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F. A. Hayek on social insurance

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F. A. Hayek on social insurance

The Road to Serfdom

By Friedrich A. Hayek

Quote from the condensed version as it appeared in the April 1945 edition of Reader’s Digest:

There is no reason why, in a society which has reached the general level of wealth ours has, (the certainty of a given minimum of sustenance) should not be guaranteed to all without endangering general freedom; that is: some minimum of food, shelter and clothing, sufficient to preserve health. Nor is there any reason why the state should not help to organize a comprehensive system of social insurance in providing for those common hazards of life against which few can make adequate provision.

http://www.iea.org.uk/files/upld-publication43pdf?.pdf

The Road to Serfdom
http://www.press.uchicago.edu/presssite/metadata.epl?mode=synopsis&bookkey=206047

Comment:

By Don McCanne, MD

“The Road to Serfdom,” the work of Nobel Laureate F. A. Hayek, has been one of the most influential books of the last century. It has been an inspiration to those who are opposed to socialism and who support free markets and libertarianism. The teachings of Hayek are frequently cited by those opposing government involvement in health insurance markets. But what did Hayek actually say?

He acknowledges that there are “common hazards of life against which few can make adequate provision.” All other nations have decided that the potential need for health care is one of those common hazards.

He recognizes that such hazards can be provided for by “a comprehensive system of social insurance.” Although the specifics of social insurance programs for health care can vary, they have in common a fund that provides for the payment of health care, an equitable source of payments made into that fund, and automatic inclusion of the individuals for which the fund was designed. It appears from his statement that Hayek would include all members of a society except perhaps those who are capable of making adequate provision for themselves.

He recognizes that the state should help organize such a comprehensive system of social insurance. Hayek was quite familiar with social insurance since his country of birth, Austria, had social insurance programs dating back to the nineteenth century.

Although an avid supporter of free markets, Hayek understood that even in a wealthy society the state should help organize a comprehensive system of social insurance.

Perhaps we should ask the free market advocates opposed to comprehensive social insurance to retrieve from their libraries their copies of “The Road to Serfdom,” and read them again. Although they don’t listen to us, just perhaps they may listen to Friedrich Hayek.

Look before you leap into McCain's idea of health coverage

By James C. Mitchiner
Other Voices
The Ann Arbor News
September 11, 2008

At first glance, it sounds like a great idea: Scrap the employer-based health insurance system in favor of individually chosen private health plans, allow individuals to purchase such plans across state borders and from groups that currently don’t sell insurance (such as faith-based organizations), and use refundable income tax credits to help pay the premiums.

Hold down costs through strategies such as competition between plans, disease management programs, prevention and wellness initiatives, and expansion of information technology. Make people prudent health care consumers by expanding Health Savings Accounts. And for those with chronic diseases, who are medically uninsurable, give them “guaranteed access plans” through federally blessed (but state-subsidized) high-risk pools. For those of you who don’t recognize this radical approach to reforming American health care, it is the gist of the plan offered by Republican presidential candidate John McCain.

Unfortunately, it won’t work.

Let’s look first at the income tax credits. The idea is for individuals and families to use these credits to purchase health insurance plans in the non-group market, i.e., from a private insurer not sponsored by your employer. Premiums would be kept reasonable because plans would compete with each other to sell health insurance to those who valued it, or at least to individuals deemed “good risks” (read: healthy people).

And what level of credits are we talking about? Senator McCain proposes credits of just $2,500 per individual, or $5,000 per family.

Given that the average annual family health insurance premium in 2007 was over $12,000, it seems to me that $5,000 is woefully inadequate. Some, in fact, have compared the effect of these tax credits to that of throwing a 10-foot rope to a man stuck in a 40-foot hole. Just to make up the difference between the credit and the premium cost, a middle class family of four with a household income of $70,000 would have to fork over 10 percent of that income, a commitment that would seriously impact the family budget.

Let us suppose, however, that a worker could find and purchase a policy for only $5,000 per year. What would it look like? My guess is that it would have either multiple coverage restrictions (non-coverage for pre-existing conditions, a prolonged waiting period before insurance became effective) or significant financial limitations (high deductibles or co-pays, puny lifetime maximums), which defeat the purpose of having insurance in the first place. Clearly, private insurers cannot make a profit by selling comprehensive insurance at premiums the average individual can afford.

Perhaps the most significant objection to tax credits, however, is that they don’t address the serious flaws inherent in for-profit insurance.

Credits would be used to purchase the same policies currently sold by private insurers, policies that are rife with administrative waste, limit which doctors you can see, restrict when and where you can be hospitalized, and impose considerable cost-sharing responsibilities on their policyholders.

The economic literature appears to back me up. In 1999, MIT economist Jonathan Gruber and colleague Larry Levitt did a simulation analysis of tax credits. They found that a subsidy of $2,000 per individual and $4,000 per family would cover no more than 30 percent of the uninsured, at a cost of almost $40 billion. More recently, the Employment Policies Institute looked at the economic impact of tax credits in terms of reducing the number of uninsured and the attendant costs. The EPI found that the credit would be used by seven times as many already insured individuals as it would by newly insured persons, at a public cost of $19.8 billion. Overall, only 1.6 million would gain coverage, at an economically inefficient price tag of $12,644 each.

Beyond tax credits, other aspects of the McCain plan are flawed.

Disease management programs, personal health and wellness programs, and electronic medical recordkeeping, while pushed by insurers and intuitively conducive to cost control, nonetheless have not been shown to have a widespread effect on holding down health care expenses.

Neither have Health Savings Accounts, which have an affinity for the healthy and wealthy, who tend to use them as convenient tax shelters.

And any guaranteed access plan for the medically uninsurable that depends on state funding is suspect, given the current precarious situation with most state budgets.

The time has come for us to stop pretending that we can reform American health care through incremental tweaks in the current system. I really see no way to accomplish the three goals of reform – expanded access, consumer choice and cost control – without ending the hegemony of the for-profit insurance industry.

This means we have to replace our shamefully inefficient multipayer system with a national, single-payer alternative, one that creates affordable access to medical care for those who are locked out, eliminates racial and ethnic disparities, and allows Americans (rather than insurers or the government) to choose their own physicians and hospitals. Doing so will not come fast and will not be easy. But when it does come, and I believe it will, the result will be well worth the effort expended.

The writer, an Ann Arbor resident, is the president of the Washtenaw County Medical Society.

No on Prop. 101: It's a false pitch that blocks reform

By Phil Lopes and George Pauk
Tucson Citizen
Guest Opinion: Health Care Choice
Published: 09.15.2008

When Arizona voters cast their ballots this November, one of the questions they face is whether to vote yes or no on Proposition 101, the misnamed Freedom of Choice in Health Care Act. They should definitely vote no.

Prop. 101 is a constitutional amendment that would forbid restrictions on “a person’s freedom of choice of private health care systems or private plans of any type.”

Sounds like more freedom, doesn’t it? In fact, Prop. 101 protects the private health insurance industry.

Its passage would give the industry a privileged place in our state’s basic law. The result would be less freedom for average Arizonans, not more.

Remember, this is the industry that diverts about 31 cents of every health care dollar toward administrative costs, including big payouts for shareholder profits, marketing expenses and outlandish executive salaries.

Prop. 101 would limit Arizonans’ choices to plans offered by these private insurers, and it would block any steps toward badly needed health care reform.
Let’s step back for a moment and ask: What kind of choices do people want in health care?

They want access to comprehensive, affordable, high-quality care. They want to choose their health practitioner. They want to choose their hospital or other service delivery site.

Under our current health insurance system, Arizonans have none of these choices.

The U.S. Census Bureau reported last month that 45.7 million Americans – including 1.2 million Arizonans – lacked health insurance in 2007.

Employer-sponsored coverage continues to shrink, as do employee health benefits. Access to care, and availability of care, especially in rural areas, is diminishing.

The Commonwealth Fund, a research group, estimates that another 25 million people were “underinsured” last year – i.e., they had insurance but still wouldn’t be able to afford care in the event of a serious illness or injury.

Health insurers are further restricting what they cover – what they’ll pay for and what they won’t – and they increasingly impose big deductibles and co-pays.

They are also constantly changing their lists of “in-network” doctors and hospitals.

Choice of doctor or hospital? What a quaint idea! Just see what happens when you go “out of network.”

Thus, in the name of “freedom” and “choice,” Prop. 101 would give us neither. It would further push Arizonans into the iron grip of an industry that is failing us – an industry in which many put profits above the delivery of sorely needed health care.

There are many potential unintended consequences of Prop. 101.

For instance, if the Arizona Department of Insurance determines that a particular health insurance carrier does not meet set criteria for fiscal solvency and wants to bar it from offering unsound policies, the department would be prohibited from doing so if only one person in the state wanted to purchase this policy.

Wouldn’t it be better if every resident were guaranteed comprehensive, high-quality health care – at least as good as what is offered to our state employees?

If each person could choose his own health practitioner, hospital or clinic (working within our private delivery system), allowing continuity of care, better follow-ups and fewer medical errors?

Wouldn’t it be better if our state’s residents didn’t have to worry about crushing medical bills because they knew a social insurance fund would cover the costs? If every Arizonan were in one big pool, spreading the risk more equitably?

If health care costs were controlled by, for example, bulk purchasing of drugs and medical supplies?

Such a plan exists: the Arizona Health Security Act. Its enactment by our Legislature would go a long way toward curing our state’s health care ills.

It’s practical, fair and eminently realistic.

But take note: The passage of Prop. 101 would prevent Arizonans from choosing that better path, among others. And it’s being bankrolled by at least $434,000 – mainly from business interests, much of it from out-of-state.

In a recent newspaper interview, Dr. Eric Novack, a Phoenix-based orthopedic surgeon and leading proponent of the measure, conceded that Prop. 101 would constitutionally preclude “certain options.”

So the real aim is to preclude certain choices, Dr. Novack?

Arizona voters should not be deceived. They should vote “no” on Prop. 101.

State Rep. Phil Lopes represents Legislative District 27 (central, west and southwest Tucson), is leader of the House Democrats and is the sponsor of the Arizona Health Security Act. George Pauk is an internal medicine physician in Phoenix and a member of Physicians for a National Health Program (www.pnhp.org).

How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007

Authors: Cathy Schoen, M.S., Sara R. Collins, Ph.D., Jennifer L. Kriss, Michelle M. Doty, Ph.D.
Summary Writer(s): Deborah Lorber
Health Affairs
June 10, 2008 | Volume 102

In the Literature

The number of underinsured U.S. adults–that is, people who have health coverage that does not adequately protect them from high medical expenses–has risen dramatically, a Commonwealth Fund study finds. As of 2007, there were an estimated 25 million underinsured adults in the United States, up 60 percent from 2003.

Much of this growth comes from the ranks of the middle class. While low-income people remain vulnerable, middle-income families have been hit hardest. For adults with incomes above 200 percent of the federal poverty level (about $40,000 per year for a family), the underinsured rates nearly tripled since 2003.

These results and others are published in How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007, (Health Affairs Web Exclusive, June 10, 2008), by The Commonwealth Fund’s Cathy Schoen, Sara R. Collins, Jennifer L. Kriss, and Michelle M. Doty.

Middle-Income Uninsured Rate Rising

The authors analyzed data from the Commonwealth Fund 2007 Biennial Health Insurance Survey, which interviewed adults ages 19 and older from June through October 2007. Respondents were identified as underinsured if they spent 10 percent of more of their income (or 5 percent if they were low-income) on out-of-pocket medical expenses, or if they had deductibles that equaled 5 percent or more of their income. An estimated 14 percent of all nonelderly adults were underinsured in 2007, and more than one of four were uninsured for all or part of the year. Adding these two groups together, 75 million adults–42 percent of the under-65 population–had either no insurance or inadequate insurance in 2007, up from 35 percent in 2003.

Lack of adequate insurance coverage, the study finds, is not a problem limited to low-income people. Adults with incomes below the poverty level were at the highest risk of being uninsured or underinsured, but “insurance erosion has spread up the income distribution well in to the middle-income range,” the authors say. For those with annual incomes of $40,000 to $59,000, the underinsured percentage rate reached double digits in 2007. Barely half of those with incomes of 200 percent to 299 percent of the poverty level were insured all year with adequate coverage.

Underinsured Go Without Needed Care

In terms of access problems and financial stress, underinsured people–even though they have coverage all year–report experiences similar to the uninsured. More than half of the underinsured (53%) and two-thirds of the uninsured (68%) went without needed care–including not seeing a doctor when sick, not filling prescriptions, and not following up on recommended tests or treatment. Only 31 percent of insured adults went without such care.

About half of the underinsured (45%) and uninsured (51%) reported difficulty paying bills, being contacted by collection agencies for unpaid bills, or changing their way of life to pay medical bills. Many reported that they took on a loan, a mortgage against their home, or credit card debt to pay their bills, suggesting “that these financial difficulties had the potential to linger into the future.” In contrast, only 21 percent of insured adults reported financial stress related to medical bills.

Benefit Design Matters

The sharp increase in the number of underinsured adults, say the authors, is partly due to design changes in insurance benefits that leave individuals financially vulnerable. Underinsured adults were more likely than those with adequate insurance to report benefit limits–for example, restrictions on the total amount a plan would pay for medical care or on the number of physicians’ visits allowed. They were also far more likely to report high deductibles: one-quarter had annual per-person deductibles of $1,000 or more. Despite benefit limits and higher deductibles, underinsured adults often reported high annual premium costs, in line with those reported by more adequately insured people.

“Benefit design matters,” the researchers conclude. Having a policy with substantial cost-sharing relative to income can undermine access to care and erode family finances. While improving insurance coverage is a worthy goal, it is important for policymakers to consider cost-sharing provisions, scope of benefits, and income when exploring coverage mandates, they say. Health care reform in Massachusetts, for example, includes graduated cost-sharing, as well as premium assistance for those with incomes up to 300 percent of the poverty level.

The goal is high-quality care and improved outcomes–not just coverage, write the authors. “[T]here is growing recognition of the need for coherent strategies that combine coverage with payment and other policies to change directions and move toward a more inclusive and higher-performing, high-value health system.”

Citation

C. Schoen, S. R. Collins, J. L. Kriss, M. M. Doty, How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007, Health Affairs Web Exclusive, June 10, 2008 w298-w309

Hundreds Gather in Albany to Launch Statewide Single Payer Health Care Coalition

New State Coalition Urges Lawmakers to Adopt a Single Payer Universal Health Care System

Single Payer New York Media Release
For Release: September 13, 2008

Doctors, nurses, consumers and community activists from throughout New York State came together in Albany today to create a statewide coalition to push for adoption of a single payer health care system at the federal and state levels. Single Payer NY will help coordinate grassroots education and outreach activities in support of single payer throughout the state. They already have county coordinators in two dozen counties.

“The American people overwhelmingly want health care for all. Labor, including the NYS AFL-CIO, have said they want health care to be a right through passage of HR 676. A majority of doctors now want a single payer national health care system because they are fed up dealing with the bureaucracy, delay and confusion of the private health care system. Everyone who studies the issue says of course it makes sense to eliminate the huge waste and expense of private health insurance. For once, we need elected officials to do what is right for Americans, not what is right for the insurance and drug companies,” said stated Mike Keenan, President, Troy Area Labor Council and a Vice President of the Capital District Area Labor Federation, AFL-CIO. The Troy Area Labor Council, AFL-CIO represents 10,000 union members and their families in Rensselaer County. The Capital District Area Labor Federation, AFL-CIO represents 100,000 union members throughout the Capital District Region.

A recent national survey by Indiana University of 2,193 doctors found a solid majority, almost 60 percent, supporting government legislation to establish national health insurance (NHI) — a 10 percent increase in support since 2002. Public opinion polls have consistently shown strong public support for a universal health care system. For instance, a March 2007 poll by CBS/ NY Times found that 64 percent of the respondents said the government should guarantee health insurance for all; 27 percent said it should not. An overwhelming majority in the poll said the health care system needed fundamental change or total reorganization.

“It is critical that New York reform its dysfunctional system in favor of one that guarantees health care access to all New Yorkers,” said Tina Gerardi, RN, chief executive officer of the New York State Nurses Association. “Access to comprehensive, quality, affordable, health care is a right, not a privilege, and must no longer be a function of income or employment status. We wholeheartedly support the mission of the Single Payer New York coalition to bring about change in the right direction.”

HR 676 (Conyers), known as Medicare for all, has 91 cosponsors, including NY Congressional representatives Engel, Hinchey, Maloney, McNulty, Nader, Owens, Rangel, Serrano, Towns, Weiner and Velazquez.

Among the dozens of groups helping to create Single Payer New York are: New York State Nurses Association, Troy Area Labor Council, Capital District Area Labor Federation, AFL-CIO, Hunger Action Network of New York State Tompkins County Health Care Task Force, Capital District Alliance for Universal Health Care, Health Care-NOW, Albany Presbytery, various chapters of the Physicians for a National Health Program, League of Women Voters of Saratoga County, Long Island Coalition for a National Health Plan, Rochester Interfaith Health Care Coalition, Green Party of NYS, and New York StateWide Senior Action

“The US spends more than twice as much on health care as the average of other developed nations, all of which boast universal coverage. Why is the U. S. so different? The short answer is that we alone treat health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to medical need,” said Mark Dunlea, Executive Director of Hunger Action Network of NYS.

“Instead of overcrowded emergency rooms, let’s plan for easy access to urgent care. Instead of harried doctors, let’s begin a restoration of physician and patient autonomy. Instead of medical debt forcing medical students into specialties, let’s have realistic and compassionate medical education funding. A great nation deserves a great healthcare system for all. Let us begin to create the system we want and need,” Richard Propp, MD, Chair Capital District Alliance for Universal Healthcare, Inc.

Nearly 50 million Americans are currently without health insurance, more than 75 million went without insurance for some length of time within the past two years, and tens of millions more have inadequate coverage. More than 18,000 Americans die annually due to a lack of insurance. Dr. Martin Luther KingJr. noted that “of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

It is estimated that a single payer national health care program could save as much as $350 billion a year (New England Journal of Medicine, 2003) by eliminating the system of private health insurance. As much as a third of every health care dollar going through private health insurance goes to pay for their overhead, profits, marketing costs and excessive CEO salaries. Doctors on average have to hire 2.5 staff people just to deal with the conflicting paperwork, rules and bureaucracy of private health insurance.

A key point of Single Payer New York is that private forprofit health insurance is a core problem and therefore can not be part of the solution. Donna Smith was featured in Michael Moore’s movie SICKO. She and husband were forced to move back in with their children due to their higher medical bill.

“Having health insurance no longer means having peace of mind. If you get sick and you are insured you may find yourself underinsured or worse — unable to get necessary care. You may have premiums rising so high that you can no longer afford both housing and health insurance. You may have deductibles and co-pays that effectively and efficiently squeeze you away from seeking care. You may have collectors pursuing medical debt hound you to the point of garnishment and humiliation — as we did. You may have an employer that no longer wants you covered by the group health insurance plan with rising premiums and huge deductibles. And you may not know these things until in the grip of a health care crisis with no options and no ability to dig out,” said Smith. “Half measures will not do. Universal, free health care must become reality,” she added.

“A prime benefit of a national single payer system is that it would save several hundred billion dollars annually by eliminating the high overhead and profits of the private, investor-owned insurance industry. Doctors and hospitals would be freed from the burdens and expenses of paperwork created by having to deal with multiple insurers with different rules – often rules designed to avoid payment,” added Dunlea. “We are the only industrialized country to allow for-profit insurance companies to be middlemen in our health system. In their drive to enroll healthy (and profitable) patients and screen out the sick, private insurance waste vast sum on billing, marketing, underwriting, utilization review and other activities that enhance profits but divert resources from care and hassle patients and physicians,” Dunlea added.

Single Payer is defined as financing health care expenditures for the entire population through a single source, presumably the government, with funds collected through progressive taxation of citizens and businesses. While the groups want to see a single payer system (e.g., HR 676) enacted at the federal level, they are also urging the state to adopt a single payer system as soon as possible. Single payer legislation (A7354 Gottfried / S3107 Schneiderman) is pending in both the Assembly and Senate. A majority of Assembly members (85) are co-sponsors of the single payer bill. This fall the State will complete a study of the various ways to provide health care to all. The Governor is then expected to make a recommendation to lawmakers.

While the United States has very skilled health providers, our health care system performs poorly, with its overall quality only ranked 37th by the World Health Organization. US spending on health care is now over 2.1 trillion dollars — nearly $7,000 per person. This is more the double the world average of $2,571. This amounts to a whopping 15.5% of our GNP on health care — far more than any other country — which puts our businesses at a competitive disadvantage in the international marketplace.

A number of state legislators issued statements in support of the organizing effort.

Assembly Health Committee Chair Richard Gottfried said “H.R. 676 is the best solution for America’s health care system. Universal, publicly-sponsored, and publicly-funded health coverage is the answer for those who have coverage, for the uninsured, for health care providers, for employers, and for taxpayers. It’s the right thing to do, whether nationally or at the state level.”

“I am proud to support the formation of the Single Payer New York coalition. The 2.6 million uninsured New Yorkers can’t afford to wait for a new Democratic president or a new Congress to get the health care they deserve. It is imperative that New York State act now to ensure that every New Yorker has access to high quality, affordable health care. Working together through the Single Payer New York coalition, I am hopeful that we can make universal health care a reality in New York State,” said Senator Eric T. Schneiderman, lead sponsor of the single payer bill in the State Senate. Gottfried is the lead sponsor in the Assembly.

“As a strong proponent of Universal Single Payer health care, I am thrilled to hear that this new coalition, Single Payer New York, is forming. The timing is ideal, as I believe many New Yorkers and Americans now understand that we are paying more for health care than other countries, but with worse outcomes overall. It is time to turn that public understanding and frustration into political action. My congratulations and thanks for taking on this critical task.,” said Barbara Lifton, Assemblymember, 125th District

“Health care is not just another issue for me, it’s a value. I believe it is everyone’s right to accessible, affordable, quality health care. In 2006, 2.8 million people in New York State, including 500,000 children, went without health insurance. We can do better, and we must do better. The United States Congress must pass H.R. 676. H.R. 676 would provide quality health insurance coverage for everyone for just about everything, restore our right to choose health care providers, cut red tape, save billions and end outside interference in personal medical decisions. As Assistant Speaker of the Assembly, a co-sponsor of a resolution urging Congress to pass H.R. 676, and a co-sponsor of Assembly legislation to create a single payer system in our state, I know how a single payer system could help all New Yorkers. I join with my friends in labor, the New York State Nurses Association, women’s organizations, and the entire coalition known as Single Payer New York in calling for a health care system that puts patients ahead of profits,” said Assemblymember Rhoda S. Jacobs, 42nd Assembly District.

Assemblywoman Donna Lupardo (D-Endwell) added, “With 2.5 million uninsured New Yorkers, we need to address this inequity as soon as possible. While we are waiting for leadership in Washington, it is important that we develop the grass roots support necessary to keep the issue of health care in the forefront. I applaud the efforts of Single Payer New York in championing the health care reform we need here in New York and across the country.”

Look before you leap into McCain’s idea of health coverage

By James C. Mitchiner
Other Voices
The Ann Arbor News
September 11, 2008

At first glance, it sounds like a great idea: Scrap the employer-based health insurance system in favor of individually chosen private health plans, allow individuals to purchase such plans across state borders and from groups that currently don’t sell insurance (such as faith-based organizations), and use refundable income tax credits to help pay the premiums.

Hold down costs through strategies such as competition between plans, disease management programs, prevention and wellness initiatives, and expansion of information technology. Make people prudent health care consumers by expanding Health Savings Accounts. And for those with chronic diseases, who are medically uninsurable, give them “guaranteed access plans” through federally blessed (but state-subsidized) high-risk pools. For those of you who don’t recognize this radical approach to reforming American health care, it is the gist of the plan offered by Republican presidential candidate John McCain.

Unfortunately, it won’t work.

Let’s look first at the income tax credits. The idea is for individuals and families to use these credits to purchase health insurance plans in the non-group market, i.e., from a private insurer not sponsored by your employer. Premiums would be kept reasonable because plans would compete with each other to sell health insurance to those who valued it, or at least to individuals deemed “good risks” (read: healthy people).

And what level of credits are we talking about? Senator McCain proposes credits of just $2,500 per individual, or $5,000 per family.

Given that the average annual family health insurance premium in 2007 was over $12,000, it seems to me that $5,000 is woefully inadequate. Some, in fact, have compared the effect of these tax credits to that of throwing a 10-foot rope to a man stuck in a 40-foot hole. Just to make up the difference between the credit and the premium cost, a middle class family of four with a household income of $70,000 would have to fork over 10 percent of that income, a commitment that would seriously impact the family budget.

Let us suppose, however, that a worker could find and purchase a policy for only $5,000 per year. What would it look like? My guess is that it would have either multiple coverage restrictions (non-coverage for pre-existing conditions, a prolonged waiting period before insurance became effective) or significant financial limitations (high deductibles or co-pays, puny lifetime maximums), which defeat the purpose of having insurance in the first place. Clearly, private insurers cannot make a profit by selling comprehensive insurance at premiums the average individual can afford.

Perhaps the most significant objection to tax credits, however, is that they don’t address the serious flaws inherent in for-profit insurance.

Credits would be used to purchase the same policies currently sold by private insurers, policies that are rife with administrative waste, limit which doctors you can see, restrict when and where you can be hospitalized, and impose considerable cost-sharing responsibilities on their policyholders.

The economic literature appears to back me up. In 1999, MIT economist Jonathan Gruber and colleague Larry Levitt did a simulation analysis of tax credits. They found that a subsidy of $2,000 per individual and $4,000 per family would cover no more than 30 percent of the uninsured, at a cost of almost $40 billion. More recently, the Employment Policies Institute looked at the economic impact of tax credits in terms of reducing the number of uninsured and the attendant costs. The EPI found that the credit would be used by seven times as many already insured individuals as it would by newly insured persons, at a public cost of $19.8 billion. Overall, only 1.6 million would gain coverage, at an economically inefficient price tag of $12,644 each.

Beyond tax credits, other aspects of the McCain plan are flawed.

Disease management programs, personal health and wellness programs, and electronic medical recordkeeping, while pushed by insurers and intuitively conducive to cost control, nonetheless have not been shown to have a widespread effect on holding down health care expenses.

Neither have Health Savings Accounts, which have an affinity for the healthy and wealthy, who tend to use them as convenient tax shelters.

And any guaranteed access plan for the medically uninsurable that depends on state funding is suspect, given the current precarious situation with most state budgets.

The time has come for us to stop pretending that we can reform American health care through incremental tweaks in the current system. I really see no way to accomplish the three goals of reform – expanded access, consumer choice and cost control – without ending the hegemony of the for-profit insurance industry.

This means we have to replace our shamefully inefficient multipayer system with a national, single-payer alternative, one that creates affordable access to medical care for those who are locked out, eliminates racial and ethnic disparities, and allows Americans (rather than insurers or the government) to choose their own physicians and hospitals. Doing so will not come fast and will not be easy. But when it does come, and I believe it will, the result will be well worth the effort expended.

The writer, an Ann Arbor resident, is the president of the Washtenaw County Medical Society.

No on Prop. 101: It’s a false pitch that blocks reform

By Phil Lopes and George Pauk
Tucson Citizen
Guest Opinion: Health Care Choice
Published: 09.15.2008

When Arizona voters cast their ballots this November, one of the questions they face is whether to vote yes or no on Proposition 101, the misnamed Freedom of Choice in Health Care Act. They should definitely vote no.

Prop. 101 is a constitutional amendment that would forbid restrictions on “a person’s freedom of choice of private health care systems or private plans of any type.”

Sounds like more freedom, doesn’t it? In fact, Prop. 101 protects the private health insurance industry.

Its passage would give the industry a privileged place in our state’s basic law. The result would be less freedom for average Arizonans, not more.

Remember, this is the industry that diverts about 31 cents of every health care dollar toward administrative costs, including big payouts for shareholder profits, marketing expenses and outlandish executive salaries.

Prop. 101 would limit Arizonans’ choices to plans offered by these private insurers, and it would block any steps toward badly needed health care reform.
Let’s step back for a moment and ask: What kind of choices do people want in health care?

They want access to comprehensive, affordable, high-quality care. They want to choose their health practitioner. They want to choose their hospital or other service delivery site.

Under our current health insurance system, Arizonans have none of these choices.

The U.S. Census Bureau reported last month that 45.7 million Americans – including 1.2 million Arizonans – lacked health insurance in 2007.

Employer-sponsored coverage continues to shrink, as do employee health benefits. Access to care, and availability of care, especially in rural areas, is diminishing.

The Commonwealth Fund, a research group, estimates that another 25 million people were “underinsured” last year – i.e., they had insurance but still wouldn’t be able to afford care in the event of a serious illness or injury.

Health insurers are further restricting what they cover – what they’ll pay for and what they won’t – and they increasingly impose big deductibles and co-pays.

They are also constantly changing their lists of “in-network” doctors and hospitals.

Choice of doctor or hospital? What a quaint idea! Just see what happens when you go “out of network.”

Thus, in the name of “freedom” and “choice,” Prop. 101 would give us neither. It would further push Arizonans into the iron grip of an industry that is failing us – an industry in which many put profits above the delivery of sorely needed health care.

There are many potential unintended consequences of Prop. 101.

For instance, if the Arizona Department of Insurance determines that a particular health insurance carrier does not meet set criteria for fiscal solvency and wants to bar it from offering unsound policies, the department would be prohibited from doing so if only one person in the state wanted to purchase this policy.

Wouldn’t it be better if every resident were guaranteed comprehensive, high-quality health care – at least as good as what is offered to our state employees?

If each person could choose his own health practitioner, hospital or clinic (working within our private delivery system), allowing continuity of care, better follow-ups and fewer medical errors?

Wouldn’t it be better if our state’s residents didn’t have to worry about crushing medical bills because they knew a social insurance fund would cover the costs? If every Arizonan were in one big pool, spreading the risk more equitably?

If health care costs were controlled by, for example, bulk purchasing of drugs and medical supplies?

Such a plan exists: the Arizona Health Security Act. Its enactment by our Legislature would go a long way toward curing our state’s health care ills.

It’s practical, fair and eminently realistic.

But take note: The passage of Prop. 101 would prevent Arizonans from choosing that better path, among others. And it’s being bankrolled by at least $434,000 – mainly from business interests, much of it from out-of-state.

In a recent newspaper interview, Dr. Eric Novack, a Phoenix-based orthopedic surgeon and leading proponent of the measure, conceded that Prop. 101 would constitutionally preclude “certain options.”

So the real aim is to preclude certain choices, Dr. Novack?

Arizona voters should not be deceived. They should vote “no” on Prop. 101.

State Rep. Phil Lopes represents Legislative District 27 (central, west and southwest Tucson), is leader of the House Democrats and is the sponsor of the Arizona Health Security Act. George Pauk is an internal medicine physician in Phoenix and a member of Physicians for a National Health Program (www.pnhp.org).

Senator Kuehl’s Open Letter to the Governor on SB 840

Re: Senate Bill 840 (Kuehl) — Request for Signature

September 10th, 2008

The Honorable Arnold Schwarzenegger
Governor, State of California
State Capitol, 1st Floor
Sacramento, CA 95814

Dear Governor Schwarzenegger:

Rather than write you a pro forma letter regarding SB 840, I am writing a longer than usual request in an effort to at least make certain you have all the facts in front of you as you consider this bill. I am writing to respectfully urge your signature on SB 840 because this legislation will bring a modern universal health care system to California, make health care predictably more affordable for California employers and families, and provide every Californian with a complete choice of their individual doctors and hospitals.

Although you vetoed similar legislation two years ago, I urge your careful reconsideration of this legislation and ask for an opportunity to answer any concerns or questions that you continue to have, in person. I have worked hard to return this legislation to your desk because I see that California’s health care system is falling behind other industrial nations in making the systematic investments that are necessary to build a state of the art health care system as well as to contain long term health cost inflation which is bankrupting our state.

California desperately needs real healthcare reform that strikes directly at the heart of insurance costs that are growing 2-3 times faster than workers wages every year. A system where each of California’s 36 million residents are segregated into dozens of different insurance plans according to whether they are young or old, sick or healthy, rich or poor, and where they live or work requires an unconscionable level of administrative complexity and constant actuarial risk analysis. It conservatively costs 30% of every dollar we spend on healthcare just to keep track of all the different populations and benefit groupings to which each person belongs.

Even more importantly, such a fragmented financing system is clearly unable to respond and adapt to the changing needs of a modern, state of the art, health care system. We have failed to make significant progress in the development of electronic infrastructure, data collection and monitoring, and we have not made necessary investments in preventive health, among many others. While I applaud your leadership on each of these issues, I ask you to ask yourself why the health insurance industry, which controls our health care funds today, has failed to invest in such proven and effective methods for improving quality and containing cost, on their own.

The answer, in part, is that, under a fragmented health care financing system, such as we now have, no “payer” has any incentive to make systematic improvements, regardless of how beneficial they may be to the larger system. It is no accident that physician adoption rates for electronic medical records in the Netherlands are at 98%, while in the United States they linger at around 28%. As other nations make innovative advancements in quality and infrastructure, dramatically reducing preventable deaths and medical errors, and saving lives at the same time they contain costs, here in California, we are falling further and further behind as any semblance of a first world health care system slips through our fingers.

Our slow adoption of cost effective quality improvement technologies is a fatal system failure. Incremental steps may sometimes help in the short term, but each small step requires enormous political effort and yet, inevitably falls far short of producing the health care system of which California is capable, and, frankly, for which it is already paying. We must have the foresight to address the deeper systemic causes underlying the health care crisis.

Importantly, SB 840 does not envision a radical remodeling of our health care delivery system. It is barely a remodeling of the delivery system, at all. It simply calls for privately delivered health care funded by a single comprehensive health insurance plan that covers all residents of the state, allowing them to choose their own doctors and hospitals.

This simple policy change – bringing all residents into one “risk pool”, instead of partitioning residents by medical risk – addresses the deepest systemic reason for our failing health care system. Multiple risk pools mean that competition between insurers is based on having a primarily healthy risk pool relative to the premiums received. This means that sicker individuals will always be undesirable “customers” and our health care resources and capitol investments will not be devoted to effectively treating or serving those patients, but instead will be devoted to attracting and keeping healthy individuals who use less health care than they pay in premiums. For example, hospital infrastructure investments will always be inadequate in low income communities with high health care needs. All the incremental market reforms in the world can never hope to reverse this basic perverse incentive; market forces will inevitably drive insurers to find new and innovative ways to circumvent them. As a result, our political will and financial resources will continue to be worn out through countless futile exercises in partial reform.

As you know, the Lewin Group, an independent analysis group that focuses on healthcare costs, predicts that the universal health care system in SB 840 would save Californians $20 billion in administrative overhead, high-cost emergency room visits and pharmaceutical costs, allowing the savings to be redirected into purchasing health care. California’s own Legislative Analyst found that Lewin’s assessments were reasonable and confirmed the billions of dollars in savings that are estimated under this reform, once it is in place.

The positive impact that SB 840 will have on California’s economy is inspiring. SB 840 provides immediate relief to California businesses most of which would save money in the first year of its implementation. Today, half of our small businesses no longer provide health benefits because costs have risen so fast, and their competitors have already eliminated employee benefits. California needs health reform that will immediately reduce health insurance premiums for those businesses that have stuck it out. Such a policy will inevitably bring new business to the state, since health care costs in California would be significantly lower than in other states and more competitive with other industrial nations.

SB 840 will save money for public employers, including the state of California, who purchase health care benefits for current employees and retirees; for this reason, many school districts, city councils, and county boards of supervisors support this legislation. Additionally, state and local governments will see significant savings in the costs of their direct care programs according to the Lewin report as well as other sources.

The savings in health care costs for working families will also help stimulate the economy, by reducing that portion of a family’s income that must be devoted to health care premiums. Additionally, electronic infrastructure investments, called for in the legislation, could easily spur a new era of economic growth in California’s high-tech industry. Instead of investing our health care resources in dead-end administrative paper-pushing, our health care dollars could be used to create new and better paying high-tech jobs that drive economic growth throughout the state.

Overall, SB 840 will make our health care system more reliable and secure by stabilizing the growth in health spending and linking spending increases to state GDP and population growth, employment rates and other relevant demographic indicators. SB 840 will combine needed cost controls with medical practice standards that make use of the best available medical science, and place an emphasis on preventative and primary care to improve California’s overall health in a way that also saves billions of dollars.

Sheila James Kuehl
Senator, 23rd District

10 Excellent Reasons for National Health Care

10 Excellent Reasons for National Health Care

Edited by Mary O’Brien and Martha Livingston

From the Foreward by Representative John Conyers Jr.:

This insightful book will provide you with the information you need to be an informed participant in the public debate about how to achieve health care for all. This information is especially important now, during this election year.

Within the chapters of this book and in the resource guide in the back, you will find cutting-edge information to help you work toward the only sensible solution to our health care crisis: a single-payer national health insurance program. Contributors to this book include doctors, nurses, patients, and an international union leader. They discuss the benefits of a single-payer plan: that it is cost-effective; will provide choice, quality, and better health for Americans; will help to reduce health care disparities; will make doctors and nurses better able to do their jobs; and will benefit both workers and businesses. They also explain why single-payer universal health care is the only approach that can guarantee Americans the health care that they need when they need it, and explain how, by working together, we can achieve the goal of health care for all.

The New Press: 10 Excellent Reasons for National Health Care
http://www.thenewpress.com/index.php?option=com_title&task=view_title&metaproductid=1711

Comment:

By Don McCanne, MD

This compact, easy to read book should be circulated widely so that all Americans can understand that there is an effective and equitable solution to our health care crisis. Read it. Then recommend it to the various organizations and grassroots coalitions with which you are now associated, and initiate efforts to expand activism to yet more individuals and organizations.

The threshold required for reform will be met once the public understands that there really is a solution.

Senator Kuehl's Open Letter to the Governor on SB 840

Re: Senate Bill 840 (Kuehl) — Request for Signature

September 10th, 2008

The Honorable Arnold Schwarzenegger
Governor, State of California
State Capitol, 1st Floor
Sacramento, CA 95814

Dear Governor Schwarzenegger:

Rather than write you a pro forma letter regarding SB 840, I am writing a longer than usual request in an effort to at least make certain you have all the facts in front of you as you consider this bill. I am writing to respectfully urge your signature on SB 840 because this legislation will bring a modern universal health care system to California, make health care predictably more affordable for California employers and families, and provide every Californian with a complete choice of their individual doctors and hospitals.

Although you vetoed similar legislation two years ago, I urge your careful reconsideration of this legislation and ask for an opportunity to answer any concerns or questions that you continue to have, in person. I have worked hard to return this legislation to your desk because I see that California’s health care system is falling behind other industrial nations in making the systematic investments that are necessary to build a state of the art health care system as well as to contain long term health cost inflation which is bankrupting our state.

California desperately needs real healthcare reform that strikes directly at the heart of insurance costs that are growing 2-3 times faster than workers wages every year. A system where each of California’s 36 million residents are segregated into dozens of different insurance plans according to whether they are young or old, sick or healthy, rich or poor, and where they live or work requires an unconscionable level of administrative complexity and constant actuarial risk analysis. It conservatively costs 30% of every dollar we spend on healthcare just to keep track of all the different populations and benefit groupings to which each person belongs.

Even more importantly, such a fragmented financing system is clearly unable to respond and adapt to the changing needs of a modern, state of the art, health care system. We have failed to make significant progress in the development of electronic infrastructure, data collection and monitoring, and we have not made necessary investments in preventive health, among many others. While I applaud your leadership on each of these issues, I ask you to ask yourself why the health insurance industry, which controls our health care funds today, has failed to invest in such proven and effective methods for improving quality and containing cost, on their own.

The answer, in part, is that, under a fragmented health care financing system, such as we now have, no “payer” has any incentive to make systematic improvements, regardless of how beneficial they may be to the larger system. It is no accident that physician adoption rates for electronic medical records in the Netherlands are at 98%, while in the United States they linger at around 28%. As other nations make innovative advancements in quality and infrastructure, dramatically reducing preventable deaths and medical errors, and saving lives at the same time they contain costs, here in California, we are falling further and further behind as any semblance of a first world health care system slips through our fingers.

Our slow adoption of cost effective quality improvement technologies is a fatal system failure. Incremental steps may sometimes help in the short term, but each small step requires enormous political effort and yet, inevitably falls far short of producing the health care system of which California is capable, and, frankly, for which it is already paying. We must have the foresight to address the deeper systemic causes underlying the health care crisis.

Importantly, SB 840 does not envision a radical remodeling of our health care delivery system. It is barely a remodeling of the delivery system, at all. It simply calls for privately delivered health care funded by a single comprehensive health insurance plan that covers all residents of the state, allowing them to choose their own doctors and hospitals.

This simple policy change – bringing all residents into one “risk pool”, instead of partitioning residents by medical risk – addresses the deepest systemic reason for our failing health care system. Multiple risk pools mean that competition between insurers is based on having a primarily healthy risk pool relative to the premiums received. This means that sicker individuals will always be undesirable “customers” and our health care resources and capitol investments will not be devoted to effectively treating or serving those patients, but instead will be devoted to attracting and keeping healthy individuals who use less health care than they pay in premiums. For example, hospital infrastructure investments will always be inadequate in low income communities with high health care needs. All the incremental market reforms in the world can never hope to reverse this basic perverse incentive; market forces will inevitably drive insurers to find new and innovative ways to circumvent them. As a result, our political will and financial resources will continue to be worn out through countless futile exercises in partial reform.

As you know, the Lewin Group, an independent analysis group that focuses on healthcare costs, predicts that the universal health care system in SB 840 would save Californians $20 billion in administrative overhead, high-cost emergency room visits and pharmaceutical costs, allowing the savings to be redirected into purchasing health care. California’s own Legislative Analyst found that Lewin’s assessments were reasonable and confirmed the billions of dollars in savings that are estimated under this reform, once it is in place.

The positive impact that SB 840 will have on California’s economy is inspiring. SB 840 provides immediate relief to California businesses most of which would save money in the first year of its implementation. Today, half of our small businesses no longer provide health benefits because costs have risen so fast, and their competitors have already eliminated employee benefits. California needs health reform that will immediately reduce health insurance premiums for those businesses that have stuck it out. Such a policy will inevitably bring new business to the state, since health care costs in California would be significantly lower than in other states and more competitive with other industrial nations.

SB 840 will save money for public employers, including the state of California, who purchase health care benefits for current employees and retirees; for this reason, many school districts, city councils, and county boards of supervisors support this legislation. Additionally, state and local governments will see significant savings in the costs of their direct care programs according to the Lewin report as well as other sources.

The savings in health care costs for working families will also help stimulate the economy, by reducing that portion of a family’s income that must be devoted to health care premiums. Additionally, electronic infrastructure investments, called for in the legislation, could easily spur a new era of economic growth in California’s high-tech industry. Instead of investing our health care resources in dead-end administrative paper-pushing, our health care dollars could be used to create new and better paying high-tech jobs that drive economic growth throughout the state.

Overall, SB 840 will make our health care system more reliable and secure by stabilizing the growth in health spending and linking spending increases to state GDP and population growth, employment rates and other relevant demographic indicators. SB 840 will combine needed cost controls with medical practice standards that make use of the best available medical science, and place an emph
asis on preventative and primary care to improve California’s overall health in a way that also saves billions of dollars.

Sheila James Kuehl
Senator, 23rd District

Health policy expertise and presidential politics

Speaking Truth to Power -- The Need for, and Perils of, Health Policy Expertise in the White House

By Jacob S. Hacker, Ph.D.
The New England Journal of Medicine
September 11, 2008

The adviser is the president’s ally — in the lingo of organizational economics, an “agent” serving the interests of a “principal.” Yet as a bearer of specialized knowledge, the adviser is also responsible to a larger profession, to its values and commitments, and ultimately to the ideal of expertise itself.

The adviser, in short, must both “speak truth to power” and aid in the exercise of power, both offering unbiased intelligence and acting as a very biased assistant. It is fashionable to pretend these two roles are the same, but they are not. An expert adviser has special knowledge, training, and skills — all of which are needed more than ever in the White House. The question is whether these talents can really be used, or be useful, in the bare-knuckles world of American politics — and, more important, whether the values they embody can be upheld when science, advocacy, and democracy collide.

Politics is about power more than truth, about winning more than being right. But expertise is about truth more than power, and being right is the whole point.

Health policy experts can do more sophisticated analyses than ever, and there are more of them than ever, too — in policy schools, departments of economics, schools of public health, think tanks, private foundations, and government. But the progress in quality of expertise has not been matched by progress in thinking about the role of the expert or about how policy advice can and should be adapted to the political realities that those receiving advice inevitably confront. Policy experts are brilliant when it comes to designing proposals but often horrible at thinking through the ways in which their proposals will be refracted through the political prism. Subtle visions of policy are wedded to crude caricatures of politics, and, not surprisingly, those visions all too often either fail to become reality or fail to work.

Worse, the expert’s claim to authority can undercut the more important wellspring of democratic leadership: the demands and wishes of the people. Experts are habitually disdainful of what ordinary citizens believe. People have opinions; experts have facts. When a well-regarded economist complains that democratic policy choice should be restricted because “irrational” voters endorse all sorts of harmful nostrums — whether trade protection or farm price supports (he might have added health insurance with low deductibles, drug price controls, and free choice of doctors) — he may be out on a limb. But the tree is one that many policy experts climb.

We badly need health care experts in the White House who offer advice based on evidence and analysis, not prejudice. But even the best experts need to know when to defer to the political process, to see the purpose of their craft as facilitating democratic debate rather than providing final answers once Americans have decided on the questions.

Winston Churchill once said that “scientists should be on tap, not on top.” That is a good starting point. But sometimes presidential policy experts should also have the good sense to get out of the way.

http://content.nejm.org/cgi/content/full/359/11/1085

Comment:

By Don McCanne, MD

“… expertise is about truth more than power, and being right is the whole point.”

In deciding whether policy is right or wrong, it is essential first to decide what goals are to be achieved by the policy decisions. In reforming health care financing, most of us would agree that the goal is to provide everyone with access to all necessary health care without having to be exposed to financial hardship.

We have available a wide range of expertise within the policy community. When you look at the various policy recommendations, some of them, if enacted, would achieve this specific stated goal, but most of them would not. Those that would not are policies that are designed to achieve other less beneficial or even detrimental goals (ownership society: own your own debts). Stated in other terms, those supporting the few policies that would work are right, and those supporting policies that fall short are wrong.

In policy, being right is the whole point.

“Politics is about power more than truth, about winning more than being right.”

Politics is represented by the great legislative battles that we are witnessing wherein one side advocates for policies that are wrong, largely because they’re inadequate, and the other side advocates for policies that are completely wrong because they make matters worse.

Without the continual involvement of members of the policy community who emphatically support that which is right, we’ll continue to witness politics that results in wrong, wronger and wrongest policies.

Is the window for reform really open?

Drop in Uninsured Unlikely to Influence Health Care Overhaul, Experts Say

By Neda Semnani
CQ HealthBeat
September 5, 2008

While new government figures show that a greater enrollment in public health programs has helped reduce the number of Americans without health insurance, experts said the data are unlikely to help make the case for expanding those programs as part of broader health care legislation next year.

David S. Johnson, the Census Bureau’s chief of Housing and Household Economics Statistics, which published the new figures, credits public programs like Medicaid and SCHIP for the increase in the insured, a trend experts believe may continue as employer-based coverage falls.

Analysts said the drop in the uninsured rate will have little influence in the broader discussion of health care legislation expected next year when a new president and Congress take office. The economic downturn and other budget priorities make it difficult for health care overhaul–a costly endeavor–to take center stage, they said.

“How much flexibility does the federal government have, given the declining economy and vast array of other problem areas? We have a lot of policy priorities. Health is an important one, but it’s not the only one,” said Joseph Antos, a health care scholar with the American Enterprise Institute, a conservative think tank. “Some kind of reform needs to happen . . . eventually. Gigantic reforms cost money. So ‘eventually’ may not happen in the first year or even in the first ten years of a new administration.”

Mark McClellan, director of the Engelberg Center for Health Care Reform with the non-partisan Brookings Institution, said, “With the fiscal outlook so tight, the challenge will be finding new ways to get costs down and coverage up, while filling gaps in quality.”

Judith Solomon, a senior fellow at the left-leaning Center on Budget and Policy Priorities, said the report examines the period just before the economic downturn and “doesn’t change what is the case for reform, it doesn’t change the case for reauthorizing strong public programs,” said Solomon, who specializes in Medicaid and the State Children’s Health Insurance Program (SCHIP).

The trend of greater enrollment in public health programs may continue in the current economic slowdown, said Karen Davenport, director of health policy with the liberal Center for American Progress. “On the one hand, we’re likely to see a greater insecurity in health coverage; on the other, a further up-tick in public coverage … The report points out just how effective these programs are in catching people when they fall. It shows that the individual market alone doesn’t work.”

http://www.commonwealthfund.org/healthpolicyweek/healthpolicyweek_show.htm?doc_id=704405

Comment:

By Don McCanne, MD

All we need to achieve comprehensive health care reform is to elect a new Congress and a new administration, and use the momentum of the first 100 days to push through Congress the voters’ mandate for reform. Right? Hmmm.

If we are going to have new legislation ready by January or February, the specifics of the proposals need to be precisely defined now so that they are ready to be converted into legislative language ASAP.

Is the McCain proposal ready? It would not be too difficult to write legislation that would diminish employer contributions to health plans by eliminating the tax advantages. It also would be fairly easy to allow sale of plans across state borders thereby creating a competitive market of the lowest common denominator of underinsurance plans. Tearing down programs that aren’t working very well and replacing them with programs that are much less effective is certainly not the reform we need.

What about creating a universal market of private plans like the members of Congress have: an FEHBP-like program? To be effective, these plans would have to cover essentially all necessary health care, and include individuals with greater health care needs. Those plans would be very expensive, certainly more than the $12,000 average premium charged for employer-sponsored plans covering healthy employees and their healthy families. Our current business-based private plans would require massive transformation to convert them into private social insurance plans characteristic of some of the European nations. Can you imagine the complexity of the legislation that would be required? Has anyone seen any serious specifics of such an approach that could be converted into legislative language within the first 100 days?

What about allowing the purchase of a Medicare-like option to complement the private insurance market? It wouldn’t be simply a provision to allow a buy-in to the current Medicare program simply because the Medicare risk pool is composed of very high-cost populations (elderly, chronically disabled, and chronic renal disease), and the premiums could never be affordable. Then what would a separate Medicare-like option look like? Good question. How comprehensive would the benefits be? How could cost-sharing be kept at a reasonable level? How much of the premium would the individual be responsible for? Would the balance be paid by the government? Would the private insurers who benefit from favorable selection be required to transfer funds to the public program? Has anyone seen any serious specifics that could be converted into legislative language in the first 100 days?

We do have legislative language for a proposal that actually would work, and it is already in a bill before Congress, with about 90 cosponsors in the House of Representatives: John Conyers’ HR 676. Oh, wait a minute; that’s not feasible, they tell us.

So what do the Democrats have in mind for the first 100 days, should they have control? Easy. They are going to expand the children’s health insurance program – SCHIP – certainly a good thing. They are going to look at the damage done to Medicare by the privatizers, but significant repairs will be too complex to enact right away; they’ll get to that later. Comprehensive reform? Not now; there are too many other important issues. Next year? Well, that’s an election year, so we can’t do it then. But we should be able to get to it possibly before the end of the president’s first term, and certainly by the end of the second.

Window slammed shut!

But don’t anyone start working on these issues now. We have more important decisions to make. Do we support the moral high ground of lipstick on a pit bull, or the moral low ground of lipstick on a pig?

In the face of all of our shameful societal problems, surely someone will come up with this answer to this most pressing problem of the day: the lipstick needs to go on the figurehead of the Swift Boat.