Friday, August 7, 2009

Lies, Damn Lies, and the Health Reform Debate: Hello Insanity!

I personally would have preferred a "hello, Cleveland!", but alas, it is not to be. The health care debate has been absolutely absurd, our leaders in Washington have been absolutely moronic at times discussing it, and the media hasn't really done a great job reporting some basic facts about what is going on - though I give some of them some credit, because their showing the ignorance and straight-up gangsta behavior by people at these town hall meetings is illustrating just how looney some of these folks are. Anyway, we here at the "Spoon" decided to do a little PSA of sorts on health care reform. We hope to have a more detailed analysis up soon, but here's a quick read that we hope will be informative. (Note: this was supposed to be a quick-read piece, but damn it all, I couldn't stop writing!)

First of all, I want to address the town hall meetings and "widespread" public dissent about President Obama's health care reform. #1, a lot of these people that are disrupting these meetings are doing so on the bill of the health insurance industry. So, that tells you something. Rachel Maddow did a nice piece detailing the connections and ties behind this nonsense the other night. Straight-up Hessians, to some degree. #2, those who aren't are saying some of the most incredible things I've heard. So, even if they're actually angrily opposed to reform (as opposed to angry because a paycheck from the insurance industry tells them to be so), they have no clue what they're talking about. That's kind of the media's fault - I realize they're sort of helping by playing these incredibly ignorant comments, but maybe they could spend more time providing basic facts about parameters of the debate on a constat basis to help. "The government needs to keep its hands off my Medicare" is priceless (since Medicare is a government-run program), along with the GOP talking point that health care reform will include a provision that will essentially force euthanasia on seniors, another ridiculous statement. Craaaa-zeee. So, yeah, the "widespread" dissent is largely either being paid for, or is informed by ignorance. Oh, and while I am happy to see public discourse and dissent, "paid for by" and ignorant dissent is not good, particularly when it gets dangerous, especially in settings where the public is actually allowed to participate, as opposed to other boisterous protests where the opposition is loud particularly because it is not ever allowed anywhere near the discussion. A fight broke out at one of the town hall meetings in Tampa where cops had to calm things down, a Texas Democrat was shouted down by right-wingers who didn't even live in his district, a Maryland congressman had an effigy of him hung in opposition to reform (following the loud cheers Rep. Todd Akin received when he joked about Democrats getting lynched at these town hall meetings), and Rep. Brad Miller from North Carolina cancelled his town hall meetings after his office received a death threat. These are troubling signs, and very emblematic of where this debate has gone. Former Right-to Lifer Frank Schaeffer offers us some chilling words on what the reform debate has become.

Second, let's talk about the government role in all of this. Look, the "bureaucrat" in the system that is going to make decisions about your care isn't the government! We already have bureaucrats in the system, except they work for the insurance companies, are often called actuaries, are not health care or medical experts, and make decisions about what is and isn't covered. Again, private insurance...bureaucrat. The public option is the government part of the plan that many on the right are angry about, arguing its socialist and will destroy the private insurance industry. I've already written a little about that in an earlier post. Well, okay, so what is the public option? Its still a work in progress, but basically, it will function as a national health exchange of sorts, essentially being a plan organized and facilitated by the government, not necessarily run by them in the classic sense of the word. The various bills on the Hill right now basically put regulations on the public plan that will require the plan to meet the same benefits and cost requirements of private insurance companies. Obviously, there will be some differences, but no government bureaucrat will sit at a desk and decide what is covered.

Plus, this isn't a single payer system AT ALL! The government is not taking over health care IN ANY REAL WAY with this plan. I can't emphasize the fact that this point needs to be made clear every single time someone raises it. Again, like I said before, the public option involves more government involvement, certainly, but its primarily setting up particular regulations on the type and scope of coverage that can be offered, which is to be modeled on regulations for private insurance. There will most likely be some level of sliding scale subsidies for coverage, based on family income. So, yes, the government will be more involved. But this in no way is even remotely equivalent with government-run health care. And, by the way, I'm not sure whether government-run health care isn't better than private insurance. Medicaid, for instance, covers a substantially sicker population at relatively reasonable per-person rates. Yes, overall Medicaid spending certainly has increased over the past handful of years, but that is being driven primarily by more individuals being covered by Medicaid...largely because employer-based care has eroded. That is to say, public programs like Medicaid and SCHIP have come through to help prevent a larger increase in the uninsured than we've actually seen. Research shows that, when adjusting for health conditions and socioeconomic status, Medicaid is actually less expensive than private insurance. That is to say, if Medicaid patients were on private insurance, getting the same care, their care would cost quite a bit more. Conversely, if people on private insurance were on Medicaid getting the same care, their care would cost less. Again, the reform being postulated isn't the government-run socialist medicine "nightmare" that people are saying it is in any way, shape, or form, but if it was, that might actually not be a bad thing.

Third, about rationing...look, there is a finite supply of money and services, so care is going to probably be rationed to some extent. This is a very hard thing to deal with when the person it affects is someone you love, but understand that we already ration care. Of course, our rationing is primarily based on class. If you have money, you usually get a distinctly different type of health care than if you're not rich. So, the 55 year-old high executive at one of the major banks, who totally blew it and should have been fired on the spot, not only keeps his job, gets bailed out by the government, gets a ridiculous bonus, this person also has great health insurance coverage for the ulcers they got when they thought they were going to be fired because they completely screwed up. A hard-working twenty-something employee at said bank, who did everything right, was a model worker, got laid off, lost a lot due to all types of investments gone awry due to the economic problems partly caused by their own executives, and is now uninsured and is now facing some serious financial difficulties due to a few medical bills. So, what we have is a highly immoral type of rationing of care. I want to have a moral rationing of care, where things like medical conditions and projected health outcomes help determine who gets what. Its far more efficient and far more humane. Again, it makes it tough for those whose loved ones are on the losing end, but at least there is a method to the madness, and we're ultimately helping more people with our difficult calls. That is not the case at all right now.

Fourth, our health care system is not the best in the world. It is, in fact, a middle-of-the-pack health care system, at best. The WHO World Health Report had us at #37 in overall system performance, and #72 in overall health. Not exactly numbers to write home about. A more recent study compared us to six other major nations, and we rank last in pretty much every category. We also ranked last among 19 countries in a survey looking at preventable deaths. We do pretty poor on both issues of access to care and quality of care, and are going in the wrong direction. But, we are number 1 in one thing...spending. This tells you one thing...we are doing a terribly inefficient job. Tons of spending, mediocre (at best) results. Any argument that we need to stay away from reform because our system is already the best in the crazy as hell.

Fifth (or fif...damn, do I miss Chappelle's Show), about choice. The proposed plan does not scrap the current system (which I think it should, but that's another story). If people feel their current employer-based insurance or whatever other form of health care coverage they have is good, they can stay on it. Nobody is being mandated to go onto government-facilitated (that is much more accurate than government-run) health care. Also...I'm sorry, choice is nice, but real coverage that is affordable, period, should be the main concern. I hate this line of arguing...I won't be able to see my normal doctor in this plan, blah blah blah. Yes, its valid to argue about that, but when you're looking at comparing that against not having real (i.e. no smoke and mirrors high-deductible plans, or other types of coverage that don't pay for much in the end, which, ultimately lead to patients foregoing necessary care) and affordable health care, I go with the latter as the most important point every time. And...again...if you like your current insurance, you can stay there!

Sixth, about costs and the problem of health care spending....we need to curtail our health care spending, no doubt about it. It will take up a greater and greater portion of our budget, but the problem with the system as it is is that we're not really going to get much for that spending. There are so many inefficiencies present - we need to alter incentives, financing mechanisms, etc., in order to really start seeing a true deceleration of costs, as opposed to just cutting back coverage (which, I'm sure the insurance industry would have no problem doing - I linked to it in my previous post, but please check out Wendell Potter's damning testimony against the insurance industry, which has not gotten nearly as much media play as it should have...Potter was a whistleblower from CIGNA who really spilled some beans on just what our insurance industry has been doing - here is a ton of info about him, his testimony, and a great interview he did with Bill Moyers. Because so many patients are underinsured or uninsured, health care providers often have to game the system to ensure that they don't lose money. This means they might perform a variety of tests that aren't quite necessary, but are expensive, for patients with good health insurance, in order to compensate for the care they provide to patients who don't have insurance, or whose insurance doesn't really cover much of anything. The incentives of the system, in general, are to do as many tests as possible, too. I'm not saying this is what providers necessarily do, but the way they are compensated, as well as how the system is financed overall, often doesn't help this issue. A major step in the right direction would be to alter the mechanisms by trying to lower the number of uninsured and underinsured. This would likely lead to a change in efforts to game the system. The public option, some other type of hybrid system that the Senate Finance Committee is looking at as an alternative to the public option, and expanded public coverage for the poor and low-income, would be ways to address this issue. Additionally, we do need to reconsider how we finance care overall. A real emphasis on prevention, with some money behind it, could help. But, keeping the disjointed system as-is, or simply providing "more choice" through tax credits, etc., will do nothing to lower costs. The tax credit argument has serious flaws in it, which research has clearly illustrated. We need a real change in the system in order to stave off major financial problems down the road. Yes, the bill isn't low - about $100-150 billion/year, or around $1 trillion over 10 years. This, of course, doesn't exclude cost savings that will occur from reform. Yes, it's still going to cost us money, but under 1% of a national income that grows at around 2.5% each year. That's not cheap, but that's not going to destroy the country's economy.

Finally, this is a point I abstractly discussed in my previous post, and intimated above, but here it is more bluntly: is an increased government role in health care a bad thing? Seriously, think about it. Again, the point of clarification (in case I didn't make it obvious enough yet), Obama's plan will NOT create government-run health care in any real sense of the word. According to the CBO report, the public option will NOT drive insurance companies out of business. However...maybe it should. Spend a few minutes going through the info Potter shells out in the link above. This is what private insurance is. Innovation? Hardly. Better prices and better services? No way in hell. I'd argue there is both correlation AND causation between our highly inefficient health care system and the private insurance industry. Look, I have no problem with profits. I'm generally cool with capitalism, in concept (not what we call capitalism, which is borderline socialism for corporations, in America - again, prior post!). But, here's the thing. These private insurance companies have clearly sacrificed the health of Americans to make money. I mean...that's the point, right? Its not exactly easy to regulate a lot of private insurance, due to ERISA preemption. For instance, many state efforts to require Wal-Mart to pay more of the costs of its health insurance for its employees (having done some research on this, I'll say that Wal-Mart health insurance plans were very expensive, which, combined with low pay, resulted in many employees not only not being able to afford insurance coverage, but then enrolling in Medicaid - California had a big fight over this, as did Maryland, and a bunch of other states) were attempted, but defeated due to ERISA preemption - its not easy to mess with employer-sponsored plans.

So, here's the thing...when we are dealing with people's lives, which we literally are with health insurance, is this really an instance where the private sector is appropriate if it is not easily regulated, and has not exactly been doing a good job up to this point? I mean, its one thing when we're talking about televisions, stereos, iPods, etc. It is entirely different when we are talking about lives. I'm not saying the private sector can't have a role in health care. I'm not even saying it can't have the major role. I'm saying that the private sector model of profit maximization is highly problematic in this area, because lives are at stake in a very direct way. Given the track record, I don't quite get why people are so dead-set on ensuring the health care industry survives intact in this debate. We can be a capitalist society (it would help if we actually were one, of course!) without every single thing being pure free market. Health care is an area where I'm not sure a free market is ideal. It could work, if we could get some real regulations in place that required certain conditions, such as ensuring people had access to real insurance at affordable prices that didn't discriminate against pre-existing conditions (or maybe even create a national high risk pool for people with pre-existing conditions). Let private insurance companies bid on big regional or national contracts for insurance, let them run things their way so long as they comply with a reasonable set of federal regulations, let them innovate and compete...they'll almost certainly still do quite well, simply because you're talking about an incredible number of people they get to enroll in their plans. But, if the industry is left as it is, where we don't have any real innovation or competition, but much more of an oligopoly, where it is hard to really regulate plans to ensure they are providing real coverage at reasonable rates and not discriminating, and where they profit more from cutting people off from coverage when they need it the most (this isn't some made-up highly-cynical scenario, this is what continuously happens)...why is this something to defend at all? Look, it is not the idea of private insurance, or the idea of a free market, that is problematic - this can certainly work if implemented correctly. However, what we have right now absolutely isn't working, so I don't understand why critics use terms like capitalism and the free market as abstract ideas that need to be defended against increased government involvement, when it is painfully obvious that the private insurance system we have in place has done a terrible job. We need a real debate about whether a real free market, or increased government involvement, in health care is the better option. This would be healthy and helpful to all. What we don't need is this nonsensical discussion where the government involvement is linked to the Soviet Union and fascism, and the current system we have is tied to Adam Smith. Neither is true.

And in the end, we get the insane debate that has happened thus far on health care reform. We're talking about nonsensical stuff, most of it based on pure lies and deception. We should be discussing far-more important issues, like what kind of delivery system works best, how do we best incentivize the incorporation of health IT and quality of care standards, what are the optimal levels of cost-sharing to ensure appropriate use of care, what are the best pooling options to maximize economies of scale, whether we can we find a way to regulate private insurance companies in a manner to ensure that they stay in check while maximizing their flexibility to capture the benefits of true capitalism in terms of competition...these are all really important discussions to be had by supporters and critics of the type of health care reform being proposed right now. There's plenty of factually-based dissent to be heard from all sides. I don't think Obama is going far enough, whereas some old-school Republicans (do they exist anymore?) might say we need to keep the government out, but stop protecting the insurance industry and make the system truly a free market. These are real and valuable discussions to be had. But, what do we get? Discussions about euthanasia, unfounded fears of a fall into autocratic socialism, and, of course, Senator Grassley talking about dragons and health care like a lunatic. I'd say shoot me now, but I might not be able to afford the co-pay for the hospitalization.

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