Paul Krugman: Health Care Hopes

Paul Krugman, unleashed (NY Times columns are now free):

Health Care Hopes, by Paul Krugman, Commentary, NY Times: All the evidence suggests that it has finally become politically possible to give Americans what citizens of every other advanced nation already have: guaranteed health insurance. The economics of universal health care are sound, and polls show strong public support for guaranteed care. The only thing we have to fear is fear itself.

Unfortunately, there’s a lot of that around.

True, one kind of fear seems, provisionally, to have been overcome: the timidity of Democratic politicians scarred by the failure of the original Clinton health plan. ...

John Edwards broke the issue of health care reform open ... when he proposed a smart and serious plan for universal health insurance — and bravely announced his willingness to pay for the plan by letting some of the Bush tax cuts expire. ...

Senator Clinton delayed a long time... Still, this week she did deliver a plan, and it’s as strong as the Edwards plan — because unless you get deep into the fine print, the Clinton plan basically is the Edwards plan.

That’s not a criticism; it’s much more important that a politician get health care right than that he or she score points for originality. Senator Clinton ... knows a good thing when she sees it.

The Edwards and Clinton plans as well as the slightly weaker but similar Obama plan achieve universal-or-near-universal coverage through a well-thought-out combination of insurance regulation, subsidies and public-private competition. These plans may disappoint advocates of a cleaner, simpler single-payer system. But it’s hard to see how Medicare for all could get through Congress any time in the near future, whereas Edwards-type plans offer a reasonable second best that you can actually envision being enacted by a Democratic Congress and signed by a Democratic president just two years from now.

To get there, however, would require overcoming a lot more fear.

There won’t be a serious Republican alternative. The health care plans of the leading Republican candidates, such as they are, are the same old, same old: they principally rely on tax breaks that go mainly to the well-off, but will supposedly conjure up the magic of the market. As Ezra Klein ... cruelly but accurately puts it: “The Republican vision is for a world in which the sick and dying get to deduct some of the cost of health insurance that they don’t have — and can’t get — on their taxes.”

But the G.O.P. nominee, whoever he is, won’t be trying to persuade the public of the merits of his own plan. Instead, he’ll try to scare the dwindling fraction of Americans who still have good health insurance by claiming that the Democrats will take it away.

The smear-and-fear campaign has already started. The ... attacks probably won’t be effective enough to prevent a Democrat from winning next year. But that won’t be the end of the story: even if the Democrats take the White House and expand their Congressional majorities, the insurance and drug lobbies will try to bully them into backing down on their campaign promises.

That’s why the long delay before Senator Clinton announced her health care plan made supporters of universal care, myself included, so nervous — a nervousness that is not completely assuaged by the fact that she finally did deliver. It’s good to know that whoever gets the Democratic nomination will run on a very good health care plan. What remains is the question of whether he or she will have the determination to turn that plan into reality.

Comments

[GlobalHealthCare]

The price of healthcare in England is about to hit the floor!!

http://news.bbc.co.uk/2/hi/health/7004581.stm

"Overseas pressure on doctors jobs

Too many doctors are competing for too few training posts because, while UK graduates are increasing, they have to compete against overseas applicants.

Now it has been suggested doctors from EU countries should have first pick on jobs, the British Medical Journal said.

The Department of Health said there was a balance to be struck to meet the needs of both doctors and patients.

The application system was thrown into disarray this year after many doctors applying for training jobs through the new computerised Medical Training Application Service failed to get their first choice or any interview at all.

But the chaos of MTAS concealed the problem of a "large surplus" of applicants for limited training places, said Dr Graham Winyard, a retired postgraduate medical dean.

In the past, the NHS had employed a large number of overseas doctors because there were too few graduates from UK medical schools.

To address this problem the government increased in the number of medical school places - 7,000 a year by 2010 compared with 5,000 in the 1990s.

Now this policy, alongside rules on allowing access to the UK for highly-skilled workers from outside Europe, has lead to doctors fighting for jobs, he said.

It is illegal for NHS trusts and medical deaneries to discriminate on the basis of the country where a doctor qualified.

Competition

Almost half the doctors competing for places this year were trained overseas.

After the end of the first round of the two-stage recruitment process, there were 14,000 doctors still looking for jobs - 4,000 of which were UK graduates.

"The implications of making medicine a career in which, after seven years of training and thousands of pounds of debt, graduates face a serious risk of permanent exclusion are enormous," said Dr Winyard.

Most other countries had two-tier systems where those trained in the country - or in the case of EU countries within Europe - were placed in training posts first, he added.

But Dr Edwin Borman, chairman of the British Medical Association's International Committee said overseas doctors were vital to the NHS as medicine became increasingly globalised.

Also writing in the BMJ, he said a policy to restrict training posts to UK graduates would be detrimental and the real fault was a lack of centralised workforce planning.

"Employing doctors from abroad stops a country having a parochial view of medicine, increases the relationships between countries and, with disease clearly being a global phenomenon, it's also really important for patient care."

He said it was to the NHS's credit that during the recent recruitment mayhem, all doctors had been treated equally.

A Department of Health spokesperson said there was a strong argument that taxpayers' investment in UK medical graduates should not be wasted because those graduates are unable to access specialist training.

"However, those factors have to be balanced against an argument that NHS patients should have access to the best doctors possible - no matter where they trained.

"We also have a responsibility to those doctors who trained abroad who currently work in the NHS. This is an important issue, and one which we need to discuss with the medical profession."

"The implications of making medicine a career in which, after seven years of training and thousands of pounds of debt, graduates face a serious risk of permanent exclusion are enormous"

--Dr Graham Winyard

Finally, I can benefit from globalized wage arbitrage in the form of cheaper medical care as the wages of doctors plummet!!! Who needs to "fix" medicare or medicaid, just let the market do it for you!!!

[supersaurus]

As Ezra Klein ... cruelly but accurately puts it: “The Republican vision is for a world in which the sick and dying get to deduct some of the cost of health insurance that they don’t have — and can’t get — on their taxes.”

and to complete that thought, "...on their taxes, which many of them also don't have because they don't have enough income to have a high enough tax for the deduction to matter".

[Denis Drew]

There is no rationale (except for chicken hearted fear of the insurance industry) to perpetuate private insurance which adds 30% to health costs -- 20 for private paperwork and 10% for doctors keeping up with myriad payment structures and available drug lists as well as procedure denial machinery -- $3000 of the $10,000 cost of a family plan!. Multiple private plans are about as useful as multiple electric grids with competing generators (IOW Medicare equates to a regulated monopoly).

Medicare is ready to go now -- no need for years of phasing in.

And Medicade should replace of Medicare -- the difference in fee payout is now so exaggerated (5X in N.Y. state) that it defeats LBJs original purpose to help the poor -- which is where we came into this movie.

Medicare is almost too easy to sell to the American public. Why give the Republican Chicken Little machine another juicy ideological target (I can hear Newt smacking his lips).

If we cover everyone with Medicare, employer paid insurance can take on the character of supplemental insurance to cover beyond what Medicare does not fully pay.

[reason]

Denis Drew..
No it is worse than a private monopoly because the funds mainly compete by adverse selection (avoiding bad risks who can't get coverage at all). The system works as long as you don't need it!

[anne]

Though I could be disappointed by Paul Krugman's endorsing of the proposals of the prime Democratic candidates for President, I am for now persuaded that only incremental change in health care insurance policy is possible, and private insurers have to be persuaded of full enough inclusion in moves to broader insurance coverage to allow for change.

A day ago, at lunch, I listened to several doctors who had met at length with Hillary Clinton and Barack Obama:

The doctors explained that a 30% cost of administration for medical care because of the private insurance industry was the critical factor in medical costs. The response from Obama and Clinton was, fine but we have to be political realists.

[reason]

Anne,
they could do much worse than consider the German system. It is not perfect, but it would be an easy system for the American system to migrate to.

[anne]

Agreed, the German health care insurance system combines basic public and supplemental private insurance in a highly desirable way. The problem here would be the anticipated loss to insurers in losing on basic coverage. As with adding Medicare drug coverage legislation, there needed to be an incentive to allow passage for the drug companies and insurers.

Essentially all that happened in Massachusetts was that the state mandated all those who had no insurance and were not deemed low income had to buy private insurance. The hope was the cost of the insurance would be reasonable as the buying pool increased. There is no evidence the mandate has been effective, though still early for proper analysis. Low income residents are insured under Medicaid.

[anne]

Mark Thoma has happily listed all of Paul Krugman's New York Times columns for us:

http://economistsview.typepad.com/economistsview/paul-krugman-columns.html

Nice.

[reason]

Um... If they don't lose something there is no savings. At best they can hope for a period of grace, where they lose gradually on old customers but gain on the uninsured. As I see it, what should happen is that everyone has the choice between private and public (as in Germany) and gradually most people will migrate to public (which provides more security at a reasonable price).

[reason]

By public, I publicly mandanted financed out of payroll tax as in Germany.

[Jean]

I have a question: if we were sucessful in eliminating private insurance in the role of health care, what impact would that have on the economy? A huge impact? None? I suppose private insurance could be used for cosmetic and other 'vanity' coverage.

[James Killus]

Jean,
If we were sucessful in eliminating organized crime from the country, what impact would that have on the economy? A huge impact? None?

Insofar as health insurance companies, I'm waiting to hear from some fans of "creative destruction." Anyone? Come on now, you're fine with it when it's the elimination of manufacturing jobs from the midwest (and a shoutout to rustbelt on that one).

[Patricia Shannon]

Bob Somerby's blog for today references this article
See the second half of http://dailyhowler.com/ for today (Sept. 21, 2007)

[Patricia Shannon]

Denis Drew says...
.....
And Medicade should replace of Medicare -- the difference in fee payout is now so exaggerated (5X in N.Y. state) that it defeats LBJs original purpose to help the poor -- which is where we came into this movie.

I'm not sure what Denis means by that. No criticism. We all make mess up our comments, esp. when making a change & forgetting to see what effect it has elsewhere in the comment.

It sounds like NY is generous in it's Medicaid benefits. Of course, it has a high cost of living.

In the southeast, Medicaid is really lacking. When I was working at Waffle House a couple of years ago, making $10,000 - $12,000 a year, I made too much for Georgia Medicaid. Earlier this year, when I was between jobs, when I applied to the state for help in paying for cataract surgery, they gave me applications to two charities (Lion's Lighthouse for the Blind, and Knights of Columbus.)

When I left Alabama in 1992 (for work), if a mother with two children made more than $3,000 a year, they made too much to be eligible for Medicaid. I'm can't remember whether single, non-disabled people were able to get it at all; I believe they could not.

[Robert Recht]

I'm sure i'll say "you have said that before" So I'll save my "breathe"

[Denis Drew]

Patricia,
In New York State Medicare pays something like $200 for a cardiac specialist visit (I can't remember the exact numbers from the NYT article -- cannot find it on line either) while Medicade pays $24. That's what I mean. I did bump into a NYT article while looking that NY Medicade wanted to lower the reimbursement for some drugs below what they cost the pharmacist! The poor don't vote. The elderly (could that be me?!) do.

On idea on saw on the SEIU's Since Sliced Bread contest was to pay people $35 to vote. That would sure get the poor out.

[Denis Drew]

Ann,
What is this business about political opposition by the insurance companies makes it "impossible" to take away their obsolete business? Aren't our Democrat candidates "big leaders"? Doesn't the public have all the votes?

(Let me see if I can sort this out.) Our big hero Dems got licked last time out (Clinton administration) by the Republicans calling PRIVATE insurance based health care "socialism". But this time around the Dems are afraid to propose PUBLIC based Medicare-for-all -- which very ironically the Repubs CANNOT GET AWAY WITH calling "socialism" as everybody knows what Medicare is -- because our Dem heros are afraid of political opposition from the private companies (who together with the Repubs knocked out the private-based program last time). (Am I making any sense?)

Maybe we need a third party: the Martian Party (or perhaps you would prefer the Venetian Party?). Ann, please tell me why you think our big heroes should be so afraid of proposing Medicare-for-all if it is the one thing that is completely understandable (and presumably completely digestible) by the only people with the ultimate power -- the voting public?

PS. I have been watching the political game since about 1961 and thought I might be able to figure it out by myself. The only thing I can figure out is that just like Hil switched sides on the Bankruptcy Bill (after being the single individual who got her hubby to veto an earlier version) -- and is now again, for whatever chicken hearted reason giving in to Chicken Little (whoever the Chicken Little of the moment may be -- confusing). Don't know why Edwards and Obama are up to the same wimpy stuff.

[anne]

Denis, please set down the reference to the New York Times article, or articles, if possible. I will look as well, since I vaguely remember references to Medicaid-Medicare cost comparisons. I need to keep records carefully, but I miss things.

[anne]

I was told authoritatively that both Hillary Clinton and Barack Obama, who are after all fine at reading political mandates, were convinced there could be no health care reform that was not joined by insurers. But, conditions change and what happens in Massachusetts may tell us more. Clinton and Obama and Edwards, whose plan I prefer, are listening to fine voices.

[anne]

Denis, you will have to be more specific about the New York Medicaid articles. I find no immediate candidates.

[anne]

http://www.nytimes.com/2005/11/23/nyregion/23medicaid.html?ex=1290402000&en=039f32ad402f57bb&ei=5090&partner=rssuserland&emc=rss

November 23, 2005

Drug Costs Run Free Under New York Medicaid
By MICHAEL LUO

Penlac Nail Lacquer rarely cures the nail fungus it is designed to treat, yet it costs $130 a thimbleful. As a result, more than 20 state Medicaid programs and dozens of private health insurers require doctors to get advance permission to prescribe it. But not New York Medicaid, which spent $12 million on the drug last year, more than eight times as much as any other state.

New York spent $74 million last year, far more than any other state, on Nexium, the "new Purple Pill" for heartburn. The drug is virtually identical to Prilosec, available at one-sixth the cost over the counter, and so at least 20 state Medicaid programs and many private health insurance companies severely restrict its use. Only now, two years after other states began imposing limits on Nexium, has New York moved to restrict it.

And those amounts are pocket change compared with the $348 million or more that New York could have saved if it were as aggressive as a state like Michigan in setting the prices it pays pharmacies for the drugs they dispense. New York frequently pays many times more for drugs than Medicaid programs in other states.

For years, New York Medicaid, the state's health care program for the poor, has been an open-air bazaar for drug companies and their wares. Prescriptions that are severely restricted in many states are often dispensed freely here, and at higher prices, costing taxpayers hundreds of millions of dollars....

[anne]

"In New York State Medicare pays something like $200 for a cardiac specialist visit (I can't remember the exact numbers from the NYT article -- cannot find it on line either) while Medicade pays $24."

This supposed difference does not make sense, and I can find no confirming or explaining article....

[anne]

http://www.nytimes.com/2005/10/17/nyregion/nyregionspecial4/17clinic.html?ex=1287201600&en=c5f3c85b6092aac7&ei=5090&partner=rssuserland&emc=rss

October 17, 2005

At Clinic, Hurdles to Clear Before Medicaid Care
By RICHARD PÉREZ-PEÑA

Atop a rise on Burnside Avenue in the Bronx, the Morris Heights Health Center looms above a bustling stretch of storefronts offering arroz con pollo and cheap clothes. The clinic is a crucial medical safety net for tens of thousands of people, many of them struggling.

It is a place of solace and deliverance and, just as often, futility and frustration, much of it linked to Medicaid, the government insurance program for the poor.

Every day, the clinic sees patients like Crystal T. Shuler, a single mother who has been a Medicaid client several times - and has seen her insurance cut off just as often, for reasons she does not grasp. She comes to Morris Heights, pregnant and without care for months, to make her third recent attempt to enroll. Her first application was rejected for minor mistakes; on her second try, she did not have all the documents she needed to satisfy New York State.

There are also people like Ronald Shinnery, asthmatic and struggling for breath, who embodies an uncomfortable reality for Morris Heights and other communities served by Medicaid: He can be his own worst enemy, ignoring basic paperwork until, for the second time, his insurance expires and his medicine runs out.

Dr. Tomasz Howard's examination of a fifth-grade girl lays bare another chronic problem. He has to explain to her parents that she has an irregular heartbeat, but cannot see a cardiac specialist for almost half a year. New York pays specialists poorly to participate in Medicaid, and many refuse Medicaid patients.

Sixteen months spent inside Morris Heights, listening to patients, clerks, nurses, doctors and administrators, provides a stark education in Medicaid as it is lived at coarse, unpredictable ground level. Those months illuminate Medicaid's sprawling good works, and how they are undermined by inscrutable rules, daunting paperwork, human frailties and, plainly, the puzzling ways New York spends the program's billions of dollars.

For the people who turn to Morris Heights and Medicaid for care, and for those at the clinic who labor to help them, Medicaid's faults and handicaps boil down to three fundamental, dispiriting truths that strike at the heart of its lofty ambitions:

¶People like Ms. Shuler have trouble getting health care through Medicaid because they do not understand the system, especially the enrollment process. That is one reason about one million eligible New Yorkers are not in the program, according to researchers. New York has recently made enrollment easier, yet it still demands more extensive documentation from applicants than any other state, requirements that can thwart qualified people and, according to experts across the political spectrum, do little to prevent fraud.

¶Patients like Mr. Shinnery often neglect their care - a failure of responsibility for some, and for others a symptom of lives so chaotic that receiving mail is no sure thing. They disregard paperwork or wait until they are seriously ill to apply; others skip appointments, tests and medications.

¶Many doctors, particularly specialists, shun patients like the girl with the heart problem, in part because New York ranks at or near the bottom among the states in what it pays doctors to treat people on Medicaid. For a large class of patients, New York pays a specialist $24 for an office visit, the lowest of any state, while poorer states like Mississippi, West Virginia and North Dakota pay well over $100, and Medicare in New York City and its suburbs pays around $200. Medicaid patients at a clinic like Morris Heights thus hunt endlessly for specialists for ailments like diabetes, heart disease and mental illness....

[anne]

These are important articles which are part of a revealing New York Times series on Medicaid in New York State.

Thank you so much, Denis.

[Denis Drew]

Anne,
I did not search far enough back; I thought I read it less than a year ago (time must fly faster when you get older :-]). It more than "doesn't make sense"; it is undermining the original purpose of Medicade: making it harder for the poor to get care. One more reason for LBJ to spin in his grave along with the minimum wage dropping almost in half (in constant dollars) even as average income doubled.

Okay, Anne, let's say our Medicare-for-all program allows anyone who wants to keep their private insurance (e.g., employee-employer agreements) get out of the added payroll tax. That should mollify the only honest opposition. I mistakenly thought Edward's plan did this, at first. My supplemental-only role for private insurers was just something I dreamed up to take that place.

But, these guys (and gal) are right back to building this big experimental system (circa 1993) -- that may or may not work -- and will take years to experimentally phase in -- and retain all the treatment and financial disadvantages of obsolete private insurance even for those who would be perfect happy to move to Medicare.

I don't think our heroes fear the public which they should; I think they fear the insurance companies which means that democracy must have gone totally limp.

[donna]

I say let the parties live by what they stand for - Democrats should get universal coverage, Republicans get nothing. Then we'll see how many Republicans really believe the crap they spew.

[anne]

http://www.nytimes.com/pages/nyregion/nyregionspecial4/index.html

NEW YORK'S MEDICAID PROGRAM

A look at the security, effectiveness and cost of New York's Medicaid program, the largest of its kind in the nation, and the state's biggest expense.

[6 articles]

http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/diabetes/index.html

A collection of articles and multimedia about diabetes published in The New York Times.

[5 articles]

Here then are 11 in depth articles on Meidcaid in New York and expressly the difficulty of treating diabetes. Paul Krugman addressed the diabetes problem in health care.

http://select.nytimes.com/2006/01/16/opinion/16krugman.html

January 16, 2006

First, Do More Harm
By PAUL KRUGMAN

[anne]

http://select.nytimes.com/2007/02/09/opinion/09krugman.html

February 9, 2007

Edwards Gets It Right
By PAUL KRUGMAN

[John Edwards has offered a health care insurance proposal that allows a general broadening of Medicare along with allowing private insurance companies to offer competing plans.

The health care proposals of Hillary Clinton and Barack Obama are more oriented to private insurers but comparable.

Dennis Kucinich alone is offering a universal health care insurance proposal under Medicare.

Political realism calls for broadening health care insurance coverage through private companies. Reducing administrative costs would call for broadening the role of Medicare.]

[anne]

http://content.nejm.org/cgi/content/abstract/349/8/768

August 21, 2003

Costs of Health Care Administration in the United States and Canada
By Steffie Woolhandler, M.D., M.P.H., Terry Campbell, M.H.A., and David U. Himmelstein, M.D.

Background

A decade ago, the administrative costs of health care in the United States greatly exceeded those in Canada. We investigated whether the ascendancy of computerization, managed care, and the adoption of more businesslike approaches to health care have decreased administrative costs.

Methods

For the United States and Canada, we calculated the administrative costs of health insurers, employers' health benefit programs, hospitals, practitioners' offices, nursing homes, and home care agencies in 1999. We analyzed published data, surveys of physicians, employment data, and detailed cost reports filed by hospitals, nursing homes, and home care agencies. In calculating the administrative share of health care spending, we excluded retail pharmacy sales and a few other categories for which data on administrative costs were unavailable. We used census surveys to explore trends over time in administrative employment in health care settings. Costs are reported in U.S. dollars.

Results

In 1999, health administration costs totaled at least $294.3 billion in the United States, or $1,059 per capita, as compared with $307 per capita in Canada. After exclusions, administration accounted for 31.0 percent of health care expenditures in the United States and 16.7 percent of health care expenditures in Canada. Canada's national health insurance program had overhead of 1.3 percent; the overhead among Canada's private insurers was higher than that in the United States (13.2 percent vs. 11.7 percent). Providers' administrative costs were far lower in Canada.

Between 1969 and 1999, the share of the U.S. health care labor force accounted for by administrative workers grew from 18.2 percent to 27.3 percent. In Canada, it grew from 16.0 percent in 1971 to 19.1 percent in 1996. (Both nations' figures exclude insurance-industry personnel.)

Conclusions

The gap between U.S. and Canadian spending on health care administration has grown to $752 per capita. A large sum might be saved in the United States if administrative costs could be trimmed by implementing a Canadian-style health care system.

[Notice that the citation list for the article extends to 2007, is complete with self-connecting Internet links, and is a terrific tool in examining administrative cost issues for American health care.]

[bakho]

The insurance industry is capable of waging a multi-million dollar ad campaign (Louise and Harry anyone?) against any program that takes too much of their pie. They also provide campaign donations (who funded the GOP in 1994?) and are a huge anchor of the K-Street project.

From Confessore:

" Private sector work has none of government's downside. Political machines thrive on closed-door decision-making; on K Street, there's no other kind. Neither are trade associations subject to inspector generals or congressional oversight; there are no rules against whom you can meet with, no reporters armed with FOIAs. These jobs also make for better patronage. Whereas a deputy undersecretary might earn $140,000, a top oil lobbyist can make $400,000. Controlling K Street also helps Republicans accumulate political talent. Many ex-Clintonites who might have wanted top lobbying positions couldn't get them, and so left Washington for posts at universities, corporations, and foundations elsewhere. But the GOP, able to dole out the most desirable jobs, has kept more of its best people in Washington, where they can be hauled out for government or campaign work like clubs in a golf bag.

But jobs and campaign contributions are just the tip of the iceberg. Control a trade association, and you control the considerable resources at its disposal. Beginning in the 1990s, Washington's corporate offices and trade associations began to resemble miniature campaign committees, replete with pollsters and message consultants. To supplement PAC giving, which is limited by federal election laws, corporations vastly increased their advocacy budgets, with trade organizations spending millions of dollars in soft money on issue ad campaigns in congressional districts. And thanks to the growing number of associations whose executives are beholden to DeLay or Santorum, these campaigns are increasingly put in the service of GOP candidates and causes. Efforts like the one PhRMA made on behalf of Bush's Medicare plan have accompanied every major administration initiative. Many of them have been run out of the offices of top Republican lobbyists such as Ed Gillespie, whose recent elevation to chairman of the Republican National Committee epitomizes the new unity between party and K Street. Such is the GOP's influence that it has been able to marshal on behalf of party objectives not just corporate lobbyists, but the corporations themselves."

http://www.washingtonmonthly.com/features/2003/0307.confessore.html

[Denis Drew]

Next to last gasp on Medicare-for-all:
One of the biggest problems with our Dem heroes leaving universal coverage in the private domain is that our industries are left competing with foreign counterparts who don't have to include -- ever more unaffordable -- employee medical coverage in their prices.

Last gasp:
It would help funding for Medicare-for-all if the great mass of patients -- who pay its regressive taxes -- were not so badly underpaid in these days of the deunionization of America, low low minimum wage (2009 version will be at least .50/hr short of 1956 minimum wage in equal purchasing power), etc. The rich don't have more livers and teeth to fix so support for doctor's incomes has to come from the incomes of the great majority.
*********************
Last gasp on private medical insurance:
If unnecessary paperwork constitutes 30% of private insurance costs (20% on the part of the insurer, 10% on the part of doctors trying to get paid -- and to not get treatment denied -- by dozens of varied insurers), that means that (rounded to the nearest 5%) private insurance ADDS 45% to health insurance costs -- 30% down means 45% up; that's the way the 8th grade math works.

45%; holy cow!

[anne]

Fine, but if possible there have to be specific references on the matter of administrative costs. Where is the data coming from, since this is important?

[Denis Drew]

Anne,
Cannot tell you where the data comes from -- I just know what I read -- I'm just a cabdriver. :-)

[Denis Drew]

Anne,
Is this what you mean?:
http://www.counterpunch.org/woolhandler09212007.html

The Gaping Holes in Massachuesetts' Health Care Plan
Mass Failure

By Dr. STEFFIE WOOLHANDLER
and Dr. DAVID HIMMELSTEIN

In 1966--just before Medicare and Medicaid were launched--47 million Americans were uninsured. By 1975, the United States had reached an all time low of 21 million without coverage. Now, according to the Census Bureau's latest figures, we're back where we started, with 47 million uninsured in 2006--up 2.2 million since 2005. But this time, most of the uninsured are neither poor nor elderly.

The middle class is being priced out of healthcare. Virtually all of this year's increase was among families with incomes above $50,000; in fact, two-thirds of the newly uncovered were in the above-$75,000 group. And full-time workers accounted for 56 percent of the increase, with their children making up much of the rest.

The new Census numbers are particularly disheartening for anyone hoping for a Massachusetts miracle. In the Commonwealth, 651,000 residents are uninsured, 65 percent more than the figure used by state leaders in planning for health reform. Their numbers came from a telephone survey done in English and Spanish. But that misses people who lack a land-line phone--43.9 percent of phoneless adults are uninsured, according to other studies.

It also skips over the 523,000 non-English speakers in Massachusetts whose native language isn't Spanish (e.g. Portuguese, Chinese, or Haitian-Creole), another group with a high uninsurance rate. In contrast, the Census Bureau goes door-to-door for its survey and has translators for almost every language. It gets a more complete picture.

In sum, Massachusetts health reform planners have been wishing away a quarter of a million uninsured people. Recent Patrick administration claims that health reform is succeeding are based on cooked books. According to the state's figures, almost half of the previously uninsured gained coverage under the health reform bill by July 1. But according to the Census Bureau, the new sign-ups amount to less than one-quarter of the uninsured. Moreover, it's likely that much of that gain has already been wiped out by shrinking job-based coverage--a longstanding and nationwide trend.

Why has progress been so meager? Because most of the promised new coverage is of the "buy it yourself" variety, with scant help offered to the struggling middle class. According to the Census Bureau, only 28 percent of Massachusetts uninsured have incomes low enough to qualify for free coverage. Thirty-four percent more can get partial subsidies--but the premiums and co-payments remain a barrier for many in this near-poor group.

And 244,000 of Massachusetts uninsured get zero assistance--just a stiff fine if they don't buy coverage. A couple in their late 50s faces a minimum premium of $8,638 annually, for a policy with no drug coverage at all and a $2,000 deductible per person before insurance even kicks in. Such skimpy yet costly coverage is, in many cases, worse than no coverage at all. Illness will still bring crippling medical bills--but the $8,638 annual premium will empty their bank accounts even before the bills start arriving. Little wonder that barely 2 percent of those required to buy such coverage have thus far signed up.

While the middle class sinks, the health reform law has buoyed our state's wealthiest health institutions. Hospitals like Massachusetts General are reporting record profits and enjoying rate increases tucked into the reform package. Blue Cross and other insurers that lobbied hard for the law stand to gain billions from the reform, which shrinks their contribution to the state's free care pool and will force hundreds of thousands to purchase their defective products. Meanwhile, new rules for the free care pool will drastically cut funding for the hundreds of thousands who remain uninsured, and for the safety-net hospitals and clinics that care for them. (Disclosure--we've practiced for the past 25 years at a public hospital that is currently undergoing massive budget cuts.)

Health reform built on private insurance isn't working and can't work; it costs too much and delivers too little. At present, bureaucracy consumes 31 percent of each healthcare dollar. The Connector--the new state agency created to broker coverage under the reform law--is adding another 4.5 percent to the already sky-high overhead charged by private insurers. Administrative costs at Blue Cross are nearly five times higher than Medicare's and 11 times those in Canada's single payer system. Single payer reform could save $7.7 billion annually on paperwork and insurance profits in Massachusetts, enough to cover all of the uninsured and to upgrade coverage for the rest of us.

Of course, single payer reform is anathema to the health insurance industry. But breaking their stranglehold on our health system and our politicians is the only way for health reform to get beyond square one.
*******************
Dr. Steffie Woolhandler and Dr. David Himmelstein co-founded Physicians for a National Health Program and are primary care doctors at Cambridge Hospital.

[anne]

Denis, you have a sparkling memory. When you can give me enough clues as before, I am likely to find your fine sources. Also, I may already have your refences which you remember better than I do. Woolhandler and David Himmelstein are thoroughly reliable. Impressive.

[anne]

Having called Massachusetts Blue Cross Blue Shield, I have a scary quote of $595.52 a month for a single adult 45 and over for a policy with a $400 deductible and co-pays for all but selected vaccinations. Scary stuff.

Denis has done us a fine favor:

Notice, then, the remarkable post criticizing the Massachusetts health care plan.

[anne]

http://www.boston.com/news/globe/editorial_opinion/oped/articles/2007/09/17/health_reform_failure?mode=PF

September 17, 2007

Health Reform Failure
By Steffie Woolhandler and David U. Himmelstein - Boston Globe

And 244,000 of Massachusetts uninsured get zero assistance--just a stiff fine if they don't buy coverage. A couple in their late 50s faces a minimum premium of $8,638 annually, for a policy with no drug coverage at all and a $2,000 deductible per person before insurance even kicks in. Such skimpy yet costly coverage is, in many cases, worse than no coverage at all. Illness will still bring crippling medical bills--but the $8,638 annual premium will empty their bank accounts even before the bills start arriving. Little wonder that barely 2 percent of those required to buy such coverage have thus far signed up....

[The better policy, I priced would cost $7145 a person for the year. While I am accustomed far better coverage. Good grief.]

[anne]

Woolhandler and Himmelstein refer to declining employer based insurance, which is confirmed in a California study showing that where 58.4% of children were covered by employer based insurance in 2000, only 51.9% were covered in 2006.

http://www.epi.org/content.cfm/bp199

Also, there is an Oregon study showing that even when there insurance coverage offered for children whose parents lose lack insurance, there is less likelihood those children will be covered.

http://www.cbpp.org/9-17-07health2.htm

[anne]

Telling a middle class Massachusetts couple to buy a relatively defective health care insurance product from $8,600 to $14,200 or pay a fine of several thousand dollars is shabby health care reform indeed, as I now understand properly.

[anne]

Reading through a defective series of personal Blue Cross Blue Shield health care insurance policies, ranging in cost to $595.52 a month, or $7145 a year for a policy filled with deductions and co-payment requirements, I am convinced the Massachusetts plan is as defective as the insurance offerings. The plan seems to be, pray for wellness and the heck with household insurance.

The fine for failing to buy insurance will seem the better risk for many in middle class households. As usual, I am startled. Remind me to makes lots of needless doctor's appointment from tomorrow on.

[Lafayette]

Why Edward's Health Care Plan Won’t "Work"

Here is a quotation from Edwards' Web-site regarding his HCP:
The Edwards Plan achieves universal coverage by:

* Requiring businesses and other employers to either cover their employees or help finance their health insurance.
* Making insurance affordable by creating new tax credits, expanding Medicaid and SCHIP, reforming insurance laws, and taking innovative steps to contain health care costs.
* Creating regional "Health Care Markets" to let every American share the bargaining power to purchase an affordable, high-quality health plan, increase choices among insurance plans, and cut costs for businesses offering insurance.
* Once these steps have been taken, requiring all American residents to get insurance.

First, let’s define what “work” means. It means that for a health care plan to be successful, it must respond to two metrics: (1) It has to cover more people AND (2) it has to be holistically affordable to the country. Not just the person receiving care, but to the nation as a whole.

Tweaking a mechanism by which those who can pay for Health Care Insurance pay for those who cannot DOES NOT MEAN AFFORDABLE. Program insurance is paid for by companies that recuperate the cost from the pricing of their products/services. That means an indirect tax on all Consumption. Medicare/SHIP is paid out of tax-base revenues.

Take a look at the first “miracle” proposal. The fact that businesses must all have HCPs does not make them more affordable nationally. Just the opposite. It’s a boon for the program insurance companies already selling their coverage – it brings them more customers. Unfortunately, it makes American labor more expensive and therefore less competitive. In the lower and unskilled labor markets, it will "kill dieing jobs dead" by exporting them.

Looking at number 2, it is obvious that employing currently tax-revenue funded resources to extend coverage achieves goal Number One but not goal Number Two. Containing health care costs will not, if directed at its bureaucracy, bring down the overall cost all that much. Most of the cost is located in health care practitian salaries. It is this cost that should be targeted by increasing either the supply or arranging for the service to be provided at lower rates. (Meaning, the government should mandate the rate.)

Once again, item 3 above helps achieve goal Number One but not Number Two. Goal Number Two will not be achieved uniformly unless we change practitian costs, which can be done through a National Health Service that employs mandated costs – not on private health care businesses that compete with one another for personnel and accept the market rate.

Item 4 is a good idea. But it simply extends coverage, not lower its cost. The Supply of health care services is relatively inelastic -- more Demand just pushes up (not down) service pricing.

It cannot be more underscored that the service-delivery costs in the form of salaries is the most prevalent component of a national health care plan. And, for as long as we think that “market pricing” is going to adequately supply trained staff, America will have one of the most expensive health care systems in the world.

Furthermore, NOTHING in the above proposals focuses upon Preventive Care, which can really, truly bring health care costs down to manageable levels. Preventive care is the mainstay instrument proposed by the World Health Organization to assure a better heath care plan for all people, particularly the poor in countries that cannot have adequate remedial services. So, why shouldn’t it work even better in advanced countries where the practitians of remedial health care are so expensive?

Besides, for Preventive Medicine to work, people in all regions must have a health care clinic they can easily go to. For as long as a program depends upon "market oriented principles", then it will NOT go into areas that are not profitable.

The challenge is like any important public service. The state must provide the infrastructure for it to work properly and at a reasonable cost. Depend upon businesses to do it, and we end up with a White Elephant.

Like the present health care system that is rated so poorly.

[Lafayette]

anne: I was told authoritatively that both Hillary Clinton and Barack Obama, who are after all fine at reading political mandates, were convinced there could be no health care reform that was not joined by insurers.

This IS the conventional wisdom. Why?

Because the AMA wants American health insurance to remain EXACTLY the way it is, but encompass more people.

The "way it is" is immensely profitable for a select group of health service practitioners. As I have said, repeatedly, corporate health insurance costs are recuperated out of the pricing of goods and services.

It is therefore an indirect tax on Consumption, the benefit of which is kicked-back to health care practitioners, after insurance companies have taken a cut. It's a lucrative business for both.

If Americans want health care to be provided by means of taxing Consumption -- that's their decision.

Still, the idea of levying a tax on Consumption to pay for Health Care is insane.

[Patricia Shannon]

Denis,

Thank you for all your information.

As for why the Dems aren't doing the best thing for health care, or other problems, remeber that the ultra-rich power elite includes the MSM (MainStream Media). If they are really opposed to a candidate, they will destroy them. Look at what they did to Kerry and Gore. In the current campaign, when their efforts to damage Edwards resulted in more campaign contributions for him, they started ignoring him.

[Patricia]

donna says...
I say let the parties live by what they stand for - Democrats should get universal coverage, Republicans get nothing. Then we'll see how many Republicans really believe the crap they spew.

Very good. My experience with Repubs is that they will dismiss other people's problems, but when they have the same problems, expect other people to sympathize with them and help them.

[anne]

Denis has done us a favor as has Patricia.

While I have been reading, I have become increasingly convinced that while the non-health-care insurance plans of the Republican presidential candidates would be intolerably harmful, the plans of the Democratic candidates save for Dennis Kucinich will simply not be effective for middle class households. The problem is administrative costs that the private insurance companies have made nightmarish.

[Denis Drew]

Just an idea:
Assuming Medicare-for-all became reality (except for employers/employees who opt for private plans -- and out of "for-all" taxes?)...
...then, a firm like GM could conceivably use Medicare as the base for employee coverage to take advantage of the 30% paperwork savings we are always hearing about -- and supply its employees with a company supplemental plan to cover the 20% of medical bills that Medicare presently doesn't pay. Don't know how much of a problem for GM workers the likely spit tax might be (6% for employer and employee?). Just a hybrid concoction.

[Lafayette]

A typical American health care story?

[Lafayette]

anne: The problem is administrative costs that the private insurance companies have made nightmarish.

No, anne, we've been through this loop before.

People keep harping about administrative costs. They are NOT the real problem. The real problem is the sky high cost of basic services. (See Bloomberg story linked above.)

I published (here) a study, done in California, some time ago that showed clearly that the primary health care cost lies in practitioner (doctors, nurses, aides) salaries.

Besides, if there were one sole provider, working off a mandated list of uniform service fees throughout the country, the "market" would be limpidly clear and administrative costs far lower.

(France recently instituted an "intelligent card" device, with an integrate circuit, that GPs employ to connect to the National Health Service. Yes, France employs a franchise on each service, so Health Care is not completely free. But, the paperwork is meaningless. In fact, there is no paper.)

Until either the prices are mandated (meaning fixed to offer a reasonable return to the practitioners) or the supply of competent agents (doctors/nurses/aides) is increased dramatically, then no tweaking of the present private health care service will work in America.

Why do you think ALL the health care public services in the top fifteen cited in the World Health Organization study are run by the state? Do any of them have the same or costs similar to America? From whence arises the fact that Americans pay FOUR times the cost as in Europe????

The present political polemic, containing the various plans, is smoke and mirrors. Until the real culprit (service pricing) is addressed, there will be NO SOLUTION to the health care mess in America.

NB: The political issue MUST address the menace of a ferocious lobby effort by the AMA in cahoots with its K-street henchmen. Public Services are the foremost battleground in America today and the only truly viable way to bring America a modicum of income equality.

[anne]

Neither General Motors nor the United Auto Workers have a national interest in health care reform, which should have been obvious for years but has not been obvious to me till now. When GM wants governmental assistance, GM gets the assistance as shown by more than 20 years of successful efforts to have no tightening of fuel efficiency standards.

The puzzle then is why neither GM nor the UAW has pushed for a national health care program. I understand finally, and ask then "why."

[anne]

There are powerful interests groups such as GM and the UAW, that could for years have worked for a national health care plan, but have not. So, while I have focused on opposition to national health care from insurance companies I have forgotten to ask seriously why there is almost no corporate support and only selected union support.

The puzzle then is why? Why is the pressure group support for national health care found in other countries, especially corporate and union groups, not found here?

[anne]

As for the idiocy on administrative costs not being costs, simply listen to Barack Obama or Hillary Clinton talk about how computer technology is the answer to cost control in health care, and laugh hysterically. A computer, imagine that, a computer in the octors office and poof poof poof there are no costs (too few poofs really).

Keep on ranting about health care costs, but never ever mention administrative costs which are evidently not costs because, well, they are not costs. Say what?

[anne]

Remember kiddies, the real problem in health care is, well health care, which we can no longer afford and had best just begin to eat the ill rather than treat them. The problem is doctors, the problem is nurses, the problem is patients. Rubbish, as always.

The problem is insurance companies, and who the heck cares even with that problem when we are going to spend an insane $217 billion on war in and occupation of Iraq in the coming year. Notice that $200 billion is now $217 billion. Say what?

[anne]

Say what?

http://www.cbpp.org/9-25-07health.htm

September 25, 2006

Administration Moves to Withdraw Health Services From Children and Adults With Mental Illness and Other Disabilities
By Judith Solomon

The bipartisan children's health insurance legislation unveiled today contains a provision to help preserve essential health care services for poor children and adults with mental illness or other serious disabilities. The legislation, to be considered by Congress this week, includes a six-month moratorium on Administration plans to institute sweeping Medicaid cuts in services for these individuals.

On August 13, 2007, the Centers for Medicare and Medicaid Services issued a proposed regulation that would eliminate federal Medicaid funding for important services provided to adults and children with disabilities (particularly those with mental illness), as well as other beneficiaries. The rule would significantly limit states' ability to provide rehabilitative services, including those designed to enable individuals with disabilities to improve their mental or physical capacities and remain out of an institution....

[anne]

"Administration Moves to Withdraw Health Services From Children and Adults With Mental Illness and Other Disabilities"

Imagine reading such a headline. Not to mention $217 billion for the insane tragedy of Iraq. Never to mention Iraq, which the University of Chicago and Alan Greenspan have told us is really costless. The nutty Greenspan is telling us that oil woul be $160 a barrel had we not invaded and occupied Iraq (precisely what I heard Greenspan say).

[Lafayette]

anne: Why is the pressure group support for national health care found in other countries, especially corporate and union groups, not found here?

Having worked in a union shop stateside, I can tell you that American unions -- perhaps aside from the truckers -- are timid by comparison with their European counterparts.

Some have even been bought out. Mind you, that happens in Europe as well. A recent scandal at Volkswagen showed the unions having been bought out (at basement prices) -- these are docile union members who are also representatives on the BoD of the company, according to German law.

It is all a matter of public clarity. Obfuscate what happens at the Board level and manipulating even a public company is easy as making a cake.

[Lafayette]

"How did this happen in America?!?"

For all the brouhaha about income inequality, the best and easiest way to obtain more of it is not just increasing the marginal tax rates at upper income levels, but spending the resulting tax income on Public Services that the poor to lower-middle class will enjoy and benefit from.

That means focusing specifically on Education (University and skills training) as well as Health Care (particularly Preventive Medicine and notably pandemic obesity) as well as mandated (price controlled) Health Care services -- perhaps through a parallel expanded Medicaid public service offering that is uniformly nationwide to those without corporate program insurance. (Of course, if people want to opt for the Medicaid-expanded health coverage, that should be a viable option -- which will inject some competition into the "market" for health services.)

And the cost of all this "blatant socialism"? ... not much more than a year in Iraq. With lives saved instead of lives lost.

That's real democracy! All the rest is just various forms of plutocracy, of Roman Empire vintage.

Americans like to think that there is no straw to break the camel's back. That people are pretty much sheepish and will accept just about anything and anyone whilst they're being fleeced -- regardless of the load to bear.

What a surprise you've got coming. One little spark and you've got Watts all over again, but nationwide ... and not just blacks. And for years afterwards, we'll have sociologists scratching their heads wondering aloud, with journalists ghost writing books for politicians about "How did this happen in America?!?"

Shit happens.

[Denis Drew]

Anne,
You know somebody on another thread raised the question of just what constitutional basis could be used by the federal government to force citizens to buy health insurance?

Motor vehicle law can force us to buy accident insurance if we want to exercise the -- privilege -- to drive. I am not sure that the federal government has a specific power even to force inoculation with vaccines. But, can the federal government force citizens to buy something just to make a policy objective workable? Have doubts.

In any case someone should start looking into it (on law blogs?). Unless I am completely off base here (I may be -- the answer may be pat and simple) there may be law suits to stop any such legislation from being implemented -- leading to more lost years before a private-base universal health scheme can work.

[anne]

Please, what nonsense listening to libertarian ravings is. The government has no problem forcing me to pay for war in and occupation of Iraq, or for Social Security or Medicare. Notice that libertarians never ever have the least problem with forcing an insane war and occupation on others. Only health care is a problem. What raving nonsense. We too can become Somalia, if only libertarians show us how.

Duh....

[anne]

Libertarians would return to the Constitutionalism of Dred Scott v Sandford, never understanding the insane contradiction; as Brad DeLong has argued. Heck, they have already returned us to Plessy v Ferguson, so who knows.

[Lafayette]

DD: You know somebody on another thread raised the question of just what constitutional basis could be used by the federal government to force citizens to buy health insurance?

Sure, people should have the constitutional right to contract influenza and infect all who come in contact with them. Or, why have driving limits on highways?

Come off it, we live in a society where there are not only rights but also duties/responsibilities as citizens.

Or, are you the "rights only" kinda guy. Plenty of those around ...

says...

Lafayette says...
.....
Besides, if there were one sole provider, working off a mandated list of uniform service fees throughout the country, the "market" would be limpidly clear and administrative costs far lower.
....
Until either the prices are mandated (meaning fixed to offer a reasonable return to the practitioners) or the supply of competent agents (doctors/nurses/aides) is increased dramatically, then no tweaking of the present private health care service will work in America.

You have some good ideas, Lafayette.

In regards to uniform payments, the U.S. is much bigger than most countries, and the cost of living is dramatically different in different places, so that should be taken into account when calculating reimbursement rates.

I was at a seminar recently for people thinking of going to college for one of several professions, one of them being the medical field. One of the representatives of a university said a problem in the U.S. is that there is a lack of teachers of doctors, because they can make so much more money practicing medicine than teaching it. I already knew this to be a problem with the supply of nurses.

says...

See this article in Vanity Fair, to be reminded of what the press, which is owned and financed by big business, will do to a political candidate they don't want

http://www.vanityfair.com/politics/features/2007/10/gore200710#content

For a continuing up-to-date on the political misinformation the MSM is currently giving us, as well as reminders of past campaigns, see

http://dailyhowler.com/

[Denis Drew]

>>Or, are you the "rights only" kinda guy.

The states have the power to force immunization. It is just a technical question whether the federal government could do so. It can regulate interstate commerce for a different example -- but can it FORCE interstate commerce; can it force you to buy something that only facilitates a general goal, not protects against an imminent threat to others (eg. polio).

Some things that states have the power to do (set speed limits) the fed cannot does not. The fed gets around it lack of power to set speed limits or force the use of motorcycle helmets by for threatening actions it has the power to do, such as withholding highway building funding from states that don't comply with its wishes (always constitutionally cloudy). It is just a technical constitutional question whether the fed can directly force you to buy something..

says...

In regards to what the government can legally require:

In Atlanta recently, a man with contagious TB refused treatment, and said he planned to return to Mexico. He was jailed until he agreed to accept treatment.

There was the man with non-catagious TB, who went overseas for his honeymoon. You all probably know the details already. Note how long it took for the press to stop claiming falsely that he had been diagnosed as contagious.

==========================

In regards to being required to pay for health insurance :

When I was working for Waffle House a couple of years ago, I got a lump on a lymph node that could have been cancer (it was not). The county health department sent me to a private health clinic that charges on a sliding scale. My first visit would cost $30. ($5 thereafter). I did not have $30. A minister at my church gave me money from the minister's discretionary fund, which allowed me to get that first visit.

Most of the people commenting here, and the people who set policy, don't understand the situation of the really poor.

[Patricia]

I forgot to sign the last two comments I made.

[anne]

Universal health care is done for years to come. My preliminary understanding is that General Motors workers have been severely hurt by the health care settlement, but more hurt is America's middle class. Terrible, terrible.

[anne]

A prominent specialist tells me in dismaying terms the General Motors settlement is terrible for labor for several reasons, but especially a harm to universal health care advocates.

[Lafayette]

anne: A prominent specialist tells me in dismaying terms the General Motors settlement is terrible for labor for several reasons, but especially a harm to universal health care advocates.

Present labor factor costs

Yes, but as regards particularly GM, it is either THAT settlement or manufacturing dislocation. GM cannot compete with its present input factor costs:
Hourly average labor cost: GM ($73.73) – Toyota ($48) [52% more for GM]
Health care cost per vehicle produced : GM ($1,525) – Toyota ($201) [658% more for GM]

So, the agreement is that the new hires will not have either the same salary or the same health care insurance as those on the job. In this manner, as the older workers retire, with their benefits, the younger ones take their places -- but at more competitive labor rates.

I don't tire of repeating here what is painfully obvious about American Health Care -- its fundamental cost, which represents an indirect tax on labor.

The Health Care System is broke. It doesn't need fixing ... rather, it begs for wholesale replacement from top to bottom with factor costs (salaries, technology, pharmaceutical, clinic accessibility, preventive medicine) that are not hallucinatory.

And, now's the time. Miss this opportunity and it wont come around again for decades.

[Lafayette]

Article: Still, this week she did deliver a plan, and it’s as strong as the Edwards plan — because unless you get deep into the fine print, the Clinton plan basically is the Edwards plan.

Smart strategic move

This represents a smart strategic move on the part of Hillary. There can be no pissing contest between the two top Dem candidates over Health Care. So, the debate has to be on a different level, one less polemical.

Which shifts the debate focus, unfortunately.

Health Care costs are the rot in American competitiveness and overall net in-the-pocket wages. They must be reduced. Neither plan goes far enough in either reducing cost structures or promoting preventive medicine - either of which can generally reduce Health Care expenditures (in a country with excessive personal habits that generate illness).

[Lafayette]

DD: A couple in their late 50s faces a minimum premium of $8,638 annually, for a policy with no drug coverage at all and a $2,000 deductible per person before insurance even kicks in. Such skimpy yet costly coverage is, in many cases, worse than no coverage at all.

Interesting reconstruction, DD.

To wit, Health Care coverage reform is nonsense until Health Care service costs are brought in line with reality.

Which can ONLY be done by mandating Health Care as a Public Service and assuring that NO ONE is left behind, regardless of their income or work situation. Both the state and the federal government should share in the burden (even if it means paying for it by raising greatly marginal income tax rates). America can afford the "world class" Health Care that it thinks it has, but doesn't.

Generalized Health Care is just common decency in a society that cares for its people, not a perquisite.