Paul Krugman: Kennedy's Big Day

Advocates of universal health care should be encouraged by "the first major health care victory that Democrats have won in a long time":

Kennedy’s Big Day, by Paul Krugman, Commentary, NY Times: ...On Wednesday, Senate Democrats ... won a huge victory on Medicare. ... Ted Kennedy, who is fighting a brain tumor, made a dramatic appearance on the Senate floor, casting the decisive vote amid cheers from his colleagues. (Only one senator was absent: John McCain.) ...

It was the first major health care victory that Democrats have won in a long time. And it was enormously encouraging for advocates of universal health care. ...

Wednesday’s vote was about restoring cuts in Medicare payments to doctors. What it was really about, however, was the fight against creeping privatization. Democrats finally took a stand...

The story really begins in 2003, when the Bush administration rammed the Medicare Modernization Act through Congress... That bill established ... Medicare Advantage plans ... in which Medicare funds are funneled through private insurance companies...

Since then, enrollment in these plans has been growing rapidly. This has had a destructive effect on Medicare’s finances: the fastest-growing type of Medicare Advantage plan ... costs taxpayers 17 percent more per beneficiary than Medicare without the middleman. It also threatens to undermine Medicare’s universality, turning it into a system in which insurance companies cherry-pick healthier and more affluent older Americans, leaving the sicker and poorer behind.

What does this have to do with cuts in doctors’ fees? Well, legislation passed a decade ago makes ... cuts automatic... This year, the automatic cuts would have reduced doctors’ payments by more than 10 percent, a pay reduction so deep that many physicians would probably have stopped taking Medicare patients.

In previous years, payments to doctors were maintained through bipartisan fudging ... to waive the rules. ...

This year, the Democratic leadership decided, instead, to link the “doctor fix” to ... reining in those expensive private fee-for-service plans. Last month, the Senate took up this bill — but Democrats failed by one vote to override a Republican filibuster. And that seemed to be that...

But then Democratic leaders decided to play brinkmanship. They let the doctors’ cuts stand for the Fourth of July holiday, daring Republicans to threaten the basic medical care of millions of Americans rather than give up subsidies to insurance companies. Over the recess period, there was an intense lobbying war between insurance companies and doctors.

And when the Senate came back in session,... the bill passed with a veto-proof majority.

If the Democrats can win victories like this now, they should be able to put a definitive end to the privatization of Medicare next year, when they’re virtually certain to have a larger Congressional majority and will probably hold the White House.

More than that, however, advocates of universal health care ... have to be very encouraged by this week’s events.

Here’s how it will play out, if all goes well: early next year, President Obama will send his health care plan to Congress. The plan will face vociferous opposition from the insurance industry — but the Medicare vote suggests that this time, unlike in 1993, Democrats will hold together.

Unless Democrats win even bigger than expected, however, they won’t have the 60 Senate votes needed to override a filibuster. What the Medicare fight shows is that the Democrats could nonetheless prevail by taking their case to the public, daring their opponents to stand in the way of health care security — so that in the end they get some Republicans to switch sides, and get the legislation through.

A lot can still go wrong with this vision. But the odds of achieving universal health care, soon, look a lot higher than they did just a couple of weeks ago.

Comments

[Bruce Wilder]

I am so sick and tired of these earnest little civics lessons from Paul Krugman.

Yes, I am hopeful, too; we are hopeful, together, I guess. Big whoop!

In our Manichean election, the good guys, weak and flawed though they may be, seem to be, more or less, winning. Yeah, team!

The Republicans, determined to nominate the Worst Candidate Ever™ to replace the Worst President Ever™, actually appear to be well on track to losing. Defending more seats in the U.S. Senate than any Party has had to defend in 50 years, with five retirements all Republican, there's a good chance the Republicans will actually lose a precious few seats. In the House, a slew of Republican retirements point to Democratic gains.

And, we chalk this all up to an anemic business expansion without wage gains followed by what promises to be the worst recession since the last worst recession since the Great Depression -- both also Republican achievements, incidentally. Oh, and did I mention that the Republicans have managed to destroy the housing market, the banking system, lose two wars, and never caught Osama bin Laden or the perpetrator of the anthrax attack?

Mr. Obama's obvious skills notwithstanding, I am not convinced that the Democrats (and I identify myself as a Democrat) know how to play the political game anymore. The Republicans are doing everything they can to lose and lose big. Will it be enough? Oooh, the suspense.

The election is being handed to the Democrats in a display of Republican incompetence and malfeasance and even bad luck, which knows few bounds. It is not as if the Democrats have managed any other legislative victories. Popular approval of the Democratic Congress has reached single digits in the polls! It is not as if the Democrats can get even passably fair treatment in the news media. (The Associated Press has practically endorsed John McCain!) But, despite all these seemingly insurmountable challenges to their ability to lose this election, Republicans soldier on to their doom. This week they had John McCain pissing on the third rail of American politics, and rolling out the most obnoxious Senator in history, Phil Gramm, as an economics advisor: the author of the banking regulatory reform that destroyed the American banking system and the Vice-Chairman of a Swiss bank, which has advised employees to avoid travelling to the U.S., for fear of criminal prosecution. And, Phil's excellent advise: tell Americans that they are whiners and should suck it up!

Democrats certainly don't act as if they expect to act next year on comprehensive health care reform. They scarcely act as if they have any sort of agenda, except enacting exactly whatever the most unpopular U.S. President in the history of polling demands.

When a Party this weak seems headed to an inevitable electoral victory on the strength of the best efforts of their opposition to lose, one has to wonder about the real prospects. It is not like the Republicans to want so badly to not govern. The lack of Democratic ambition is so habitual, that it is difficult to imagine an alternative.

[Richard H. Serlin]

There's a crucial little known fact that Paul Krugman and everyone else for universal healthcare needs to know:

The bill for it can be structured so it's not filibusterable.

So it only needs 50 votes (with a Democratic vice president).

It's therefore far more realistic to achieve than people think, and we don't have to compromise and not have a true universal health care plan as Obama has done at least so far (although he's said things to leave himself wiggle room to propose a true universal healthcare plan after being elected.)

New Republic Senior Editor Jonathan Chait describes this in his 2007 book, "The Big Con: The True Story of How Washington Got Hoodwinked and Hijacked by Crackpot Economics"

On page 204:

Perhaps the most incredible thing about the [1993 Clinton] health care debacle is that the Democrats could have avoided the filibuster that ultimately killed the reform if not for the stubborn insistence of one senator – a liberal Democrat, at that. Passage would have been all but guaranteed if the senate had included health care as part of a "reconciliation bill". This is a senate term for an annual piece of legislation dealing with the budget. A reconciliation bill, unlike any other, cannot be filibustered and therefore can pass with a simple 51-vote majority. Given that the Democrats controlled 57 senate seats, the numbers would have allowed for easy passage even with a half dozen defections.

Yet the Democrats did not do this because West Virginia's Robert Byrd adamantly refused. Byrd was an old fashioned New Deal Democrat who supported reform but cared more about the traditions of the Senate than anything else. He was given to interminable speeches quoting Cicero and other orators of antiquity, and his sense of importance exceeded even Moynihan's. Byrd objected on the grounds that reconciliation bills could be subjected to a twenty-hour debate limit, and he felt the issue too important to be so circumscribed. He would not budge in the face of pleas from Clinton and his fellow senators, and his ability to tie the senate in knots if so inclined deterred the Clinton administration from crossing him. In the end, Dole spearheaded a filibuster that killed the potential reform.

End Quote

See also, the Washington Post article from March 14th, 1993, "Shortcut for Health Care Plan Blocked", available at:

http://pqasb.pqarchiver.com/washingtonpost/access/8550246.html?dids=8550246&FMT=ABS&FMTS=ABS&date=Mar+14%2C+1993&author=Dewar%2C+Helen&pub=The+Washington+Post&edition=&startpage=A9&desc=Shortcut+for+health+care+plan+blocked

As I've written before, enacting universal health care would create such enormous political capital, it would be well worth making any enemies in the Senate. And once it was enacted, like old age Social Security and Medicaid, people would clearly see how much better off they were with it than before, and the Republicans would (probably) never be able to get rid of it. It would be political death, another third rail of American Politics. So there's no need for a hopefully new Democratic administration to be scared to go for a true universal health care plan. I hope everyone in a new Democratic administration understand this.

[Lafayette]

Health Care Feeding Frenzy

Article: If the Democrats can win victories like this now, they should be able to put a definitive end to the privatization of Medicare next year, when they’re virtually certain to have a larger Congressional majority and will probably hold the White House.

As for the political prognostications, let's hope so. But, nothing is assured and Mr. Krugman may well be asked to eat his words by swallowing whole the paper this article can be printed on. ;^)

As for Health Care, is it a propitious moment to propose a Health Care system that works, like the one from which European benefit? To which America might aspire by simply extending judiciously Medicare to the masses?

This would require (1) a parallel system of Universal Medicare-managed HC-services performed by Medicare-salaried practitioners and (2) capping of HC service costs for both Preventive and Remedial Medicine. Neither are easy tasks.

Both are anathema to the AMA and Private Insurance companies. GP average annual revenues would tumble from $150,000 to perhaps half that -- meaning fewer fat cat doctors roving about in BMW SUVs. (‘Tis a pity, that; but did they never take the Hippocratic Oath?)

So, first, the Dems must tackle these two powerful lobbies – the AMA and BigInsurance. One might be led to think, given the highly vested interests in maintaining the status quo, they should go after both with a bludgeon.

It is imperative, for any functional HC-system in the world, to have an access-to-GP-consultation cost that is minimal. This cost should be less than $40-$50 per consultation – partially (85%) reimbursed by Medicare. This access cost could allow Preventive Care to prevail over far more costly Remedial Care. Clinics and hospitals must be available to people at a cost that does not represent a barrier to utilization. That might seem obvious to most. If so, why isn’t it the case?

To think that present ERs perform this function is dead wrong. ERs perform remedial palliative care. If anyone goes there with a serious problem, and they have no insurance, their "case" ends up before a "Board of assessors" to decide if they are "worthy" of free Health Care. If accorded, the cost is recuperated by adding the benevolent HC-cost to that of Private Insurance programs, which companies and institutions purchase.

This sort of Benevolence Health Care is haphazard and inapt at the task of providing Universal Health Care, which is a social birthright. Here follows the notion that we must assimilate: Health Care is not just another Service Business.

It is a high-cost Public Service. As citizens we must "expect" its provision in the same manner as we "obtain" national security and defence, or local police security, or firemen. How is it, then, that this nation can spend trillions on the DoD and let languish truly Universal Health Care? In America, fully 16% of the workforce has NO HC-insurance and another 30% have inadequate HC-insurance.

Our folly, however, would be to think that tweaking the present model of American Health Care will achieve universality. It won't because it can't.

The cost mechanism of private HC-insurance will not allow it -- there are just too many blubbery fingers on the pie, not just practitioners but hi-tech companies with new devices and, of course, the pharmaceutical companies. They are all feeding off the same voluptuous tart.

[Lafayette]

The World's Best

Serlin: It's therefore far more realistic to achieve than people think, and we don't have to compromise and not have a true universal health care plan as Obama has done at least so far

However it passes Congress, tweaking the present system WILL NOT provide truly Universal Health Care. It's like trying to make a leopard change its spots. It jess aint gonna happin.

Read my previous comment. Tell me how I am wrong.

PS1: I live in France. My previous comment outlines a system based upon the French one, which is largely funded in the same manner as the US HC-system, but where Private Insurance is relegated uniquely to the role of top-up insurance. This system was recognized by the World Health Organization (WHO), because of two criteria (high professionalism and low-cost access to preventive care), as the World's Best.

PS2: Of the top fifteen in the WHO's classification of world health systems, there are ten European countries. All of them have nationalized Health Care.

[anne]

"On Wednesday, Senate Democrats capitulated to the Bush administration on wiretapping — with Barack Obama joining the coalition of the craven."

Right.

[Lafayette]

BW: The lack of Democratic ambition is so habitual, that it is difficult to imagine an alternative.

Good rant, BW. We need some well articulated rants in this forum. Your's is up to snuff ... it points accurately the finger. The Dem mentality is hellbent upon self-destruction. Because, imho, it has no unifying agent, just a bunch of prima donnas.

IF Obama gets elected -- yes, BIG, BIG, BIG little "if" -- he will have the opportunity very early on to bring the "Change in Washington" he talks so much about (but defines so little).

That can be done by fixed term limits that cut out the career politicians who "play the game". That spawn such neolithic political animals like Phil Graham. That create a Senate constituted at 40% of millionaires. Whose vested interests are these millionaires looking after? For sure, not mine.

He could also bring about definitive campaign funding limitations. His own record in the matter is telling -- he's supposedly not taken any large donations. Let's hope so. Another PotUS elected by middle-east and national BigOil money is NOT what this nation needs.

But, he can't do any of that without Congress! How does Congress adopt measures that sanitize American politics and political decision making, but go squarely up against the vested interests of career politicians?

[Lafayette]

On Wednesday, Senate Democrats capitulated to the Bush administration on wiretapping — with Barack Obama joining the coalition of the craven.

How many have actually read the bill in question? How many are familiar with its controversial nature?

If so, please explain the "craven" bit.

The controversy in this matter is complex. I suggest anyone further interested read about it, here, before forming an opinion.

[...]

I have to agree with BW and Anne. If the Democrats do not have the courage to defend the Bill of Rights on the FISA vote, how can we expect them to take on big insurance?

I'm afraid that at the very least, the insurance lobby will successfully neuter whatever universal health bill Congress does manage to pass.

[anne]

http://www.nytimes.com/2008/07/10/washington/10fisa.html?hp&pagewanted=print

July 10, 2008

Senate Backs Wiretap Bill to Shield Phone Companies
By ERIC LICHTBLAU

WASHINGTON — More than two and a half years after the disclosure of President's Bush's domestic eavesdropping program set off a furious national debate, the Senate gave final approval on Wednesday afternoon to broadening the government's spy powers and providing legal immunity for the phone companies that took part in the wiretapping program.

The plan, approved by a vote of 69 to 28, marked one of Mr. Bush's most hard-won legislative victories in a Democratic-led Congress where he has had little success of late. Both houses, controlled by Democrats, approved what amounted to the biggest restructuring of federal surveillance law in 30 years, giving the government more latitude to eavesdrop on targets abroad and at home who are suspected of links to terrorism.

The issue put Senator Barack Obama of Illinois, the presumptive Democratic nominee, in a particularly precarious spot. After long opposing the idea of immunity for the phone companies in the wiretapping operation, he voted for the plan on Wednesday. His reversal last month angered many of his most ardent supporters, who organized an unsuccessful drive to get him to reverse his position once again. And it came to symbolize what civil liberties advocates saw as "capitulation" by Democratic leaders to political pressure from the White House in an election year.

Senator Hillary Rodham Clinton of New York, who was Mr. Obama's rival for the Democratic presidential nomination, voted against the bill.

The outcome was a stinging defeat for opponents who had urged Democratic leaders to stand firm against the White House after a months-long impasse....

[markg]

Krugman states a fact I have been trying to emphasize on this board; insurance ADDS to the cost of health care. Just because everyone is insured doesn't mean everyone gets health care. Health care requires doctors, nurses, medical equipment, etc. - not insurance.
The best solution is govt subsidized health savings account (HSA) and catastophic (high deductible) insurance. Refund the unused amount in the HSA. This will promote healthier lifestyles, "shopping around" for the most cost effective health care, and reduced over treatment - all of which will contain the cost of health care. Oh yeah, all that time dealing with insurance companies will be gone too!

[wjd123]

I suspect that millions of people like me who joined Medicare Advantage plans--because otherwise they would be nickled and dimmed to death with traditional Medicare's co-payments and deductibles--will be the losers here. They will end up paying more for their health care or cutting back on their health care once their co-payments are increased.

I'm for universal health care but not universal health care at the expense of people's health. It has been shown time and time again that when a decision has to be made by congress between the bottom line of the pharmaceutical companies or the health insurance companies, or the AMA and people's health it's people's health that comes in a distant second.

I know the difficulties our jerry-built health care system caused me when I was working. But when rationalizing a system there can't be a thousand criterion. There should be one goal the most health care for the most people for the dollars avaiable and one criterion, affordability.

Krugman is pushing ahead without doing any of the spade work to see that congress puts people's health first. Better health care is no more likely with the Democrats if they become the protectors of the bottom line of the giants in the health care industry.

Hopefully, millions of people like me will band together to boot out of office any politician that sells their office to these giants. Let's make any increase in co-payments and deductibles another third rail for politicians. Let our motto be "Beware office holders, you're on a short leash."

[Aaron]

anne says...

Let me paraphrase a line from the movie “To Die For”

Suzanne Stone Maretto: You're not anybody in America unless you're being listened to. Wire taps is where we learn about who we really are. Because what's the point of saying anything worthwhile if nobody's listening? And if people are listening, it makes you a better person.

Wire taps don't leave a mark. So what's the big deal?

[anne]

http://krugman.blogs.nytimes.com/2008/07/11/why-pffs-may-go-pfft/

July 11, 2008

Why PFFS May Go Pfft
By Paul Krugman

Are private fee-for-service plans under Medicare Advantage really that bad?

Yes: *

* http://www.senate.gov/~finance/hearings/testimony/2008test/013008mmtest.pdf

Good explanation of what really went down in the Senate: **

** http://www.thehealthcareblog.com/the_health_care_blog/2008/07/senate-votes-to.html

[anne]

Wjd123:

"I suspect that millions of people like me who joined Medicare Advantage plans--because otherwise they would be nickled and dimmed to death with traditional Medicare's co-payments and deductibles--will be the losers here. They will end up paying more for their health care or cutting back on their health care once their co-payments are increased."

Please explain further.

[Melancholy Korean]

As a Republican and Obama supporter, I stopped reading Krugman long before he started getting hysterical about the "unfair" press treatment of the Hill-Billy. (The Dems can be so humorless sometimes, and, well, insensitive to irony.) But I read this one, I agree with his analysis, I even hope he's right.

I think hell just froze over.

[anne]

Markg:

"Krugman states a fact I have been trying to emphasize on this board; insurance ADDS to the cost of health care."

31% in 1999 *

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

[anne]

"As a Republican and Obama supporter, I stopped reading Krugman long before he started getting hysterical about the 'unfair' press treatment of the Hill-Billy."

Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy....

Rottenness.

[save_the_rustbelt]

I have been following this issue on a daily basis for years, PK makes this into a good-vs-evil drama more so than it really is.

The Democrats are in denial about reining in Medicare costs, the GOP wants to do it with a machete. Neither party wants to do the detailed reform that would improve the system long-term.

Back to "wait for next year."

Given this is an election year, perhaps that is the best we can hope for.

[Aaron]

anne says...

Many Clinton supporters feel that Hillary Clinton was treated unfairly by the press. As someone who has voted for republicans since Jimmy I say to them welcome to our world.

Rottenness.

Not really, unless mocking the Clintons is Rottenness.

[hari]

I will make a prediction that Dems will fail to find a consensus amongst their own side on universal healthcare legislation. There is adequate evidence from patriotic gentry above to make the point that unless you somehow break-up this ossified DemParty, there is little chance for the next occupant of WH (BO) to move the country forward for the good of the uninsured lot today.

The disconnect is like the last three decades of *deregulation* of hi fi sector - for the benefit of whom?
[Read Dionne's piece in WP today].

Whereas, in EU-27, we recognize and accept the ideological differences of established parties, on matters of health care and social security there is across-the-board consensus. A politician would be asking for suicide(!) if he proposed to curtail existing benefits and so on.

In US, the bastian of free market capitalism (that's what you guys love to call it!) the society-at-large is seldom the focus of the elected Congress - actual beneficiary of the system are represented by the licensed K-street lobbists and their industrial clients.

So, the way forward, might I say, will more or less emerge out of the break-up of the current set-up inside the DemParty. I know what happened, in 1960s, when CDA was created with Humphery leading it....

[anne]

Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy....

Rottenness, vile sexist rottenness. Get it?

[Aaron]

hari says...

Around 87 percent of all Americans have very good healthcare. We have less rationing then in the EU. The reason healhcare legislation went down in 1993 was because the 87 percent were not convinced that they would be made better off by extending formal healthcare to the remaining 13 percent.

I also think that more than half of the uninsured choose not to purchage healthcare insurance because they are not sick and the expected benefit of participation is far less than the cost of coverage.

I like the idea of getting individuals back in the drivers seat making decision on their own healthcare. If the government is to get involved for the under 65 population then they could have a role providing insurance for catastrophic events.

[Greg]

No Anne, just because she is a woman doesn't mean the reason we are mocking her is because she is a woman.

[Aaron]

anne says...

Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy, Hill-Billy....

Rottenness, vile sexist rottenness

Is it really sexist? it seems more to me they are maligning hillbillies.

[Cynthia]

If privatization adds an extra layer of cost to providing services, then it oughta be a no-brainer *not* to push to privatize all things public -- be it medicare, social security or even defense. And now that privatization has become somewhat of a dirty word, I wouldn't be the least bit surprised to learn that pushers of privatization will replace this word with a cleaner sounding one -- like "personalization". Gotta say though, "let's personalize medicare" does have a nice clean ring to it. Just don't let the pushers know this!

[Bruce Wilder]

markg: "The best solution is govt subsidized health savings account (HSA) and catastophic (high deductible) insurance."

hari: "Around 87 percent of all Americans have very good healthcare. We have less rationing then in the EU. . . . I like the idea of getting individuals back in the drivers seat making decision on their own healthcare."

This is what the popular opposition to effective health care reform looks like. These are some of the popular ideas and prejudices that BigInsurance and BigPharma and the AMA and all the rest have to work with.

Realistically, the best the Democrats can hope to achieve in 2009 is to design a "reform" that will wreck the "system", perhaps by putting the insurance companies in a downward spiral. This will require more cleverness than folding health care reform into a budget reconciliation bill (which I seriously doubt can carry authorization legislation let alone an appropriation, in any case). And, I fear, more cleverness than the Democrats are capable of. In any case, Ted Kennedy, a master of the Senate and a health care wonk, won't be around to shepherd, and that's sad. Maybe like Moses not entering the Promised Land sad, which, I guess, is hopeful!?

says...

"No, just because she is a woman doesn't mean the reason we are mocking her is because she is a woman."

Just because she is a woman is precisely the reason sexist creeps are mocking her. That is the whole point of the sexist creeps who would mercilessly mock, forever mock, the only viable woman candidate for President in our history.

The point is to destroy Hillary Clinton, destroy this woman, because destruction is what the mocking by sexist creeps is about.

[anne]

That was me, and please, please, please let's have more in the way of disdain for Hillary Clinton because disdain in general and disdain for women in particular is what we are all about these days.

Think hard now of more mocks. please do, after all distinguished supposedly progressive university professors have been happily leading the way in just such thinking.

[JeffF]

I don't know that this presages much of anything beyond possibly the end of this stupid medicare privatization plan. The vote on this bill was under heavy pressure from the doctor's, who are a very important and wealthy interest group which influences both parties.

I don't get the feeling that doctors are nearly so uniformly on board for universal health care.

[JRossi]

Once again Lafayette makes his usual idiotic comments on physician salaries, suggesting FP (not GP in the US, thank you) salaries will go to 75k per year under health care reform. Eleven years of education after high school for 75k per year. When prospective med students are college students with the highest academic credentials. When my brother-in-law, an electrical engineer with a bachelor's degree and ten years in the workforce, earns more than that. When in June of this year the Medicare Payment Advisory Commission recommends increasing primary care salaries to help with the shortage. When we live in the United States, not France. Does anyone at this blog take his nonsense seriously? If not, I'll stop responding to it. And another thing: The Hippocratic Oath is taken on graduation from med school, and the issue is whether people will be willing, at 75k per year, to go to med school in the first place.

[kthomas]

JRossi, you make a good point, but it's not written in stone that Med students, no matter thier highest of credentials, should earn large salaries. And besides, if everyone elses salaries are flat or going down, who is supposed to support all these Doctors and RN's making 100K?

Money does not grow on trees, Dr.

[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, Terry Campbell, and David U. Himmelstein

ABSTRACT

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.

[anne]

"Hari says...

Around 87 percent of all Americans have very good healthcare. We have less rationing then in the EU. The reason healhcare legislation went down in 1993 was because the 87 percent were not convinced that they would be made better off by extending formal healthcare to the remaining 13 percent."

Notice, there is no such comment by Hari.

[anne]

"Hari says...

Around 87 percent of all Americans have very good healthcare."

This is not Hari's style of writing, however, since this comment was made I would like a reference.

[JRossi]

k thomas, Of course it's not written in stone. It's written with labor supply and demand curves, with opportunity costs influencing the supply curve. Lower the salaries, get a worse shortage. Econ 101; see the rent control example in any elementary text.
That said, some specialists are probably overpaid, if overpaid means one could lower the salaries and still get adequate supply. Derm and ophthalmology come to mind. Pick on them, if you must, not FPs. And I don't own a BMW, but by neighbor (in "computers")does. No lie.

[NLS]

JRossi, the supply of doctors has been limited by the AMA. There are quite capable people who want to go to med school but can't. Therefore, doctors should be getting paid less. FREEdom MARKET!

[Bruce Wilder]

anne: "Notice, there is no such comment by Hari."

Huh?!?

[JeffH]

Lafayette says...

This sort of Benevolence Health Care is haphazard and inapt at the task of providing Universal Health Care, which is a social birthright. Here follows the notion that we must assimilate: Health Care is not just another Service Business.

Can anyone here take a moment to point toward some quality reading related to the concept of "universal health care, ...a social birthright."?

I am having some trouble getting my mind around the concept and most of the reading I have found to date is not very well supported or convincing.

Thank you.

[anne]

"Around 87 percent of all Americans have very good healthcare."

Unless my "search" is not working, the supposed comment by Hari is not on this thread. Also, the comment is not in Hari's style. Also, my search finds no such "original" comment on this thread only an attribution to Hari.

[Cynthia]

Looks like Aaron is using Hari as his own personal sockpuppet.

[hari]

@ Anne -

You're absolutely right *Aron* somehow arrogated rights to identify his views by saying *hari says...*

The quote was used by BW also and commented upon...I'm sorry but I didn't make that comment. Desperately sorry for it.

[anne]

Hari evidently never wrote this:

"Around 87 percent of all Americans have very good healthcare. We have less rationing then in the EU. The reason healhcare legislation went down in 1993 was because the 87 percent were not convinced that they would be made better off by extending formal healthcare to the remaining 13 percent."

However, I would like to have a reference since the comment makes no sense to me. Do we have less rationing than in the European Union? Do 87 percent of Americans have very good healthcare? Please explain.

[Bruce Wilder]

I am not a physician, but I'll second JRossi in objecting to the physician salary bashing. That's a simple-minded approach.

The role of the physician in medical care has changed, and is continuing to change, as the practice of medicine is re-organized to be more hierarchical and bureaucratic. Inevitably, that entails some changes in the sociology of physician compensation, but there's no way that doctors are not going to continue to be among the best compensated professionals in society, and deservedly so, necessarily so. We're not talking about star salaries driving up the cost of basketball tickets. We're talking about persuading capable people to invest a lot in what has to be an elite occupation, critical to a literally vital function in economy and society.

The self-employed physician of yore is just a memory, and the AMA, which represented him (and it was a "him", but not anymore) against the threat of "socialized medicine" is just a good-bye. The sociology changes the politics, and I expect the AMA to be on the side of the angels going forward, or, at least, against the insurance companies.

[Bruce Wilder]

mea culpa. mea culpa. mea maxima culpa.

my apologies to hari.

I try not to engage with Aaron, and wouldn't quote him. Criticizing another's possibly mistaken belief is part of the exchange in comments. Aaron is just a liar; there's no percentage in engaging with liars.

[anne]

http://www.cbpp.org/5-13-08health.htm

May 13, 2008

Informing the Debate About Curbing Medicare Advantage Overpayments
By Edwin Park

Bipartisan Senate negotiators are now working on the details of Medicare legislation that would avert a cut in physician payments scheduled to take effect at the end of June. This legislation could also serve as an opportunity to curb, at least to a modest extent, overpayments to private insurance plans that participate in the Medicare Advantage program; doing so could offset, in full or in part, the cost of that legislation. There continues to be significant confusion, however, about these overpayments, the benefits that Medicare Advantage plans offer, who enrolls in those plans, and the marketing practices some of those plans employ. Adding to this confusion, some material on these matters being disseminated by the health insurance industry presents data very selectively and makes dubious claims.

This primer uses a question-and-answer format to clear up possible misunderstandings or confusion on various issues related to private plans that participate in the Medicare Advantage program. The primer is intended to help inform the debate on these issues.

1. Do private plans cost more than it costs the regular Medicare program to cover the same beneficiaries?

2. How do Medicare Advantage overpayments affect Medicare's finances?

3. How do Medicare Advantage overpayments affect beneficiary premiums?

4. Did the private plans once take the position that they should be paid at the same levels as regular Medicare?

5. If private plans were paid at the same rates as regular Medicare, would risk remain that Medicare Advantage plans still would be overpaid to some degree?

6. Can private plans reduce some existing Medicare benefits?

7. Do private plans disproportionately enroll low-income and minority beneficiaries?

8. What is the most efficient approach to help low-income and minority Medicare beneficiaries afford health care?

9. Do private plans disproportionately enroll rural beneficiaries?

10. Do private plans offer quality of care that is higher, the same, or lower than under regular Medicare?

11. Do the abusive marketing practices of some Medicare Advantage plans bear similarities to past marketing abuses associated with Medigap policies or the EITC health insurance tax credit of the early 1990s? ....

[Lafayette]

An ounce of prevention

Through all this polemic I maintain that what has not been understood is a simple fact: Without Preventive Health Care, then expensive Remedial HC is a foregone conclusion.

And, you can't have Preventive HC if periodic GP check-ups are not systematic and thorough -- regardless of age. And a nation cannot undertake Preventive HC if a GP visit costs more than the lowest social level is prepared to pay. Frankly, they should be free along the lines of "an ounce of prevention is worth a ton of cure".

Who talks about Preventive HC? All we hear about is Universal HC, which is a boon for Specialists doing Remedial HC? They laugh all the way to the bank ... in their BMWs.

Here are the stats, from the BLS (here) of workplace illness / injury by age group requiring medical attention:

Age group ----- Employment fraction

16 to 19 ------- 0.032

20 to 24 ------- 0.103

25 to 34 ------- 0.235

35 to 44 ------- 0.256

45 to 54 ------- 0.233

55 to 64 ------- 0.116

65 and older --- 0.025

Total ---------- 1.000

It should be obvious that "middle set" workers are not as healthy as we think. In the age group between 25 and 55, about a quarter of them are sick at one time or another.

These, I submit, are significant amounts of people requiring full coverage. Those rates could come down if we, as a nation, accented Preventive HC instead of Remedial HC.

We are like cars. You don't employ preventive maintenance, it breaks down. With our obesity pandemic, the general level of health can only worsen with time.

[JRossi]

NLS, I appreciate the desire to stick it to spoiled, selfish, self-righteous medicos. I've felt that way myself, especially while listening to some droning, overpaid ass in medical staff meetings.
The number of practicing doctors is limited by Congress, through its funding of residency slots. The AMA's voice, though important, is not determinative.
You are correct that some qualified applicants don't get into US med schools and that if more slots were available, there would be more MDs. Of course the AAMC is currently trying to make this happen. But remember the whole point of this thread. It's about HC costs. Would having more MDs lower MD salaries? Quite possibly. Would it lower HC costs, which is what we really care about? Quite possibly not. Why? Because although MDs control much HC spending, through their orders, only about 22% (see the blog Health Beat, January 18, 2008)of that spending is MD reimbursement. The rest goes to non-MDs and hospitals, etc. So, by expanding the MD supply, you would in fact increase overall HC spending, as all those extra MDs give more orders, The MD salary savings would be swamped by the extra spending. Now the extra spending might be valuable, but if current experience is any guide, much of it might be wasted, particularly if much of this extra money is spent providing care of minimal (or even negative) benefit to patients.
Here's a better idea: Primary care is known to provide more medical benefit for less cost. Pay PCPs more so as to ensure an adequate supply. Cut reimbursements for less effective care.

[anne]

What I cannot find is evidence of individual gains from Medicare Advantage plans, despite the 17% additional cost. However, advertising by the plans may be effective in convincing those who sign up otherwise. The extensive set of references from

http://www.cbpp.org/5-13-08health.htm

however appear to show the plans offer no systematic patient gains. Additional costs appear to go to administration and advertising and insurer profit.

[anne]

Correction:

What I cannot find is evidence of individual gains from Medicare Advantage plans, despite the [13%] additional cost.

http://www.cbpp.org/5-13-08health.htm

1. Question: Do private plans cost more than it costs the regular Medicare program to cover the same beneficiaries?

Answer: The Medicare Payment Advisory Commission (MedPAC) — Congress' expert advisory body on Medicare payment policy — estimates that in 2008, private plans are paid 13 percent more, on average, than it would cost traditional Medicare to cover the same beneficiaries.[1] According to analysis by George Washington University researchers for the Commonwealth Fund, these overpayments are estimated to average approximately $1,000 for each beneficiary enrolled in a private plan.[2]

[Aaron]

anne says...
Hari evidently never wrote this:

However, I would like to have a reference since the comment makes no sense to me. Do we have less rationing than in the European Union? Do 87 percent of Americans have very good healthcare? Please explain.

The main point is that most Americans did not see changing the system would make them better off. 87 percent is taking 40 million uninsured / 300 million population. That gives you 86.6667 percent which rounds up to 87 percent. If you want make a more precise estimate be my guest. We can disagree on both the composition of the numerator and the denominator. In the numerator you can find a number as high as 48 million. Over 10 million of the 48 are not U.S. citizens, so that’s an argument for dropping it. 48 million gets you to 84 percent of 300. The current U.S. population is actually around 304 million, and I don't know if this is everyone or an estimate of U.S. citizens.

I think so long as you're in the 80 percent range you can call it most Americans. And also, of the 13-20 percent uninsured many choose to not buy insurance and perceive that forcing them into buying it would make them worse off. This is just the way it is even though you may think it should not be that way.

Blaming speculators for rising oil prices, k-street for the failure in the earlier healthcare initiative, the swift boat veterans for John Kerry's defeat are all in various degrees an exercise in fantasy and escapism.

[Aaron]

Bruce Wilder says...

Aaron is just a liar; there's no percentage in engaging with liars.

And on the other topic I reduced you down to agreeing with the facts and saying "So What". It looks like you take time to process information. You do try my patience though with your scurrilous accusations.

[hari]

@ Aron - I would like you to apologize for misleading us all on this thread by making unsubtantiated statements and using my name or *Hari says* - that's not only despicable, in my view, but outright dishonour of our good host, Mark Thoma.

[goombah]

Wilder - can you answer Aarons point from a real politics perspective? You do like to go on so please make it a short one. And please strike the word "narrative" as you misuse it all the time. Looks like Aaron has provided a good analysis of the incentive not to change.

[anne]

The questions are important. What sort of healthcare rationing is there, say, in France or Germany or Norway or the Netherlands? What sort of satisfaction with private healthcare insurance coverage is there in America? After all, public insurance accounts for about 50% of healthcare spending. What sort of satisfaction is there, since there must be enough given the response to Harry and Louise insurance company ads in 1993 and similar ads by Barack Obama in recent months.

Voters evidently responded better to Obama's refusal to move to a healthcare insurance requirement than to Clinton's proposal. Why?

[anne]

http://krugman.blogs.nytimes.com/2008/02/01/obama-does-harry-and-louise-again/

February 1, 2008

Obama Does Harry and Louise, Again
By Paul Krugman

"Hillary's health care plan forces everyone to buy insurance, even if you can't afford it. Is that the best we can do for families struggling with high health care costs?"

[This is not meant as criticism, though I was critical of the advertising, but as a question. Why were the Obama ads so successful? We will need to understand.]

[Bruce Wilder]

goombah: "can you answer Aarons point from a real politics perspective?"

I could try, but I don't think it would be a productive conversation. Short enough for you?

[Patricia Shannon]

Is Aaron another alias for Icarus? Why does a slimy liar deserve an answer?

[anne]

Notice how easily we can be led to arguments that are self-defeating. Ordinary Medicare services which are privately provided, suddenly become 13% more expensive when insurance companies become involved even though there is no evidence of gains in patient care. Even, then, with Medicare there are important and immediate gains to be made by simply offering no advantage to insurance companies. The problem, however, is the formiddable advertising strength of insurance companies.

Franklin Roosevelt noticed the sort of strength beginning in trying to convince ordinary workers that Social Security was a threat to them, and of course employers could make Social Security seem threatening.

[PSP]

Reform will require splitting the doctors and the Insurance companies. Bevan's response to how he convinced the BMA to accept the NHS was: "I stuffed their mouths with gold."

And that is the answer how to split the AMA from the Insurance companies, not cutting medicare reimbursement by 10%. There are a lot more doctors than insurance companies. They live and employ people in every congressional district. And, who really likes insurance companies anyways?

[LBS]

To anyone interested in understanding why health care cannot be treated like just another kind of market I recommend Arnold S. Relman's "A Second Opinion". He is a practicing MD, but his knowledge of economics is good. For markets to work well, it is important for consumers to have or be able to easily secure information on the product they are buying. This is almost never possible with health care. We would all need to have MD degrees. Furthermore,our needs for health care are unpredictable and when we need health care we are limited by place and what is available wherever we are.

[anne]

http://www.fdrlibrary.marist.edu/od2ndst.html

October 31, 1936

Announcing the Second New Deal
By Franklin Roosevelt

Here is an amazing paradox! The very employers and politicians and publishers who talk most loudly of class antagonism and the destruction of the American system now undermine that system by this attempt to coerce the votes of the wage earners of this country. It is the 1936 version of the old threat to close down the factory or the office if a particular candidate does not win. It is an old strategy of tyrants to delude their victims into fighting their battles for them.

Every message in a pay envelope, even if it is the truth, is a command to vote according to the will of the employer. But this propaganda is worse- it is deceit.

They tell the worker his wage will be reduced by a contribution to some vague form of old-age insurance. They carefully conceal from him the fact that for every dollar of premium he pays for that insurance, the employer pays another dollar. That omission is deceit.

They carefully conceal from him the fact that under the federal law, he receives another insurance policy to help him if he loses his job, and that the premium of that policy is paid 100 percent by the employer and not one cent by the worker. They do not tell him that the insurance policy that is bought for him is far more favorable to him than any policy that any private insurance company could afford to issue. That omission is deceit.

They imply to him that he pays all the cost of both forms of insurance. They carefully conceal from him the fact that for every dollar put up by him his employer puts up three dollars, three for one. And that omission is deceit....

[Really, the original Harry and Louise sort of advertising.]

[Bruce Wilder]

"Hillary's health care plan forces everyone to buy insurance, even if you can't afford it."

I can read the above statement and see why it strikes fear. I pay for my own health insurance out of fear, and it is a lot of money. If I couldn't afford it, I would be even more afraid. What is mysterious about the fear?

Like it or not, Clinton's mandate plan, at its heart, rested on the idea that it could be partially financed by forcing some people to pay, who are now choosing not to pay. So, Obama's fearful statement had the additional advantage of being true, in a purely factual sense. The only rebuttal was a dubious reassurance that the promised subsidies and assistance would actually be there, and be sufficient. That's a very weak rebuttal.

[anne]

http://www.nytimes.com/2007/04/28/opinion/l28medicare.html

Medicare and the Market

To the Editor:

"The Plot Against Medicare," by Paul Krugman, and your editorial "The Medicare Privatization Scam" correctly noted the higher costs of private for-profit health insurance. They might also have noted that a recent J. D. Powers survey found consumers more satisfied with not-for-profit private insurance plans than with investor-owned plans.

Even more important, as I have documented in my new book, "A Second Opinion," there is good evidence that investor-owned medical care facilities are usually less efficient than comparable not-for-profit facilities. Further, their services are often of lower quality — occasionally with serious consequences for the health of patients.

Until we rid ourselves of the myth that the private market outperforms other alternatives in health care, we will never develop a good-quality, affordable system that covers everyone.

Arnold S. Relman, M.D.
Boston, April 21, 2007
The writer, professor emeritus of medicine and social medicine at Harvard Medical School, was the editor of The New England Journal of Medicine, 1977-91.

[anne]

Bruce Wilder:

"Like it or not, Clinton's mandate plan, at its heart, rested on the idea that it could be partially financed by forcing some people to pay, who are now choosing not to pay. So, Obama's fearful statement had the additional advantage of being true, in a purely factual sense. The only rebuttal was a dubious reassurance that the promised subsidies and assistance would actually be there, and be sufficient. That's a very weak rebuttal."

Precisely as in Massachusetts, but unless there is actually universal healthcare insurance coverage, reform will necessarily be ineffective. The point must be to offer subsidies and low cost comprehensive coverage.

[kthomas]

Healthcare, Banking, Energy, Airlines.....all of them have been turned into dirt for the sake of a monied few, in the name of ideology. Who can say "re-regulation"? I'm buying quite a bit of Banking stock, in anticipation of the re-regulation movement. If someone preaches the virtues of de-regulation, go for your sidearm!

[Jrossi]

LBS, Thanks for the post on Relman's book--he's past editor of NEJM. I'll read it one of these days. Your comment on asymmetric information is spot-on--one of the reasons consumer-driven HC is not the way ahead.

[mik]

the most obnoxious Senator in history, Phil Gramm, as an economics advisor: the author of the banking regulatory reform that destroyed the American banking system and the Vice-Chairman of a Swiss bank, which has advised employees to avoid travelling to the U.S., for fear of criminal prosecution. And, Phil's excellent advise: tell Americans that they are whiners and should suck it up!

It is only half of it. xSenator Gramm wife, Wendy Gramm, is a quite a character in her own right (from wikipedia):

Wendy Gramm is chairman of the Regulatory Studies Program at George Mason University's Mercatus Center, a free-market think tank based in Washington D.C.

In her role at the Mercatus Center, Gramm generally calls for deregulation of the energy industry. Previously, Gramm was a head of the Commodity Futures Trading Commission among other positions. After a lobbying campaign from Enron, the CFTC exempted it from regulation in trading of energy derivatives.

Subsequently, Gramm resigned from the CFTC and took a seat on the Enron Board of Directors. While on the board of directors she received donations from Enron to support the Mercatus Center.

After the Enron scandal, Gramm and the other directors of the energy company were named in several investor lawsuits, many of which have been settled. In particular, Gramm and other Enron directors agreed to an $168 million dollar settlement in a suit led by the University of California. As part of that settlement, the directors agreed to collectively pay $13 million to settle claims of insider trading.

If Wendy Gramm would have been a white man she would have been a poster boy of government-private corruption run wild.
As an Asian woman she is untouchable.

[Aaron]

Patricia Shannon says...

Is Aaron another alias for Icarus? Why does a slimy liar deserve an answer?

Aaron spelled backwards is Noraa. The character codes for Norra sum to 514, which we all know is the devil's number.

[Bruce Wilder]

anne: "Precisely as in Massachusetts, but unless there is actually universal healthcare insurance coverage, reform will necessarily be ineffective. The point must be to offer subsidies and low cost comprehensive coverage."

Respectfully, my judgment on this is somewhat different from your own. My expectation is that the Massachusetts plan will erode and fall apart under pressure from health care cost inflation and from its own Rube Goldberg complexity.

The point, in my view, is that we have to get to tax-financed health care. Tax-financing is the only administratively efficient way to overcome adverse selection and enrollment problems.

Tax-financing does not have to eliminate private insurers, per se, and so is not necessarily absolutely equivalent to single-payer.

But, without explicit, probably dedicated tax-financing, a plan featuring, instead, mandates lacks credibility when it comes to asserting that subsidies will available to make health insurance "affordable".

Tax-financing of health care also leaves the door open to diverting resources into public health measures, which don't involve enrolling every individual with a personal physician, an often unrealistically bourgeois model with regard to a significant part of the neediest, uninsured population. (The emphasis in the Mass plan on primary physician care is proving a weakness, as it strains available resources.)

[anne]

LBS:

"For markets to work well, it is important for consumers to have or be able to easily secure information on the product they are buying. This is almost never possible with health care."

Important.

[anne]

http://www.nytimes.com/2008/06/03/health/policy/03health.html?hp&pagewanted=print

June 3, 2008

Study Finds State Gains in Insurance
By KEVIN SACK

Massachusetts reduced its proportion of uninsured adults by nearly half in the first year of mandatory health coverage and made gains in the share of people receiving routine preventive care, according to the first major study of the 2006 law.

The decline in the share of residents without insurance was nearly equivalent for those with low or moderate incomes and those with higher incomes.

The study, conducted by the Urban Institute and scheduled for online publication Tuesday by the journal Health Affairs, found no evidence that residents were dropping private health coverage to take advantage of state-subsidized policies, or that employers viewed the availability of new public programs as a reason to eliminate health benefits.

"The entire increase in coverage appears to have been drawn from the ranks of the uninsured, because there is no evidence that publicly funded programs are crowding out employer coverage," wrote the study's author, Sharon K. Long, a principal research associate with the Urban Institute, a nonpartisan research group in Washington.

Indeed, contrary to national trends, the share of residents receiving insurance through their employers increased in Massachusetts by nearly three percentage points from fall 2006 to fall 2007. Nationally, the percentages of employers that offer benefits and of workers who receive them have been sliding steadily throughout the decade.

Undercutting the positive trends for Massachusetts are signs that the state's supply of primary care physicians is not sufficient to handle the increased demand created by newly insured residents. Though there were overall declines in the percentage of residents who said they were not receiving needed care, the study showed increases in the share who said they did not get care because they could not find a doctor.

That finding may support anecdotal reports from internists and family practitioners that they have been stretched by an influx of newly insured patients, causing long delays for some appointments. The study actually found a slight increase in the share of low-income residents who sought treatment in hospital emergency rooms for conditions that were not urgent.

"It would appear that there are opportunities to improve access to community-based care," Ms. Long wrote.

Jon M. Kingsdale, director of the state authority that oversees the health plan, questioned whether the unmet demand for primary care was more severe in Massachusetts than elsewhere. Regarding emergency room use, he said the state was sometimes finding it easier to enroll the uninsured than to break their longstanding links to local hospitals.

"We've clearly identified that as behavior that has to be changed," Mr. Kingsdale said.

The Massachusetts law, which took effect last year, made the state the largest to strive for universal coverage and a laboratory for federal policies proposed by Democratic presidential candidates. Senator Hillary Rodham Clinton has proposed mandatory coverage for all Americans, similar to the Massachusetts plan, while Senator Barack Obama would require coverage only for children, promising to make premiums affordable enough for adults that no mandate would be necessary.

Massachusetts residents were required to obtain insurance beginning in 2007, and state subsidies were provided on a sliding scale to make policies affordable for low-income residents. The 86,000 residents who did not comply faced modest first-year tax penalties of $219. The penalties will stiffen this year.

Mr. Kingsdale said that more than 350,000 of the estimated 600,000 residents who were uninsured before the program began had since gained coverage. Exemptions were granted to about 60,000 people who demonstrated that they could not afford even subsidized insurance. Enrollment in the subsidized plans has exceeded projections, and lawmakers and Gov. Deval Patrick, a Democrat, are negotiating a tobacco-tax increase to help sustain the program.

The Urban Institute survey found that 7 percent of Massachusetts adults ages 18 to 64 remained uninsured in the fall of 2007, compared with 13 percent in 2006. Those still uninsured are largely male, low-income and healthy, and a third of them said they did not know health insurance was now mandatory....

[anne]

http://www.nytimes.com/2008/06/16/opinion/16mon1.html?ref=opinion&pagewanted=print

June 16, 2008

The Massachusetts Model

Massachusetts's pioneering plan to provide universal health coverage is off to a good start and is heartening evidence that national health care reform may be possible if sufficient skill and determination are applied to forge a political consensus.

The state requires that all residents take out health insurance or suffer tax penalties if they don't. It also requires employers to offer coverage to their workers or make alternative payments if they don't. As it enters what could be a critical year in determining its viability, the plan can claim some substantial successes.

It has already covered some 350,000 of the uninsured — more than half of the roughly 650,000 residents who were estimated to be uninsured when the plan began in 2006. Two-thirds of the new enrollees signed up for subsidized coverage available to low-income people. The rest signed up for private commercial insurance, either through their employers, or on their own, or through a new "connector" organization that funnels people to unsubsidized private plans.

Critics — opponents of new entitlement programs are watching closely — are accurate when they say that coverage is hardly universal if 300,000 people still don't have insurance. But the plan is in its early days. Enrollment has grown faster than expected, especially for a complex, newly established program.

The real test will come this year, when higher penalties for those who fail to get coverage will kick in and we will see whether coverage can really be made mandatory without sparking political resistance. So far, polls show increasing public support.

Massachusetts has also held premium increases in the unsubsidized component of the program to 5 percent, far less than the previous double-digit increases. It has reformed the costly individual insurance market so that everyone can now get insurance at low group rates — an opportunity unavailable elsewhere.

Two of the original concerns — that people might drop private insurance to gain subsidized coverage or that businesses might dump employees on the state program — have not materialized. On the downside, many of the newly insured reported difficulty finding a primary care physician, and the share of low-income residents using emergency rooms for nonemergency care rose slightly, the opposite of what was supposed to happen.

The chief criticism, however, is that costs have risen faster than the original projections, forcing the state to raise its spending estimates for the current fiscal year from $472 million to $625 million and from $725 million to $869 million for next year. The shortfall occurred mostly because the state underestimated the number of uninsured residents and how fast low-income people would sign up for subsidized coverage....

[anne]

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.4.w270v1

June 3, 2008

On The Road To Universal Coverage: Impacts Of Reform In Massachusetts At One Year
By Sharon K. Long

Abstract

In April 2006, Massachusetts passed legislation intended to move the state to near-universal coverage within three years and, in conjunction with that expansion, to improve access to affordable, high-quality health care. In roughly the first year under reform, uninsurance among working-age adults was reduced by almost half among those surveyed, dropping from 13 percent in fall 2006 to 7 percent in fall 2007. At the same time, access to care improved, and the share of adults with high out-of-pocket costs and problems paying medical bills dropped. Despite higher-than-anticipated costs, most residents of the state continued to support reform.

[save_the_rustbelt]

What I cannot find is evidence of individual gains from Medicare Advantage plans, despite the [13%] additional cost.

My mother is in an Advantage plan through an integrated network, and here is the trade-off.

1. she pays less out of pocket
2. a few treatments and therapies are not covered
3. she has limited choice, in her metro area she can only choose from 1200 physicians and 6 hospitals instead of 1600 physicians and 8 hospitals - not much of a hardship!

[Aaron]

anne,

One thing you might look at is cost shifting by Medicare. Just about everything that gets done in a hospital has a code that makes its way to a claim form. I would be interesting to compare costs between private insurance and Medicare for the same service. Some charge that because Medicare low balls what they pay to make up for it hospitals change private insurance a higher rate for doing the same thing. This is something you could test if you had the data.

[anne]

"What I cannot find is evidence of individual gains from Medicare Advantage plans, despite the 13% additional cost."

"My mother is in an Advantage plan through an integrated network, and here is the trade-off.

1. she pays less out of pocket"

13% less? 12%? 10%? 8%?

[anne]

http://www.cbpp.org/5-13-08health.htm

May 13, 2008

Informing the Debate About Curbing Medicare Advantage Overpayments
By Edwin Park

1. Do private plans cost more than it costs the regular Medicare program to cover the same beneficiaries?

2. How do Medicare Advantage overpayments affect Medicare's finances?

3. How do Medicare Advantage overpayments affect beneficiary premiums?

4. Did the private plans once take the position that they should be paid at the same levels as regular Medicare?

5. If private plans were paid at the same rates as regular Medicare, would risk remain that Medicare Advantage plans still would be overpaid to some degree?

6. Can private plans reduce some existing Medicare benefits?

7. Do private plans disproportionately enroll low-income and minority beneficiaries?

8. What is the most efficient approach to help low-income and minority Medicare beneficiaries afford health care?

9. Do private plans disproportionately enroll rural beneficiaries?

10. Do private plans offer quality of care that is higher, the same, or lower than under regular Medicare?

11. Do the abusive marketing practices of some Medicare Advantage plans bear similarities to past marketing abuses associated with Medigap policies or the EITC health insurance tax credit of the early 1990s?

....

10. Question: Do private plans offer quality of care that is higher, the same, or lower than under regular Medicare?

Answer: Some plans have sought to justify the overpayments they receive as promoting better quality of care relative to traditional Medicare. MedPAC recently reported, however, that although many Medicare Advantage plans perform well on quality measures, such plans are not exhibiting the same rate of improvement in quality of care as plans that operate in the private insurance market or as managed care plans that contract with state Medicaid programs.[40] In addition, newer plans that first began participating in Medicare Advantage in 2004 or later did worse on quality measures than older plans. While it is difficult to assess differences in the quality of care between Medicare Advantage and fee-for-service due to the lack of comparative quality measures, levels of beneficiary satisfaction were relatively similar, with traditional Medicare receiving slightly higher ratings than Medicare Advantage with regard to beneficiaries receiving care they needed, overall quality of care, and patient satisfaction.[41]

[anne]

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.63v1

February 2, 2005

Illness And Injury As Contributors To Bankruptcy
By David U. Himmelstein, Elizabeth Warren, Deborah Thorne, and Steffie Woolhandler

Abstract

In 2001, 1.458 million American families filed for bankruptcy. To investigate medical contributors to bankruptcy, we surveyed 1,771 personal bankruptcy filers in five federal courts and subsequently completed in-depth interviews with 931 of them. About half cited medical causes, which indicates that 1.9-2.2 million Americans (filers plus dependents) experienced medical bankruptcy. Among those whose illnesses led to bankruptcy, out-of-pocket costs average $11,854 since the start of illness; 75.7 percent had insurance at the onset of illness. Medical debtors were 42 percent more likely than other debtors to experience lapses in coverage. Even middle-class insured families often fall prey to financial catastrophe when sick.

[anne]

http://www.epi.org/content.cfm/bp203

November 1, 2007

The Erosion of Employment-Based Insurance: More working families left uninsured
By Elise Gould

The decline in health insurance coverage continued unabated in 2006, driven primarily by the continued erosion in employer-provided health insurance. In 2006, 47 million Americans were uninsured, up nearly 8.6 million since 2000. The rate of those without insurance has grown 2.1 percentage points during this period, from 13.7% in 2000 to 15.8% in 2006.

Employment-based coverage is still the most prominent form of health insurance in the United States at 59.7% of all Americans; however, the rate of this coverage has fallen in every year since 2000. In 2000, 64.2% of Americans had employer-provided health insurance. By 2006, this percent had fallen 4.5 percentage points. Nearly 2.3 million fewer Americans had employment-based insurance in 2006 than in 2000. This decline does not take into account population growth. As many as 13 million more people would have had employer-provided health insurance in 2006 if the coverage rate had remained at the 2000 level.

Because of these large declines in employer-provided health insurance, workers and their families have been falling into the ranks of the uninsured at alarming rates. There were almost 5 million more uninsured workers in 2006 than in 2000. While uninsured workers are disproportionately young, non-white, less educated, and low wage, workers across the socio-economic spectrum have experienced losses in coverage. Even the most highly educated and highest wage workers had lower rates of insurance coverage in 2006 than in 2000.

As with workers, the downward trend in employer-provided coverage for children (through their parents' employers) continued into 2006: 3.4 million fewer children had employment-based coverage in 2006 than in 2000....

[mrrunangun]

In terms of an insurance plan, I do not understand what is wrong with medicare for everyone. It has been good enough for its beneficiaries for over 40 years now and little in the way of complaints have been heard from beneficiaries or those who provide products and services. It could be funded from general revenue plus a targeted payroll tax. Rent seeking from special pleaders would have to be withstood by some mechanism with a cost-benefit analysis excluding political influence, otherwise scams galore will divert resources. A way of financing care for illegally employed aliens who would presumably not be eligible for the national plan will be necessary, otherwise the resources of impacted locales will be drained away leaving the local populace with diminished service.

The immediate problem is where the added capacity will come from to provide the additional product and service volume envisioned by the planners. We already have a terrific shortage of hospital nursing personnel and of primary care doctors and we are talking about providing money for such services to the 12 percent of the population without much such service now. In our suburban/exurban area it is often difficult for doctors to get a patient admitted to the county's five hospitals because of lack of capacity. Patients wait under treatment on cots in the hallways of the ERs if they are too ill to be sent home to await an available inpatient bed.

[Francois]

""Hillary's health care plan forces everyone to buy insurance, even if you can't afford it."

I can read the above statement and see why it strikes fear. I pay for my own health insurance out of fear, and it is a lot of money."

And that is why we need a radical departure from individual payments, mandates versus non-mandates and all that jazz.

First off, it is important to understand that apart from insurance companies overhead and excessive expenses, another very important factor explaining the high cost of HC in the US is the utter lack of COORDINATION of care.

For instance, a common but serious condition like heart failure requires multiple interventions (access to medications, changes in lifestyle and nutrition etc.) by different HC professionals. That is, if you want an optimal outcome and minimal stays in urgent hospitalization.

Turns out we do a very poor job in this country. It has been estimated (heard on Science Friday @ NPR) that the cost of this non coordination of care for heart failure is around 85 billions!...per year mind you.

That is beaucoup bucks, by any measure.

Another example: People with respiratory problems requiring oxygen @ home get serviced by private companies. A GAO study showed that these services could be obtained at much lesser cost with better controls. When they heard of the proposals, guess what was the response of the oxygen services companies? They went to their customers and started a fear-mongering blitz about big bad go-vermin that would PREVENT them to get their oxygen at home (pure bullshit) and all sorts of calamities on par with the seven plagues of Egypt. Needless to say they were encouraged to contact their Senator and Representative, who in turn, without having any idea of the problem, but very anxious to avoid any political trouble, killed any hint of reform.

The taxpayer in all this? The needs of other people with diseases? "Sorry, but I do not CARE" was the attitude. Above all, let's avoid political problem with this constituency and that is that!!

I could go on and on with examples of excessive expenses that could be curbed. The bottom line is that there are big savings that could be made in the HC delivery without sacrifice in quality. But that is NEVER explained in the HC debate.

Second, it is possible to reduce the (arbitrary) role of the government in a universal HC system. Lawrence Kotlikoff (The Health Care Fix) suggest vouchers for everyone. Said vouchers would be predicated on age, sex and medical condition, with catastrophic care (car accidents work accidents and the likes) being provided and paid for outright. I encourage anyone interested by the HC debate to read the book. At the very least, it'll force you to think differently and outside the boundaries of the sterile debate we've had for the last several decades.

[Francois]

"Like it or not, Clinton's mandate plan, at its heart, rested on the idea that it could be partially financed by forcing some people to pay, who are now choosing not to pay."

Sorry but the last thing we need in HC area a bunch of free-riders that will, of course, insist on receiving care once they get sick.

Also, having free-riders means higher costs for those who pay. Prof Krugman had a table with comparative costs (mandates vs non-mandates) in his blog, and the difference was substantial. There is nothing equitable in that.

That people don't WANT to pay is understandable, but should have no bearing on the decision to impose mandates. This is clearly a case of common good vs. "individual choice". Simple economics and fairness dictates the common good solution.

[anne]

http://krugman.blogs.nytimes.com/2008/02/02/healthcare-numbers/

February 2, 2008

Healthcare Numbers
By Paul Krugman

Jonathan Gruber, one of the country's leading health care economists — and someone not affiliated with any of the campaigns — has a new paper * on covering the uninsured. He makes use of a detailed simulation model that he's been developing for several years to assess alternative strategies.

One conclusion is that trying to cover the uninsured with tax credits, Bush-style, is — surprise, surprise — a very inefficient strategy: lots of revenue loss, while most of the people who get the benefits would have been insured anyway.

But the big conclusion, relevant to current debates, is on the role of mandates. Gruber compares a program of mandate-less subsidies to help people pay for insurance — broadly similar to the Obama plan — with a program that combines subsidies with mandates — broadly similar to the Edwards and Clinton plans.

The table below summarizes the key results. The mandate-less plan covers only about half the uninsured. The plan with mandates gets almost everyone, at an additional cost of $22 billion — about $1,000 per additional person covered.

Next time you hear someone telling you that the dispute over mandates is unimportant, remember this table:

Without Mandate With Mandate

Reduction in number of uninsured
23 45

Total cost
102 124

Cost per newly insured
4400 2700

Yes, mandates matter.

* http://www.nber.org/papers/w13758

[anne]

http://www.nytimes.com/2008/02/04/opinion/04krugman.html?ref=opinion

February 4, 2008

Clinton, Obama, Insurance
By PAUL KRUGMAN

An Obama-type plan would also face the problem of healthy people who decide to take their chances or don't sign up until they develop medical problems, thereby raising premiums for everyone else. Mr. Obama, contradicting his earlier assertions that affordability is the only bar to coverage, is now talking about penalizing those who delay signing up — but it's not clear how this would work.

So the Obama plan would leave more people uninsured than the Clinton plan. How big is the difference?

To answer this question you need to make a detailed analysis of health care decisions. That's what Jonathan Gruber of M.I.T., one of America's leading health care economists, does in a new paper.

Mr. Gruber finds that a plan without mandates, broadly resembling the Obama plan, would cover 23 million of those currently uninsured, at a taxpayer cost of $102 billion per year. An otherwise identical plan with mandates would cover 45 million of the uninsured — essentially everyone — at a taxpayer cost of $124 billion. Over all, the Obama-type plan would cost $4,400 per newly insured person, the Clinton-type plan only $2,700.

That doesn't look like a trivial difference to me. One plan achieves more or less universal coverage; the other, although it costs more than 80 percent as much, covers only about half of those currently uninsured.

As with any economic analysis, Mr. Gruber's results are only as good as his model. But they're consistent with the results of other analyses, such as a 2003 study, commissioned by the Robert Wood Johnson Foundation, that compared health reform plans and found that mandates made a big difference both to success in covering the uninsured and to cost-effectiveness....

[anne]

http://krugman.blogs.nytimes.com/2008/07/11/why-pffs-may-go-pfft/

July 11, 2008

Why PFFS May Go Pfft
By Paul Krugman

Are private fee-for-service plans under Medicare Advantage really that bad? Yes: *

* http://www.senate.gov/~finance/hearings/testimony/2008test/013008mmtest.pdf

I’m seeing a number of comments to the effect that Ted Kennedy is getting private-sector healthcare, and is therefore a hypocrite — I suspect that this line is being pushed by right-wing blogs somewhere.

It is, of course, an argument that presumes that readers are stupid. Medicare doesn’t run a health care system — in fact, unless you’re in the military or a veteran, Americans don’t even have access to government-run health care. Medicare provides government insurance — as everyone on the system, or anyone who knows anyone over 65, knows perfectly well. And as a U.S. Senator, Kennedy has — shocking! — government-provided insurance. No hypocrisy at all.

A good explanation of what really went down in the Senate: **

** http://www.thehealthcareblog.com/the_health_care_blog/2008/07/senate-votes-to.html

[anne]

http://krugman.blogs.nytimes.com/2008/02/01/obama-does-harry-and-louise-again/

February 1, 2008

Obama Does Harry and Louise, Again
By Paul Krugman

The Obama campaign sends out an ugly mailer. * Sorry, but this is just destructive — like the Obama plan, the Clinton plan offers subsidies to lower-income families. And BO himself has conceded that he might have to penalize people who don't buy insurance until they need care. So this is just poisoning the well for health care reform. The politics of hope, indeed.

Ezra Klein ** adds a screenshot of the original Harry and Louise ad — they've obviously deliberately copied it. Just to remind everyone, Harry and Louise were the center of the vile smear campaign the insurance lobby waged against health care reform in 1993 — and this time a Democratic candidate is doing the smearing for them.

Ezra also points *** us to an Urban Institute study that shows that yes, mandates are essential. The key passage:

"Voluntary measures would tend to enroll disproportionate numbers of individuals with higher cost health problems, creating high premiums and instability in the insurance pools in which they are enrolled."

I know that Obama supporters want to hear no evil, but this is really, really bad.

"Hillary's health care plan forces everyone to buy insurance, even if you can't afford it. Is that the best we can do for families struggling with high health care costs?"

Obama does Harry and Louise, again [Mailer]

* http://www.politico.com/blogs/bensmith/0108/More_negative_mail.html

** http://www.prospect.org/csnc/blogs/ezraklein_archive?month=02&year=2008&base_name=health_care_debate_mandates_as

*** http://www.prospect.org/csnc/blogs/ezraklein_archive?month=02&year=2008&base_name=do_individual_mandates_matter

[Lafayette]

Aaron: The main point is that most Americans did not see changing the system would make them better off.

No, YOU miss the main point -- not us.

The rationale of any National Health Care system is that it must be preventive for it work. For Preventive HC to work, it must be accessible. That is not possible in a country that has twice the cost rates of, say, comparable care in Europe. If there is no mandated fee pricing, then mandating universal health care is useless.

This entire polemic is fixated on the supposition that ONLY remedial HC is important. It isn't. Preventive HC is by far the more important of the two.

And, for it to work, it must be accessible to all at reasonable rates. Why? Because, any plan will require patient participation (to prevent abuse) and that threshold will represent a formidable barrier depending upon social class. Meaning the poor will not avail themselves of the service, regardless of whether they are covered or not. And, given an adverse economic climate, even the middle class will go without, in order to spend the money elsewhere. That's human nature.

Consequently, whether universal HC is implemented or not, the fact remains that people do not use the system. If they don't use the system, then illnesses, especially long-term varieties, go undetected until they become either incurable or remediable but only at great cost.

This isn't rocket science. It is Health Care Policy that has been discussed for a donkeys' age amongst HC professionals. It is also supported by the World Health Organization.

PS: The Massachusetts system is for too young from which to interpret any conclusions. I am confident that HC premiums will increase significantly in order to cover the previously uninsured. You don't get something for nothing.

[jeff hoffman]

I have heard the argument made many times, usually from the same people, that preventive medicine is less costly, but I can't find the data. And it can be said to be considerably more complex than rocket science insofar as there are substantial regional differences in age adjusted cost of medicine as well as longevity shifts over time within different parts of the US, which likewise are substantial. The argument for preventive medicine as an ECONOMIC plus can clearly be made for those with preventible illness during their income generating years (Tony Snow for example). Beyond those, however, your argument needs supportive data. Do you think it's less expensive to extend life into the 80's when the cost of nursing home care enters into it?* With every decade of age advancement beyond the 60's the cost of healthcare advances nonlinearly, as can reasonably be expected. This is not an argument against preventive medicine, mind you (it is at least 40-50% part of what I do), only a suggestion that alot of loose generalizations get bandied about here regarding the cost effectiveness of increasing longevity for which I can't find supportive evidence. Because that argument, from an economic standpoint, is dependent on age of onset and specific disease process. Same thing with comparing the salaries of primary physicians in France vs US without any reference to their relative efficiencies. No doubt the salary structure across subspecialties in this country is inappropriately apportioned but in the realm of primary care, note that in a country with far less obesity and its multiple attendant disease processes it takes almost 50% more primary (MD) providers per capita to service the French population. I can only find anecdotal information on the internet regarding the French physicians' workday, from which I am skeptical that their work days are comparable in intensity to those in the US, but I don't have enough data. Factor also into the equation the relative number of vacation days annually and the substantial reduction in taxes afforded the French physician, and his/her cost may well exceed that of the ARNP and PAs that provide a substantial quantity of primary care to this population. That math isn't rocket science, but it isn't even considered by those who would like to compare the two grups of providers as if they are turning out widgets on identical assembly lines on either side of the Atlantic (the widgets aren't even comparable given the obesity issue). And my condolences to JRossi who thinks that he deserves to be paid more then a tech educated tradesman, for some reason, much to the consternation of those who would hold him to the hippocratic oath, having never apparently read the document.

*Scitovsky (1988) argued that both the elderly and persons who die consume a disproportionate share of medical resources. Roos (1987) found that people dying at older ages have more expensive deaths than people dying at earlier ages, attributing much of the excess to heavy nursing home use by the very elderly. Spillman and Lubitz (2000) estimated that total expenditures from the age of 65 years until death increase substantially with longevity, from $36,000 for persons who die at the age of 65 to more than $230,000 for those who die at the age of 90, in part because of steep increases in nursing home expenditures for very old persons.

[Matt]

Did you see the Bunk study stating 2/3 of doctors in America want National Health Care. The doctors who did this study also conducted one in 2002 and found that the majority of doctors did not want national health care, the problem with this is that the 2 question surveys drastically differ in there 2nd question. I found this article, 60% of Physicians Surveyed Oppose Switching to a National Health Care Plan, It's worth a read.

[Lafayette]

How do we manufacture a Volkswagen with the input factor costs of a Ferrari

BW: The only rebuttal (to Hillary's proposition by Obama) was a dubious reassurance that the promised subsidies and assistance would actually be there, and be sufficient. That's a very weak rebuttal.

All the more so because those Health Care subsidies and assistance at today's prices are monumental. Particularly because they focus, in terms of expenditure, on Remedial HC. Only an aggressive transfer of focus on Preventive HC will reduce total HC-costs, presently generated by principally by Remedial HC.

Why does this simple logic, expressed by the larger part of HC-professionals worldwide, not sink in?

With GP/Specialists earning an average of $150,000 per annum, how is that Remedial HC will ever be affordable without massive federal subventions. Do Americans expect Universal Health Care on a shoestring? Let's hope not, because that will never happen.

I will keep hammering away at this Key Point that commenters in this blog refuse to comprehend: A nation CANNOT HAVE affordable Health Care by tweaking the present system.

It has no or little focus on Preventive Health Care, which is essential. Its Remedial HC-costs are over the moon, due to a constraint in supply, and not likely to come down anytime in the future. (Unless we ship the seriously ill off for treatment to India or Thailand.)

Tweaking the present system to provide "Universal Health Care" is a travesty upon the word "universal". Universal for who? Overpaid Health Care practitioners?

Somebody please explain how we manufacture a Volkswagen with the input factor costs of a Ferrari.

[Lafayette]

Matt: "60% of Physicians Surveyed Oppose Switching to a National Health Care Plan", It's worth a read

ONLY 60%? Faulty polling methods, I'd think.

Let's presume that America switched to a National Health Care Plan, as exists in Europe. That would mean it descends from double the operational costs of most European plans. That kind of significant reduction can only be accomplished by reducing the revenues of HC-practitioners.

Who wants, therefore, to take a cut in annual salary from an average of $150,000 to $75,000? They'd have to trade-in the BMW SUV for a Toyota.

Can't have that, can we? You see, the purpose of American HC policy is for doctors to have all the trappings of an affluent life-style. After all, if Golden Boys can make Megabucks, why shouldn't a good doctor make a mere $150,000?

This is the sort of asocial mentality that has installed itself in America.

[anne]

Matt:

"Did you see the Bunk study stating 2/3 of doctors in America want National Health Care.... I found this article, 60% of Physicians Surveyed Oppose Switching to a National Health Care Plan, It's worth a read."

"It's worth a read." Huh???

http://jaajoe.com/Politics/Sixty-Per-Cent-of-Physicians-Surveyed-Oppose-Switching-to-a-National-Health-Care-Plan.html

April 7, 2008

Sixty Per Cent of Physicians Surveyed Oppose Switching to a National Health Care Plan
By Cisco

With apologies to the leftist anti-war crowd, I will steal and bastardize one of their favorite mantras: “Ackerman lied, health care freedom died.” Now that I have said it, I have to admit that it does not have all of the fluidity of the anti-war slogans. Maybe that is because “Ackerman” has three syllables and “Bush” has just one. Or maybe that is because you need to be a brainless leftist in order to construct a really enjoyable brainless slogan that can be chanted ad nauseam at rallies where people are not expected to do any critical thinking.

"It's worth a read." Huh???

[anne]

http://www.annals.org/cgi/content/abstract/139/10/795

November 18, 2003

Support for National Health Insurance among U.S. Physicians: A National Survey
By Ronald T. Ackermann and Aaron E. Carroll

Background: Nearly 40 million persons in the United States were without health insurance for all of 2000. National health insurance would remedy this situation, and many believe the success of reform efforts in this direction may depend on physician support.

Objective: To determine the general attitudes of U.S. physicians toward the financing of national health care.

Design: Cross-sectional study.

Setting: National mailed survey.

Participants: 3188 randomly sampled physicians from the American Medical Association Physician Masterfile.

Measurements: Physicians were asked whether they support or oppose 1) governmental legislation to establish national health insurance and 2) a national health insurance plan in which all health care is paid for by the federal government. Weighted multivariate logistic regression analyses were performed to identify factors that independently predicted support for each of these strategies.

Results: Sixty percent of eligible participants returned a survey. Forty-nine percent of physicians supported governmental legislation to establish national health insurance, and 40% opposed it. Only 26% of all physicians supported a national health insurance plan in which all health care is paid for by the federal government. In analyses adjusting for differences in personal and practice characteristics, physicians in a primary care specialty, physicians reporting that at least 20% of their patients had Medicaid, and physicians practicing in a nonprivate setting or in an inner-city location were statistically significantly more likely to support governmental legislation to establish national health insurance.

Conclusions: A plurality of U.S. physicians supports governmental legislation to establish national health insurance. This support may be relevant to the success of future efforts to reform national health care.

[anne]

http://www.pnhp.org/news/2008/april/physician_opinion_ti.php

March 31, 2008

Physician Opinion Tips in Favor of National Health Insurance
By Charles Bankhead

INDIANAPOLIS — A majority of U.S. physicians support national health insurance, according to findings from a nationwide survey.

Almost 60% of 2,200 physicians surveyed said they favor government legislation to establish a national health insurance plan, Aaron Carroll, M.D., and Ronald Ackermann, M.D., of Indiana University, said in a letter published in the April 1 issue of Annals of Internal Medicine.

The results represented a 10-point swing in physician opinion since a similar survey was conducted in 2002 and seem to leave practicing physicians and organized medicine staring at each other across a wide philosophical chasm.

In the 2002 survey, 49% of respondents favored national health insurance. Given that the U.S. has about 800,000 physicians, the 10-point swing means that 80,000 physicians have changed their minds about national health insurance in the past five to six years....

[anne]

http://www.pnhp.org/news/2008/april/physician_opinion_ti.php

March 31, 2008

Overall, 59% of respondents expressed support for legislation to establish a national health insurance program (28% "strongly" and 31% "generally"). Additionally, 32% opposed national health insurance (17% strongly and 15% generally), and 9% of respondents had no opinion.

By medical specialty, the survey showed that some form of national health insurance was favored by:

* 83% of psychiatrists
* 69% of emergency physicians
* 65% of pediatricians
* 64% of internists
* 60% of family physicians
* 55% of general surgeons

About 55% to 60% of physicians representing medical subspecialties, pathology, and obstetrics and gynecology also favored national health insurance.

Specialties whose physicians opposed national health insurance were surgical subspecialties (about 45% support), anesthesiologists (40%), and radiologists (30%).

The results also showed that 55% of physicians favored an incremental approach to universal coverage (14% strongly, 41% generally), whereas 25% opposed incremental reform (14% strongly, 10% generally). Additionally, 14% of respondents expressed support for incremental reform but opposed national health insurance....

[anne]

Lie....

"The doctors who did this study also conducted one in 2002 and found that the majority of doctors did not want national health care...."

Truth....

http://www.annals.org/cgi/content/abstract/139/10/795

November 18, 2003

Support for National Health Insurance among U.S. Physicians: A National Survey
By Ronald T. Ackermann and Aaron E. Carroll

Results: Sixty percent of eligible participants returned a survey. Forty-nine percent of physicians supported governmental legislation to establish national health insurance, and 40% opposed it....

[Lafayette]

Look, Anne, the studies mentioned did not ask, "Even if Universal Health Care means a reduction in your overall income, do you favor its adoption?"

For the present, Universal-UC means more inclusive numbers of patients ... but at the same service rates.

How could a doctor not want his patient numbers not expanded, if possible? The crunch comes when a National Health Service mandates prices, as it does for Medicare.

Then we'll see how many doctors are willing to accept the lower pricing ...

[Jrossi]

Lafayette on HC is a veritable fount of nonsense. Readers beware. Preventive health care is much more important than remedial care? Wrong again, Lafayette. See The Tufts Medical Center CEA registry on the web, the best database for cost-effectiveness. Although it's a bit user-unfriendly, it lists cost/QALY for a large number of treatments and preventions. The ratios section is interesting. The results: some treatments are very cost-effective, some not. Same with preventions. These things must be judged individually. So a blanket statement that prevention is much more important than treatment shows he really doesn't know what he's talking about.
A pity really. Some of his ideas are actually good--HC for all is a good idea. France does have a good system, no doubt.

[Jrossi]

Anne, You have cited the most recent study and you are right that most docs now support national health insurance. I'm a bit chagrined that support is only 60% among FPs. Note again Lafayette's ignorance of basic facts.

[Lafayette]

JR: Note again Lafayette's ignorance of basic facts.

Right, JR. So elucidate me on the facts of which I am ignorant.

It's a public blog. You've made an ad hominem remark. Now have the professional dignity to justify it.

I'm waiting ...