Inkwell: Authors and Artists
Joe Flower (bbear) Sat 20 May 06 14:31
>How did we get in this situation, with employers considered responsible for healthcare insurance? I believe that, like Kaiser, it started as a response to WWII, with employers coming out of the Depression, suddenly scrambling for workers, and employing many women for the first time (and women are and always have been the gatekeepers of healthcare for the family) but constrained by wage controls from offering higher wages - so they offered other things, including healthcare insurance. After WWII, unions were very strong, and demanded that this precedent be expanded and reinforced. There were efforts under Truman and Eisenhower to offer federal healthcare coverage for all. Republican Eisenhower was actually the first to offer a bill - written by Peter Drucker, who would go on to become one of the nation's top business strategists. The bill went nowhere. Johnson tried again, but eventually decided to scale it back to cover only the populations that needed it the most - the elderly, the poor, and the disabled. And despite its many problems, it must be said that the Medicare/Medicaid package has been remarkably successful at expanding healthcare for those populations. It is one of the main reasons why we have such a burgeoning elderly population today, compared to 40 years ago.
Joe Flower (bbear) Sat 20 May 06 14:40
>What's in it for providers? Why is the AMA opposed? I think largely for historical reasons. Most doctors are small business people, either independent, or in small-to-medium corporations which they own as partners. Even Doctor Eshleman (whose participation here, by the way, I particularly welcome) is a part owner of a rather large for-profit medical corporation. Small business people do not like government interference. And single-payer is associated in almost everyone's mind with government control. In the current situation, thought, doctors have lost a great deal of their power to the insurers, so dealing with one controller might be a lot easier than dealing with many.
Joe Flower (bbear) Sat 20 May 06 14:46
But single payer need not mean centralized bureaucratic control. Suppose that we left the present system intact, with these differences: Healthcare insurance is no longer a tax deductible business expense, for anyone (which means, of course, that most employers would stop offering it for most employees). Take the tax revenues gained, and give them back to the people in the form of funded medical savings accounts and a basic, government-backed catastrophic healthcare insurance program. If you have the money, and want healthcare with better guarantees, and access to the high-pockets specialists or whatever, fine, you pay for the insurance with after-tax dollars. But everybody is covered and, because the money is in MSAs, there is still competition among providers and insurers for those dollars - and not particularly any more government control than there is now.
Diane Brown (debunix) Sat 20 May 06 15:53
I find this conversation particularly interesting in part because of a term paper I did for a history of medicine course at UC Berkeley. I took advantage of a large collection of Kaiser papers at the Bancroft library to study the history of the Kaiser system. I remember astonishment at the vehemence of the reaction to Kaiser--the very idea of the HMO was decried as socialist, if not outright communist, by the AMA and politicians of both major parties alike. Today I find something equally astonishing: the incredible number of capable people who are working in health care not delivering care, but tending to coverage issues--former nurses reviewing charts to see that they're compliant with insurer requirements, and on the other side, insurance industry people spending time trying not to pay for services. That's a huge, huge waste of money and human capital. And what I see in the hospital is only the tip of the iceberg.
Alan M. Eshleman (doctore) Sat 20 May 06 17:12
In the 1950s Kaiser doctors were excluded from membership in California county medical societies--just part of the McCarthyite hysteria of the time. BTW, highly recommended is the May 18 issue of the New England Journal of Medicine, which arrived in my mailbox today. There are two lead articles about the Massachusetts plan for universal coverage. A few factoids from the articles: *Public opinion polls now show that a majority of Democrats, Republicans,and Independents favor universal health care coverage. *in 2004, per capita health care expenditures were $6,280 (16%of the GDP) *in 2005, the average [I think they mean "mean"] monthly cost of coverage through job-based health insurance was $335 for an individual and $907 for a family. The Massacusetts plan, in brief: *requires everyone who can afford it, to buy health insurance *assesses business a charge of $295 per employee per annum if they do not already offer a health insurance plan This money is earmarked to subsidize insurance for those who cannot otherwise afford it. * extends Masscare (their version of Medicaid) to children in families with incomes up to 300% of the Federal poverty standard or about $60K per year. *Extends the same to indiviudals with incomes up to 100% of the poverty standard *gives subsidies to individuals with incomes between 100 and 300% of the poverty level. Will it work? Let's hope so. The mandate that those who can must buy insurance is very similar to what Switzerland requires of its citizens. In Switzerland, citizens purchase a basic package from private insurers who are restricted in how much they can charge. In return ,these private insurers can sell all sorts of supplemental plans (Botox benefits and the like) to those who can afford them. Massachusetts will make sure that people buy insurance by checking their coverage at state income tax filing time. If they haven't purchased insurance by then, they will be assessed a penalty. Finally, I think the power of the AMA is overrated, especially in layman's mind. Patients often ask me what the AMA's policy is about particular therapies, assuming such policies exist. They don't. Certainly the conservative elements of the AMA come in to play in the debate over medical economics, but the AMA is no longer any sort of king-maker.
Andrea McKillop (divinea) Sat 20 May 06 17:36
Alan, I'm also appreciating your participation here, and was also happy to see Dr. Diane drop in. I don't think that the AMA is the political juggernaut it may once have been (heavy on the maybe there), but I do think that organized physician opposition to single payer concepts could and should be a concern. One interesting thing I turned up is the AMPAC pattern of political contributions, described in the links below: <http://www.opensecrets.org/orgs/summary.asp?ID=D000000068> <http://content.nejm.org/cgi/content/short/330/1/32> I do not, however, want to see this discussion derailed onto a siding, so I'll drop this at this point , and leave the links for anyone interested in knowing more.
Andrea McKillop (divinea) Sat 20 May 06 17:48
I want to thank you for the summary of the Massachussetts plan, as well, Alan. It will be very interesting to see not only the anticipated impacts and outcomes, but also the unintended ones. I wonder if this kind of mandate could be a bridging step toward the goal of a single payer system.
Alan M. Eshleman (doctore) Sat 20 May 06 18:00
Slippage. The New England Journal stuff is 14 years old...Interesting, though. Organized physician *support* is also very necessary. One problem with the Clintons' plan was that Hillary and her brain trust went off to private meetings and drew up a plan with almost no input from physicians in the trenches. That process pissed a lot of people off, me included! Without much organized support, it was easy for the insurance industry (not the AMA) to roll out the Harry and Louise campaign and shoot the whole thing down. Massachusttsis aiming for 90-95% coverage per the articles I mentioned.
Andrea McKillop (divinea) Sat 20 May 06 18:10
The Open Secrets link updates the twelve year old study, fwiw. And it's rather interesting that no one seems to have analyzed those donations in detail since, especially in light of the tobacco issue. I agree that one of the mistakes made by the Clintons et al was the perceived secrecy around the development of the plan, although I can understand why the myriad political pressures on the process led them that way. No new paradigm or plan is going to succeed without early and intense stakeholder involvement. Along that line, I'd like to go back to go back to a point that Diane made about the amount of time spent on coverage issues now. One of the major traits of the health care reimbursement morass is its opacity. I spent a lot of time professionally working with coding and reimbursement problems, and I now have a casual sideline in EOB interpretation for friends and family. Translating payor-beneficiary communication has become a sort of subspecialty of its own. From the provider end, it has become increasingly difficult for even trained, educated, professionals to understand what the insurers are telling them, and what is actual policy requirement vs. what is interpretation. In the opinions of a lot of people in the field that I've worked with, there are too many medical/treatment/discharge decisions being made by bureaucrats, rather than by health care professionals. Could a single payer system do something similar to what the IRS has attempted: revolutionize communication between all parties by conducting it in plain English? Could the rules be simplified such that they are understandable to all?
Alan M. Eshleman (doctore) Sat 20 May 06 19:04
Sure, why not? If everyone had the same basic insurance policy and if there were limits on what was covered (medicine is an enterprise where demand always outstrips supply, and a good deal of the demand is unnecessary)it should be possible to describe things simply. And I have to say, one of the nice things about being a Kaiser doc is that never in almost 20 years has any bureaucrat ever attempted to trump my medical decisions. Disagreement among colleagues? Sure. Limits on the formulary? Yes. We don't automatically cover every new blockbuster drug. But no medication has ever been denied if there was no alternative.
Cogito, Ergo Dubito (robertflink) Sat 20 May 06 19:17
A great topic and gratifying in that observations and comments reinforce and enlarge my own thoughts about the matter. In a previous life, I had contact with public health officials for some developed and some less developed countries. A consistent view I got was that the major health problems were due to individual choices. When I protested that this cannot be true where there is poverty, I was assured that even where choices were severly limited, bad choices were made. If there is some truth to this, will single-payor offer a better way to attack the problem of bad life choices by individuals? How do existing single-payor systems attempt to get at the problem?
Joe Flower (bbear) Sat 20 May 06 21:05
Thanks for the summary of the Mass. plan, <doctore>. The politics and other factors of our situation show that this is the kind of solution we can expect -cobbled together, not radical, not sidelining the insurance companies or employers, but at least covering most people. The opacity of the current system is, of course, unnecessary. If insurance companies found it in their interests to be transparent and helpful, that's what they would be. It is not in their interest to be truly trnsparent or helpful.
Joe Flower (bbear) Sat 20 May 06 21:10
Robert, public health officials who say that health status is merely the result of individual bad choices are merely reflecting the prejudices of their class. There is extensive and well-documented literature showing that, while some health problems are due to choices, those choices are heavily influenced by socioeconomic class, and opportunity. In brief, those people are healthiest who have the most feeling of control over their lives. The entire global "healthier communities" movement is built around this notion.
Carl LaFong (mcdee) Sat 20 May 06 21:27
I think we'd find that the number of people who have not made bad choices in some aspect of their lives to be quite small. I agree with much of what you're saying, Joe, but as you know, don't think we should carry the insurance companies like a millstone around our next for all eternity just because they employ a very large number of people. People used to say that all sorts of economic disasters would ensue if we ended child labor. We've muddled throught somehow.
FROM PATRICIA ZENTARA (davadam) Sun 21 May 06 09:06
Patricia Zentara writes: Hi, Joe and all! . Am just a first time guest.I have been interested in The Well for years.. . I seem to get that Americans have a "Drive-through" syndrome for instant gratification...to very complex issues. . I am not referring to anyone here because I am more than weary at what I have seen In newsgroups and in the media...... The desire to lay blame on any entity. Honest discourse seems lacking and pervasive. And when one takes a stand ...the reward is not positve. . I observe there are many "trips" and anyone not in line with us must be wrong. . My own, limited, point of view is that our society has been raised to believe that life is fair...it is anything but. . So...re; Medical Insurance? We got here I think,because we have given up on~or never searched alternative methods of healh care for openers. And if we find out we have to pay for it...my goodness..what upsets occur! . The money we spend on the latest technological toys/cars..vacations takes precedence over heath care, . I stay away from MD's and I am not young...I think the Medicare D does promise.... too much for some and it does work for others.So far, it works for me. . What I am trying to say is that we should seek new and more creative ways to care for ourselves and others. . I do think President Kennedy was right on point when he said: "Ask not what your country can do for you~ ask what you can do for your country"... . I hope I can do something to make a difference in some way to this world. . Peace to all~ Patricia Zentara Lodi, California
Allegro ma non tofu (pamela) Sun 21 May 06 15:13
Wonderful discussion, and thanks to everybody. I had back-to-back experiences with the Japanese and the American healthcare systems (same injury). The Japanese, for about $85, diagnosed and recommended action (which would've cost more than $85, but even so...) When I got back to NYC, I got the same diagnosis, had the surgery, yadda yadda. What utterly flummoxed me was that the Japanese had taken all the particulars down in Kanji on electronic notepads: diagnosis, X-rays, therapy, all ended up in a databank. In NYC, a guy young enough to have grown up on videogames took the same info into 1932-style three-ring binders by hand. Same old questions--allergies, previous surgeries, etc. This is at a hospital where I'd had a 25-year history of whatever allergies to medicine, anesthesia. and so forth. At this point I was livid (and in real pain) and read him the riot act. A few weeks later, when I'd recovered my equanimity, I emailed a pal at Columbia-Pres who is in medical informatics, about why there was such a difference JUST IN INFORMATION TECHNOLOGIES, whose implementation saves a lot when it's done right. Same answer: we need a single-payer system to reconcile all the gazillions of little doc- and hospital- and insurance-operated systems extant. When, oh Lord?
Cogito, Ergo Spero (robertflink) Sun 21 May 06 20:22
>reconcile all the gazillions of little doc- and hospital- and insurance-operated systems extant.< Standardized record systems offer economies and other benefits, no doubt. My experience in developing similar systems to describe medical device function and mal-function made me concerned that the zeal to categorize for ease of data handling may gloss over some unique aspects. I remember one MD saying "The patient can have as many diseases as he damn well pleases". Certainly, any record system can miss information. Standardized coding appropriate for data handling will help characterize a population of patients to the systems benefit. Individual patients, however, may find that their particular combination of health problems and issues may not be well-reflected when placed in predetermined categories. As usual, the devil is in the detail
Cogito, Ergo Dubito (robertflink) Sun 21 May 06 20:38
>There is extensive and well-documented literature showing that, while some health problems are due to choices, those choices are heavily influenced by socioeconomic class, and opportunity.< Joe, I'm certain that public-health officials everywhere would agree with you but the point was that major health problems result from choices that individuals are free to make even where choice is limited by such things as class and opportunity. Further, we see people that are highly advantaged having health problems due to choices made. The "healthier communities" you note sounds like a positive step to get the peer group to support the individual to make better choices.
Joe Flower (bbear) Mon 22 May 06 15:58
>we need a single-payer system to reconcile all the gazillions of little doc- and hospital- and insurance-operated systems extant. The need for information transparency is not a argument for a single-payer system. It is an argument for industry data-transfer standards, which already exist, and are spreadng with the slow spread of digitization through the industry. For an example, just look at the credit card industry: credit cards are issued and administrated by thousands of independent institutions around the world, yet they communicate their informatino seemlessly, instantaneously, accurately. One could easily imagine a single-payer system with munged information standards that prevented prompt and accurate communications between, for instance, different government programs, or between clinical and administrative sides, or between different types of providers. For me, the relationship of information technology to the single-payer question is that both are about the quality and efficiency of the basic transactions of healthcare. Healthcare that is not only digitized by automated and networked would be hundreds of times more transaction-efficient and high quality than today's healthcare. And a healthcare that replaced an insurance sector that adds no value with a simple and universal flow-through payment system would also greatly reduce transaction costs.
Joe Flower (bbear) Mon 22 May 06 16:12
>major health problems result from choices that individuals are free to make even where choice is limited by such things as class and opportunity This is true, but in ways that are so limited as to be useless in making public policy judgments. Fetal alcohol syndrome, for instance, results from the mother's poor choices. And those choices are heavily modulated by socioeconomic status, as well as by population genetics. So? Knowing that does nothing for the child, or for the society that must deal with the child's many developmental problems, and which will eventually be burdened with an adult that is less educable, productive and socially useful. The suggestion here is that looking at healthcare as a unified social good that we provide for ourselves as a society, rather than a private good, is more likely to provide comprehensive social and medical answers to such problems. The best book I have encountered on this subject Is "Why Are Some People Healthy And Others Not," by Evans et al. For a quick but deep intro to this subject, here is an interview I did with Fraser Mustard: http://www.imaginewhatif.com/Pages/Mustard.html Please forgive the "broken" look of the page. It's a part of my web site I have not cleaned up yet. More writing on the subject (from back when I was doing a lot of it) is available at http://www.well.com/~bbear/hc_articles.html
Allegro ma non tofu (pamela) Mon 22 May 06 16:59
Joe, I take your point that a transparent and efficient IT system isn't *necessarily* an argument for a single-payer. And in today's news, we hear that some functionary at the VA managed to get burgled of a CD that had more than 25 million veterans' records and SS numbers. In a healthcare system, that would be just swell. (Not that the private sector with its gazillions of independent operators has had a much better record of guarding privacy.) Interesting that, in your view, the insurance sector adds no value. A strong statement. I'm willing to believe it on faith, but can you say more?
Andrea McKillop (divinea) Mon 22 May 06 18:04
Thanks to all of you for the excellent questions. Joe, can you speak to HIPAA standards, digitization and the protection of patient confidentiality? How might a single payer system impact or be influenced by the need to protect those records as we move into digital records and transmittal?
Cogito, Ergo Spero (robertflink) Mon 22 May 06 18:16
Joe, thanks for the link to the Fraser Mustard interview.
Joe Flower (bbear) Tue 23 May 06 10:27
> Interesting that, in your view, the insurance sector adds no value. A strong statement. I'm willing to believe it on faith, but can you say more? The reason that we have insurance is to spread risk - to turn what would have been rare but financially catastrophic into a regular, calculable cost of doing business. The risk is spread across time and across populations. Three points: 1) Healthcare does not really fit that model. A few people require almost no healthcare - they grow up relatively disease-free, then get hit by a bus or blown up in Iraq. Sad, but not much cost to the system. A few people need huge amounts of healthcare for long periods of time - people with MS, AIDS, and so forth. Most of us need varying amounts, increasing as we age, then relatively large amounts as we fight our inevitable death. This is not a good model on which to attempt to spread risk, and becomes less so as we manage to extend the elderly stage of life. When healthcare insurance, even living past 65 was a relatively rare event - 3% of the population in the 1940s. 2) Insurance companies are increasingly using their vast informatino structures to narrowly target populations with special offerings which in effect avoid spreading risk. 3) It poorly serves the health of the population to have some people covered and some not. When people avoid healthcare because they cannot afford it, they tend to spread more communicable disease vectors. So for poorly spreading risk, and aggregating customers to strong-arm costs downwards, insurance companies take 25% of the healthcare dollar.
Joe Flower (bbear) Tue 23 May 06 10:34
> HIPAA standards . . . digitization . . . privacy . . . single payer I am not sure that these are not completely separate issues, except for this: the vast amount of information that insurance companies have isused constantly, in every way legally available to them, to separate out the "outliers" and deny them coverage in one way or another. In a single-payer system, the worry would go away.
Members: Enter the conference to participate