Getting There from Here: How should Obama reform health care?

by Atul Gawande
The New Yorker
January 26, 2009
People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse — especially for those who already have dependable coverage and access to good doctors and hospitals.
Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.
Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have.
Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.
Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area — even if prices, taxes, and competition are stiffer.
Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge, allowed our choices to be constrained by history and by vested interests. But that’s too simple. …consider a health-care example: the 2003 prescription-drug program for America’s elderly.
On January 1, 2006, the program went into effect nationwide. The result was chaos. There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices: insurance companies offered 1,429 prescription-drug plans across the country. People arrived at their pharmacy only to discover that they needed an insurance card that hadn’t come, or that they hadn’t received pre-authorization for their drugs, or had switched to a plan that didn’t cover the drugs they took. Tens of thousands were unable to get their prescriptions filled, many for essential drugs like insulin, inhalers, and blood-pressure medications. The result was a public-health crisis in thirty-seven states, which had to provide emergency pharmacy payments for the frail. We will never know how many were harmed, but it is likely that the program killed people.
This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.
Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.
Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents.
The results have been remarkable. After a year, 97.4 per cent of Massachusetts residents had coverage, and the remaining gap continues to close.
The Massachusetts plan didn’t do anything about medical costs, however, and, with layoffs accelerating, more people require subsidized care than the state predicted. Insurance premiums continue to rise here, just as they do elsewhere in the country. Many residents also complain that eight per cent of their income is too much to pay for health insurance, even though, on average, premiums amount to twice that much.
For years, about one in ten of my patients — I specialize in cancer surgery — had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.
For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage.
It will be no utopia. People will still face co-payments and premiums. There may still be agonizing disputes over coverage for non-standard treatments. Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation — which is to say, a health-care system that works. And there are ways to get there that start from where we are.
http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande

Atul Gawande is a highly respected physician who has a well deserved reputation as a gifted writer. This commentary should not be construed as an attack on him; rather, it is an attack on his message. On his writing skills I give him an A, but on his content, a D-.
This article represents what I believe to be a misuse of framing. Gawande uses overly simplistic framing, but then bends, breaks or even replaces his frames as he develops his theme.
Gawande uses the linear polarity that I condemned in a recent qotd comment. In the four dimensional model that I described, he places single payer at one end of a linear polarity, free marketeers at the other end, and pragmatists in the middle.
His stated goal is a health care system that works, a goal that most of us share. Single payer is not only a financing system, but it is an administrative system that is specifically designed to make our health care system work for all of us. It is a system designed to address our problems not only in breadth, not only in depth, but throughout the three dimensions of all parameters, and over the fourth dimension of time. It is a system that is not “on the left” as he states, but, by design, it constitutes the health care universe in its four dimensions.
The free marketeers do not provide us with a universal system, but rather would disassemble much of what we have. They would have us each attend to our own needs, paying for whatever health care we need, or purchasing private health plans, even if the premiums alone are 16 percent of our income. No serious student of health policy would ever consider that to be a system that would work for all of us. At least Gawande is correct when he places the free marketeers out “on the right.”
What about the pragmatists? Of course, pragmatism is the theme of Gawande’s article. He cites path dependency as the natural model to achieve reform. Use what we have, and build on it to bring us closer to our goals.
But what is it that we do have? We have an expensive, dysfunctional health care delivery system that needs extensive repair along with adoption of efficiencies so that we can pay for it. Within the health care delivery system, we need to build on what is working, and replace that which isn’t.
But what else is it that we have? We have a health care financing system that is wasting tremendous resources, while impairing access to much needed health care, and exposing individuals to financial hardship or even financial ruin. Gawande’s major error in framing is that he conflates our health care delivery system with our health care financing, as if they were one and the same. Since we need to build on our existing delivery system, he includes as a given that building on our current fragmented financing system is an integral part of the process.
Look at the example that he gave us: the Medicare drug benefit. By the model of path dependency that he supports, drug coverage should have been added to Medicare as yet another benefit in the program, and it would have served us very well. Instead, it followed another path dependent road – our dependency on private health plans to cover prescription drugs. As Gawande states, this decision has likely killed people. Yet he insists that building on a financing system dependent on private insurers is essential because it’s path dependent.
He leaves us with an example of a successful application of path dependent reform – the Massachusetts “system of universal health coverage.” He glosses over the point that their system is not universal, although he does concede that the plan has done nothing to control costs, even though humane cost containment is an absolute imperative of any reform program.
But then it is hard to dispute Gawande’s perception that the Massachusetts plan is a success. After all, his surgical fees are being paid.
The pragmatic approach to financing reform is to follow a path dependent program that works, and discard those that don’t. With improvements, Medicare would work well for all of us; private health plans would work for those of us who are relatively healthy and have good incomes, like Dr. Gawande.

by Atul Gawande
The New Yorker
January 26, 2009

People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse — especially for those who already have dependable coverage and access to good doctors and hospitals.

Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.

Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have.

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area — even if prices, taxes, and competition are stiffer.

Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge, allowed our choices to be constrained by history and by vested interests. But that’s too simple. …consider a health-care example: the 2003 prescription-drug program for America’s elderly.

On January 1, 2006, the program went into effect nationwide. The result was chaos. There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices: insurance companies offered 1,429 prescription-drug plans across the country. People arrived at their pharmacy only to discover that they needed an insurance card that hadn’t come, or that they hadn’t received pre-authorization for their drugs, or had switched to a plan that didn’t cover the drugs they took. Tens of thousands were unable to get their prescriptions filled, many for essential drugs like insulin, inhalers, and blood-pressure medications. The result was a public-health crisis in thirty-seven states, which had to provide emergency pharmacy payments for the frail. We will never know how many were harmed, but it is likely that the program killed people.

This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.

Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents.

The results have been remarkable. After a year, 97.4 per cent of Massachusetts residents had coverage, and the remaining gap continues to close.

The Massachusetts plan didn’t do anything about medical costs, however, and, with layoffs accelerating, more people require subsidized care than the state predicted. Insurance premiums continue to rise here, just as they do elsewhere in the country. Many residents also complain that eight per cent of their income is too much to pay for health insurance, even though, on average, premiums amount to twice that much.

For years, about one in ten of my patients — I specialize in cancer surgery — had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.

For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage.

It will be no utopia. People will still face co-payments and premiums. There may still be agonizing disputes over coverage for non-standard treatments. Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation — which is to say, a health-care system that works. And there are ways to get there that start from where we are.

http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande

Comment:

By Don McCanne, MD

Atul Gawande is a highly respected physician who has a well deserved reputation as a gifted writer. This commentary should not be construed as an attack on him; rather, it is an attack on his message. On his writing skills I give him an A, but on his content, a D-.

This article represents what I believe to be a misuse of framing. Gawande uses overly simplistic framing, but then bends, breaks or even replaces his frames as he develops his theme.

Gawande uses the linear polarity that I condemned in a recent qotd comment. In the four dimensional model that I described, he places single payer at one end of a linear polarity, free marketeers at the other end, and pragmatists in the middle.

His stated goal is a health care system that works, a goal that most of us share. Single payer is not only a financing system, but it is an administrative system that is specifically designed to make our health care system work for all of us. It is a system designed to address our problems not only in breadth, not only in depth, but throughout the three dimensions of all parameters, and over the fourth dimension of time. It is a system that is not “on the left” as he states, but, by design, it constitutes the health care universe in its four dimensions.

The free marketeers do not provide us with a universal system, but rather would disassemble much of what we have. They would have us each attend to our own needs, paying for whatever health care we need, or purchasing private health plans, even if the premiums alone are 16 percent of our income. No serious student of health policy would ever consider that to be a system that would work for all of us. At least Gawande is correct when he places the free marketeers out “on the right.”

What about the pragmatists? Of course, pragmatism is the theme of Gawande’s article. He cites path dependency as the natural model to achieve reform. Use what we have, and build on it to bring us closer to our goals.

But what is it that we do have? We have an expensive, dysfunctional health care delivery system that needs extensive repair along with adoption of efficiencies so that we can pay for it. Within the health care delivery system, we need to build on what is working, and replace that which isn’t.

But what else is it that we have? We have a health care financing system that is wasting tremendous resources, while impairing access to much needed health care, and exposing individuals to financial hardship or even financial ruin. Gawande’s major error in framing is that he conflates our health care delivery system with our health care financing, as if they were one and the same. Since we need to build on our existing delivery system, he includes as a given that building on our current fragmented financing system is an integral part of the process.

Look at the example that he gave us: the Medicare drug benefit. By the model of path dependency that he supports, drug coverage should have been added to Medicare as yet another benefit in the program, and it would have served us very well. Instead, it followed another path dependent road – our dependency on private health plans to cover prescription drugs. As Gawande states, this decision has likely killed people. Yet he insists that building on a financing system dependent on private insurers is essential because it’s path dependent.

He leaves us with an example of a successful application of path dependent reform – the Massachusetts “system of universal health coverage.” He glosses over the point that their system is not universal, although he does concede that the plan has done nothing to control costs, even though humane cost containment is an absolute imperative of any reform program.

But then it is hard to dispute Gawande’s perception that the Massachusetts plan is a success. After all, his surgical fees are being paid.

The pragmatic approach to financing reform is to follow a path dependent program that works, and discard those that don’t. With improvements, Medicare would work well for all of us; private health plans would work for those of us who are relatively healthy and have good incomes, like Dr. Gawande.

Getting There from Here: How should Obama reform health care?

by Atul Gawande
The New Yorker
January 26, 2009

People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse — especially for those who already have dependable coverage and access to good doctors and hospitals.

Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.

Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have.

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area — even if prices, taxes, and competition are stiffer.

Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge, allowed our choices to be constrained by history and by vested interests. But that’s too simple. …consider a health-care example: the 2003 prescription-drug program for America’s elderly.

On January 1, 2006, the program went into effect nationwide. The result was chaos. There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices: insurance companies offered 1,429 prescription-drug plans across the country. People arrived at their pharmacy only to discover that they needed an insurance card that hadn’t come, or that they hadn’t received pre-authorization for their drugs, or had switched to a plan that didn’t cover the drugs they took. Tens of thousands were unable to get their prescriptions filled, many for essential drugs like insulin, inhalers, and blood-pressure medications. The result was a public-health crisis in thirty-seven states, which had to provide emergency pharmacy payments for the frail. We will never know how many were harmed, but it is likely that the program killed people.

This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.

Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents.

The results have been remarkable. After a year, 97.4 per cent of Massachusetts residents had coverage, and the remaining gap continues to close.

The Massachusetts plan didn’t do anything about medical costs, however, and, with layoffs accelerating, more people require subsidized care than the state predicted. Insurance premiums continue to rise here, just as they do elsewhere in the country. Many residents also complain that eight per cent of their income is too much to pay for health insurance, even though, on average, premiums amount to twice that much.

For years, about one in ten of my patients — I specialize in cancer surgery — had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.

For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage.

It will be no utopia. People will still face co-payments and premiums. There may still be agonizing disputes over coverage for non-standard treatments. Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation — which is to say, a health-care system that works. And there are ways to get there that start from where we are.

http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande

Comment:

By Don McCanne, MD

Atul Gawande is a highly respected physician who has a well deserved reputation as a gifted writer. This commentary should not be construed as an attack on him; rather, it is an attack on his message. On his writing skills I give him an A, but on his content, a D-.

This article represents what I believe to be a misuse of framing. Gawande uses overly simplistic framing, but then bends, breaks or even replaces his frames as he develops his theme.

Gawande uses the linear polarity that I condemned in a recent qotd comment. In the four dimensional model that I described, he places single payer at one end of a linear polarity, free marketeers at the other end, and pragmatists in the middle.

His stated goal is a health care system that works, a goal that most of us share. Single payer is not only a financing system, but it is an administrative system that is specifically designed to make our health care system work for all of us. It is a system designed to address our problems not only in breadth, not only in depth, but throughout the three dimensions of all parameters, and over the fourth dimension of time. It is a system that is not “on the left” as he states, but, by design, it constitutes the health care universe in its four dimensions.

The free marketeers do not provide us with a universal system, but rather would disassemble much of what we have. They would have us each attend to our own needs, paying for whatever health care we need, or purchasing private health plans, even if the premiums alone are 16 percent of our income. No serious student of health policy would ever consider that to be a system that would work for all of us. At least Gawande is correct when he places the free marketeers out “on the right.”

What about the pragmatists? Of course, pragmatism is the theme of Gawande’s article. He cites path dependency as the natural model to achieve reform. Use what we have, and build on it to bring us closer to our goals.

But what is it that we do have? We have an expensive, dysfunctional health care delivery system that needs extensive repair along with adoption of efficiencies so that we can pay for it. Within the health care delivery system, we need to build on what is working, and replace that which isn’t.

But what else is it that we have? We have a health care financing system that is wasting tremendous resources, while impairing access to much needed health care, and exposing individuals to financial hardship or even financial ruin. Gawande’s major error in framing is that he conflates our health care delivery system with our health care financing, as if they were one and the same. Since we need to build on our existing delivery system, he includes as a given that building on our current fragmented financing system is an integral part of the process.

Look at the example that he gave us: the Medicare drug benefit. By the model of path dependency that he supports, drug coverage should have been added to Medicare as yet another benefit in the program, and it would have served us very well. Instead, it followed another path dependent road – our dependency on private health plans to cover prescription drugs. As Gawande states, this decision has likely killed people. Yet he insists that building on a financing system dependent on private insurers is essential because it’s path dependent.

He leaves us with an example of a successful application of path dependent reform – the Massachusetts “system of universal health coverage.” He glosses over the point that their system is not universal, although he does concede that the plan has done nothing to control costs, even though humane cost containment is an absolute imperative of any reform program.

But then it is hard to dispute Gawande’s perception that the Massachusetts plan is a success. After all, his surgical fees are being paid.

The pragmatic approach to financing reform is to follow a path dependent program that works, and discard those that don’t. With improvements, Medicare would work well for all of us; private health plans would work for those of us who are relatively healthy and have good incomes, like Dr. Gawande.

Great Expectations — The Obama Administration and Health Care Reform

By Jonathan Oberlander, Ph.D.
The New England Journal of Medicine
January 22, 2009
Health care reform is back. For the first time since 1993, momentum is building for policies that would move the United States toward universal health insurance. President Barack Obama has made health care a central part of his domestic agenda, and key members of Congress have promised to introduce ambitious health care reform legislation in 2009.
The lessons of 1993 and 1994 are also well understood in Congress. Two key Senators — Max Baucus (D-MT), chair of the Finance Committee, and Edward Kennedy (D-MA), chair of the Health, Education, Labor, and Pensions Committee — are developing legislation that largely tracks the Obama plan. Consequently, this time around, congressional Democrats may be more unified around a health care reform strategy. Baucus’s support for reform is crucial, given the importance of financing issues, and Kennedy’s staff has been holding meetings with stakeholders in an effort to build consensus. Both senators are determined to move quickly, fearing that delay could dissipate momentum, as it did in 1993.
Financing health care reform in this fiscal climate will be an extraordinary political challenge, deep divisions persist in Congress, and many thorny problems are nowhere near resolution. Throughout the past century, reformers pursuing comprehensive change in the U.S. health care system have failed to overcome similar barriers. But the fact that reform has failed before does not mean it is fated to fail forever. As the election of Barack Obama vividly reminds us, history is not always repeated. Sometimes it is made.
http://content.nejm.org/cgi/content/full/360/4/321

And…

Which Way to Universal Healthcare?

By Ezra Klein
In These Times
January 19, 2009
Ezra Klein: Your opening statements demonstrate a congruency in values, but obviously your approaches are different. It seems to me you each balance the politics and the policies of the issue differently. So, let me start with you, Steffie: How does single payer pass the Senate Finance Committee?
Steffie Woolhandler (PNHP): Well, you build a popular movement among the American people, much in the way that Obama was able to succeed by building a popular movement. If you’d asked me five years ago, what was more likely, passing single-payer or electing a black president, I probably would’ve said single-payer and you probably would’ve, too. But the thing that changed was a kind of populist sentiment in this country, and that’s what it’s going to take.
Ezra Klein: Richard, a lot of what you said today has been reliant on the idea of the public plan, but my congressional reporting suggests that one plausible outcome for your plan is that when you try to get to 60 votes in the Senate, the public plan gets bargained away. Is the public plan a bottom line? If the public plan vanishes, but the rest of the plan is structurally similar to your principles, is that a plan that’s beneath the level of acceptability? Is that a plan that therefore merits opposition?
Richard Kirsch (HCAN): We haven’t as a coalition had a discussion yet about how we look at this whole plan when it passes, and what’s acceptable and what is not.
We’re a long way policy-wise and politically — although maybe not that long on the calendar, potentially only nine or so months — of seeing something enacted. But we’re not there yet, so we’re just going to fight in every way for the best system that is achievable.
http://www.inthesetimes.com/article/4159/which_way_to_universal_healthcare/

Jonathan Oberlander is one of the nation’s more astute observers of the politics of health care reform. After a long dry spell of pessimism, he is finally able to justify a very cautious note of optimism, though it still risks being a fleeting message. The most reassuring component of his message is that Congressional Democrats, especially Sen. Baucus and Sen. Kennedy, are rapidly moving forward with comprehensive reform in a process designed to prevent as much as possible the errors of the past.
So the politics is in motion, but with which policies?
Although there is a growing populist sentiment for single payer reform, that has not translated into political action. Congress is moving forward with reform based primarily on covering more individuals with private health plans. Many of those supporting public insurance have decided that the politics require that we must follow the lead of the Washington politicians regardless of the Medicare-for-all populism. Thus they are pushing for a public insurance option in a market of private plans.
Ezra Klein is quite correct when he states that “my congressional reporting suggests that… when you try to get to 60 votes in the Senate, the public plan gets bargained away.” And what is the strategy to prevent this outcome? Richard Kirsch of the HCAN coalition states, “We haven’t as a coalition had a discussion yet…” and “We’re a long way policy-wise and politically…” and “we’re not there yet…”
The boat has left the dock and is leaving behind the better-than-Medicare option, and the HCAN coalition hasn’t solidified either the policies or the politics, other than to agree on abandoning single payer.
Is there any way that we can convert Medicare-for-all populism into political action? In his NEJM article, Professor Oberlander states, “Finally, in Barack Obama, health care reform has a president who could effectively use the bully pulpit to rally the public behind change.” Populism got President Obama to where he is. Can’t we take it one step further?

By Jonathan Oberlander, Ph.D.
The New England Journal of Medicine
January 22, 2009

Health care reform is back. For the first time since 1993, momentum is building for policies that would move the United States toward universal health insurance. President Barack Obama has made health care a central part of his domestic agenda, and key members of Congress have promised to introduce ambitious health care reform legislation in 2009.

The lessons of 1993 and 1994 are also well understood in Congress. Two key Senators — Max Baucus (D-MT), chair of the Finance Committee, and Edward Kennedy (D-MA), chair of the Health, Education, Labor, and Pensions Committee — are developing legislation that largely tracks the Obama plan. Consequently, this time around, congressional Democrats may be more unified around a health care reform strategy. Baucus’s support for reform is crucial, given the importance of financing issues, and Kennedy’s staff has been holding meetings with stakeholders in an effort to build consensus. Both senators are determined to move quickly, fearing that delay could dissipate momentum, as it did in 1993.

Financing health care reform in this fiscal climate will be an extraordinary political challenge, deep divisions persist in Congress, and many thorny problems are nowhere near resolution. Throughout the past century, reformers pursuing comprehensive change in the U.S. health care system have failed to overcome similar barriers. But the fact that reform has failed before does not mean it is fated to fail forever. As the election of Barack Obama vividly reminds us, history is not always repeated. Sometimes it is made.

http://content.nejm.org/cgi/content/full/360/4/321

And…

Which Way to Universal Healthcare?

By Ezra Klein
In These Times
January 19, 2009

Ezra Klein: Your opening statements demonstrate a congruency in values, but obviously your approaches are different. It seems to me you each balance the politics and the policies of the issue differently. So, let me start with you, Steffie: How does single payer pass the Senate Finance Committee?

Steffie Woolhandler (PNHP): Well, you build a popular movement among the American people, much in the way that Obama was able to succeed by building a popular movement. If you’d asked me five years ago, what was more likely, passing single-payer or electing a black president, I probably would’ve said single-payer and you probably would’ve, too. But the thing that changed was a kind of populist sentiment in this country, and that’s what it’s going to take.

Ezra Klein: Richard, a lot of what you said today has been reliant on the idea of the public plan, but my congressional reporting suggests that one plausible outcome for your plan is that when you try to get to 60 votes in the Senate, the public plan gets bargained away. Is the public plan a bottom line? If the public plan vanishes, but the rest of the plan is structurally similar to your principles, is that a plan that’s beneath the level of acceptability? Is that a plan that therefore merits opposition?

Richard Kirsch (HCAN): We haven’t as a coalition had a discussion yet about how we look at this whole plan when it passes, and what’s acceptable and what is not.

We’re a long way policy-wise and politically — although maybe not that long on the calendar, potentially only nine or so months — of seeing something enacted. But we’re not there yet, so we’re just going to fight in every way for the best system that is achievable.

http://www.inthesetimes.com/article/4159/which_way_to_universal_healthcare/

Comment:

By Don McCanne, MD

Jonathan Oberlander is one of the nation’s more astute observers of the politics of health care reform. After a long dry spell of pessimism, he is finally able to justify a very cautious note of optimism, though it still risks being a fleeting message. The most reassuring component of his message is that Congressional Democrats, especially Sen. Baucus and Sen. Kennedy, are rapidly moving forward with comprehensive reform in a process designed to prevent as much as possible the errors of the past.

So the politics is in motion, but with which policies?

Although there is a growing populist sentiment for single payer reform, that has not translated into political action. Congress is moving forward with reform based primarily on covering more individuals with private health plans. Many of those supporting public insurance have decided that the politics require that we must follow the lead of the Washington politicians regardless of the Medicare-for-all populism. Thus they are pushing for a public insurance option in a market of private plans.

Ezra Klein is quite correct when he states that “my congressional reporting suggests that… when you try to get to 60 votes in the Senate, the public plan gets bargained away.” And what is the strategy to prevent this outcome? Richard Kirsch of the HCAN coalition states, “We haven’t as a coalition had a discussion yet…” and “We’re a long way policy-wise and politically…” and “we’re not there yet…”

The boat has left the dock and is leaving behind the better-than-Medicare option, and the HCAN coalition hasn’t solidified either the policies or the politics, other than to agree on abandoning single payer.

Is there any way that we can convert Medicare-for-all populism into political action? In his NEJM article, Professor Oberlander states, “Finally, in Barack Obama, health care reform has a president who could effectively use the bully pulpit to rally the public behind change.” Populism got President Obama to where he is. Can’t we take it one step further?

The Swiss and Dutch Health Insurance Systems: Universal Coverage and Regulated Competitive Insurance Markets

By Robert E. Leu, Frans F. H. Rutten, Werner Brouwer, Pius Matter, and Christian Rütschi
The Commonwealth Fund
January 2009
Universal coverage attained through a mandate that every individual purchase a basic insurance plan
Building on a previous system of social and private insurance, the individual mandate in the Netherlands took effect in 2006. The Swiss have operated with a mandate since 1996. In both countries uninsured rates are low (estimated at about 1.5 percent of the population in the Netherlands and below 1 percent in Switzerland).
Enforcement of mandatory health insurance
Switzerland
On the other hand, some people who are nominally covered are not paying their premiums. Since 2005, insurers have been permitted to suspend payments on behalf of such people, meaning that providers are left with unpaid bills or consumers are denied services. These suspensions can last 8 to 24 months, because of the time it can take to ascertain whether a consumer is unable to pay the premium (in which case cantons or communities will often assume financial responsibility) or is simply unwilling to pay. About 120,000 people, or 1.6 percent of the population, were affected by suspensions in 2006.
Netherlands
Before the new Health Insurance Act, there was a fear that, despite the mandate, many individuals would opt not to obtain coverage. In fact, the number of uninsured at the end of 2006 was about the same as before the new mandate took effect — 241,000 people, or 1.5 percent of the population.
Almost an equal number of people — 240,000 as of the end of 2007 — were enrolled with an insurer but were not paying their premiums. Beginning July 1, 2007, insurers were allowed to expel enrollees who have not paid premiums, but these enrollees simply switched to other insurers and failed to pay them as well. To prevent this, the government has forbidden people from switching plans when they are behind in paying their premiums. There is also a proposal to allow garnishing of wages or unemployment or disability benefits.
http://www.commonwealthfund.org/usr_doc/Leu_swissdutchhltinssystems_1220.pdf?section=4039

The Commonwealth Fund is joining the chorus of those who say that we should look to the Swiss and Dutch systems as potential models for universal coverage in the United States. What is meant by universal coverage? It means that everyone is covered (except for the one percent or so who are not, and the one and one-half percent who have been suspended for failure to pay their premiums).
If we were to adopt a “universal” program that left about two and one-half percent without coverage, that means that about 7.5 million U.S. residents would be left out. The population of Switzerland just happens to be 7.5 million. Does anyone else see any irony in adopting a Swiss-like insurance system that would leave out the equivalent of the entire population of Switzerland? Perhaps some might argue that the Swiss population is more worthy of coverage than would be the 7.5 million that we would leave out.
This report is very supportive of the private insurance industry. The lead author, Robert E. Leu, Ph.D., serves as a director on the board of the largest private hospital group and a large health insurance company in Switzerland. Rate of coverage is only one of the many policy issues covered in a favorable light in this report. Those who have been following our national dialogue on health policy will recognize many other sections in this report that seem to be more intent on marketing their model to the United States than to caution us against the deficiencies in their systems.
Their faith in the social value of the private insurance industry is certainly noteworthy. For instance, when discussing the Swiss nonprofit plans for basic coverage, and for-profit plans for supplemental coverage, they state, “There may be synergies between the two lines — for example, in provider relations — and some insurers may use health information from basic coverage when deciding to whom to offer supplementary insurance (this is illegal but difficult to control).” Does isolating this statement parenthetically sterilize it, making it a fundamental business principle?
Private insurers, whether for-profit or nonprofit, are businesses. They will always advance innovations that enhance their business models. No matter how tightly they are regulated, they will engage in activities that are “illegal but difficult to control.” Of course, since not every potential loophole could possibly be covered by laws and regulations, some of the innovative, immoral business behaviors technically might not be illegal, even though they should be.
In a single payer public health program, everyone is covered for life, automatically, including the 7.5 million deemed less worthy (?) than all of the citizens of Switzerland. Not only that, we would also remove from our midst an expensive, superfluous industry that thrives on immoral or illegal (but difficult to control) business practices. Now really, isn’t single payer a better model for the United States?

By Robert E. Leu, Frans F. H. Rutten, Werner Brouwer, Pius Matter, and Christian Rütschi
The Commonwealth Fund
January 2009

Universal coverage attained through a mandate that every individual purchase a basic insurance plan

Building on a previous system of social and private insurance, the individual mandate in the Netherlands took effect in 2006. The Swiss have operated with a mandate since 1996. In both countries uninsured rates are low (estimated at about 1.5 percent of the population in the Netherlands and below 1 percent in Switzerland).

Enforcement of mandatory health insurance

Switzerland

On the other hand, some people who are nominally covered are not paying their premiums. Since 2005, insurers have been permitted to suspend payments on behalf of such people, meaning that providers are left with unpaid bills or consumers are denied services. These suspensions can last 8 to 24 months, because of the time it can take to ascertain whether a consumer is unable to pay the premium (in which case cantons or communities will often assume financial responsibility) or is simply unwilling to pay. About 120,000 people, or 1.6 percent of the population, were affected by suspensions in 2006.

Netherlands

Before the new Health Insurance Act, there was a fear that, despite the mandate, many individuals would opt not to obtain coverage. In fact, the number of uninsured at the end of 2006 was about the same as before the new mandate took effect — 241,000 people, or 1.5 percent of the population.

Almost an equal number of people — 240,000 as of the end of 2007 — were enrolled with an insurer but were not paying their premiums. Beginning July 1, 2007, insurers were allowed to expel enrollees who have not paid premiums, but these enrollees simply switched to other insurers and failed to pay them as well. To prevent this, the government has forbidden people from switching plans when they are behind in paying their premiums. There is also a proposal to allow garnishing of wages or unemployment or disability benefits.

http://www.commonwealthfund.org/usr_doc/Leu_swissdutchhltinssystems_1220.pdf?section=4039

Comment:

By Don McCanne, MD

The Commonwealth Fund is joining the chorus of those who say that we should look to the Swiss and Dutch systems as potential models for universal coverage in the United States. What is meant by universal coverage? It means that everyone is covered (except for the one percent or so who are not, and the one and one-half percent who have been suspended for failure to pay their premiums).

If we were to adopt a “universal” program that left about two and one-half percent without coverage, that means that about 7.5 million U.S. residents would be left out. The population of Switzerland just happens to be 7.5 million. Does anyone else see any irony in adopting a Swiss-like insurance system that would leave out the equivalent of the entire population of Switzerland? Perhaps some might argue that the Swiss population is more worthy of coverage than would be the 7.5 million that we would leave out.

This report is very supportive of the private insurance industry. The lead author, Robert E. Leu, Ph.D., serves as a director on the board of the largest private hospital group and a large health insurance company in Switzerland. Rate of coverage is only one of the many policy issues covered in a favorable light in this report. Those who have been following our national dialogue on health policy will recognize many other sections in this report that seem to be more intent on marketing their model to the United States than to caution us against the deficiencies in their systems.

Their faith in the social value of the private insurance industry is certainly noteworthy. For instance, when discussing the Swiss nonprofit plans for basic coverage, and for-profit plans for supplemental coverage, they state, “There may be synergies between the two lines — for example, in provider relations — and some insurers may use health information from basic coverage when deciding to whom to offer supplementary insurance (this is illegal but difficult to control).” Does isolating this statement parenthetically sterilize it, making it a fundamental business principle?

Private insurers, whether for-profit or nonprofit, are businesses. They will always advance innovations that enhance their business models. No matter how tightly they are regulated, they will engage in activities that are “illegal but difficult to control.” Of course, since not every potential loophole could possibly be covered by laws and regulations, some of the innovative, immoral business behaviors technically might not be illegal, even though they should be.

In a single payer public health program, everyone is covered for life, automatically, including the 7.5 million deemed less worthy (?) than all of the citizens of Switzerland. Not only that, we would also remove from our midst an expensive, superfluous industry that thrives on immoral or illegal (but difficult to control) business practices. Now really, isn’t single payer a better model for the United States?

President Barack Obama
January 20, 2009
The question we ask today is not whether our government is too big or too small, but whether it works – whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified. Where the answer is yes, we intend to move forward. Where the answer is no, programs will end. And those of us who manage the public’s dollars will be held to account – to spend wisely, reform bad habits, and do our business in the light of day – because only then can we restore the vital trust between a people and their government.
http://www.nytimes.com/2009/01/20/us/politics/20text-obama.html?pagewanted=all

President Barack Obama

January 20, 2009

The question we ask today is not whether our government is too big or too small, but whether it works – whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified. Where the answer is yes, we intend to move forward. Where the answer is no, programs will end. And those of us who manage the public’s dollars will be held to account – to spend wisely, reform bad habits, and do our business in the light of day – because only then can we restore the vital trust between a people and their government.

http://www.nytimes.com/2009/01/20/us/politics/20text-obama.html?pagewanted=all