PNHP

“Why Not Single Payer?” A Response to Paul Krugman and the Leading Democratic Presidential Contenders.

“Why Not Single Payer?” A Response to Paul Krugman and the Leading Democratic Presidential Contenders.

Miles Mogulescu
The Huffington Post
Posted October 10, 2007
Part I

Faster than you can say the word “Sicko” and turn around 3 times, the Democrats’ promise of health care for all has gone from “Universal Medicare For All” to “Individual Insurance Mandate”. In Monday’s New York Times, Paul Krugman defends that reversal in an article entitled “Why Not Single Payer?”

The possibility, after the 2008 elections, of a Democratic-controlled Congress which could pass Medicare For All (a/k/a Universal Single Payer Health Insurance) and a Democratic President who would sign it, could bring about the best chance to enact Medicare For All since Harry Truman first proposed it in 1948.

Yet without firing a shot and with no debate, the leading Democratic Presidential Contenders–Hillary Clinton, John Edwards and Barack Obama–as well as a good part of the Washington progressive infrastructure of think tanks and lobbying groups–have given up the fight for Medicare For All. Instead they propose variations of an Individual Mandate plan developed over the past 15 years by the “moderate” corporate wing of the Republican Party, a version of which Mitt Romney enacted in Massachusetts and which Arnold Schwarzenegger is proposing in California as an alternative to the single payer plan which the Democratic California legislature passed last year that he vetoed.

The thing is, I can’t quite figure out why the Democrats are in such rapid retreat from Medicare For All before the first battle has even been joined. Is it another example of the political cowardice by which the only Iraq resolutions that can pass the Democratic controlled Senate are a Republican-driven bill condemning MoveOn.Org. and praising Gen. Petraeus and another declaring the Iranian Revolutionary Guards a terrorist organization? Is it because the Democratic candidates are afraid of being accused by Republicans of supporting socialized medicine? (If so, it won’t help because Giuliani, Thompson, and Romney–whose Massachusetts plan Hillary largely imitates–all quickly claimed that Hillarycare 2.0 is socialized medicine, anyway.) Is it because they’ve been bought off by insurance companies and drug companies or fear that too many other Congress and Senate members have?

Or is it because they think that the insurance companies and drug companies are just too politically powerful to take on: Therefore the only way to insure most Americans is to make a deal with the devil that requires profit-making insurance companies to waive pre-existing conditions and charge everyone similar premiums regardless of age or health, in exchange for Congress delivering them 50 million guaranteed new profit-making customers, partly subsidized by the government?

Paul Krugman’s NY Times column is one of the first direct attempts by a liberal former supporter of single payer to try to make the case for adopting the Individual Mandate approach instead. According to Krugman, “basically it looks like something that could actually happen in the next administration, while enacting a single-payer plan…excellent as those plans are, might take a very long time.”

First, Krugman argues than an Individual Mandate would not require a big tax increase, although he admits (thus defeating his own argument) that taxes which most people would pay for single payer would most likely be lower than premiums that an Individual Mandate would require them to pay out of their pockets to buy insurance. Second, he argues than an Individual Mandate won’t make people feel that they’re “being forced into a government plan”. But the essence of an Individual Mandate plan is that the federal government forces the uninsured to buy health insurance. It involves even more government coercion than Medicare For All.

Finally, he argues that the Democrats’ proposals generally include a Medicare-like public insurance alternative which individuals may buy into and which “would evolve into single-payer over time.” Krugman never quite explains how this piece of alchemy will occur. Moreover, he admits that this is the part of the Democrats’ plan that the insurance industry will fight “tooth and nail”. If the Democrats have already surrendered on Medicare For All without firing a shot, isn’t it likely that the public alternative (the “socialized medicine” part) will be the first part of the plan to be compromised away when the legislative battles start in Congress and the insurance lobby starts exercising its muscle with its hundreds of lobbyists and tens of millions of dollars in campaign contributions?

In short, I find Krugman’s notion that an Individual Mandate is somehow more politically pragmatic than Medicare For All unconvincing and I don’t buy his argument that it’s a backdoor way to eventually get there. I even wonder how strongly he believes his own arguments. Only last January, in critiquing Schwarzeneggers’s Individual Mandate plan for California as a complicated “Rube Goldberg” device, Krugman argued that “the plan requires a much more intrusive government role than a single-payer system. Instead of reducing paperwork, the plan adds three new bureaucracies: one to police individuals to make sure they buy insurance, one to determine if they’re poor enough to receive aid, and one to police insurers to make sure they don’t discriminate against the unwell.” If you then add a public Medicare-like alternative that individuals can buy into, you need a fourth bureaucracy to administer that system.

Thus, when Hillary Clinton claims that her plan requires no new government bureaucracy, she’s not being candid with the voters. That lack of candor will quickly be exploited by the Republicans and the insurance and drug lobbies. While Republicans are wrong that her plan amounts to “socialized medicine”, such charges will still ring true since, in fact, her plan will require intrusive government regulation of the private insurance industry and coercive action to be sure that all citizens are obeying the individual mandate to buy health insurance. That’s one of the big reasons why, once the debate really starts, an Individual Mandate will not necessarily be a popular plan with the voters–Using the political pragmatism test, it stands a better chance of being rejected by the public and meeting the same fate as Hillarycare 1.0 than does Medicare For All, for which the political arguments are simple and clean.

Whatever Clinton might claim, Hillarycare 2.0 in fact requires a highly intrusive government presence in the lives of both businesses and individuals. As with Hillarycare 1.0, this is likely to be the biggest club that Republicans and their insurance company allies will use to defeat her or another Democrat as they did in 1994, unless so many compromises are made to water down the plan that insurance and drug companies decide it’s in their interest to accept the 50 million new mandatory government subsidized customers to pad their bottom lines. (Remember that with private insurance, approximately 30% of the healthcare dollar goes to administration, executive salaries and profits, compared to 2%-3% for Medicare; when all the political deals are finally cut, the private insurance and drug industries might find a new government subsidy for their bottom line an attractive deal.) If an Individual Mandate plan is more politically expedient than Medicare For All, it’s not for any of the reasons which Krugman cites and not because it’s likely to be more politically popular with the voters. The real reason is that with a few backroom political compromises, it could become a that plan the insurance and drug industries could learn to love.

Miles Mogulescu is an entertainment attorney and former Senior Vice-President at MGM before it was sold to Sony. In his professional capacity, he recently negotiated the distribution arrangements for the film “Bobby” about the assassination of Bobby Kennedy. He has been a lifelong progressive since the age of 12 when his father helped raise substantial sums of money for Dr. Martin Luther King, who was a guest in his home several times. He will never forget the impression which that extraordinary man made on him, which helped lead to a lifelong commitment to social justice.

Nurses are tired of seeing patients left behind

By PHYLLIS BROWN
Napa Valley Register
Tuesday, October 09, 2007

While Michael Bartos is right that the tens of millions of uninsured and underinsured Americans need help (“Single-payer won’t work, but universal care is the goal,” Oct. 2), his opposition to a single-payer style, Medicare-for-all that would guarantee healthcare for all is simply an embrace of our dysfunctional status quo and a broken healthcare system that primarily benefits insurance companies at the expense of the rest of us.

Registered nurses sponsored the billboard on Highway 80 that Bartos cites precisely because we are tired of seeing our patients left behind; infants who can’t get a healthy start because mom can’t afford prenatal care, children who can’t get immunizations and proper dental care because mom and dad can’t afford it, and patients who can’t afford the medications they’ve been prescribed. It doesn’t have to be this way.

Single-payer healthcare, as would be established by HR 676 in Congress and SB 840 in California, is the only effective, genuine cure for our current healthcare nightmare. It is the only health reform that is universal, that assures uniform, comprehensive benefits for all, that guarantees patients’ choice of doctor or medical facility, and that ends the routine, callous denial of care by insurance companies. It’s also the only reform that restores health security for American families by bringing an end to ever-rising insurance premiums, deductibles, co-pays and rising drug and hospital charges.

While Bartos’ experiences with Medicare are unfortunate, they remain unique and anecdotal. The majority of private practitioners who experience difficulty in being paid for services rendered are battling not with Medicare, but with insurance companies. The heart of the claims problem is that insurance companies aim to make a profit. Medicare doesn’t. Insurance companies earn profits by denying payment, therefore, the more payment denied, the greater the profits. Insurance companies have an operating overhead of 30 percent, Medicare, 3 percent. Medicare exists to serve the healthcare needs of American citizens. Insurance companies exist to create attractive portfolios for their stockholders.

We’ve all heard the same tired anecdotes about waiting times in countries with more humane health care systems but studies show that waiting times in the U.S. are as bad as, or worse than, Canada. Unlike the U.S., in Canada no one is denied needed medical care, referrals or diagnostic tests due to cost, preexisting conditions or because it wasn’t pre-approved.

Proponents of preserving market-based healthcare like Dr. Bartos ignore the colossal failure of the system that is collapsing around us. It’s all well and good to talk about public subsidies for our lowest income, but a mountain of evidence is accumulating to document that the crisis now touches more American families every day.

A recent survey by the influential Consumer Reports organization, for example, states that four in 10 Americans can now be classified as “underinsured.” Among those, more than half of the “underinsured” postponed needed medical care due to cost and a third had to dig deep into their savings to pay for medical expenses. Another third of those over 50 said decisions about their retirement were adversely affected by healthcare costs, one quarter had outstanding medical debt, 38 percent postponed home or car maintenance repairs due to medical bills, and only 37 percent said they were prepared to financially handle unexpected major medical costs in the next year.

The point of “Sicko,” and the nurses’ endorsement of the movie, is that the people who live in the wealthiest nation in the world deserve the same standard of care that exists in all of the world’s other industrialized countries. America is a society founded upon the principle of equality, but the message sent by our current healthcare system, or lack thereof, is that you are only entitled to the healthcare you can afford. By redefining health as a commodity, as we have in this nation, we are restricting that fundamental right.

(Brown is a registered nurse who lives in Napa.)

David Lazarus gets personal

Nation's healthcare crisis gets personal

By David Lazarus
Los Angeles Times
October 7, 2007

I write a lot about healthcare reform. Now it’s personal.

I was diagnosed this past week with diabetes. As of Friday, I was injecting myself with insulin, something I’ll be doing four or five times a day, every day, for the rest of my life. Without the injections, I’ll likely die.

Scared? You’re damn right I’m scared. What’s going to happen to me? What’s going to happen to my family?

I got past the shock pretty quickly and am now stuck somewhere between denial and anger. Depression will soon arrive, followed eventually by acceptance. Something to look forward to.

This is an uncertain time for me, but I know this much: I’m more convinced than ever that our medical system is a mess and that a single-payer insurance program is the only realistic way we can achieve universal coverage, promote preventive treatment and make healthcare affordable to all.

And if contracting diabetes is frightening for a relatively well-insured person like myself, what must it be like for any of the 47 million Americans who lack health insurance?

According to the American Diabetes Assn., nearly 21 million U.S. adults and kids have the disease — 7% of the population. About 15 million of this number have been diagnosed. The rest have no idea that they’re afflicted.

With obesity rates soaring, as many as 54 million others are strongly at risk of contracting diabetes in the future.

In my case, diabetes struck not because I stuff my face with Big Macs and fried chicken, which I don’t. I take good care of myself and am not overweight — considerably less so since unexpectedly dropping about 15 pounds over the past couple of months.

No, it’s almost certain I got nailed because a genetic time bomb finally exploded.

My father, Paul N. Lazarus III, who produced the movies “Westworld” and “Capricorn One,” has Type 1 diabetes and is now nearly blind. My younger brother has Type 1 and is doing well enough. My aunt had Type 1 before it blinded and then killed her.

The doctors say diabetes — almost certainly Type 1 — has been lurking in my DNA since I was a child, waiting for its time to strike.

But why now? I’ve lived 46 fairly healthy years, except for certain pharmaceutical pursuits during college. I don’t drink. I don’t smoke. I exercise as regularly as I can. What did I do wrong?

Probably nothing. The stress of my recent move to L.A. and starting a new job didn’t help, but it’s not to blame. This was going to happen no matter what.

I had a good idea something was wrong when I noticed that my weight kept going down no matter what I ate, and that I was consumed with a thirst of biblical proportions (accompanied by a commensurate increase in bathroom breaks).

I visited my doctor and had a blood test. The bad news came just days later. I was immediately referred to a specialist, whom I’ll call Dr. B.

Dr. B was great — knowledgeable, sensitive, empathetic. Problem was, Dr. B didn’t take insurance.

Excuse me? I said.

Dr. B explained that it just wasn’t cost-effective for him to seek reimbursement from insurance companies. It was too much hassle, he said, and he didn’t get paid enough for his efforts. Dr. B said an increasing number of doctors were cutting ties with insurers for the same reasons.

If I wanted to see him at his private practice, which was most convenient to my home, each visit could cost me hundreds of dollars — not the most appealing prospect when one’s facing a chronic disease.

Dr. B said I could try to deal with insurance reimbursements on my own, but that’s the last headache I wanted to inflict on myself at this point.

So I had to quickly find a doctor who would take insurance. My insurer’s website had a directory of possible choices, but you’re essentially pulling a name out of a hat — not the best way to make decisions when your blood-sugar level is three or four times normal.

This led me to Dr. W, who was equally knowledgeable if perhaps a bit lacking in the empathy department. He also had what seemed to me unconventional ideas about how diabetes can be treated with certain drugs and a rigidly monastic diet of his own devising.

This ultimately led me to Dr. D at UCLA’s Gonda (Goldschmied) Diabetes Center, whom I’m very fortunate to have found. Not only does he know what he’s doing, but he also has the resources of a world-class medical facility that focuses exclusively on what’s trying to put me under dirt.

It was Dr. D who finally made the call that I needed to start insulin injections, and it was he who made sure I knew how to handle that first, life-changing moment when needle touched skin.

Clearly I’m receiving the best available treatment, and I’d rather be here than anywhere in the world.

But the quirks and complexities of the insurance system border on madness. Through my employer, I have about as much insurance coverage as anyone. Yet that wasn’t good enough for Dr. B.

I have to wonder where else my private-sector insurance will fail me in years ahead.

And what happens if I get fired tomorrow? With a preexisting condition, I’m virtually uninsurable in the individual insurance market. Will diabetes leave my family destitute?

In the past, I always wrote about the uninsured in a largely abstract way — a faceless mass of millions of people confronted with a broadly defined medical challenge. I know better now.

The terrifying possibility of my own loss of coverage gives me an acute sense of what the uninsured must deal with, the dreadful awareness that you and your loved ones are only one medical misstep from catastrophe.

That’s unacceptable for any person who lives in the wealthiest, most advanced nation in the history of the world.

I’ll have a lot more to say about this in the future, especially as my own situation takes shape. But this much at least is evident:

* Universal coverage must be our goal, and it must allow ready access to all aspects of the medical system at affordable prices.

* The emphasis must be on treatment, not bureaucracy. As it stands, researchers at Harvard University estimate that about a third of the $2 trillion in annual healthcare spending is squandered on bureaucratic overhead.

* Employer-based healthcare is obsolete. As costs continue climbing, businesses can no longer meet their historical obligation of being the primary provider of coverage to American families.

* Quality medical treatment is a right, not a benefit.

Unfortunately, nearly all healthcare-reform proposals on the table center on expanding the existing system and pushing the uninsured into high-cost individual policies that will make private insurers even more profitable.

That can’t be the answer.

Single-payer isn’t perfect. Critics say it can involve long waits for treatment and can stifle innovation.

My belief is that Americans can get it right. We can learn from the examples of other nations and refine things so that our healthcare is second to none. It won’t be easy. Then again, how much worse could it be than the way things are now?

As of this moment, I’m completely dependent on the U.S. healthcare system to keep me alive. I, and you, shouldn’t have to settle for anything but the best.

http://www.latimes.com/business/la-fi-lazarus7oct07,1,7915141,full.column?coll=la-utilities-business&ctrack=2&cset=true

Comment:

By Don McCanne, MD

David Lazarus now not only reports it; he lives it.

Private plans fail Medicare audits

Medicare Audits Show Problems in Private Plans

By Robert Pear
The New York Times
October 6, 2007

Tens of thousands of Medicare recipients have been victims of deceptive sales tactics and had claims improperly denied by private insurers that run the system’s huge new drug benefit program and offer other private insurance options encouraged by the Bush administration, a review of scores of federal audits has found.

The problems, described in 91 audit reports reviewed by The New York Times, include the improper termination of coverage for people with H.I.V. and AIDS, huge backlogs of claims and complaints, and a failure to answer telephone calls from consumers, doctors and drugstores.

Of the audits conducted by the Department of Health and Human Services, 39 focused on drug benefits, 44 focused on managed care plans and 8 examined other types of private plans.

The companies include three of the largest participants in the Medicare market, UnitedHealth, Humana and WellPoint.

The audits document widespread violations of patients’ rights and consumer protection standards. Some violations could directly affect the health of patients — for example, by delaying access to urgently needed medications.

For years, Democrats have complained about efforts to “privatize Medicare,” and they are likely to cite the findings as evidence that private insurers cannot be trusted to care for the sickest, most vulnerable Medicare recipients.

Medicare has taken “vigorous action” to halt marketing violations, said Abby L. Block, a Medicare official.

But David A. Lipschutz, a lawyer at California Health Advocates, a nonprofit group, said that Medicare’s generous payments to private plans still encouraged predatory sales practices.

“Every enrollee in a private Medicare plan is a potential source of substantial profits,” Mr. Lipschutz said.

http://www.nytimes.com/2007/10/07/us/07medicare.html?ref=health&pagewanted=all

Comment:

By Don McCanne, MD

So Democrats “are likely to cite the findings as evidence that private insurers cannot be trusted to care for the sickest, most vulnerable Medicare recipients.” So why do the leading Democratic candidates insist that private insurers be included in their models of health care reform for the rest of us?

Not only can the private insurers not be trusted, but they waste resources that should be redirected to health care. And we all pay for that waste, directly or indirectly.

When is enough enough?

"No Worry" health plan

Health insurers introduce plans with "predictable premiums."

American Medical Association
Morning Rounds
October 9, 2007

The Wall Street Journal (10/9, D3, McQueen) reports, “Guardian Life and Humana Inc. are introducing multiyear plans designed to make health-insurance premiums more predictable from year to year for smaller employers.” However, “workers could face sharply higher deductibles and co-payments for prescriptions and office visits if medical costs rise more than expected.” Guardian Life will make available its “Premium Protect” plan “in the next week or two in five states and the District of Columbia for employers with 51 to 150 employees.” Meanwhile, Humana already introduced its plan, called “No Worry,” in February. “The Humana plans require employers [of 51 to 99 staff] to hand over a large percentage of workers’ phone and email contact information to get annual premium rises of no more than 6%.” The Journal notes, “Guardian achieves its rate-increase lock-in by charging employers an upfront fee of 3% to 4% in return for a guaranteed increase of 0%, 6% or 9% in the second year of a two-year plan.” In contrast, Humana “guarantees annual rate increases won’t exceed 6%.” However, “employers who terminate the contract before the end of the three-year period face a $25,000 penalty.”

http://www.ama-assn.org/

Comment:

By Don McCanne, MD

No worry. Employers can now lock in their premium rates by merely agreeing in advance to pass on health care cost increases to their employees through yet higher deductibles and co-payments.

And you were beginning to think that the private insurance industry was incapable of adressing the problem of escalating health costs.

There is a problem though. If employers really do care about the welfare of their employees, they will need to provide bankruptcy counselors for those whose families actually need medical care.

Nation's healthcare crisis gets personal

By David Lazarus
Los Angeles Times
October 7, 2007

I write a lot about healthcare reform. Now it’s personal.

I was diagnosed this past week with diabetes. As of Friday, I was injecting myself with insulin, something I’ll be doing four or five times a day, every day, for the rest of my life. Without the injections, I’ll likely die.

Scared? You’re damn right I’m scared. What’s going to happen to me? What’s going to happen to my family?

I got past the shock pretty quickly and am now stuck somewhere between denial and anger. Depression will soon arrive, followed eventually by acceptance. Something to look forward to.

This is an uncertain time for me, but I know this much: I’m more convinced than ever that our medical system is a mess and that a single-payer insurance program is the only realistic way we can achieve universal coverage, promote preventive treatment and make healthcare affordable to all.

And if contracting diabetes is frightening for a relatively well-insured person like myself, what must it be like for any of the 47 million Americans who lack health insurance?

According to the American Diabetes Assn., nearly 21 million U.S. adults and kids have the disease — 7% of the population. About 15 million of this number have been diagnosed. The rest have no idea that they’re afflicted.

With obesity rates soaring, as many as 54 million others are strongly at risk of contracting diabetes in the future.

In my case, diabetes struck not because I stuff my face with Big Macs and fried chicken, which I don’t. I take good care of myself and am not overweight — considerably less so since unexpectedly dropping about 15 pounds over the past couple of months.

No, it’s almost certain I got nailed because a genetic time bomb finally exploded.

My father, Paul N. Lazarus III, who produced the movies “Westworld” and “Capricorn One,” has Type 1 diabetes and is now nearly blind. My younger brother has Type 1 and is doing well enough. My aunt had Type 1 before it blinded and then killed her.

The doctors say diabetes — almost certainly Type 1 — has been lurking in my DNA since I was a child, waiting for its time to strike.

But why now? I’ve lived 46 fairly healthy years, except for certain pharmaceutical pursuits during college. I don’t drink. I don’t smoke. I exercise as regularly as I can. What did I do wrong?

Probably nothing. The stress of my recent move to L.A. and starting a new job didn’t help, but it’s not to blame. This was going to happen no matter what.

I had a good idea something was wrong when I noticed that my weight kept going down no matter what I ate, and that I was consumed with a thirst of biblical proportions (accompanied by a commensurate increase in bathroom breaks).

I visited my doctor and had a blood test. The bad news came just days later. I was immediately referred to a specialist, whom I’ll call Dr. B.

Dr. B was great — knowledgeable, sensitive, empathetic. Problem was, Dr. B didn’t take insurance.

Excuse me? I said.

Dr. B explained that it just wasn’t cost-effective for him to seek reimbursement from insurance companies. It was too much hassle, he said, and he didn’t get paid enough for his efforts. Dr. B said an increasing number of doctors were cutting ties with insurers for the same reasons.

If I wanted to see him at his private practice, which was most convenient to my home, each visit could cost me hundreds of dollars — not the most appealing prospect when one’s facing a chronic disease.

Dr. B said I could try to deal with insurance reimbursements on my own, but that’s the last headache I wanted to inflict on myself at this point.

So I had to quickly find a doctor who would take insurance. My insurer’s website had a directory of possible choices, but you’re essentially pulling a name out of a hat — not the best way to make decisions when your blood-sugar level is three or four times normal.

This led me to Dr. W, who was equally knowledgeable if perhaps a bit lacking in the empathy department. He also had what seemed to me unconventional ideas about how diabetes can be treated with certain drugs and a rigidly monastic diet of his own devising.

This ultimately led me to Dr. D at UCLA’s Gonda (Goldschmied) Diabetes Center, whom I’m very fortunate to have found. Not only does he know what he’s doing, but he also has the resources of a world-class medical facility that focuses exclusively on what’s trying to put me under dirt.

It was Dr. D who finally made the call that I needed to start insulin injections, and it was he who made sure I knew how to handle that first, life-changing moment when needle touched skin.

Clearly I’m receiving the best available treatment, and I’d rather be here than anywhere in the world.

But the quirks and complexities of the insurance system border on madness. Through my employer, I have about as much insurance coverage as anyone. Yet that wasn’t good enough for Dr. B.

I have to wonder where else my private-sector insurance will fail me in years ahead.

And what happens if I get fired tomorrow? With a preexisting condition, I’m virtually uninsurable in the individual insurance market. Will diabetes leave my family destitute?

In the past, I always wrote about the uninsured in a largely abstract way — a faceless mass of millions of people confronted with a broadly defined medical challenge. I know better now.

The terrifying possibility of my own loss of coverage gives me an acute sense of what the uninsured must deal with, the dreadful awareness that you and your loved ones are only one medical misstep from catastrophe.

That’s unacceptable for any person who lives in the wealthiest, most advanced nation in the history of the world.

I’ll have a lot more to say about this in the future, especially as my own situation takes shape. But this much at least is evident:

* Universal coverage must be our goal, and it must allow ready access to all aspects of the medical system at affordable prices.

* The emphasis must be on treatment, not bureaucracy. As it stands, researchers at Harvard University estimate that about a third of the $2 trillion in annual healthcare spending is squandered on bureaucratic overhead.

* Employer-based healthcare is obsolete. As costs continue climbing, businesses can no longer meet their historical obligation of being the primary provider of coverage to American families.

* Quality medical treatment is a right, not a benefit.

Unfortunately, nearly all healthcare-reform proposals on the table center on expanding the existing system and pushing the uninsured into high-cost individual policies that will make private insurers even more profitable.

That can’t be the answer.

Single-payer isn’t perfect. Critics say it can involve long waits for treatment and can stifle innovation.

My belief is that Americans can get it right. We can learn from the examples of other nations and refine things so that our healthcare is second to none. It won’t be easy. Then again, how much worse could it be than the way things are now?

As of this moment, I’m completely dependent on the U.S. healthcare system to keep me alive. I, and you, shouldn’t have to settle for anything but the best.

Medicare for All seems to be embraced by all

Saul Friedman
Gray Matters
Newsday
October 6, 2007

There is something in the air besides autumn. I’ve been waiting for readers to take me to task for the Gray Matters of Aug. 4, in which I suggested that all of us – young and old – needed a single-payer universal health plan, Medicare for All, even if it meant raising some taxes.

But if you go to Newsday online and read the comments, several of which I list below, you’ll see that no one dissented. And while the e-mail and regular mail voiced skepticism that our politicians would overcome the conservative opposition and the lobbies of the medical-industrial complex, virtually everyone welcomed the possibility of universal Medicare for every American, as if to say with a deep sigh, “It’s about time.”

Alas, the presidential candidates, especially most of the Democrats, have not caught up with the voters. They still are trying to avoid a single-payer plan to pacify the insurance industry and minimize their opposition

Yet, the messages of the past couple of years have sunk in with readers, if not the pols. Just last month the National Center for Health Statistics reported that while life expectancy has risen among white American males to 77.9 years, the United States has dropped from 11th to 42nd place in 20 years. But we’re first in the problem of obesity and the number of people (47 million) without health coverage. Wednesday, President George W. Bush vetoed a bill that would have expanded government health insurance for children.

And every day there’s another horror story about someone whose insurance failed them and left them broke as well as sick. Consumer Reports last month said that 29 percent of insured persons who were surveyed said their coverage was so meager that they often postponed medical care. And 43 percent with insurance said they were financially unprepared to cope with serious illness.

One writer from Brooklyn made a point by attaching a Newsday story about the naval ship Comfort, which had just completed a mission to provide free medical care for 25,000 patients in Belize and Guatemala. “It appears that the U.S. provides free medical care to everyone but U.S. citizens,” said the writer.

From Johannes in Gallatin, Tenn.: “Several hundred billions for a war that was supposedly meant to protect Americans, but billions for universal health care could protect Americans. I’ve heard people say health care is a privilege and not a right.”

But Mag, from Katy, Texas, replied, “When the uninsured quit buying cell phones and cable TV and eating out at every fast-food place … I might care about their plight.”

To which Johannes replied, “How do you know that people buying fast-food, cell phones and cable TV are all uninsured? … A great many uninsured people have jobs and would love to pay for insurance but insurance companies don’t like to cover everyone.”

And Judy K, from New York, wrote, “I watched ‘Sicko’ yesterday and I cried for the people in the film and for all other Americans in similar positions. I am so angry. Our government has let us down on every level.”

The e-mail from Daryl Altman, 52, of Lynbrook, was clinical, reflecting his profession. He’s a pediatrician and an allergist for the school health program of New York City’s Health Department. And he supplements his income treating poor patients at a community health center. But, as he writes, “I’m also a patient like everyone else.” And in the summer, when there is no school, he’s furloughed and loses his health insurance. “So right now, my family and I are among the millions of uninsured Americans.” He added, “But I’m lucky. I’m a doctor and I earn a decent living. I see patients every day, mostly American citizens, working poor who can afford my care because of my clinic’s sliding scale. But they won’t get better because they can’t afford their asthma medication. It’s obvious to me that the only answer is Medicare for all. Medicare works for senior citizens. Why are the rest of Americans denied this plan?” Altman digressed to analyze most Republican plans, like one offered by former Mayor Rudy Giuliani, which depends on giving tax credits of up to $15,000 to workers to buy insurance. Good insurance for a family of four might cost near that much.

But citing the IRS tax tables, Altman pointed out that a person qualifying for $15,000 in credits is earning $80,000. But the median family income in the U.S. is $46,000, with taxes amounting to $6,860. Even if the worker got every penny back in credit, it wouldn’t buy much health insurance. “The larger issue,” Altman said, “is why should insurance companies exist at all? Why should non-medical people at remote locations be making medical decisions for my patients? Why should shareholders speculate with our health care money? The money wasted by insurance companies could easy fund Medicare for all.”

Coincidentally, the aforementioned Consumer Reports analysis found that the median income of families without health insurance was $58,950 a year. But between 2001 and 2005, employer-based health coverage for middle-income households – a family of four earning between $40,000 and $80,000 – declined by 4 percent.

“An explanation isn’t difficult to find,” said Consumer Reports. “Health plans are offloading more and more expenses onto consumers. Co-pays and deductibles have risen steadily.”

Dr. Don McCanne, of Physicians for a National Health Program, says, “Private insurers have had their day. They have been ineffective in expanding coverage and affordability, while being the greatest cause of the expanding inefficiency of our system.”

Tell that to the presidential candidates.

WRITE TO Saul Friedman, Newsday, 235 Pinelawn Rd., Melville, NY, 11747-4250, or by e-mail at saulfriedman@comcast.net.

Medicare Audits Show Problems in Private Plans

By ROBERT PEAR
The New York Times
Published: October 7, 2007

WASHINGTON, Oct. 6 — Tens of thousands of Medicare recipients have been victims of deceptive sales tactics and had claims improperly denied by private insurers that run the system’s huge new drug benefit program and offer other private insurance options encouraged by the Bush administration, a review of scores of federal audits has found.

The problems, described in 91 audit reports reviewed by The New York Times, include the improper termination of coverage for people with H.I.V. and AIDS, huge backlogs of claims and complaints, and a failure to answer telephone calls from consumers, doctors and drugstores.

Medicare officials have required insurance companies of all sizes to fix the violations by adopting “corrective action plans.” Since March, Medicare has imposed fines of more than $770,000 on 11 companies for marketing violations and failure to provide timely notice to beneficiaries about changes in costs and benefits.

The companies include three of the largest participants in the Medicare market, UnitedHealth, Humana and WellPoint.

The audits document widespread violations of patients’ rights and consumer protection standards. Some violations could directly affect the health of patients — for example, by delaying access to urgently needed medications.

In July, Medicare terminated its contract with a private plan in Florida after finding that it posed an “imminent and serious threat” to its 11,000 members.

In other cases, where auditors criticized a company’s “policies and procedures,” the effects on patients were not clear.

The audits show the growing pains that Medicare has experienced as it introduced the popular new drug benefit and shifted more responsibility to private health plans.

For years, Democrats have complained about efforts to “privatize Medicare,” and they are likely to cite the findings as evidence that private insurers cannot be trusted to care for the sickest, most vulnerable Medicare recipients.

But federal officials point with pride to their efforts to police the Medicare market, and they say that competition among private plans has been a boon to beneficiaries, offering more choices at lower cost than anyone expected.

“The Medicare drug benefit is saving seniors an average of $1,200 a year,” said Michael O. Leavitt, the secretary of health and human services.

Medicare officials said the audits also showed that insurers would be held accountable.

“The start-up period is over,” said Kerry N. Weems, the new acting administrator of the Centers for Medicare and Medicaid Services. “I am simply not going to tolerate marketing abuses.”

The same insurance companies that offer stand-alone drug plans also sell Medicare Advantage plans, which provide a full range of benefits including coverage of doctor’s visits and hospital care. Enrollment in Medicare Advantage plans has grown rapidly, to more than 8 million, from 4.7 million in 2003. Federal auditors found the same types of violations in both parts of the program.

Of the audits conducted by the Department of Health and Human Services, 39 focused on drug benefits, 44 focused on managed care plans and 8 examined other types of private plans.

Medicare officials said that compliance problems occurred most often in two areas: marketing, and the handling of appeals and grievances related to the quality of care.

Many of the marketing abuses occurred in sales of the fastest-growing type of Medicare Advantage product, known as private fee-for-service plans. In June, the government announced that seven of the leading companies in this market, including UnitedHealth, Humana and Coventry, had agreed to suspend marketing of these plans. Medicare recently allowed them to resume marketing after they took steps to monitor their sales agents more closely.

Each Medicare plan has a list of preferred drugs, known as a formulary. Under federal law, patients can request coverage of other drugs that may be medically necessary. But many insurers do not have procedures to handle such requests, auditors said.

John H. Wells, the compliance officer at Bravo Health, defended the company’s record, but he said: “The appeals and grievance process is very complex. It is very difficult for any plan to be fully compliant. In many cases, the government’s guidance is unclear, so it’simpossible for a business to know what to do.”

These findings were typical of the deficiencies described in Medicare audit reports:

UnitedHealth, which serves more than six million Medicare beneficiaries, did not have an “effective program” to supervise its marketing representatives, agents and brokers. In some cases, United improperly denied claims without giving any explanation to beneficiaries. Peter L. Ashkenaz, a company spokesman, said, “We terminated a few agents and brokers for misrepresenting our products.”

WellPoint, one of the nation’s largest insurers, had “a backlog of approximately 354,000 claims” at certain Medicare plans offered through its UniCare subsidiary. The company’s call center took an average of 27 minutes to answer phone calls from its members and 16 minutes to answer calls from health care providers. More than half the callers hung up before speaking to a company representative. Karen Brown, a spokeswoman for WellPoint, had no immediate comment.

In March, Sierra Health Services ended drug coverage for more than 2,300 Medicare beneficiaries with H.I.V./AIDS, saying they had not paid their premiums. In many cases, the premiums had been paid, and beneficiaries had canceled checks to prove it. Sierra initially refused to reinstate them, but eventually agreed to do so after repeated requests from federal officials. Peter O’Neill, a vice president of Sierra, said this particular drug plan, which attracted people with very high drug costs, would not be offered in 2008.

Humana, which covers more than 4.5 million people on Medicare, promised to investigate every complaint about its marketing practices, but it received so many complaints that it could not keep up. Many beneficiaries said they had received incorrect information from Humana agents. Medicare officials said some agents had not been adequately trained or supervised. Thomas T. Noland Jr., a senior vice president of Humana, said the company had taken “corrective action to improve the situation.”

Humana did not always tell beneficiaries about changes in its list of covered drugs. In some cases, Humana did not explain its reasons for denying claims and did not inform beneficiaries of their appeal rights.

The Sterling Life Insurance Company, a subsidiary of the Aon Corporation, did not pay claims correctly or handle appeals in a timely way. The company has “a demonstrated pattern of failure” to meet Medicare performance standards. Problems were compounded by a rapid growth in enrollment. Sterling said it had taken steps to improve compliance.

Two sponsors of popular Medicare drug plans, MemberHealth and Bravo Health, did not act on requests for coverage of specific drugs within 72 hours, as required by the government. Bravo did not comply with federal rules requiring doctors to review all claims denied for a “lack of medical necessity.”

D. Alan Scantland, senior vice president of MemberHealth, a subsidiary of the Universal American Financial Corporation, said, “We don’t believe that we were compromising any beneficiaries’ health because of what we were doing or not doing.”

Representative Bart Stupak, a Michigan Democrat who is chairman of the investigations subcommittee of the House Energy and Commerce Committee, said he had “verified countless stories of deceptive sales practicesby insurance agents who prey upon the elderly and disabled to sell them expensive and inappropriate private Medicare plans.”

Kathleen Healey, a lawyer at the Alabama Department of Senior Services, said: “Despite the prohibition of door-to-door marketing, agents arrive on residents’ doorsteps stating that the president sent them, or that they represent Medicare. Some telemarketers insist they are calling from Medicare, and they tell beneficiaries that they will lose their Medicare if they do not sign up for the telemarketer’s plan.”

Medicare has taken “vigorous action” to halt marketing violations, said Abby L. Block, a Medicare official.

But David A. Lipschutz, a lawyer at California Health Advocates, a nonprofit group, said that Medicare’s generous payments to private plans still encouraged predatory sales practices.

“Every enrollee in a private Medicare plan is a potential source of substantial profits,” Mr. Lipschutz said.

“No Worry” health plan

Health insurers introduce plans with “predictable premiums.”

American Medical Association
Morning Rounds
October 9, 2007

The Wall Street Journal (10/9, D3, McQueen) reports, “Guardian Life and Humana Inc. are introducing multiyear plans designed to make health-insurance premiums more predictable from year to year for smaller employers.” However, “workers could face sharply higher deductibles and co-payments for prescriptions and office visits if medical costs rise more than expected.” Guardian Life will make available its “Premium Protect” plan “in the next week or two in five states and the District of Columbia for employers with 51 to 150 employees.” Meanwhile, Humana already introduced its plan, called “No Worry,” in February. “The Humana plans require employers [of 51 to 99 staff] to hand over a large percentage of workers’ phone and email contact information to get annual premium rises of no more than 6%.” The Journal notes, “Guardian achieves its rate-increase lock-in by charging employers an upfront fee of 3% to 4% in return for a guaranteed increase of 0%, 6% or 9% in the second year of a two-year plan.” In contrast, Humana “guarantees annual rate increases won’t exceed 6%.” However, “employers who terminate the contract before the end of the three-year period face a $25,000 penalty.”

http://www.ama-assn.org/

Comment:

By Don McCanne, MD

No worry. Employers can now lock in their premium rates by merely agreeing in advance to pass on health care cost increases to their employees through yet higher deductibles and co-payments.

And you were beginning to think that the private insurance industry was incapable of adressing the problem of escalating health costs.

There is a problem though. If employers really do care about the welfare of their employees, they will need to provide bankruptcy counselors for those whose families actually need medical care.

Nation’s healthcare crisis gets personal

By David Lazarus
Los Angeles Times
October 7, 2007

I write a lot about healthcare reform. Now it’s personal.

I was diagnosed this past week with diabetes. As of Friday, I was injecting myself with insulin, something I’ll be doing four or five times a day, every day, for the rest of my life. Without the injections, I’ll likely die.

Scared? You’re damn right I’m scared. What’s going to happen to me? What’s going to happen to my family?

I got past the shock pretty quickly and am now stuck somewhere between denial and anger. Depression will soon arrive, followed eventually by acceptance. Something to look forward to.

This is an uncertain time for me, but I know this much: I’m more convinced than ever that our medical system is a mess and that a single-payer insurance program is the only realistic way we can achieve universal coverage, promote preventive treatment and make healthcare affordable to all.

And if contracting diabetes is frightening for a relatively well-insured person like myself, what must it be like for any of the 47 million Americans who lack health insurance?

According to the American Diabetes Assn., nearly 21 million U.S. adults and kids have the disease — 7% of the population. About 15 million of this number have been diagnosed. The rest have no idea that they’re afflicted.

With obesity rates soaring, as many as 54 million others are strongly at risk of contracting diabetes in the future.

In my case, diabetes struck not because I stuff my face with Big Macs and fried chicken, which I don’t. I take good care of myself and am not overweight — considerably less so since unexpectedly dropping about 15 pounds over the past couple of months.

No, it’s almost certain I got nailed because a genetic time bomb finally exploded.

My father, Paul N. Lazarus III, who produced the movies “Westworld” and “Capricorn One,” has Type 1 diabetes and is now nearly blind. My younger brother has Type 1 and is doing well enough. My aunt had Type 1 before it blinded and then killed her.

The doctors say diabetes — almost certainly Type 1 — has been lurking in my DNA since I was a child, waiting for its time to strike.

But why now? I’ve lived 46 fairly healthy years, except for certain pharmaceutical pursuits during college. I don’t drink. I don’t smoke. I exercise as regularly as I can. What did I do wrong?

Probably nothing. The stress of my recent move to L.A. and starting a new job didn’t help, but it’s not to blame. This was going to happen no matter what.

I had a good idea something was wrong when I noticed that my weight kept going down no matter what I ate, and that I was consumed with a thirst of biblical proportions (accompanied by a commensurate increase in bathroom breaks).

I visited my doctor and had a blood test. The bad news came just days later. I was immediately referred to a specialist, whom I’ll call Dr. B.

Dr. B was great — knowledgeable, sensitive, empathetic. Problem was, Dr. B didn’t take insurance.

Excuse me? I said.

Dr. B explained that it just wasn’t cost-effective for him to seek reimbursement from insurance companies. It was too much hassle, he said, and he didn’t get paid enough for his efforts. Dr. B said an increasing number of doctors were cutting ties with insurers for the same reasons.

If I wanted to see him at his private practice, which was most convenient to my home, each visit could cost me hundreds of dollars — not the most appealing prospect when one’s facing a chronic disease.

Dr. B said I could try to deal with insurance reimbursements on my own, but that’s the last headache I wanted to inflict on myself at this point.

So I had to quickly find a doctor who would take insurance. My insurer’s website had a directory of possible choices, but you’re essentially pulling a name out of a hat — not the best way to make decisions when your blood-sugar level is three or four times normal.

This led me to Dr. W, who was equally knowledgeable if perhaps a bit lacking in the empathy department. He also had what seemed to me unconventional ideas about how diabetes can be treated with certain drugs and a rigidly monastic diet of his own devising.

This ultimately led me to Dr. D at UCLA’s Gonda (Goldschmied) Diabetes Center, whom I’m very fortunate to have found. Not only does he know what he’s doing, but he also has the resources of a world-class medical facility that focuses exclusively on what’s trying to put me under dirt.

It was Dr. D who finally made the call that I needed to start insulin injections, and it was he who made sure I knew how to handle that first, life-changing moment when needle touched skin.

Clearly I’m receiving the best available treatment, and I’d rather be here than anywhere in the world.

But the quirks and complexities of the insurance system border on madness. Through my employer, I have about as much insurance coverage as anyone. Yet that wasn’t good enough for Dr. B.

I have to wonder where else my private-sector insurance will fail me in years ahead.

And what happens if I get fired tomorrow? With a preexisting condition, I’m virtually uninsurable in the individual insurance market. Will diabetes leave my family destitute?

In the past, I always wrote about the uninsured in a largely abstract way — a faceless mass of millions of people confronted with a broadly defined medical challenge. I know better now.

The terrifying possibility of my own loss of coverage gives me an acute sense of what the uninsured must deal with, the dreadful awareness that you and your loved ones are only one medical misstep from catastrophe.

That’s unacceptable for any person who lives in the wealthiest, most advanced nation in the history of the world.

I’ll have a lot more to say about this in the future, especially as my own situation takes shape. But this much at least is evident:

* Universal coverage must be our goal, and it must allow ready access to all aspects of the medical system at affordable prices.

* The emphasis must be on treatment, not bureaucracy. As it stands, researchers at Harvard University estimate that about a third of the $2 trillion in annual healthcare spending is squandered on bureaucratic overhead.

* Employer-based healthcare is obsolete. As costs continue climbing, businesses can no longer meet their historical obligation of being the primary provider of coverage to American families.

* Quality medical treatment is a right, not a benefit.

Unfortunately, nearly all healthcare-reform proposals on the table center on expanding the existing system and pushing the uninsured into high-cost individual policies that will make private insurers even more profitable.

That can’t be the answer.

Single-payer isn’t perfect. Critics say it can involve long waits for treatment and can stifle innovation.

My belief is that Americans can get it right. We can learn from the examples of other nations and refine things so that our healthcare is second to none. It won’t be easy. Then again, how much worse could it be than the way things are now?

As of this moment, I’m completely dependent on the U.S. healthcare system to keep me alive. I, and you, shouldn’t have to settle for anything but the best.

Audience at health care forum backs single-payer proposal

By David Montero
Rocky Mountain News
October 5, 2007

BOULDER – There may be five proposals being considered to reform health care in Colorado, but only one seemed to satisfy most of the 150 gathered at the Millennium Hotel on Thursday night.

That proposal was the so- called single-payer system.

One after another, they strode to the microphone – breast cancer survivors, parents of children with autism and even a few people with no illnesses – all asking members of the Blue Ribbon Commission for Health Care Reform to radically restructure the current system.

People like William Starr, a healthy 84-year-old Boulder resident.

“I have the feeling that this is all a put-on if you’re making a fifth proposal that is backing the insurance companies when there is only one proposal that fits what your guiding principles were,” Starr said, advocating the single-payer system.

The public comment sessions were set up by the commission to gather public input on how to change the way health care is delivered for state residents.

Four separate proposals sponsored, respectively, by a powerful union, a consortium of underwriters, health care industry officials and the single-payer plan went through several drafts and changes this year and could be forwarded to state lawmakers this winter for consideration. A fifth proposal is currently in its first draft and won’t be reviewed by the commission until the middle of the month.

Regina Hathorne, a 55-year- old Boulder resident, said the proposed cap of $50,000 for catastrophic care was “laughable” when put into context of what is considered catastrophic.

“This country is currently experiencing economic racism when it comes to health insurance,” she said. “The question is do we all deserve the same health insurance? It’s a huge change in society’s values.”

The five proposals appear to be a stab at that, with Gov. Bill Ritter urging the state to find a way to cover the more than 780,000 Coloradans currently without health insurance.

Though the tide at the Boulder meeting was decidedly toward single-payer, commissioners were quick to point out that the sentiment might be different as they solicit public comments throughout the state.

And at least one speaker, Brian Schwartz, proposed getting government out of health care entirely – calling Medicaid a “failure” and an example of why single-payer won’t work. Instead, he advocated the free-market system.

“Should we have single-payer food and housing?” he asked. “Didn’t we settle that with Soviet Russia and North Korea? Why is health care different?”

The Garden Hose Health Care Brigade

Matthew Holt
San Francisco
Oct. 4, 2007

It’s been a strange old week for me in healthcare. Half was spent working with new Health 2.0 technology companies who are trying change every conceivable aspect of the patient and physician relationship. The rest was spent hanging out with a bunch of right wing lunatics. In the background the major healthcare policy stories of the last few weeks have been Sen. Hillary Clinton’s announcement – at last! – of her plan for universal coverage, and President George Bush’s vetoing of the children’s health insurance program.

So, I guess it’s my job to try to make sense of all of this. And, well, I can. But not in ways you may like.

The politics of the moment is very strange indeed.

On the one hand, a deeply unpopular president has gone against moderate members of his own party by vetoing a bill to help “the children” by expanding government-backed health care for young Americans. If there is a more powerful sound bite for Democratic candidates during the next year, I haven’t seen it. Nor have you.

On the other hand, the Democrat presidential candidates have come up with a series of proposals that the Republicans have already dismissed as socialized or, worse, French. This despite the fact that the French health care system is commonly known as one of the best in the world and is actually one that Americans would rather like.

Meanwhile, inside the beltway and on WMUR, the only TV station that matters in Manchester, N.H., a myriad of interest groups are now focusing on the uninsured. The American Cancer Society is spending all of its publicity budget for the next year on the uninsured, while Physicians for a National Health Program (an advocate of the single-payer system) is attacking Democratic candidates because they all leave a role for private insurance companies in their policy proposals. The American Medical Association (AMA) is plastering the Washington DC Metro subway with exhortations to listen to the voice for the uninsured, hoping, I guess, that you’ll conveniently forget the AMA’s role in stopping any sort of national universal insurance program for the past century or so.

What this all comes down to is an open, raging and actually somewhat interesting philosophical battle about how best to provide insurance coverage. Which is how I found myself on a stage – with someone calling himself an “Objectivist” in that fine Ayn Rand tradition – speaking to an audience of knee-jerk libertarians. The Objectivist wasn’t very objective, but boy did he object to virtually everything done on behalf of the community. Why? In his philosophy anything done on behalf the community is, by definition, something done to somebody against their will. I have met plenty of people who want to abolish Medicare and Medicaid, without providing any substitute (and they are mostly young and rich). But this is the first time I’ve met someone wanting to abolish the publicly-funded fire department in favor of a garden hose brigade. My pleas that he support his contention that the private sector works better in healthcare than the public sector with actual data were roundly ignored so, faced with this sort of audience, I couldn’t help but feel some sympathy for the struggle any politician will have to get some level of common understanding of the real health care problems confronting America.

It’s quite possible to have a rational conversation with a libertarian and eventually convince them that a free market in health insurance is not the same as a free market in home insurance. After all, the health insurance seller is – through medical records and queries about your health, habits and well-being – able to see which house is already a simmering fire before they write an insurance contract. Yes – that’s what health insurance underwriting actually does–what do you think those “family history” questions are all about?. But if that objectivist doesn’t care that the sick person with the (figurative) house on fire is going to suffer, or agree that that somehow society should help them out, it’s pretty hard to understand how you come up with a solution that will keep them happy.

Which gives Democrats a two-faced dilemma if they really want to change the current system. First, can they get enough Americans with a shared general understanding of the problems facing the entire healthcare system so they can actually win an election on the issue? Democrats main chance of taking back the White House and keeping the Congress rests on people’s belief that they are better for domestic policy, particularly healthcare. Which is why the Republicans are playing to the gallery and decrying all things French (except wine, cheese, and in the case of Mrs. Rudolph Giuliani, handbags).

Assuming the Democrats get over that hurdle, then they actually have to try to get something passed. Now it gets really tricky.

I’ve said repeatedly on this site that I think things aren’t bad enough yet for enough Americans to clamor for a change in the health care system. Although most American have horrible health insurance, the majority of them don’t know it. And they have no idea that the medical care they are receiving is massively suboptimal. Getting that particular message across is very difficult. Who wants to hear that their doctor is a dope? Or that, by extension, they’re dope for having a bad doctor? No one. So Hillary Clinton, Sen. Barack Obama’s and to a lesser extent former Sen. John Edwards’ proposals all stress that they’re not trying to change employer-based health insurance, which most Americans have and, it seems, tolerate. Instead, the politicians say they are merely trying to add a little wraparound for those people for whom employer-based health insurance is not available.

When you burrow into the details of the proposals – and you can be assured that the lobbyists for the healthcare industry will – it becomes clear that at some stage employers and insurance companies, not to mention the Medicare program, will have to start acting very differently. No rational end payer – put in the situation of not be able to easily get out of covering people who are sick and therefore expensive – is going to just let the healthcare system continue on in cruise control as it is done for the past 50 years or so. The folks who pay the bills are going to demand changes. And changes aren’t going to be much loved by the folks who have been running health care for the past half-century. That means that despite their high-fallootin’ rhetoric about the uninsured, the AMA (not to mention the drug companies, hospitals and everyone else with a nose in the trough) is going to find itself in stark opposition to much of what health care reform will mean.

The question then is pretty basic: Is the disgust of the American public with the healthcare system enough to overcome the healthcare industry’s inertia? My guess is that much more pain and education is required. The group that I spoke with last week had no comprehension of the concept of spreading risk and cost for health care across the community or society. Worse, the discussion was also hijacked by several outright loonies who thought that all problems in American health care were due to illegal immigrants – as if there’s a rash of elderly cancer patients swimming across the Rio Grande. There’s lots of fear-mongering – on the left and the right – and gets in the way of genuine efforts for change.

Perhaps what’s needed is a real down-and-dirty political operative like Otto von Bismarck, President Lyndon Johnson or even – God help us – Dick Cheney who knows how to focus attention on selling healthcare reform the way they sold the idea of invading other countries: As some kind of patriotic duty. If you question that you’re some kind of traitor.

Failing that, I can see Sen. Hillary Rodham Clinton spending two presidential terms trying – really trying – to have a sensible conversation about healthcare reform with an objectivist who wants to abolish the fire department so we can all put out mountain fires with our garden hoses.