Blog of Jeff

MSNBC had an article last Friday talking about new changes being proposed by Obama’s team because it turns out that they weren’t 100% confident that illegal immigrants wouldn’t receive services under the proposed health care reform. Story Here. The basic idea was that the original plan said undocumented Americans would not be allowed to participate. However, there was very little in the bill about checking their documenting status so it would have been easy for some percentage to slide into the system. The revised White House plan adds some of the additional verification mechanisms that Representative Joe Wilson wanted.

So, calling the president a liar can get you somewhere.

The sad and ironic part is that we are being completely stupid and short-sighted by NOT covering illegal immigrants. I am a staunch anti-illegal immigrant person, because I believe that undocumented immigration is a security threat and reduces wages of minimum skilled Americans. I want fences and strong enforcement against employers that hire illegal immigrants. With all that in mind though, I believe health care policy trumps immigration policy. Immigrants will still receive more expensive emergency room treatment and they will still spread contagious diseases. Making sure that all the people in this country, regardless of immigration status, have access to basic medical care and vaccinations lowers costs and risks for all of us. Also, they would be paying premiums into the Exchange. If there are any government program where we should be OK with undocumented workers participating, it should be the one that requires putting money into the system.

I’m not normally very religious but in discussing health reform with my aunt, I started to wonder what Jesus would think about the current debate. She is strongly a small-government conservative who wants government to stay out of health care altogether. She also has a very strong christian faith.

To me, it is very hard to reconcile the current conservative love of free-market based health care and the image of Jesus as a person who always promoted reaching out to the sick, regardless of economic condition, and without regard to personal risk. He treated the poor; he treated the contagious; he never asked for payment; and he encouraged his followers to do the same. He also promoted paying taxes and giving Caesar his due.

With all that in mind, Jesus strikes me as a very public option fellow. He did not believe that a person’s income should determine how much or how good of care they should receive. In fact, he sometimes healed the rich just to show how irrelevant income should be and that he believed in helping all people. And he felt that taxes for governmental services were legitimate. Let’s see, what would we call a system that finds all people equally deserving of health care, regardless of income, and involves paying taxes? I believe that term of art is socialized health care.

Helping the sick was a very, very big deal in the New Testament and Jesus specifically helped rich and poor alike to make the point that their lives were equal before the eyes of God. There is no way, no how, that anyone can make the case that Jesus would have approved of a system where access to health care is based on economic status. It is an absolute contradiction to his teachings. In fact, I think it is fair to say that Jesus would have frowned mightily on the whole notion of people making money by deciding who does and who doesn’t get treatment. You can’t “love thy neighbor” and simultaneously cash a bonus for denying his claim due to a pre-existing condition. Jesus would have passed on the bonus and approved the treatment. We all know that’s what he would have done, because that’s the kind of guy he was.

Conservatives are always talking about how we’re a Christian country, but they sure don’t endorse practicing it in our real public policy. They just want the cosmetic Christianity, with the Ten Commandments monument at every courthouse but they don’t want it any real policy, because Jesus was not a big free-market guy and that just doesn’t work in today’s world. Apparently for conservatives, the free-market trumps Christianity, which trumps government in the pecking order. That’s a shame, because I think some liberals could embrace Christianity if they got to see some conservatives approach health care like Jesus did. (I am pretty sure that Jesus would even have treated illegal immigrants, but that’s a fight for another day …)

One of the good things about all the health insurance policy discussion is that it is an opportunity to learn about aspects of the American health care system that a lot of people don’t know. Today, there was an article on Slate (http://www.slate.com/id/2227082/) about how Medicare and private insurers slant towards specialists instead of primary care physicians. The reform in Massachusetts is cited as an example of how those incentives play out. MA has great hospitals, almost everyone is insured, more medical professionals per capita than other states, and yet has a shortage of primary care physicians.

The bottom line is that they system is built to favor procedures performed by specialists over face-to-face care by a primary care physician. So, the med schools are filled with medical students that see huge financial reasons to take a specialty. I didn’t realize that the body that determines payment rates for medical services is comprised primarily of specialists or that budget caps in Medicare maintain those relative values and squeeze the already thin primary care profit margins even more.

This is the kind of important information that can easily get lost in the debate. Both sides talk about maintaining the relationships between patients and their primary doctors. But all of our current incentives say that’s the least valuable part of the whole system. It won’t do much good to give everyone coverage if there aren’t enough good primary care physicians to serve them. If was building a system from scratch, I would invest heavily in primary care physicians since that’s where preventative care and early detection is going to happen.

One of the weird symptoms of Obama’s approach to health care is that he managed to get seniors opposed to his plan. That’s a very interesting point because it means that the people in this country on Medicare, which is the group that is the happiest with their health care, the people who have a single payer system, the people who have completely 100% socialized medicine (At least, that’s what Reagan said when he fought hard to prevent Medicare.) are now working diligently to prevent anyone else getting any of those things. What the hell did we ever do to them? And when did they start thinking entitlement program cutting, Reagan-loving republicans are friendlier to Medicare than democrats?

Anyway, the other major problem that Obama and the democrats have is that seniors carry even more weight as a voting block in mid-term elections than in presidential elections, which is why congressmen with any sort of competition are getting nervous. Several politicians are already campaigning on their opposition to Obama’s vision of health care reform knowing that polls show seniors really, really hate fear it.

Obama is in danger of destroying his entire party because of his failure to build a message for seniors. Would it have been so hard to use simple language, like “we’re not cutting Medicare benefits, the government isn’t going to decide what care is best for you, etc.” Instead, he talked about the long-term cost curve and the fact that health insurance will devour the GDP in twenty years if we don’t do something. He also feels obligated to mention that we’re going to have to ration care someday instead of clearly saying that we’re not going to ration services in this plan. (It’s a stupid argument for him to have anyway because we already ration. People without insurance don’t get basic care or preventative care. That’s rationing. In fact, a message that he’s going to reduce rationing by giving more people access to care would have been a simply delightful answer.)

Here’s a point that Obama might ought to have considered when framing that argument. People who are in their 70’s don’t give a damn about the long term cost curve. They care about seeing their doctor tomorrow and surviving dialysis next week. They are the most powerful voting block in the country and they care about the here and now. And they probably would have stayed quietly on the sidelines if Obama had been able to just reassure them that he wasn’t going to cut their benefits, force anything on them, or even not kill them. He couldn’t do any of those things and now his whole party has a problem.

It’s driving me really nuts that Obama, a house majority, and a senate majority are going to blow this. I want the big, major, “change the nature of the country” kind of reform that can only happen when one party controls everything. And it’s looking more and more like we’re not going to get it. Obama’s not going to have those congressional majorities for much longer, so in future years, he will be even wimpier than this.

I really like Ezra Klein (public policy guru who writes for the Washington Post) but I don’t quite agree with his dismissal of the recent deficit news as being irrelevant to health reform. His basic take was that the deficits were largely the fault of the past republican leadership in DC, that the recent miscalculations reflect good governance (stopping a depression, lengthening COBRA, more unemployment insurance, etc.), and that since Obama has committed to a deficit neutral health reform, the recent news that the deficit will be worse than expected just doesn’t matter. I agree with points 1 and 2 but the I think the deficit does matter on a couple of fronts related to how Obama’s messaging is failing with both his supporters and detractors.

First, there is the basic question of how much trust can we put into political leaders to make any “deficit-neutral” program when they miscalculated the deficit by over a trillion dollars. The deficit news is a huge hit to the credibility front in that area. My guess is the argument there is that if the law is written to have automatic cuts or matching revenues, it will be guaranteed to be deficit neutral. But again, there is a basic lack of trust that health reform will have those provisions.

And, even if it does, it brings up the second point, which is that many Americans fear that health reform will bring about reductions in the quality of services they are currently receiving (seniors worry about Medicare cuts and privately insured citizens worry about their plans going away). It is not unreasonable to think that Americans who believe that health reform will be deficit neutral might start wondering what services will have to be cut to maintain that promised deficit neutrality. If health care reforms cost an extra 200 billion than expected and the law mandates corresponding cuts, then services will get cut.

This is where Obama’s messaging is really bad. People who don’t trust him have a reason to be afraid of the plan (may cost way more than advertised) and people who do trust him have a reason to be afraid of the plan (may require service cuts to meet his budget promises). I lean fiscally conservative but support major health reform, including a full-fledged public option. I’d even be OK with a single-payer system. (You know, like Medicare, that crazy socialist program that Reagan swore would kill us all …)

The fiscal conservative in me just wants Obama to come out and say that health reform is going to be expensive but will be worth it. Instead, he’s promising to expand coverage, avoid increasing the deficit, maintain everyone’s existing health insurance plans, not cut any services, and wondering why people are skeptical. Basic math screams “liar, liar, pants on fire.” And once reasonable people start thinking he’s a liar, it’s really easy for less reasonable people to start talking about death panels and the British secret desire to kill Stephen Hawking because of the cost of his care.

A very fundamental issue in health insurance reform is one that isn’t really getting a lot of discussion. Is it truly possible for a group of business executives who have a fiduciary duty to maximize shareholder wealth to also provide quality health insurance? In most countries, health insurance is either a non-profit industry or it is replaced by a single payer (government) system.

Business schools continuously pound home the idea that a manager’s primary duty is to maximize shareholder wealth. That is why insurance companies seek to have the highest possible premiums, use pre-existing conditions to avoid covering sick people, and use all sorts of strange processes to deny claims. There is no mystery to why that happens nor should it be unexpected. We shouldn’t even blame the health insurance companies because that is what for-profit industries try to do; they seek to make profits.

With that in mind, I don’t see how any health care reform that relies totally on for-profit health insurance companies can possibly give people the peace of mind that people in this country really want. The fear of not being able to get coverage, the fear that claims really won’t be paid even with insurance, and the fear of suddenly losing coverage are all fears based on insurance companies seeking profits.

I’d much rather face an inefficiency and apathy of a DMV-style governmental agency that doesn’t care about me at all than deal with an insurance company paying very smart people to work very hard to make sure I don’t take up more of their resources than they are willing to allow. Give me apathy versus direct opposition any day of the week.

There is a new law on the way that will prevent insurance companies from using genetic information against people. (LA Times Story Here) President Bush has said that he will sign it, so it should be law soon. But this will create an interesting scenario. If a percentage of the population finds our that they are high-risk for a disease and another percentage of the populations finds out they are low-risk, those populations will naturally choose insurance plans based on those predispositions. So, people likely to get cancer will add cancer riders, while those unlikely to get cancer will avoid those riders. We still don’t know enough to be conclusive on those sorts of things, but scientists are getting better at it all the time.

At its core, insurance is a bet on an unknown event. Insurance companies make money when they correctly calculate the odds of an event happening and base premiums on those odds. Insurance companies lose money when they incorrectly calculate those odds. And usually, invididual people have little idea about the odds. If we are about to enter a realm where individuals may know more than the insurance company, it may throw insurance way out of whack. If only people who will get cancer have cancer riders, those riders will become incredibly expensive just so the insurance companies can stay afloat. The net impact of that scenario is financial discrimination of exactly the sort this law hopes to avoid.

The only way this works out is if people cannot opt out of insurance policies (or choose not to get full coverage), so that the pool stays large and the majority of people in the pool do not suffer the events for which they are covered. In many ways, this may be a foreshadowing of the need for single payer (governmental) health insurance. If everyone in the country had the same policy, people learning about their genetic predispositions to various diseases could be irrelevant to their insurance premiums and coverage and this law works as intended. If you expect insurance to remain in the realm of the free market, then this law may cause the exact sort of problem it seeks to avoid. If only people predisposed to terrible diseases buy insurance against terrible diseases, the whole system breaks down.

My guess is that there are a million hypotheticals that can and will test this law over the next two decades. I’m willing to bet that technology will present some completely unexpected challenge to this law that will throw our courts into confusion. I also suspect that this story and this law will follow the model that the biggest news of the day is never the top story of the day. In the very near future, this law, for better or worse, may be one of the most important laws in the country. Technology is moving that fast and genetics is developing in thousands of directions .

I ended up posting a lot of the following on another person’s blog a little while ago, because of an interesting posting there about health insurance. (http://medrants.com/index.php/archives/3152) The idea was suggested that it is OK to have a ”winners” and “losers” free market system where some people have access to medical care and some do not. I love the free market, but I think there are too many hidden costs in the current system that will not begin to be reduced until we really get the vast majority of people covered somehow.

The question of whether or not health care is a right is an interesting one, but in effect, it has already been answered. Those without health insurance turn to hospitals and charity run clinics where they are given health care, usually care that is more expensive than the preventative care that is available to the insured. The costs of that care are then passed along to everyone else through higher insurance premiums and out-of-pocket expenses. In a true free-market system with “winners” and “losers,” the losers would be denied care allowing the winners to avoid carrying the hidden costs of the losers.

I’m a free-market lover myself, but in the case of health insurance, I favor government intervention. If we acknowledge that the uninsured will not be denied treatment, then the question moves along to how we can get the uninsured into preventative care models that are more cost effective than having them show up at ER’s in critical condition.

Getting those people into a nationwide plan would be the simplest way to get more people into preventative care. The costs of those folks are in the system and we are paying for them anyway. A national health insurance plan is as much about redistributing and reducing existing expenses as it is income.

One nice thing about blogging is that I can post my ideas here and there and there and a little more here … I like this blogging thing.