The Amazing Maze of US Health Care

Howard Dean says the health bill would do more harm than good.

Bill Clinton says “Don’t let the perfect be the enemy of the good.”

A snow job?

How did we get this close to health care reform legislation, but many progressives believe that it could actually do more harm than good.

Because the “progressive” position was already a compromised position?

Because “single payer” was never on the table.  Because political operatives and policy makers didn’t trust the American people.

The current health care debate certainly demonstrates the power of money over popular sentiment.  But could it be that the power of money was so intimidating to some reformers that they chose to misrepresent public opinion?

But what is the popular sentiment?

Despite outrageous and obstreperous tactics by right wing opponents of health care reform during the August congressional research, polls indicated support for health care actually ticked up in the early fall.

Kip Sulllivan recently asked the question, why do some polls show support for a single payer system and some don’t?

How did the “public option” come to the fore of policy discussions?

The short answer – people use the polls that support their position, and when they don’t support their position, they make it sound like they do and if that fails, they make stuff up.

Those are my words, not Sullivan’s

Over six lengthy articles on the web site of Physicians for a National Health Plan, Sullivan describes polls that demonstrate broad support over a long period of time for a single payer health system.

He examines closely the polls that show support for a single payer solution and those that show less support.

His conclusion – the more poll respondents know about single payer – the more they like it.

Questions that offer accurate information to explain single payer and give examples to illustrate a single payer system, Medicare, Canada, England, consistently show that two-thirds of Americans support a single payer.

I have just condensed into a few paragraphs what Sullivan exquisitely details over several thousand words.

He shows us the polls, the results, the questions.

Three of the polls asked doctors about single payer revealing that physician support for single payer is only slightly lower than it is in the general population.

For Sullivan, the best example of the judgement of an informed citizenry is the citizen jury.  He cites two citizen jury panels convened to review health reform options in the nineties to prove his point that an informed judgement is a judgment for single payer..

The citizen jury is a concept developed by the Jefferson Center.  In 1993 at the height of the debate over President Bill Clinton’s health reform legislation, 24 randomly selected jurors were convened to hear a panel of 30 experts present and discuss three health reform ideas – Clinton’s managed competition plan, a free market approach that has since evolved into what is called “consumer driven health care”. and a single payer approach.

Although the panel was ostensibly balanced, only one of the speakers is clearly identified with the single payer approach, Senator Paul Wellstone, (D-MN).  Of the thirty panelists, only one was invited back – twice, Senator Paul Wellstone.

The lopsided panel produced lopsided results.  But not exactly what was expected.  After 5 days, the citizen jury voted 24- 0 against the consumer driven health care concept.  They voted 19-5 against Clinton’s managed competition plan.  They voted 17-7 in favor of the single payer approach.  That’s 71% in support of single payer proposal that relied on a single proponent to explain it.  When citizens have the opportunity to hear and question all of the options themselves, they will support a single payer.

A briefer version a few years later produced similar results.

How did we get lost?

So how did we get from strong support for a single payer system to luke warm support for a watered down compromise called the public option.

Sullivan goes on to detail how thought leaders like Jacob Hacker, author of the public option idea, and political operatives like Roger Hickey, co-director of Campaign for America’s Future, sold the American public short early on.  By distorting some of the very same poll results cited by Sullivan, they convinced many in the progressive community that the American public would not support a single payer system.

According to Sullivan, Hickey enlisted the Herndon Alliance who hired Celinda Lake, one time single payer booster, to create poll results that showed the public preferred a public option strategy to a single payer approach.  Actually, Sullivan doesn’t use the word “create”, but he challenges Lakes methodology of her focus groups and their lack of transparency and the objectivity of her polls.  Unlike the citizen jury approach, Lake has refused to reveal the questions used in her focus groups.

One might argue that a public option is a satisfactory political compromise, given the overwhelming power of the health care status quo.

The tragedy is that the American public was sold down the river early in the debate.  Sullivan goes on to say that policy should not be driven by polls, but by what is good policy.  But when polls support good policy, why run away from them?

Unless they don’t support your policy.

Reform 2.0

by Michael J. Klag

I have to find a new doctor.

Last month, my primary care physician wrote me a letter. He said he was leaving private practice. He’s an outstanding physician—a doctor’s doctor whom I’ve known since he was a medical student. His reason for closing up shop? The sheer frustration of getting paid by private insurance companies.

When a physician of his stature and skills departs private practice for a reason like that, it is an indictment of our health care system—that is, if we had a health care system. We all know the U.S. has great physicians and the world’s best medical technology. But the best health care system? Not in the least. Our crazy patchwork quilt is an accident of history and one that we need to fix. It fails us in so many ways, from its gross inefficiencies to the fact that it has left 47 million Americans without health insurance.

Open Mike – Departments – Johns Hopkins Public Health Magazine

When a 2,000 page piece of legislation traverses the legislative sausage making process, it is a large target for those who want to take pot shots.

When you are trying to fix a system that is broken in lots of places, it is not an easy process.

Let’s remember what we are trying to fix.

The system does not cover everybody.  Estimates on the number of uninsured range from 30 million to 70 million depending on whom and how you are counting.

It’s expensive.  Our economy already sets aside more resources per person than any other country on the planet.  We pay more in taxes for health care than any other country on the planet.

We are not a healthy country.  Relative to other industrial countries, we don’t live long.  Our babies die before they reach their first birthday.  Our pregnant mothers die in child birth.

That’s a lot of fixes. Read the rest of this entry »

There is nothing simple about our health care maze.  Fixing it is not easy.

I prefer to look for the simple.  The complexity will evolve naturally.

Congress prefers to start with the complex and make it more so.

Spreading the medical risk

There  are two major challenges to fixing the customer side of the health care mess – spreading the medical risk and spreading the financial costs.

Spreading medical risk requires that everyone be in the system.  That spreads medical risk evenly between the sick and the healthy.  That can be accomplished by a system of automatic eligibility or a system of required enrollment.

Automatic eligibility describes a single payer system.  All citizens are enrolled by virtue of their citizenship.  To draw from known models, automatic enrollment describes Part A Medicare, Department of Defense medicine, and to a lesser extent, the Veterans Administration.

Funding for those programs is separate from enrollment and may or may not rely on direct participant financing.

A system of mandatory enrollment implies a system of mandatory participant financing.  That is where we bump into the second challenge.

Spreading the financial costs

How do we transfer money from those who have it to those who need it? Read the rest of this entry »

Allan Brett, M.D. published a thoughtful piece in the New England Journal of Medicine on “American values” and health care in the United States.

Of course, thoughtful has not proved to be very useful in advancing any political cause.

Emotional, yes.  Thoughtful, nice try.

Nevertheless, the coupling of the terms ”unique” and “American values” to derail a policy that Americans clearly want deserves at least some thoughtful reflection.

What are American values and are they unique? Read the rest of this entry »