Friday, November 20, 2009

"Health Care Reform" - A Bad Bill Is Not Better Than No Bill

Getting ready for my winter sojourn in the Holy Land, I spent a couple of days counting pills and refilling prescriptions. US law doesn't just forbid me to import identical but cheaper drugs from abroad. It also forbids my mail-order pharmacy from mailing my pills to me in Tel Aviv. So, once a year, I become a traveling pharmacy. If this sounds lame to you, you're right.

Any day now, the e-mails and the robo calls from Obama's Organizing for America (the ongoing campaign to maintain the grassroots support that got him elected in the first place) and the AARP (American Association of Retired Persons), America's largest lobbying group for senior citizens (which they define as anyone over 50) will start flooding in. They're going to ask me, yet again, to support whatever mess Congress finally gags up as "health care reform" because a bad bill that sort of seems to do some of the things we need to get done is better than no bill at all. Sorry, this time I'm not on board for the fantasy express. A bad bill that leaves us at the mercy of insurance companies and Big Pharma will not assure universal coverage at a reasonable cost. I'd rather have no bill and work for a single payer system.

In 2010, my medical insurance will cost more for less coverage. Rather than the 15% or so rate increase that is now metastasizing its way through US medical insurance, I'm getting a 3% bump but my deductibles and co-pays will increase, raising my total cost by some as yet undetermined amount. What can I say. Don't get old and don't get sick. It seems I'm not alone, however, as most small businesses are looking at 15% rate increases. Just before Congress acts on a Bill which the insurance industry fears might actually put a lid on what they can charge. What a coincidence.

Want another coincidence? Big Pharma and the President made a big deal out of how Big Pharma would reduce consumers' costs by $80 billion and support (or at least not oppose) a health care reform bill. At the time, the bills kicking around Congress would have saved about $160 billion in drug costs. Since then drug prices have been going up at a rate of 9% a year for brand name drugs under patent protection (this while the rest of the economy has been deflating). So, by the time Congress passes something, Big Pharma will have taken in more than the $80 billion that they'll then make a big show of giving back by discounting their prices. As a famous business writer likes to say, pretty slick.

In addition to counting pills, I've been trying to get vaccinated against Swine Flu. No luck. None of my doctors has the vaccine and the town I live in may get some but children, teachers, health care workers and first responders are all in line ahead of me. I don't mind having the lower priority but I do mind being told I need to vaccinate myself against the worst pandemic since the 1919 flu plague and then told that private industry just could not produce and distribute enough vaccine before the season began. But I do have an alternative. I wrote to my cousin in Jerusalem. She is both a Family Doctor and our family's doctor. She can get us the shots when we're in Israel but expressed surprise that I could not get vaccinated in the US. I explained that this is because Israel has a serious national health care system that responds on a national level to things like flu pandemics while the US system is f****d up beyond all recognition.

When Congress came up with the Medicare drug bill, a $450 billion giveaway to Big Pharma, AARP argued that a bad bill was better than no bill. US taxpayers buy some drugs for some seniors but we're not allowed to negotiate the price because that would somehow be unfair to the pharmaceutical companies. We were told by the Bush Administration that drug prices would be controlled by free market competition. Wanna bet? Within 6 months of the drug companies' initially enrolling retirees at low ball rates, the price of prescription drugs began to spike upward and have never looked back. What we got, all dressed up as reform, was the biggest giveaway to private industry since the Feds gave the railroad barons the rights of way west of the Mississippi.

Americans will probably continue to spend more money on health care than any other country but actually be less healthy than citizens of comparable, first world countries. The problem with health care in the US arises mainly from the lousy method of allocation of resources and the uneven methods of payment. Its all driven by profits and all maintained in the name of free market capitalism using the canard of patient "choice" as the "on" button. We are all programmed by constant, mass advertising to demand the latest, most expensive forms of treatment and will sue if we don't get them (or sue if we do get them and they don't work). As anyone willing to really look around them knows, unfettered free market capitalism doesn't really work if your concern is the general welfare of the entire citizenry. Its great for a handful of investment bankers and hedge fund managers but not so wonderful for factory workers or retail store employees. The cure is a single payer system.

First let's get over ourselves and talk about what single payer is not. Its not socialism. Why not? A truly socialist medical system would involved public ownership and control over not just the funding but also the providers of health care and the manufacturers of the drugs and equipment they use. Single payer would leave the actual practice of medicine and all its related goods and services in private hands (except of course for public services like the VA hospitals). Single payer would involve the representatives of the US taxpayers negotiating prices and working on quality assurance.

A doctor friend of mine once said he opposed government-run health care because he did not want medical care rationed based on economics. To which I replied, "What the hell do you think goes on now?" And, if you're out there screaming in terror about "death panels," let me be the first to tell you the truth. We've had death panels for years under euphemisms like "managed care" and "peer review" and "bankruptcy court."

What single payer would be is a way to reduce costs and open the health care field to improvements in quality (like a national computer data base of medical records and drug prescriptions which would cut down on medical errors which would cut down on tort awards and save us all billions) and best practices based on patient care and not on how large a bonus the CEO of the insurance company will get this year. It's no accident that the best health care at the most affordable prices is available from not-for-profit, community-based health care systems.

What would single payer cost compared to what we're spending now? The cost of single payer would involve a tax higher than the current Medicare tax but less than the total employers and employees now spend on Medicare taxes plus the cost of private health care insurance. Do you own a business? If you could get health care coverage for yourself and your employees for less than the current cost of such insurance plus your Medicare taxes, would you take the deal? Damn right you would. You can add. Congress can't.

You see, Congress and the Administration, having taken billions in political contributions from insurers, drug companies and other health care players, did not have the political nerve to dare interfere with our relationship with our health care insurer. They won't do what's right because they are afraid we will be upset over having the government disrupt our wonderful, fulfilling relationship with our health insurers. Ask me if I care about my deep, sensitive relationship with my health care insurer. Funny you should ask, but no. What I do care about is my relationship with my cardiologist and the other doctors who have spent considerable time and effort keeping me alive. And single payer, just like my Medicare, leaves me free to keep the doctors I have and choose new ones and that's what matters. Not how they get paid.

By the way, when you add Medicare taxes, plus state taxes for Medicaid plus the Federal tax advantages given to medical expenses plus the cost of Federal health care programs for the military (both active and veterans), the US income taxpayer currently foots the bill for about 60% of the total cost of health care in the US. That's before our own expenses for private coverage. Bottom line, we're paying most of the cost of health care now and, in return, we live in a country where the infant mortality rate is comparable to that of Bangladesh.

How do we go to single payer? The financing side is easy enough. Start with the Medicare law and take out the age and disability limitations. Just cover everyone. Then we can go to work on improving quality, on negotiating fair reimbursement rates for providers and all the rest. Every individual and employer has to pay into the system or can opt out for private coverage but still pay a tax. This way private insurers can't cherry-pick the young and healthy out of a system meant to insure everyone. Anyone who wants to buy private insurance is always free to do so.

So where do we find enough money to pay for expanding Medicare to cover everyone? Well, let me count the ways for you. First, Medicare delivers a dollar of benefits for about 4 cents in overhead. Private insurers spend up to 30 cents per dollar. Administrative costs alone would represent a saving of about $500 billion dollars over ten years. Make a serious dent in unnecessary procedures by insisting on best practices and setting reimbursement rates to favor keeping patients well and you save another $850 billion. (These are AARP estimates.) Let's see, we need a trillion and single payer saves us at least 1.35 trillion. And there's the cost reduction described above. You do the math. Congress doesn't seem to be up to the task.

Single payer would also take Medicaid and similar programs off the books of state governments. Yes, your Federal taxes will go up but, just this once, your state income and maybe your property taxes will go down. Go find a Governor who wouldn't love to shove Medicaid expenses back up to the Federal level.

But no one, except maybe Bernie Sanders, the only socialist in Congress, is advocating for single payer. Why not? You'd think AARP would follow the logic of its own research. But they seem to be too busy trying to sell me health insurance to get to work on real health care reform. The rest of Congress is too busy accepting campaign contributions and after-office jobs from insurers and Big Pharma to get too worked up over your health.

Finally, I don't know why the CEOs and CFOs of every S&P 500 company (other than the health care insurers) are not raving socialists when it comes to health care expenses. To use an oft-cited example, it costs about $2000 less to build a car in Japan or Canada because those countries have national health insurance. Its the same for most other industries. Its a mystery to me why otherwise cold, calculating business people don't jump at the chance to get this albatross off their bottom lines.

And just what are we getting instead of single payer? We seem to be on the verge of getting some modest rule changes so some people can't lose coverage just because they lose their health or their jobs. Plus some, but not all, of the uninsured (most of whom have jobs and pay taxes) get coverage through a "health care exchange." That's why AARP and Obama will tell me soon that a bad bill is better than no bill. But given that the exchange, which may or may not have a public option along with 5 or 6 private options, may not be allowed to seriously negotiate prices, its not clear how "reform" will control costs or improve the quality of care.What we do know is that the exchange, which may or may not be open to a wide group of employers and individuals, is based on some flow charts which, in turn, are based on work done by Jacob Hacker, a Yale University professor of political science. They look like this:

That's right. These flow charts were given to 535 US legislators and they were asked to come up with major health care legislation. When I first saw these charts I had one of those moments of clarity in which it become clear that the world has really gone insane this time around. I believe I can sum up my take on the pending legislation in two words, "We're f****d." (And that's not even taking into account the Stupak Amendment which will send women's health care back into the middle ages.)

But don't take my word for it. Here's a message from a Canadian health care consultant using a form of communication that Americans are sure to understand -- a beer advertisement:

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