and nongroup market — whether it sells policies through the state’s exchange or not — will be free to set its own premium for a given policy. But within a given age group, it must apply the same premium to all comers, regardless of their health and their gender. Furthermore, the health plan cannot reject any applicant willing to pay that premium, a provision called “guaranteed issue,” or cancel existing policies.
In other words, the X_i based on the individual’s health status in the equation above will be replaced by the average expected health spending per insured, with the average calculated over the insurer’s entire anticipated risk pool of insured members of a given age. To calculate the average, the insurer must consider as one single risk pool all enrollees in all health plans offered by the insurer, whether or not they are offered on the exchange.
This form of premium setting is known as “community rating.” Because it forces healthier individuals to subsidize sicker individuals through the community-rated premiums, it has been much debated.
Community rating invites “cherry-picking” by insurers — i.e., attempts to attract mainly low-risk applicants. To limit the profit potential from cherry-picking, there will be post-enrollment risk adjustments through which funds are transferred from insurers ending up with relatively healthier risk pools to those ending up with relatively higher risk pools.
The community rating under the law is not the pure version found in the social insurance systems of Europe (e.g., Switzerland, the Netherlands and Germany) or Asia, where even age is not considered in setting premiums. Rather, the American version is called adjusted community rating, because it does allow insurers to adjust the community-rated premium for the age of the applicant.
Age-adjusting is done by multiplying the community-rated premium for the youngest members in the expected risk pool by a standard, multiplicative age ratio to be used by all insurers. Thus the quoted premium can increase step by step with age, but only up to a multiplicative factor of 3. At a given age, smokers can be charged up to 1.5 times the regular premium.
The change from what was in place before the Affordable Care Act to post-law arrangements in the nongroup market can be illustrated graphically. In the chart below, we assume initially that all members of a given population are covered by either medically underwritten or community-rated health insurance, with a given package of covered health benefits. The white line represents the premium individuals would have to pay under medical underwriting. The dashed segment of that line is meant to show the actuarial cost and the premium range in which insurers in the real world would reject applicants outright. The green line shows the community-rated premium for this same population. We assume here that age is either not factored into the premium or the population in question is all of the same age, which is why the green line is horizontal.

Premium Shock
As the chart illustrates, a switch from medically underwritten premiums to community-rated ones raises the premiums for the relatively healthier members of the insurer’s risk pool. Many of them will suffer what has come to be called premium shock.
Younger and healthier members of the pool should realize that, in effect, they are buying a call option that allows them to buy coverage at a premium far below the high actuarial cost of covering them when they are sicker. The price charged the healthy for this call option is the difference between the premium they must pay and the current lower actuarial cost of covering them.
Furthermore, for Americans in households with incomes below 400 percent of the federal poverty line, the green and red lines exaggerate the impact of the law on their spending. These Americans will be granted often quite generous, income-dependent federal subsidies toward the premiums they face on the exchanges and their out-of-pocket costs for health care. This makes it well-nigh impossible to make general statements, based on averages, about the net after-subsidy impact of the law.

'Premium Shock' and 'Premium Joy' Under the Affordable Care Act - NYTimes.com

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NEJM — Netherlands and Managed Competition

NEJM —

The myth that competition has been key to cost containment in the Netherlands has obscured a crucial reality. Health care systems in Europe, Canada, Japan, and beyond, all of which spend much less than the United States on medical services, rely on regulation of prices, coordinated payment, budgets, and in some cases limits on selected expensive medical technologies, to contain health care spending.5 Systemwide regulation of spending, rather than competition among insurers, is the key to controlling health care costs. The Netherlands, after all, spent much less on medical care than the United States with virtually universal insurance coverage long before it began experimenting with managed competition in 2006.

The Dutch experience provides a cautionary tale about the place of private insurance competition in health care reform. The Dutch reforms have fallen far short of expectations — a reminder that policy intentions should not be confused with outcomes and that managed competition is hardly a panacea. The idea that the Dutch reforms provide a successful model for U.S. Medicare to emulate is bizarre. The Dutch case in fact underscores the pitfalls of the casual use (and misuse) of international experience in U.S. health care reform debates.5 Before we learn from other countries' experiences with medical care, we first need to learn about them.

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In Conservative Arizona, Government-Run Health Care That Works - Kaiser Health News

 

APACHE JUNCTION, Ariz. – In a low-slung building in the vast desert expanse east of Phoenix, a small school of tropical fish peer out, improbably, from a circular tank into the waiting lounge of the Apache Junction Health Center. The hallways of the nursing home are still. Only half of the rooms are filled, and the men and women who live here seem surely in life’s final season. “These are folks that have chronic cognitive and physical disabilities that are not going to improve,” said George Jacobson, administrator of the nursing home.

That this nursing home is sparsely filled with residents too disabled in mind or body to return home is a stunning achievement for Arizona’s public health insurance agency. A decade ago, 60 percent of Arizonans covered by Medicare and Medicaid, and deemed sick, frail or disabled enough to live in a nursing home, resided in a skilled nursing facility. Today, only 27 percent of them do, and the rest – nearly three out of four– live in assisted living facilities or at home with the help of nurses, attendants and case managers provided by government-paid health plans.

As Congress debates an ambitious and far-reaching effort by the Obama administration to streamline medical care and rein in spending for the nation’s sickest and most expensive patients, Arizona – with its finger-wagging Republican governor and Tea Party enthusiasts – is occupying an unusual place in the national landscape: as a model for how a generously-funded, tightly regulated government program can aid vulnerable, low-income patients.

In Conservative Arizona, Government-Run Health Care That Works - Kaiser Health News

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The Bomb Buried In Obamacare Explodes Today-Hallelujah! - Forbes

The Bomb Buried In Obamacare Explodes Today-Hallelujah! - Forbes:

This is the true ‘bomb’ contained in Obamacare and the one item that will have more impact on the future of how medical care is paid for in this country than anything we’ve seen in quite some time. Indeed, it is this aspect of the law that represents the true ‘death panel’ found in Obamacare—but not one that is going to lead to the death of American consumers. Rather, the medical loss ratio will, ultimately, lead to the death of large parts of the private, for-profit health insurance industry.

Why? Because there is absolutely no way for-profit health insurers are going to be able to learn how to get by and still make a profit while being forced to spend at least 80 percent of their receipts providing their customers with the coverage for which they paid. If they could, we likely would never have seen the extraordinary efforts made by these companies to avoid paying benefits to their customers at the very moment they need it the most.

Today, that bomb goes off.

Today, the Department of Health & Human Services issues the rules of what insurer expenditures will—and will not—qualify as a medical expense for purposes of meeting the requirement.

As it turns out, HHS isn’t screwing around. They actually mean to see to it that the insurance companies spend what they should taking care of their customers.

- Sent using Google Toolbar

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AHIP's Commissioned Report

In case you're looking for good analysis of the AHIP shot across the bow...

http://www.newamerica.net/blog/new-health-dialogue/2009/health-reform-ahip-got-what-it-paid-15314


http://www.newamerica.net/blog/new-health-dialogue/2009/health-reform-gloves-are-15299

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George Lakoff: The PolicySpeak Disaster for Health Care

George Lakoff: The PolicySpeak Disaster for Health Care:

The narrative is simple:
Insurance company plans have failed to care for our people. They profit from denying care. Americans care about one another. An American plan is both the moral and practical alternative to provide care for our people.

The insurance companies are doing their worst, spreading lies in an attempt to maintain their profits and keep Americans from getting the care they so desperately need. You, our citizens, must be the heroes. Stand up, and speak up, for an American plan.
Language
As for language, the term 'public option' is boring. Yes, it is public, and yes, it is an option, but it does not get to the moral and inspiring idea. Call it the American Plan, because that's what it really is.
The American Plan. Health care is a patriotic issue. It is what your countrymen are engaged in because Americans care about each other. The right wing understands this well. It's got conservative veterans at Town Hall meeting shouting things like, 'I fought for this country in Vietnam, and I'm fight for it here.' Progressives should be stressing the patriotic nature of having our nation guaranteeing care for our people.
A Health Care Emergency. Americans are suffering and dying because of the failure of insurance company health care. 50 million have no insurance at all, and millions of those who do are denied necessary care or lose their insurance. We can't wait any longer. It's an emergency. We have to act now to end the suffering and death.
Doctor-Patient care. This is what the public plan is really about. Call it that. You have said it, buried in PolicySpeak. Use the slogan. Repeat it. Have every spokesperson repeat it.
Coverage is not care. You think you're insured. You very well may not be, because insurance companies make money by denying you care.
Deny you care... Use the words. That's what all the paperwork and administrative costs of insurance companies are about - denying you care if they can.
Insurance company profit-based plans. The bottom line is the bottom line for insurance companies. Say it.

Private Taxation. Insurance companies have the power to tax and they tax the public mightily. When 20% - 30% of payments do not go to health care, but to denying care and profiting from it, that constitutes a tax on the 96% of voters that
have health care. But the tax does not go to benefit those who are taxed; it
benefits managers and investors. And the people taxed have no representation.
Insurance company health care is a huge example of taxation without representation. And you can't vote out the people who have taxed you. The American Plan offers an alternative to private taxation.
Is it time for progressive tea parties at insurance company offices?

Doctors care; insurance companies don't. A public plan aims to put care back into the hands of doctors.
Insurance company bureaucrats. Obama mentions them, but there is no consistent uproar about them. The term needs to come into common parlance.

Insurance companies ration care. Say it and ask the right questions: Have you ever had to wait more than a week for an authorization? Have you ever had an authorization turned down? Have you had to wait months to see a specialist? Does
you primary care physician have to rush you through? Have your out-of-pocket
costs gone up? Ask these questions. You know the answers. It's because insurance
companies have been rationing care. Say it.
Insurance companies are inefficient and wasteful. A large chunk of your health care dollar is not going for health care when you buy from insurance companies.
Insurance companies govern your lives. They have more power over you than even governments have. They make life and death decisions. And they are accountable only to profit, not to citizens.

The health care failure is an insurance company failure. Why keep a failing system? Augment it. Give an alternative.

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Anthony Weiner Leaves Joe Scarborough Momentarily Speechless When Arguing for Health Care Reform | Video Cafe

Anthony Weiner Leaves Joe Scarborough Momentarily Speechless When Arguing for Health Care Reform Video Cafe:

"Isn't it amazing what a little clarity to your argument can bring you isn't it? Like arguing for real reform instead of the mushy middle. Anthony Weiner did a fantastic job on Morning Joe today and he actually left Scar speechless for a moment when trying to get him to answer just what the insurance industry does to benefit anyone. Of course Scarborough turned that around into 'You're arguing for a government takeover of health care' shortly afterwards, but he never could give any decent defense of why this country needs the insurance industry."

From Crooks and Liars, what a great video! An articulate advocate for Single Payer.

I'll ask the question again: What value do private insurers add to health care?

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Rationing? Say it ain't so!

Blue Cross praised employees who dropped sick policyholders, lawmaker says - Los Angeles Times:

But documents obtained by the House Committee on Energy and Commerce and released today show that the company's employee performance evaluation program did include a review of rescission activity.

The documents show, for instance, that one Blue Cross employee earned a perfect score of '5' for 'exceptional performance' on an evaluation that noted the employee's role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.

WellPoint's Blue Cross of California subsidiary and two other insurers saved more than $300 million in medical claims by canceling more than 20,000 sick policyholders over a five-year period, the House committee said.

'When times are good, the insurance company is happy to sign you up and take your money in the form of premiums,' Stupak said. 'But when times are bad, and you are afflicted with cancer or some other life-threatening disease, it is supposed to honor its commitments and stand by you in your time of need.

'Instead, some insurance companies use a technicality to justify breaking its promise, at a time when most patients are too weak to fight back,' he said.

Lawmakers -- Republicans and Democrats alike -- decried the practice of canceling policies of ill policyholders and grilled insurance executives about it.

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Health Affairs - 2 articles on the cost of private insurers to the system

Two articles from Health Affairs regarding the cost of Private Health Insurers, for profit and not for profit, to physicians' practices, bottom lines, time and aggravation.

Peering Into The Black Box: Billing And Insurance Activities In A Medical Group -- Sakowski et al. 28 (4): w544 -- Health Affairs:

"Billing and insurance–related functions have been reported to consume 14 percent of medical group revenue, but little is known about the costs associated with performing specific activities. We conducted semistructured interviews, observed work flows, analyzed department budgets, and surveyed clinicians to evaluate these activities at a large multispecialty medical group. We identified 0.67 nonclinical full-time-equivalent (FTE) staff working on billing and insurance functions per FTE physician. In addition, clinicians spent more than thirty-five minutes per day performing these tasks. The cost to medical groups, including clinicians’ time, was at least $85,276 per FTE physician (10 percent of revenue)."


What Does It Cost Physician Practices To Interact With Health Insurance Plans? -- Casalino et al. 28 (4): w533 -- Health Affairs: "Physicians have long expressed dissatisfaction with the time they and their staffs spend interacting with health plans. However, little information exists about the extent of these interactions. We conducted a national survey on this subject of physicians and practice administrators. Physicians reported spending three hours weekly interacting with plans; nursing and clerical staff spent much larger amounts of time. When time is converted to dollars, we estimate that the national time cost to practices of interactions with plans is at least $23 billion to $31 billion each year."

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Study Links Medical Costs and Personal Bankruptcy - BusinessWeek

Study Links Medical Costs and Personal Bankruptcy - BusinessWeek:

"Medical problems caused 62% of all personal bankruptcies filed in the U.S. in 2007, according to a study by Harvard researchers. And in a finding that surprised even the researchers, 78% of those filers had medical insurance at the start of their illness, including 60.3% who had private coverage, not Medicare or Medicaid.

"Medically related bankruptcies have been rising steadily for decades. In 1981, only 8% of families filing for bankruptcy cited a serious medical problem as the reason, while a 2001 study of bankruptcies in five states by the same researchers found that illness or medical bills contributed to 50% of all filings. This newest, nationwide study, conducted before the start of the current recession by Drs. David Himmelstein and Steffie Woolhandler of Harvard Medical School, Elizabeth Warren of Harvard Law School, and Deborah Thorne, a sociology professor at Ohio University, found that the filers were for the most part solidly middle class before medical disaster hit. Two-thirds owned their home and three-fifths had gone to college."

The abstract is here, I cannot access the full text, unfortunately.

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Missoulian: Single-payer mentions draw cheers at Baucus-sponsored health care talk

Missoulian: Single-payer mentions draw cheers at Baucus-sponsored health care talk

The hearing ranged broadly over the possibilities for reform, but what clearly resonated for McArthur was something Baucus' chief of staff, Jon Selib, said a couple of times.

Discussing why a single-payer system of health insurance wasn't viable, Selib made reference to the more than 150 million Americans who are covered by some sort of employer-provided health care.

“A lot of people like that,” Selib said.

When the time came for questions, McArthur stood up and asked a simple question. Looking across a standing-room-only crowd of about 275, he asked how many were happy with their employer-based health insurance.Less than 10 people raised their hands.

“The number is bogus,” McArthur said. “It's not working for 95 percent of us.” McArthur drew resounding applause.

In fact, any mention of single-payer health care insurance brought raucous cheers and clapping.

Any other solution to health care reform - including Baucus' “balanced” plan that would create a mix of public and private plans - was received more coolly.

Tuesday's session was one of a handful of events Baucus is sponsoring around the state this week. He chairs the Senate's powerful Finance Committee, and is the point man on health care reform.

He did not attend Tuesday's meeting, but Selib did, and he heard what the senator himself has heard since he announced that single-payer wasn't really on the table.

As Selib worked to massage that point, one man barked out, “Oh bull----.”

Tom Roberts, president of the Western Montana Clinic and moderator at the session, asked the crowd to be civil, but the man had made his point.

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McKinsey: What Matters: Way too much for way too little

McKinsey: What Matters: Way too much for way too little

The title says it all. A great review of the American health care non-system.

Goes over administrative waste (83 cents of premium dollars go to actual health care at most in PHI market), outcomes, costs and prices, administrative burden, practice variation, and rationing (QALY's CER).

Some good response letters as well.

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COST: Is This What They Went to Med School For? | New America Blogs

COST: Is This What They Went to Med School For? New America Blogs:

Excellent summary by Joanne Kenen at New America:

"Two new studies released this week online by Health Affairs examine how health care providers, particularly physician practices, interact with insurers. One study found that doctors personally spend the equivalent of three full weeks a year on billing and related insurance information. The overall cost to their practices (their time as well as other medical and clerical personnel) was about $31 billion a year (in 2006)—which as study author Larry Casalino noted, was about six times what we spent at the time on the State Children's Health Insurance Program and nearly 7 percent of total national expenses on physician and clinical services. Primary care practices spent more time on these administrative tasks than specialists. Very little of the data—only about two hours a year for the doctor—pertained to quality data.

"The second study looked at the billing and insurance-related activities at one large multi-site, multi-specialty California group practice. The cost (in physician and clerical time) turned out to be $85,276 per physician, or 10 percent of operating revenue. (And that excluded the time the doctors spent recording procedure and diagnosis codes). And this California practice isn't bogged down in paper; they already use electronic medical records for both clinical and billing data. (Some older studies, before medicine began its slow and not always so steady migration to Health IT, showed even more time and money spent on administration in the days of pure paper.)"

Additionally, from the second paper:

Impact of complexity. Previous reports have suggested that the complexity inherent in the current multipayer financing system is responsible for increasing the administrative burden associated with medical groups' transaction processing.15 During our interviews, informants frequently described the contributions of complexity in the payment system to billing and insurance burden. For example, the patient population of our study site is covered by hundreds of insurance plans, each with its own rules about benefits covered and under what conditions, payment rates, and often billing procedures. This complexity adds burden to billing and insurance tasks, including procedure coding, drug formulary authorizations, discussions with patients, submission and appeal processes, and receipt of payments. The complexity also increases the chance for error and dispute, increasing the likelihood of payment follow-up and collections. Even high-deductible plans, which might appear to avoid administrative burden for initial services during the year, impose billing/insurance costs because each service, including those within the patients' deductibles, must be evaluated and processed.

I've also classified this under Physician Income and Physician Autonomy, because these burdensome duties and their concomitant expenses impact both significantly. If you think your PHIs are paying you more than Medicare, you need to factor this into the equation.

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Senate Finance Committee Hearing on Expanding Health Care Coverage

"Roundtable Discussion on “Expanding Health Care Coverage”
May 5 , 2009, at 10:00 a.m., in 106 Dirksen Senate Office Building

Over at the PNHP Blog, Don McCanne points out that the voices for single payer are being stifled and excluded because of the view of most in the Congress that it is a politically unviable proposition, though he "respects" their views.

Even more problematic was an exchange later in the hearings between Sen. Pat Roberts and Scott Serota, CEO of the Blue Cross and Blue Shield Association.

Sen. Roberts told the tale of how a group of surgeons and anesthesiologists surrounded him after his knee surgery and told him and said they'd all quit if we went to a national health plan or even, I believe, to a public option and their reimbursements were to be decreased.

I don't have the transcript, but he went on to say something along the lines of how there was no way to control costs in a national health system and then asked Serota what he thought.

Of course, Serota explained in that patrician way of so many how there was no way in the world to produce high quality and lower costs than we have in the US now with private insurance.

Now, if Sen. Baucus doesn't want single payer advocates around because he doesn't think it is politically viable, that is one thing. But what he doesn't seem to realize is that having a knowledgeable single payer advocate and someone knowledgeable about international comparative health care in the room would have resulted in the particular line of BS that Roberts and Serota were peddling to be swatted down without breaking a sweat.

That is why it is so critical to have a broader range of views at the table. There was no one there willing to point out the obvious: Reducing future surgeons' income from $500 K to $400 K, for example, will not bring the world to a halt. Essentially every country in the world controls costs and maintains quality at massive savings compared to the disastrously inefficient US private insurance industry.

But there was no one at the table willing to tell them that.

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Insurers shun those taking certain meds - Costs of Care - MiamiHerald.com

Insurers shun those taking certain meds - Costs of Care - MiamiHerald.com:

"Trying to buy health insurance on your own and have gallstones? You'll automatically be denied coverage. Rheumatoid arthritis? Automatic denial. Severe acne? Probably denied. Do you take metformin, a popular drug for diabetes? Denied. Use the anti-clotting drug Plavix or Seroquel, prescribed for anti-psychotic or sleep problems? Forget about it.

"This confidential information on some insurers' practices is available on the Web -- if you know where to look.

"What's more, you can discover that if you lie to an insurer about your medical history and drug use, you will be rejected because data-mining companies sell information to insurers about your health, including detailed usage of prescription drugs.

"These issues are moving to the forefront as the Obama administration and Congress gear up for discussions about how to reform the healthcare system so that Americans won't be rejected for insurance."

No surprises here, just documenting.

But it does make an interesting contrast to a letter written to the New York times on their piece on a public insurance option by a rather alarmist (and ill informed) physician:

"The unfair competition from a public plan would destroy the private health insurance industry. The inevitable result would be the rationing and other horrors of a Canadian-style single-payer system, which most Americans neither wish nor deserve."

Rationing, in America! God forbid.

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The Concerns of "Harry and Louise" circa 1994

YouTube Link to videos here.

Because my daughter is working on her undergraduate thesis on comparing the health care reform policy environment in 1994 and now, we were looking at the old Harry and Louise videos.

It is funny, because there are two issues raised in the commercials. In the first, set "Sometime in the Future,"the concern is about having to choose among "insurance plans designed by government bureaucrats" and the lack of choice among doctors, hospitals, etc., should this happen. And the cute little line about, "Remember our old plan? That was a good one."

Well, of course, those ships have all sailed. Our insurers now dictate our provider choices ever more restrictively. If you've ever changed your insurer, you probably have come to terms with looking through the provider book and figuring out which PCP practice to switch to, whether to go "out-of-network" to keep your old specialists, and whether to drive to a new hospital in your network. Unless, of course, you are in a federal plan, designed by bureaucrats, which generally will provide you with substantially more choice than your private plan.

It's also worth saying that in most markets, insurance consolidation has resulted in ever dwindling choice in private insurers. So, the choice thing? Not so much.

The second commercial talks about the dangers of "community rating" to the premiums of the younger and healthier. This is exactly right, and Uwe Reinhardt has been warning about this lately. If not forced to buy insurance, those who are at lower risk of needing health insurance will opt out, driving up the premiums for those buying insurance, particularly small employers who can't spread the risk out. A genuinely fair concern that is still in the mix of issues that need to be dealt with today.

So, how to deal with it? Everyone must be in. We must accept the societal bargain that when we are healthy, we subsidize those who are not. When our kids are healthy, we subsidize our neighbors' kids with diabetes and autism and cancer. When our parents have chronic illnesses, we spread the risk amongst us all.

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