There's been a lot of attention to the comments of Sue Lowden, who is running as the Republican frontrunner for the U.S. Senate seat now held by Senate Majority Leader Harry Reid in Nevada. At a town hall meeting, when describing her alternative to the health reform bill that passed, Lowden talked about going back to the world where patients would "barter" with their doctor. In a follow up interview, she didn't back down from this quaint notion, and in fact talked about "taking a chicken to the doctor."
But Lowden clearly meant what she said, and deserves the ridicule. But there's a serious debate here that should not be overlooked. One is that some folks really do want to just go back to the good old days, as if medicine hasn't advanced and gotten more complicated and expensive in the process. Harkening back to history isn't a good way to deal with our current and future challenges in health care.
Let's take away the (admittedly humorous) statements about "chickens" and even "bartering." It is equally ridiculous to suggest that individual consumers are in a position to bargain with their doctor. Yet it is an article of faith among some politicians that the real solution to increasing health care costs is to shift the costs onto individuals, have them pay cash, which would "empower" them to bargain for a good price.
For those who raise the fear that reform would make health care like a trip to the DMV, it's strange to argue that health care should really be more like a trip to a used car salesman. Not only would that be needlessly stressful to have to bargain (especially at a time when you were sick), but the individual has little market power. Those who have been the best at negotiating have been large purchasers, like big employers or CALPERS, that negotiate on behalf of hundreds of thousands of people, that have the staff wherewithal to examine the data, make comparisons, and challenge insurer statements.
This is a relevant debate right now. As part of implementating federal health reform, there are bills to set up a new health insurance exchange, AB1602(Perez) and SB900(Alquist/Steinberg), in the California legislature. It is critical that this new exchange use its bulk purchasing power as an "active purchaser," to bargain on behalf of the millions that will get coverage through the exchange, for the best price and value.
So there's two different visions. One is an exchange that negotiates for the best cost and quality. Another is to simply let any insurer sell anything, and let individual consumers fend for themselves, and get deal on their own, with chickens or whatever else--frankly, it's less of a free market than a flea market, letting the buyer beware.
In this continued health reform debate, in Nevada and here in California, we shouldn't be chicken in our efforts to defend consumers.
Health Access California has a long and proud tradition as an independent state coalition here in our state, without a national parent. Our policy decisions are made by Californians, for Californians.
But we are pleased to have good, strong connections with national groups that provide useful assistance and resources, including information and linkages with DC-based groups and with other state consumer advocates across the country. During this past health reform effort, these connections were essential in our efforts to integrate the on-the-ground field work with national advocacy.
For example, we were proud to be the lead partner organization in California for the Health Care for America Now! coalition, working with national groups like USAction. We have a long history working with Families USA, co-releasing reports and speaking at their annual DC conference. And we have greatly appreciated the work with Community Catalyst, on both federal health reform, and on projects that we lead in California, the Consumer Voices for Coverage effort and the Hospital Accountability Project. All of these groups are useful resources for us and our partner organizations, and their websites are useful resources for you, too, to find out more about health reform.
We thank these and other national experts, advocates and groups who have helped us in the last two years make a difference in the health reform debate. The Community Catalyst folks sent their own message of appreciation to advocates in the states as well. (I would say it's NSFW, but you would get the wrong idea.) It's even more strange when you know these people. So, with affection:
I have been struck that I have been more optimistic about the prospect of health reform that others, and I wonder why. My sense of things is based on my trips to DC, conversations with Hill staffers and stakeholders, etc. I know the pitfalls and policy issues, but also understand the commitment that exists in various quarters to seeing this through.
But there's one advantage I also have: I don't watch a lot of cable news. And this is one area where the more you watch, the less you may know. Unless, of course, you get the perspective of from Comedy Central's Daily Show:
I had to laugh out loud in my sedan while listening to the local NPR affiliate station recently. Think of it as an absurd, tragic-comic commentary on the present state of our health care delivery system. It was a blurb of no more than 5-10 seconds paid for by the underwriter of the local broadcast. A prominent managed health care plan touted its name, followed by a marketing slogan intended to attract more consumers:
". . . where doctors take extra time to get to know each patient."
In our current health care system, that's not standard, that's a selling point.
While the anti-reform protestors got attention by shouting at town halls, some of the most memorable pro-reform protests have been by singing, from the "Billionaires for Wealthcare" that were featured at our Health Care for America Now! events in Los Angeles and San Francisco to the "Hey Mackey!" flashmob at a Whole Foods in Oakland.
In his first show after a three week vacation, Stephen Colbert interviewed Richard Kirsch, the national campaign director for Health Care for America Now!, the coalition of over 1,000 organizations working for quality, affordable health care for all, this year. Health Access California is proud to be the lead partner organization for HCAN in California.
I've known Richard for over a decade, as he is on leave from being the longtime executive director of Citizen Action of New York, where I got to know him when I was at New Jersey Citizen Action. He has his own humor, but in these situations, his job was to be the straight man, which he did well despite the grilling by Colbert. Colbert's questions were only slightly more ridiculous than some of the allegations thrown out by right-wing media. Enjoy.
While we wait for the end-of-session, here's a rock video worth watching, which goes through the list of countries that have better health indicators than the United States--and refers to more recent developments in the health reform debate as well.
The city hall featured is right here in California, in Santa Monica.
The video is so up-to-date it even manages to even get a picture of the now-infamous Rep. Joe Wilson. Amusingly, his opponent has raised over $1 million in the 48 hours since the South Carolina Republican's outburst during the President's speech.
Jon Stewart seems concerned that the bill is 1,000+ pages long.
But first of all, bills in Congress use bigger font and have super-big margins, more than most of the children's book I read my 2-year old.
But more specifically, health care is complicated! Or more relevantly, the current status quo is complicated. The bill has to recognize that people currently get health coverage in lots of different ways: from employers, many different government programs, and buying it on their own. You want to provide safeguards to prevent unintended consequences.
Even the single-payer bill in California, SB810(Leno), which is promoted in part for the simplicity of the concept, is many pages, and would probably need more to fully spell out the transition from the current complicated, confusing, fragmented system. Even if the solution is simple, the path to the solution is not.
H.R. 3200 work to make people secure in the coverage they have--however they have it, throught employers, government programs, or the individual or small group markets--while also providing new choices and guarantees.
An iPod is complicated inside, even though the user's experience is simply. No one should be concerned about the length of the bill, but how the patient experiences his or her health care afterwards. And H.R. 3200 would improve that experience by securing and expanding coverage, and working to bring down the costs and financial risk to families.
One of the scary things about health reform bills is that you forget how bad the status quo really is... But then I read parts of the legislation and remember how many problems in our health system aren't the exceptions, but the rules themselves, as they exist today. It's amazing how much of health reform bills like H.R. 3200 are putting in place rules than seem so common sense that you wonder why they aren't in place already.
Federal health reform has arrived. The Senate Health, Education, Labor, and Pensions (HELP) Committee started the "markup" of their bill today. Other proposals are expected from the Senate Finance Committee, and from the House of Representatives.
The debate didn't start great, with Senators Enzi, McCain, and Gregg coming out guns blazing, not exactly setting a bipartisan tone.
To get a sense of the debate, Senator Judd Gregg likened the legislation to something you'd get if "Rube Goldberg, Ira Magaziner, and Karl Marx" got together to which Senator Barbara Mikulski replied, "Our current system is a combination of Adam Smith, Darth Vader and the Invasion of the Body Snatchers."
Perhaps they should leave the health reform humor to the professionals:
While this could be an important breakthrough in science, medicine, and health, there are some concerns, encouraged by the . Leave it to Comedy Central's The Colbert Report to provide a counterpoint:
Colbert brings up some of the legitimate critique of PhRMA: that their research is focused more on finding a steady income stream from existing drugs than on new discoveries. “This is a great breakthrough in the battle to find things to prescribe to people who don’t need them...True, the drug costs $100 a month... But that is a small price to pay to not have the heart attack that there’s no way of knowing that you would have had.”
After a clip of Stanford cardiologist Mark Hlatky urging caution, Colbert quipped, “sounds like someone hasn’t gotten enough free Crestor pens.” Health Access California, CALPIRG, California Labor Federation and other senior and consumer groups supported a bill earlier this year to place limits on the drug company giveaways to medical providers, but the active opposition of PhRMA blocked it. Maybe now that the issue has gotten the famous "Colbert bump" (along with the city of Sacramento), we can be more successful in the future.
This story from the satirical newspaper, The Onion, is actually supposed to be a joke -- but really, it's dead on:
After years of battling crippling premiums and agonizing deductibles, local resident Michael Haige finally succumbed this week to the health insurance policy that had ravaged his adult life. Haige, who had suffered from limited medical coverage for nearly a decade, passed away early Monday morning. According to sources, the 46-year-old was laid to rest at Fairplains cemetery, surrounded by friends, family members, and more than $300,000 of mounting debt. ...
According to an independent study released last month by the Mayo Clinic, health insurance is the nation's No. 2 cause of death, claiming the lives of some 400,000 Americans each year. A silent killer, health insurance often strikes without warning, its harmful and profit-based policies avoiding detection until it is far too late. Although the cruel bureaucratic disorder does not discriminate, statistics have shown that senior citizens, young dependents, and those woefully underemployed are most at risk.
Actually, there is a statistic, which relates to the uninsured. According to the Institute of Medicine, it's more like 18,000 annually who die from lack of insurance, making it the sixth most common cause of death
When we saw him, he was on a "How The Man Sticks It To The Little Guy" run when he used health insurance as an example. First, he mentioned how lucky most of us feel if we can buy insurance through our employers (unspoken subtext: because if we get health insurance at work, we don't have to worry about being denied coverage because of preexisting conditions). But then we don't feel so lucky if we get sick and, even with coverage, get a pretty big bill. At least then, Jake joked, we could complain about how our boss was "sticking it to us." But some of us have to purchase our own insurance directly, so, he deadpanned: "I end up sticking it to myself! That doesn't seem right."
Then, in surprisingly fluent health insurance-speak, Jake went off about how he could barely keep up when his insurance broker was trying to explain his policy choices: an HMO, an HMO with a POS, a PPO, and variances between the deductible, premiums, co-pays, co-insurance and out-of-pocket maximums.
Jake asked "but which one is best" and the broker replied "it depends on the individual." And Jake, being a comedian, said: "Let's say, hypothetically, that the individual is me." The broker responded: "You have to make your own decision about what's best for you." At which point, Jake made a funny face that meant "You've got to be kidding" and the audience responded with gales of laughter.
Ha ha. To be honest, the retelling doesn't seem that funny... it just seems sad because it's so true. Some have argued that we don't need reforms to standardize the individual insurance market--like the pending SB1522(Steinberg)--because people have access to brokers. If you are lost (as many consumers are), it is useful to ask for directions, and it is useful to have a map. One doesn't obviate the need for the other. Both are helpful.
The blogger from the centrist New American Foundation agrees that the humor doesn't quite translate:
As things currently stand, no one (not even those of us who work on health policy for a living!) can make truly informed decisions about which health care policy is best for us. It is difficult to determine whether paying more up-front or taking the risk of paying more later or having more or less provider choice is the way to go. This kind of confusion is not funny, which is why transparency and consumer-friendly decision support tools (real ones, that real people can understand) must be part of any health reform.
As we await to see what the Budget Conference Committee does about imposing more paperwork burdens to have hundreds of thousands of children fall off coverage, here's something for your holiday weekend amusement. From the Onion News Network, it's the only support I've seen for cutting children's health care:
After his well-deserved Emmy, Jon Stewart of The Daily Show has taken brief breaks from their war coverage for some short commentary on health care.
On Wednesday, he spotlighted the coverage of Hillary Clinton's health plan, and the howls of "HilliaryCare," "socialized medicine," and "big government" from the right-wing pundits. He corrected a clip of Newt Gingrich, who suggested to call the plan "Daughter of HillaryCare"; Stewart responded, "Wouldn't that be ChelseaCare?"
He spotlighted CNN's chiron, which really did state, remarkably, "Clinton on Health Care: Why is she trying again?"
On Thursday, Stewart mocked the President's attack of the SCHIP program as a "government-run" program: "Oh my god, there's gonna put communism in our kids' drinking water! And inject them with the gay and load them onto Micheal Moore and float them to Cuba! Wake up America!"
In responding to Bush's statement that he instead wanted "to empower people and their doctors...," Stewart said, "I figured out the disconnect. You see, he thinks the uninsured have doctors."
It would be funny if it wasn't sad. Back to the war.
As somebody looking at and trying to understand the specific details of the new health reform proposals this year, such as AB8(Nunez/Perata), it is a bit surreal to then hear the kind of very broad debate this afternoon in Assembly Health Committee on SB840(Kuehl).
When the debate over other bills was largely haggling over wording and amendments, the discussion between the Democratic legislators in support of SB840, and the Republican legislators in opposition, was a view from 10,000 feet, strident arguments that resembled this Tom Tomorrow cartoon.
Some might say that SB840 lends itself to this kind of debate, since the Governor has stated his intent to veto the proposal again, yet the Democratic legislators continue to pass the proposal as a statement of their values and goals. But the legislative discussion is similar to that of the many previous debates for this and other health reforms, this year and last.
Perhaps when the ideological issues are so big, the details don't matter. But they do, to the health care consumers who have to live with them. That's the work of this summer.
"Wal-Mart has begun opening 400 health clinics in their stores. Wal-Mart says the clinics are important because 50% of the people they will treat there won't have health insurance. Those people are called Wal-Mart employees."
Future "Tonight Show" host O'Brien is broadcasting from San Francisco next week. Bets on what California politicians might visit the show? Maybe talk about health reform?
Some laughter at an unexpected part of the conversation at the hearing yesterday... Senator Perata was detailing the various measures in his bill intended to control costs. For example, he stated that "we are in the freaking stone age in terms of medical records," and said that we "are killing people" by not using modern electronic technology to deal with medical records.
Beyond his own bill, he went on a short rant about prescription drug advertising, and the large amount of money spent on the television commercials for "the little blue pill," and the impact it has on health costs in general. He was very skeptical that as a patient he should be asking his doctor about any medication beyond aspirin. "What the heck do I know?" he inquired, wondering why he should be pestering his doctor about drugs, rather than the other way around.
He said if one looks at the sports show, all the advertisements are for "beer, cars, and pills--and not in that order." With a bemused smile, we commented on all TV commercials "and all those smiling men."
Not finished, he even interjected "you don't see the women smiling, only the men."
And then the conversation went back to health reform.
On a more serious note, one way to deal with the issue of prescription drug advertising is at the federal level, in a bill by California Congressman Henry Waxman, as described in this blog post by Steve Blackledge of CALPIRG. Not so seriously, he managed to invoke a comparison to Steve Martin in The Jerk.
Apparently, entertainers who get into politics have a tendency to be interested in "universal health care."
Satirist Al Franken--and candidate for the U.S. Senate--was on David Letterman's show last week, and that was the first policy goal he mentioned, in the midst of a running commentary about whether he could funny, while "trying to do serious things for people."
So Letterman asked "what are issues that made you want to run?" Franken reponded, "We gotta get to universal health care. We just have to. This doesn't mean single-payer, where the government pays for everything; we can get to it different ways in different states." He has previously said he supported a universal single payer system; his joke last night was that he understood people's distrust in government, given the leadership of the last several years.
Letterman, who often gives a surprisingly good political interview, didn't want to let the topic go, and asked, "In terms of the world picture. where does the United States rank among nations that provide health care?"
Franken: "According to the World Health Organziation study, we rank number 37 in health care, even though we spend more than anybody per person. We spend 16% of our GDP, no other nation spends 11% We are 37th as a health care system, right between Costa Rica and Slovenia. And Slovenia, I think, is making its move."
Humorist Molly Ivins passed away today, after battling breast cancer. May she rest in peace.
Here's a 2002 column of hers on the need for health reform. And here's a 2000 column that mentions her battle with cancer, as part of a witty but accurate review of what works in health reform, and what doesn't. It also happens to critique President Bush's health care plan, which doesn't seem to have changed in seven years--in fact, it seems to have gotten worse...
Just don't get sick by Molly Ivins September 14, 2000
AUSTIN, Texas -- When I was in my 20s, the subject of insurance was so vastly boring that it was a way to describe a bad date: "like talking to an insurance salesman." It's still sort of like your teeth -- something you'd rather not think about but have to take care of -- so let's plunge in.
As Jonathan Cohn pointed out in the May 1 New Republic, the object of health insurance is to get as many people as possible into one big pool, mixing the sick with the healthy. This way, the healthy pay a little more than they otherwise would, but those who get sick pay a lot less. Since everyone gets sick eventually, if only from old age, it works out fairly. Your chances of never being sick a day in your life and then dropping dead of an undiagnosed heart condition at an early age are less-than-lottery-slim. In most advanced countries, this led logically to national health insurance -- everybody in the same pool, only one administrative agency instead of hundreds...
As a cancer survivor, I am now part of a network regularly called upon to help raise $300,000 to $400,000 for some individual whose insurance company has found a way to drop her. Always a life at stake. The hundreds of thousands of you who have had your HMOs fold under you know how chancy the present system is.
George W. Bush's solution is to promote medical savings accounts -- MSAs. Individuals buy a cheap insurance plan covering only catastrophic illness and then put money aside, tax-free, to cover their medical bills. If there's any left over at the end of the year, they get to keep it. The theory is that this will discourage people from spending frivolously on health care.
"In reality, MSAs simply allow people who expect to be healthy to opt out of larger insurance pools," said Cohn. "Small businesses like the accounts because they transfer the onus for medical coverage more squarely onto individuals. But most experts who have looked at MSAs have concluded that, by further segregating healthy and sick in the health-care market, they make it tougher for people likely to incur high health-care bills to get insurance."
The other piece of the Bush plan is to set up association health plans allowing small businesses to clump together to buy health insurance as cheaply as the big corporations do.
The Catch-22 is that most states already have small businesses clumped together in an insurance pool. The only difference the Bush plan would make would be to exempt those plans from state regulation -- i.e., requirements for minimum benefits like mental-health coverage. The result would be further segregation of health coverage -- employees healthy, rates go down; a couple of employees get very sick, rates go up; company can no longer afford coverage, drops policy; end result, more uninsured.
Neither move is going to help the 44 million uninsured in this country, and both are likely to increase their number. This is not a solution. For the uninsured, Bush proposes a $2,000 tax credit per family to allow them to buy their own health insurance -- but $2,000 doesn't nearly cover the cost, and nothing is more expensive than buying health insurance as an individual....
For those whose faith in the free market is religious, this is not something to debate. But even Adam Smith admitted that the free market can't take care of everything. And one of the things that no country has yet found a way to make it do is health care. The upside to having government as the only insurer is that it's cheaper because profits don't enter into it.