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Uwe Reinhardt on ethics and economics of end-of-life care

Uwe Reinhardt on ethics and economics of end-of-life care

End-of-Life Care: Where Ethics Meet Economics

By Uwe Reinhardt
The New York Times
August 14, 2009

… the debate — really, shouting match — over health-care reform has focused on end-of-life care in recent weeks…

An earlier report in The Wall Street Journal had quoted physicians at Memorial Sloan-Kettering Canter Center in New York stating that “the standard treatment regimen for advanced colon cancer, which can include Erbitux [and Eloxatin and Avastin] in the mix, is close to $250,000 for 19-20 months of treatment. … And for that money, patients may get only a few months [of added life].”

And therein lies a dilemma increasingly faced by modern societies.

Readers are well advised to read Senator Isakson’s thoughtful comments on end-of-life planning, along with an equally thoughtful research brief “Advance Care Planning: Preferences for Care at the End of Life,” published in March 2003 by the Agency for Health Care Research and Quality.

The thrust of that research brief, as of the Senate bill and of Section 1233 of the House bill, was to enhance the probability that the end-of-life care actually received by a person should conform to his or her own preferences, rather than either the physician’s or the government’s preferences.

Health spending in the United States has doubled every 10 years during the past four decades. It may well do so again in the coming decade. As health spending grows year after year roughly twice as fast as the payroll that supports private health spending in this country, Americans sooner or later will have to confront the hard questions about access to expensive treatments, perhaps after a rational national conversation, if such can still be had in America.

Posted reader comment:

Ethics meets economics not only at the end of life, but throughout a lifetime of health care. Economics provides us with various alternatives on financing health care, and ethics provides us with the decency to do it the right way.

But the pervasive noise seems to be drowning reason out. For example, when a protester complained to Sen. Specter that he wasn’t listening to what they wanted, Sen. Specter asked him to tell him just that. The protester was flummoxed, and only after being prompted by several others in the audience, he said, “tort reform.”

It would be tragic if those crafting reform allow themselves to be influenced by those who understand neither the economics nor the ethics. Perhaps it would be even worse if they allow themselves to be influenced by the moneyed interests who understand very well the economics, but could care less about the ethics.

— Don McCanne, MD

http://economix.blogs.nytimes.com/2009/08/14/end-of-life-care-where-ethics-meet-economics/#more-26155

Helen Thomas on single payer

Health care for all

By Helen Thomas
San Francisco Chronicle
Politics Blog
August 12, 2009
It’s all so sad. Well-organized conservatives have launched a full-scale attack on health care reform. And they appear to be winning — for now.
I covered the battle to create the Medicare system back in the 1960s. The cries of “socialized medicine” worked for years until President Johnson rammed Medicare through Congress in 1965.
What kind of a nation are we if we do not provide everyone with the excellent medical care that only some of us now receive?
I continue to think the so-called single-payer system is the only answer to the nation’s obligation to make sure that no one lacks health care. Yes, single payer means a government-run health insurance program for all — the prevailing system in Canada and in many nations in Europe.
President Obama is making a big mistake by ignoring the single-payer proposal.
In 2003 before he became a U.S. senator from Illinois, Obama actually called himself a single-payer “proponent.” But now that he is president, Obama has buckled to Republicans and conservative Blue Dog Democrats in pursuit of consensus. My question is if Congress passes a watered-down version of health care that doesn’t truly cover everyone, is the result worth it?
President Obama should lay down markers for real health care reform — meaning we all kick in to a national program instead of fattening the pocketbooks of the insurance financiers.
Instead, the president has given up on Medicare for all, calling single payer “impractical.”
He still has time to do the right thing and nothing to lose.
For the full article:
http://www.sfgate.com/cgi-bin/blogs/nov05election/detail?blogid=14&entry_id=45426

Helen Thomas doesn’t ever give up, thank goodness. As she writes, President Obama “still has time to do the right thing.”

Helen Thomas on single payer

Health care for all

By Helen Thomas
San Francisco Chronicle
Politics Blog
August 12, 2009

It’s all so sad. Well-organized conservatives have launched a full-scale attack on health care reform. And they appear to be winning — for now.

I covered the battle to create the Medicare system back in the 1960s. The cries of “socialized medicine” worked for years until President Johnson rammed Medicare through Congress in 1965.

What kind of a nation are we if we do not provide everyone with the excellent medical care that only some of us now receive?

I continue to think the so-called single-payer system is the only answer to the nation’s obligation to make sure that no one lacks health care. Yes, single payer means a government-run health insurance program for all — the prevailing system in Canada and in many nations in Europe.

President Obama is making a big mistake by ignoring the single-payer proposal.

In 2003 before he became a U.S. senator from Illinois, Obama actually called himself a single-payer “proponent.” But now that he is president, Obama has buckled to Republicans and conservative Blue Dog Democrats in pursuit of consensus. My question is if Congress passes a watered-down version of health care that doesn’t truly cover everyone, is the result worth it?

President Obama should lay down markers for real health care reform — meaning we all kick in to a national program instead of fattening the pocketbooks of the insurance financiers.

Instead, the president has given up on Medicare for all, calling single payer “impractical.”

He still has time to do the right thing and nothing to lose.

For the full article:
http://www.sfgate.com/cgi-bin/blogs/nov05election/detail?blogid=14&entry_id=45426

Comment:

By Don McCanne, MD

Helen Thomas doesn’t ever give up, thank goodness. As she writes, President Obama “still has time to do the right thing.”

Healthcare reform: Locum tenens perspective on single payer

By Daniella Grossman
Modern Medicine
August 15, 2009

This is the first in a series of reports analyzing various aspects of healthcare reform Congress is considering. –Ed.

Sixteen years after the late Democratic Sen. Paul Wellstone proposed the American Health Security Act of 1993, which would have created national health insurance and extended benefits to all Americans, lawmakers are once again considering a single-payer healthcare system.

On both sides of the ideological battle, policy makers, analysts, and healthcare providers agree that reform is needed. A shortage of primary care physicians, imbalanced coverage, and exorbitant costs that don’t always correspond with exorbitant care are just a few of the countless reasons why the healthcare status quo, which left more than 43 million people in the United States without insurance in 2007, is under attack.

“A single-payer system in theory can help control costs and help with patient outcomes,” says Kevin Pho, MD, an internist practicing primary care in Nashua, New Hampshire. “But a lot of physicians are against it, based on the idea of a Medicare-for-all system where the government will be the only payer. Politically, it’s very controversial.”

Several bills introduced in Congress isolate a clear culprit for the biggest failings of the healthcare system: insurance companies. “There’s no question that the private insurance companies would be most negatively affected,” Dr. Pho says. “They won’t exist in a single-payer system.”

Private insurance companies would be eliminated, in addition to current benefits through government programs such as Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP). States would operate their own health-security programs to cover all citizens, nationals, and legal residents.

In mid-July, the House Committee on Education and Labor approved an amendment to the national healthcare reform bill that would enable individual states to adopt single-payer, Medicare-for-all style reforms. Introduced by Rep. Dennis Kucinich (D-Ohio), the amendment would remove potential legal impediments for states to pass single-payer bills by waiving federal exemptions that apply to employer-sponsored health plans.

The amendment passed on a bipartisan vote of 25-19, with the support of both progressive, single-payer Democrats and many Republicans who endorsed the ability of individual states to pass their own versions of healthcare reform.

THE SUPPORT

For Anne Scheetz, MD, a single-payer healthcare system is both socially and financially sound. She’s one of 16,000 members with Physicians for a National Health Program (PNHP), she serves as the Chicago co-chair for the Illinois Single Payer Coalition, and she’s an ardent advocate of national health insurance. “We have two slogans,” Dr. Scheetz says of PNHP. “One is ‘everybody in, nobody out,’ and the other is ‘one nation, one plan.’ Although some people say it’s not politically feasible, it’s inevitable. We can’t survive without it, economically or as a citizenship that stands together.”

Dr. Scheetz makes house calls to her mostly elderly patients, all of whom are insured through Medicare. She says the fragmented network of multiple payers that most doctors, nurses, and technicians rely on takes critical time away from medical work. With one source of reimbursement, providers could spend more time caring for patients instead of arguing with insurers on the phone. “Right now, with private insurance companies you don’t know what’s covered until you don’t get paid for it, and you don’t know how they arrived at that decision,” she notes. “It’s not good for the patient-physician relationship [to say], ‘I know you need this, but your insurance company won’t pay for it.'”

A single healthcare payer could also mean major budget cuts and less paperwork at most doctors’ offices. Dr. Scheetz says national health insurance would be “a tremendous administrative relief.” Healthcare-NOW! campaign coordinator Tom Knoche says his friend, a primary care doctor in Camden, New Jersey, bills more than 200 insurance plans, each with its own regulations. “He has to have a staff just to figure out who’s responsible for what,” Knoche adds. “That’s incredibly cumbersome and adds a tremendous amount of overhead to his practice.”

Another case for single payer, Dr. Scheetz argues, is that patients will have complete choice since everyone is covered by the same plan. She would rather have patients who see her because they have similar values than patients who have been “coerced into coming to me through an HMO or PPO.”

According to Knoche, every healthcare professional, salaried or temporary, will benefit from the security that national insurance could bring to the system. “Patients will have continuity of care and care regardless of whether their life situation changes–if they get divorced, change jobs, have a mental health issue,” he explains. “For doctors and nurse practitioners, it’s the whole idea that nobody’s going to be involved in treatment other than patients and the healthcare professional they choose.”

THE OPPOSITION

While Dr. Scheetz, Knoche, and Kucinich stand behind a Medicare-for-all model as the answer to healthcare woes, critics believe it is too focused on costs and too simplistic a “solution” for the system’s complicated failings.

“We need a system that is more responsive to patient needs and what patients value, and this proposal does not take this into account,” says Robert Book, PhD, a senior research fellow in health economics at the Heritage Foundation. “It’s totally focused on spending and limiting the amount of healthcare available–limited access to care for everybody.”

Book argues that the top-down structure proposed by the bill is restrictive, rather than liberating, for patients and doctors alike. As state health-security programs create global budgets for individual facilities every year, Book says the lack of financial flexibility is dangerous.

If a certain neighborhood in Dallas sees a flu surge and the majority of patients are all going to the same hospital, which has a lower annual budget than the hospital 10 miles away, he says the proposed legislation provides no way to move resources from the second to the first, where they would be most needed. “Now, they can hire more nurses and technologists if there’s a greater need. Now, money follows the patient,” Book says. “With this system? Money follows the facility. And there will be less demand for temporary [healthcare] workers of all sorts. They won’t be able to hire more people unless they pay less.”

As far as the administrative relief logic goes, Book and Dr. Pho dismissed the real value of trading in paperwork from multiple sources for bureaucratic paperwork from the government. “There’s a myth that Medicare has fewer overhead costs and less administrative paperwork, but it’s just as onerous as with a private insurer,” Dr. Pho comments.

Another concern for Book and other single-payer detractors is a substantial change in earnings. “Doctors’ incomes are going to have to be cut, and the same goes for other allied health professionals” to allow hospitals and health organizations to handle millions of new patients across the country, Book notes.

Dr. Pho agrees that lower salaries will be a real issue if the single-payer legislation becomes law. He says that Medicare–the single largest insurer in the United States–only covers 60 to 70 percent of costs at the doctor’s office. “Doctors see Medicare patients, they lose money on that, and with any business like a doctor’s office, you can’t sustain your business that way,” he says.

And with a serious shortage of working healthcare professionals, a broad set of medical mandates from the government will not help matters much. “How would you feel if you were told your income could never go up, no matter how hard you work?” Book asks of the medical community. “And you’re going to be fighting for your slice of a fixed pie of your industry that won’t be allowed to grow. ”

Healthcare professionals will not only be limited in their financial resources, but in their decision-making power, as well. Book says a single-payer system could dramatically threaten the doctor-patient relationship because the American Health Security Standards Board, to be created under proposed legislation, would actually prohibit through its broad oversight healthcare workers from serving their patients’ needs on an individual, case-by-case basis. “[The board] decides what the best treatment is for everybody, for the average patient,” Book says. “What if you aren’t average?”

THE STAFFING

No matter what their views on national insurance, reform advocates all agree that the healthcare system faces a severe staffing shortage that needs to be addressed before millions of previously uninsured patients can receive quality care.

Dr. Pho and Knoche say the primary care field, which the newest single-payer bill confronts, needs a serious boost. Some proposals set a benchmark
for medical students by state, of which at least 50 percent would be primary care residents in five years or the government will reduce funding. “There’s a several hundred thousand dollar a year discrepancy between primary care and specialty doctors’ salaries,” Dr. Pho notes. “[Students] are not stupid; that’s where they’ll go unless the incentive changes.”

A stronger corps of primary care doctors could also reduce costs over time. “That’s where people can be most effective in catching things in the early stages, seeing that they’re treated before they become costly and complicated issues,” Knoche adds.

Dr. Scheetz says underemployment is worst in the emergency room, where employees work “under terrible stress” with a high volume of patients and must quickly decide how to treat them based on their insurance.

With regard to nursing, Pat McFarland, RN, executive director of the Association of California Nurse Leaders, says that there’s a “false sense of security” about the end of a nursing shortage. “Older nurses are continuing to work longer or they’re picking up more shifts,” she says. “We are going to see a huge number of nurses retiring in the next 10 years or so, [and] we have to make sure there’s an infrastructure to train and replace them.”

While McFarland says that temporary or traveling healthcare professionals could be more vulnerable under a single-payer system, if permanent employees put off retirement and hospitals begin operating with a fixed annual budget, their prospects aren’t too different from those of their salaried medical colleagues.

“At all levels, professionals would be challenged to be responsive and really focused on the patient,” says Kathy Flaster, RN, the CEO of California-based staffing company HRN Services. “Where do you begin to say this is a program that would service all interests, all levels of care?”

Flaster says the current demand for physicians, nurses, pharmacists, and allied health professionals through HRN Services reflects the magnitude of the system’s shortcomings. Education is a vital part of solving the reform riddle, and the earlier the better. “We need to do much more in the way of promoting and illuminating healthcare careers, and we need to start young,” she says. “You have to start academic preparation as well as stimulate interest and tickle the intellect of people as early as elementary school.”

Like McFarland, Flaster rejects a single-payer model as too simplistic. When it comes to healthcare, “There are so many issues sociologically, and you run into what is often in the literature [called] the ‘moral hazards’ of what is in front of us,” she explains. “Do we really have an obligation to provide healthcare to the homeless? To pay for the able-bodied who choose not to work and accept government programs as their standard of living? If you think about how huge these issues are to our quality of life, we are so far removed from making an intelligent choice about single payer.”

In the end, national health insurance is a “horizon question,” Flaster says, “and there is much more traffic that needs to be navigated” before such a major policy change takes effect in an already distressed healthcare system.

Questions for Dr. Marcia Angell

By Anne Underwood
Prescriptions Blog
New York Times
August 12, 2009

Jodi Hilton for The New York Times Dr. Marcia Angell, a senior lecturer at Harvard University and former editor of The New England Journal of Medicine, in her office in January.

Dr. Marcia Angell is a senior lecturer in social medicine at Harvard Medical School and former editor of The New England Journal of Medicine. A longtime critic of the pharmaceutical industry, she has called for an end to market-driven delivery of health care in the United States. She spoke with freelance writer Anne Underwood.

Q. President Obama hopes to increase the number of Americans with insurance and to rein in costs. Do you believe any of the plans under consideration by Congress will accomplish those goals?

A. They won’t, and that’s the essential problem. If you keep health care in the hands of for-profit companies, you can do one or the other — increase coverage by putting more money into the system, or control costs by decreasing coverage. But you cannot do both unless you change the basic structure of the system.

Q. Segments of the health care industry — pharmaceutical companies, for instance — are promising to cut costs.

A. It’s not going to happen. These are investor-owned companies. Their fiduciary responsibility is to maximize profits. If they behaved like charities, heads would roll in the executive suites.

Q. But what about market mechanisms for reducing costs? Wouldn’t the public option, for instance, provide competition for the insurance companies?

A. Theoretically it would, but I doubt the public plan will pass. Industry is lobbying against it, and the president has not said this is a “must.” Even if it does pass, I’m afraid the private insurance industry will use their clout in Congress — and they have enormous clout in Congress — to hobble the public option and use it as a dumping ground for the sickest while they cream off the young and healthy for themselves.

Q. How? Won’t insurance companies have to cover all applicants regardless of health status?

A. It’s hard to regulate an enormous industry without setting up a bureaucracy to oversee it. That’s very expensive and creates a whole new set of problems.

Q. How about the individual mandate? Wouldn’t it reduce costs per capita by bringing in young, healthy people who are currently uninsured?

A. No. In Massachusetts [which enacted an individual mandate in 2006], there is no real price regulation. Essentially what the mandate does is say to people, you will go into this treacherous market and buy insurance at whatever price the companies choose to charge. In effect, it’s delivering a captive market to these profit-oriented companies.

Q. Are people at least getting better health care in Massachusetts now?

A. Massachusetts already spends one-third more on health care than other states, and costs are rising at unsustainable rates. As a result, they’re chipping away at benefits, dropping beneficiaries and increasing premiums and co-payments.

Q. Then what’s the path to meaningful cost control?

A. The only way to both control costs and have universal comprehensive coverage is a single-payer system — a nonprofit, single-payer system. Nothing else will work. All other advanced countries have some form of a single-payer system, and they pay less than half as much per person as we do. We should be asking, why is that so? It’s not because we provide more basic services. We do provide more tests and procedures for those who can pay, but not more basic services — and we don’t cover everybody. So why is it so? We are the only advanced country that delivers health care in a system that’s set up to generate profits, not to provide care.

Q. If a single-payer system isn’t feasible politically, aren’t the current proposals at least better than doing nothing? Isn’t half an aspirin better than none?

A. I think not. As costs continue to soar, people will not say, “That didn’t work. Let’s try a single-payer system.” Instead, they’ll try to pay for the costs in piecemeal ways, by increasing co-pays and deductibles, by limiting services, by making the system less equitable and less comprehensive. I’m afraid the lesson they’ll draw is that universal care is impossible.

But I’m not convinced that getting a single-payer system now is politically infeasible. The public would be happy with Medicare for all. Polls have shown that the public loves Medicare. The problem isn’t the public. It’s Congress, which caves in to special interests.

Q. If Congress is reluctant to cut out the insurance companies, is that partly because they, like the major banks, are too big to fail?

A. A nonprofit, single-payer system would lead to job losses in this sector, which constitutes 17 percent of the economy. But what about the other 83 percent of the economy? They’re being bled to death. Businesses can’t compete globally because the cost of providing coverage to their workers is so exorbitant. Whatever loss of jobs you might see would be more than offset by benefits and job gains in the rest of the economy.

[As for the insurance companies,] you could introduce the program incrementally. You could do it state by state. Or probably better, you could do it decade by decade. Medicare kicks in at age 65. In the first stage, you could take it down to 55. Between 55 and 65, people are vulnerable. They’re losing jobs, losing health care. They’re starting to have more medical needs. After a few years, you could drop it to 45, then 35. It would give insurance companies time to adjust.

Q. But Medicare is already hugely expensive. How can we afford such a plan for everyone?

A. Medicare costs are rising at an unsustainable rate because care is provided in a profit-maximizing system. The prescription drug benefit was nothing but a bonanza for the pharmaceutical industry. I would change that. I would also adjust the fee schedule, which preferentially rewards highly paid specialists for very expensive tests and procedures. For the system to work, it would have to be a nonprofit delivery system.

Q. How much could we save in administrative costs?

A. On average, the private insurance industry takes 15 to 20 percent right off the top of the premium dollar for its administrative costs and profits. That’s a lot to siphon off by an industry that adds almost nothing of value. It’s just a middleman. Medicare has overhead costs of less than 3 percent.

With the money in the system right now, we could cover everyone for every medically necessary service. But the system has to be distributed according to medical need and not as it currently is — as a commodity. Today, those who can pay get lots of M.R.I.’s they don’t need, while those who are uninsured can go without ones they do need.

Q. Military historians say we’re always fighting the last war. Is Mr. Obama now fighting the last health care war, in which Congress rejected the Clinton plan partly because it was developed without consulting other interested parties?

A. Yes. Mr. Obama has decided that he will listen to everybody. But it’s not working for him, because the public can’t become enthusiastic about a plan that doesn’t exist. That’s what he’s asking. Now Congress has gone home, and for the next month the special interests will be out there scaring people with stories of rationing and socialized medicine.

Q. Is the president really bringing everyone to the table?

A. He’s bringing everyone to the table except the single-payer people. It’s very odd. When he was a state senator, he emphatically favored a single-payer system. And in his July 22 press conference on health care, he stated that the only way to provide universal health care is with a single-payer system. Then he moved right on, as if that was somehow self-evidently absurd.

Q. So are you opposing this reform?

A. I am, though not for the same reasons as the Republicans and Blue Dogs. I’m opposing it more in sorrow than in anger. I’m afraid the president squandered a good opportunity.

Inside Story on Town Hall Riots: Right-Wing Shock Troops Do Corporate America's Dirty Work

How the health-care industry, the GOP and one media mogul made common cause with the anti-government fringe.

By Adele M. Stan
Alternet
August 10, 2009

The recent spate of town hall dustups may look like an overnight sensation, but they’ve been years, even decades, in the making.

Since the days in the late 1970s, when the New Right began its takeover of the Republican Party, it has cultivated a militia of white people armed with a grudge against those who brought forth the social changes of the ’60s.

These malcontents have been promised their day of retribution, a day for which they are more than ready. Few seem to understand that they are merely dupes for a corporate agenda that will only worsen the conditions in which they live.

Why, you may ask, would men of power and fame shake the rough, unmanicured hands of gun enthusiasts, conspiracy theorists, gay-haters, misogynists and racists?

Because somebody’s got to do the dirty work. Magnates don’t like to soil their French cuffs, and it’s hard for a bunch of rich guys to garner sympathy for threats to their bottom lines. It’s the classic inside-outside game that the right wing of the GOP has played for the last two decades.

The Health-Care Industry Executive

Imagine you’re an executive at a pharmaceutical company. Your U.S. operations are your cash cow; they earn you wild net profits because, unlike in other industrialized nations, you do not experience the price controls of a government-administered program in which the government negotiates for the best price on prescription drugs and devices.

Along comes a government plan for health-insurance reform that includes a public, government-financed plan. The public option, they call it. As part of the plan, you will be required to negotiate with the government for the price of medications and devices to be distributed within the plan.

Now that could really screw up your massive profit margins. Private plans might then insist on prices more like those the government is getting.

Instead of increasing your profit by double digits in the worst year the economy has seen since the Great Depression, as did an outfit called The Medicines Co., your shareholders may have to settle for profits more in line with the overall growth of the economy. And wouldn’t that just stink?

Meanwhile, polls show a clear majority of Americans–you know, regular Americans, the kind who don’t want to own an AK-47, or who do accept the president’s citizenship status–favor the public option. In fact, in June, CBS News found that majority to be 72 percent.

So, whaddaya do? Well, if your lobbying firm counts former Rep. Dick Armey, R-Texas, as its senior policy adviser, you don’t have do much. Dick will take care of the rest through FreedomWorks, the ostensibly grassroots, nonprofit organization of anti-taxers, cold warriors and affirmative-action opponents, which he chairs.

Need to make it look like regular Americans oppose the health-insurance reform bills now being considered by Congress? Make sure a handful of those angry white people turn up at the town hall meetings now being conducted by members of Congress throughout the country. Make sure they disrupt the meeting and rattle the congressperson.

Capture it all on amateur video and put it up on a faux, amateur-looking Web site, and try to kid the media into thinking there’s a widespread rebellion happening. After all, the media are gonna want that dramatic footage.

The Republican Member of Congress

Now, suppose you’re a Republican member of Congress. Your party got totally throttled in the 2008 election, and if you don’t derail this health care thing, it’s going to be a big win for your Democratic opponents, as millions of underinsured and uninsured Americans finally have some health care coverage–one bright spot in a largely dismal economy.

Meanwhile, you get a lot of your campaign cash from health-care-related industries and from the Wall Street bankers and brokers who want to keep those profits soaring.

A public option is going to stink for you, too. So, while Armey’s army of taxphobes is useful to you, it would be great to get some really hard-core types to further stoke the fires–especially if marshaled by guys who know how to really tar Democrats with racist imagery and slurs of unpatriotic behavior.

That’s where Grassfire.org and its brother networking site, ResistNet, come in. Sen. Jim DeMint, R-S.C., who promised to make health-care reform President Obama’s “Waterloo,” is a big fan. Says so right there on the Grassfire Web site. ResistNet is yet another right-wing hub for organizing the disruption of health-care town hall meetings.

The Media Mogul

Okay, now put on the hat of a media mogul, one who rails against the minimal restrictions the U.S. has on multi-outlet ownership, and one for whom the bottom line is everything. In fact, you actually own the Wall Street Journal.

If you can nip this health care thing in the bud, you could stand in the way of a president who wants to rein in Wall Street’s worse excesses and who may depress the profit margins of health-care companies in which your readers invest with his dastardly public option. What’s a mogul to do?

Why not hire a guy known for riling the discontented to host a show on your cable news channel, and empower him as an organizer? Let him create a little project pegged to fear and nationalism — something, say, like 9/11–through which he mobilizes bands of those aggrieved by the fact of a black president to disrupt town hall meetings.

That’s exactly what Rupert Murdoch did when he hired Glenn Beck to host a Fox News Channel show and to put together a little organizing site called The 9-12 Project.

Although Beck’s stated goal is to bring America back to where it was on Sept. 12, 2001–a nation pulled together in the wake of the terrorist attacks the day before–he draws together only those who embrace the goals of the right.

But his project site is shaped like a social-networking tool, and activists in Florida credit the Tampa 9-12 chapter as turning them out to a town hall they helped turn into a ruckus.

Put these three scenarios together, and you have the phenomenon that has become the summer of the town-hall scuff, a heated season of right-wing disruptions of civic fora.

Add to that an oppressed-white-people narrative that has its roots in the origins of what used to be called the New Right, and you have a confluence of interests ready to elevate to prime-time status a disgruntled and paranoid minority with a penchant for misplaced blame.

FreedomWorks and the K Street Lobbyist

In Washington’s K Street corridor, Dick Armey is a very important man–so important, in fact, that he was scooped up, upon his retirement from Congress, by the lobbying firm DLA Piper.

It’s been widely reported that Piper lobbies on behalf of health-care industry interests, including Bristol-Myers Squibb, but its top health-care-industry client, according to OpenSecrets.org, is The Medicines Co., a small, below-the-radar firm that has paid Armey’s lobbying firm nearly $2.4 million since the beginning of 2008–nearly 15 percent of DLA Piper’s overall lobbying income for the period.

I called The Medicines Co., requesting an interview with someone on staff who could spell out the company’s position on the pending health care bills, and I got back a rather empty, generic statement via e-mail from the company’s public relations firm, FD:

The Medicines Co., a small biotech company, was founded on and continues to follow our mission of saving lives, improving patient outcomes and reducing health care costs. Any suggestion that the Medicines Co. has opposed or retained anyone to oppose the pending health care reform bills is entirely mistaken.

I sent an e-mail back, asking for the company’s position on the health-care bills what it spent $2.4 million to lobby for, and received no response by press time.

The Medicines Co. operates so below the radar that it is not even listed as a member on the Web site of the Pharmaceutical Research and Manufacturer’s Association (PhRMA), which opposes the House bill because it empowers a non-elected panel of experts to oversee cost-containment in public programs.

PhRMA also claims the House plan will raise premiums on senior citizens enrolled in the Medicare prescription drug plan, a plan, as currently construed, largely seen as a giveaway to the pharmaceutical companies.

Last year, The Medicines Co. saw net earnings on its major product, the anti-coagulant Angiomax, increase 17 percent over the course of a single year.

Because of The Medicines Co.’s tight lips, we may never know whether it feels it’s getting its $2.4 million worth out of Piper, or its senior policy analyst, Armey, in his effort to derail health care through the FreedomWorks astroturf site.

Go to the site, and you’ll find a Health Care Action Kit (PDF), complete with talking points and Armey’s “ObamaCare translator” of key terms in the health care discussion, laced with Armey’s own witticisms. There’s even a mock “ObamaCare insurance card” (PDF) you can print out and pass around at town halls. It promises, among other things on a bulletted list, “Rationed health care” and “Anxiety, pain, risk of death.”

At the risk of mixing messages (a big public-relations no-no), Armey also advises health-care protesters to raise their opposition to the energy-reform provision called “cap and trade” in the health-care town halls.

Coincidentally, DLA Piper’s lobbying portfolio includes a number of oil and energy companies.

Then, there are the actual members of FreedomWorks, who leave the most enlightening comments on the Web site:

This, from Constantine Ivanov:

June 27, 2009 — 3:40pm

The problem is that no matter how passionately we are here condemning the socialized (better to say “Socialistisized”) Medicine, “die eisernen Stiefel” (the iron jackboots) of Obamistas are methodically and systematicly destroying the very core of our country.

And I recall German troops who at a steady gait moved as close as 10 miles to Moscow in 1941.

Or, this, from Joe Massana:

June 27, 2009 — 4:00pm

[Obama] and his socilist party are ruining this country … I know that if I was a black man right now, I would be able to get help from the government with my construction business and household bills.

If an entity providing 15 percent of the lobbying income at Armey’s day job took objection to any of this, do you think Armey would be overseeing the FreedomWorks outfit?

DLA Piper also earned $300,000 since early last year lobbying on behalf of the American Council of Life Insurers, which opposes the long-term care provisions in the House bill, which it sees as competition.

Grassfire and ResistNet

The FreedomWorks commenters are tame by comparison with those found on ResistNet, a project of Grassfire.org. Using a social-networking platform, Grassfire claims some 400,000 members who are dedicated to “resisting” the “Democratic agenda,” which, by their lights, includes “open borders” and “taxpayer-funded abortions.”

A 501(c)(4) nonprofit, Grassfire has been named as a “stealth political action committee” by Public Citizen. Its founder and president, Steve Elliott, has held up MoveOn.org as a model for where he would like to take his organization.

ResistNet, has become a major hub for turning out hard-core right-wingers to health-care town hall meetings. The organization took in $1.5 million in 2007 (the most recent year for which information is publicly available).

It’s difficult to find out much of anything about Elliott; he manages to keep a very low profile. But SourceWatch and Public Citizen report that Grassfire is represented by the Washington public relations firm Shirley & Bannister, whose principal is Craig Shirley, the man who gave us the Willie Horton ad of the 1988 presidential election.

Shirley promoted the movie, Stolen Honor, a Swiftboat-style smear piece made about 2004 presidential candidate Sen. John Kerry, D-Mass. Today, Shirley’s clients, according to the Shirley & Bannister Web site, include the National Rifle Association, author Ann Coulter, religious right co-founder Richard Viguerie, and other religious right figures.

But Shirley & Bannister retains ties to GOP establishment figures; its Web site bears an endorsement from William Kristol, who served in the administration of the first George Bush, who happens to be the candidate whose campaign reaped some of its victory from Shirley’s Horton ad.

The firm also promotes the books of former Rep. Joe Scarborough, R-Fla., (now of MSNBC) and former George H.W. Bush speechwriter Peggy Noonan (who promised us a “kinder, gentler nation”) — books published by Rupert Murdoch’s HarperCollins.

The site also lists several other major publishers as clients for the promotion of books by right-wing authors.

I called Shirley & Bannister on Friday morning, asking if Grassfire/ResistNet was its client, since it is not listed on the Web site. I was told that Amy Haas, the person who could answer my question, was on the phone, and would get back to me. She did not.

On its introductory page, Grassfire.org complimentary words from Rep. Mike Pence, R-Ind., and Sen. DeMint.

“Grassfire has done a great job and has done a great service to the American people,” reads the DeMint quote.

Grassfire makes the point often that it will show the president respect and refrain from personal attacks, as ResistNet, which touts a “no tolerance policy” (they can’t say “zero tolerance,” since “Zero” is the nickname by which many of their members call Obama–a play on the first letter of his last name) for “personal attacks, lewd or profane language, or militancy against Barack Obama or others.”

Yet a boxed statement on the opening page of the ResistNet site offers this: Welcome to the online community for patriotic citizens who are opposing the Obama-led socialist agenda …”

ResistNet is full of comments and blog posts that violate its purported “no tolerance” policy, including those calling for social insurrection and even the death of Obama. It promises that such comments will be removed by a moderator, and yet they live on the site for months.

Here’s a comment that appears below a letter one ResistNet member named Joel wrote to his congresswoman:

Comment by RBJ 1 day ago

Joel, I hate to be the one to tell you this, you remember the old saying about “Sticks and stones may break my bones, but words will never hurt me.”

Well that is all that we are doing here, just throwing words at the crowd of Socialist in D.C., aka “D.C.Terrorist”…

As we all know, when words fail, reach over and get a 2 X 4 and get after it. Words don’t hurt, but a good solid A$$ Whooping will get there attention everytime!

Once you have their attention, then you can talk.

Or check out this one, posted by George and Pat Wilkins on Aug. 6, in which they close a long post warning that “the statists will pass socialized medicine in September” by wishing for the death of the president:

Waiting lines will be long, those waiting will find operable conditions be found to be inoperable, Hospice and palliation for comfort will be their fate. Others will die. Why is this being done? back door reparations. I pray that God will strike Obama dead, and all who stand with him they are evil.

And those just two recent examples. Posted on July 2, and still living on the ResistNet site as I write is a video by the Rev. James David Manning, who warns that “white folks are gonna riot in the streets, and I’m gonna join them.” Throughout the video, Manning, an African American, refers to Obama as a “half-breed Mack Daddy”–slang for a kind of megapimp.

Then there’s this charming bit of propaganda, Obama = Hitler (which you can view at the bottom of this story), which dubs video of Obama delivering a speech with the voice of Adolf Hitler, and interposes swastikas and Obama’s campaign logo; Obama is shown wearing a swastika armband; Hitler is shown with the Obama logo as a belt buckle.

Footage of Obama supporters, most of them African American, is run side-by-side with Hitler’s adoring crowds. As Obama waves and moves his mouth, the dub is Hitler yelling, “Sieg Heil!”

The ResistNet site is also peppered with posts touting the birther conspiracy, and other right-wing favorites. After Thursday’s scuffle at the Tampa, Fla., health care town hall, Eric Erikson (cross-posting from RedState) blamed the violence on “SEIU thugs,” an emerging right-wing theme reported earlier by Steve Benen.

I tried to contact Grassfire President Steve Elliott to ask him about the conflict between ResistNet’s “no tolerance” policy and the vitriol I found on his site. I also wanted to find out if there are health-care interests among his donors. Elliott, said Tina, the woman who answered the phone, was traveling, and his spokesman, Ron DeJong, was on vacation. She promised to text Elliott with my contact information, but I never heard back.

Glenn Beck and the 9-12 Project

Which brings us to Glenn Beck. There’s little I can add to what’s been reported (click here for AlterNet’s Tana Ganeva writing on Beck’s racism), except that when I went to the Web site of Beck’s 9-12 Project, another hub of organizing for disrupters of health-care town hall meetings, I found that the comments section had been shut down.

The message left by someone named “Editor” bore no time stamp, only a date: August 6, the date of the infamous Tampa brouhaha at which anti-health-care protesters, according to the St. Petersburg Times, said they had been inspired by Beck and his project.

Each of these organizations have this in common: They’re all promoting a march on Washington for Sept. 12. Others in the mix include TeaPartyExpress.org, and the Our Country Deserves Better PAC, which was founded by Howard Kaloogian in the heat of the presidential campaign.

Kaloogian was the chairman of the “Recall Gray Davis Committee,” which succeeded in unseating the Democratic governor of California. Our Country Deserves Better ran the “Stop Obama” bus tour during the 2008 presidential election, and was faulted by Fact Check.org for airing misleading anti-Obama advertising.

The Inside-Outside Game

The right wing of the GOP has long played this kind of inside-outside game, from the earliest days of the founding of the religious right by Richard Viguerie, Howard Phillips and the late Paul Weyrich. All were veterans of the 1964 Barry Goldwater campaign, and all had experience within the establishment Republican Party.

Viguerie, following a model pioneered by Morris Dees for the 1972 Democratic primary campaign of Sen. George McGovern, D-S.D., harnessed the power of direct-mail solicitations to land Ronald Reagan in the White House. Weyrich founded the Heritage Foundation, which became a fax-generating spin and policy factory for the Reagan administration.

Phillips took the game outside, organizing on-the-ground misanthropes, and eventually founding his own political party, the U.S. Taxpayer’s Party (now the Constitution Party) to exert pressure on the GOP from the outside.

The strategy firmly established the right’s foothold in the GOP, leading to the party’s takeover. Any remnant of the old establishment of the Republican Party was crushed in 1996, when defeated presidential candidate Patrick J. Buchanan, now a MSNBC commentator, threatened to walk the delegates he had won in his primary war against Sen. Bob Dole, R-Kansas, out of the Republican National Convention and into the arms of Phillips’ U.S. Taxpayer Party if the GOP platform did not firmly enough oppose abortion. He also insisted the platform incorporate a host of other right-wing demands, such as a condemnation of the United Nations.

The GOP forked over the writing of its platform to Phyllis Schlafly (another veteran of the Goldwater campaign) and Buchanan’s sister, Bay, and the takeover was complete. The right wing became the Republican establishment.

All of the narratives today embraced by the ResistNet, FreedomWorks and the Glenn Beck crowd find their legs in the one-man clearinghouse that is Howard Phillips.

Through his Conservative Caucus, Phillips disseminated the “birther” theory that Obama is not an American citizen, gave right-wing operative Cliff Kincaid an award for researching Obama’s alleged socialist roots, and for years has railed against “socialized medicine”–even arguing that Medicare is unconstitutional and warning darkly of a time when the government might determine who shall live and who shall die.

“[W]hen the supply of medical care is controlled by politicians and bureaucrats,” Phillips told a 1997 gathering of his Conservative Caucus Foundation, “and the demand for that care exceeds the supply, then individual human beings created in God’s image become price factors in the eyes of medical gatekeepers–they’re not even medical, they’re bureaucratic gatekeepers–who determine medical decisions not on the basis of medical needs, but on the basis of bureaucratic priorities.”

Phillips’ disdain for feminists is palpable, and his language about LGBT people, routinely labeled on his Web site as “perverts,” “homos” and “sodomites” is contemptible. He refers to Planned Parenthood as “Murder Incorporated.”

I called Phillips for comment on this article, but he was en route to Mexico where he has convened a press conference to protest the nonexistent North American Union, another right-wing conspiracy theory. (Rep. Ron Paul, R-Texas, is an invited speaker.)

Phillips advanced the career of Randall Terry, founder of the militant anti-aborton group Operation Rescue. At one point, it seemed that his U.S. Taxpayer’s Party was to Operation Rescue what Sinn Fein is to the Irish Republican Army–the political wing of a movement steeped in violence. (In Terry’s case, the violence was in rhetoric and obstruction designed to incite others to act.)

Conspiracy of Silence

On Aug. 4, Terry, who is seeking to make a comeback with his new organization, Operation Rescue Insurrecta Nex, sent out an e-mail blast urging followers to attend health care town halls convened by members of Congress.

Trotting out the trope the that health-care reform bills provide for taxpayer-funded abortions, he urges his followers:

Stir up some dust!

Be “unreasonable!”

In fact, you might want to be a little noisier and a little more intense than you might normally be.

I put it this way: If you were in danger of being murdered, and I could possibly save you at a town hall meeting, how would you want people to behave in a town hall meeting?

At a July press conference, Terry warned of “random acts of violence” that would occur if the health-care bill passed. There would be violent “reprisals against those deemed guilty,” he said.

Think Terry’s too out on the fringe to matter? Think again. When AlterNet reported that the Supreme Court nomination hearing of Judge Sonia Sotomayor was being disrupted by Terry’s followers, not one Republican senator condemned him by name.

When Terry staged a demonstration outside the White House featuring men in Obama masks “whipping” him, not a distancing word was placed between him and the GOP establishment.

And now he is promulgating the false Republican claim that health-care reform will mean socialized euthanasia for the aged.

Former Alaska Gov. Sarah Palin also has links to Phillips; for seven years, her husband, Todd, claimed membership in the Alaska affiliate of the Constitution Party–the secessionist Alaska Independence Party, whose convention Palin addressed last year via video.

Every other day, it seems, I receive an e-mail from one right-wing organization or another, warning of the grave consequences of health-insurance reform.

The subject line in an e-mail from Human Events magazine screams at me “Grandmas and babies exterminated by Obama ‘health’ plan,” even as another of its e-mails asks, “Obama birth certificate destroyed?” The anti-gay American Family Association warns: “Liberals seek to silence and demonize those who oppose their socialism.”

Tony Perkins of the Family Research Council sent a plea for money to finance a television ad that features an elderly couple complaining of the government’s denial of surgery for the man while financing abortion with taxpayer dollars.

Think these organizations are not the Republican establishment? Consider that the annual Values Voter Summit sponsored by the Family Research Council’s PAC will feature former “moderate” GOP presidential candidate Mitt Romney as a keynote speaker.

In the corridors of Washington’s K Street lobbying offices, in the district offices of Republican members of Congress, and in the executive suite of one singular mogul, the men of power must be well-pleased with themselves, watching YouTube videos of the mayhem they have unleashed on the rest of us. But they may just get their pound of flesh.

Health care for all

By Helen Thomas
San Francisco Chronicle
Politics Blog
Aug. 13, 2009

It’s all so sad. Well-organized conservatives have launched a full-scale attack on health care reform. And they appear to be winning — for now.

Their victory strategy involves deliberate distortions of the truth and scare tactics. Under the plans Congress is considering, a government bureaucrat will come between you and your doctor, their TV ads intone ominously. You will lose your private health insurance, dumping you into an inferior government plan. You won’t be able to choose your doctor, they say.

The desperate opposition also claims we will have “socialized medicine,” rationed care and forced euthanasia for the elderly.

Those falsehoods and calls to disrupt congressional town hall meetings are being peddled by right-wing organizations such as Freedomworks.org, which is directed by former House Majority Leader Dick Armey, R-Texas, now a Washington lobbyist with clients including a major international pharmaceuticals company.

I covered the battle to create the Medicare system back in the 1960s. The cries of “socialized medicine” worked for years until President Johnson rammed Medicare through Congress in 1965.

Johnson signed the Medicare legislation on former President Harry Truman’s desk in Independence, Mo. Truman had first proposed a health care program for the elderly back in the 1950s.

Truman, still feisty at age 81, was all smiles.

I remember a newsman went up to Johnson and told him “my mother thanks you.”

Johnson turned to him and said: “You should thank me,” meaning Medicare would help families with the increasingly heavy financial burden of caring for seniors.

What kind of a nation are we if we do not provide everyone with the excellent medical care that only some of us now receive?

I continue to think the so-called single-payer system is the only answer to the nation-s obligation to make sure that no one lacks health care. Yes, single payer means a government-run health insurance program for all — the prevailing system in Canada and in many nations in Europe.

At this point under the current employer-provided private health insurance system, 47 million Americans have no coverage and more are losing what they have every day through job loss in this devastating recession.

President Obama is making a big mistake by ignoring the single-payer proposal.

Because the words “single payer” have been subjected to such pervasive demagoguery and misrepresentation, its polling numbers do not reflect how popular it really is.

In a Kaiser Family Foundation poll last month, 58 percent of Americans either strongly or somewhat favored a program to provide insurance “through an expanded, universal form of Medicare-for-all.”

That’s basically the same as single payer. But once the same poll actually used the words “single payer” to describe the program, support dropped to 51 percent.

In 2003 before he became a U.S. senator from Illinois, Obama actually called himself a single-payer “proponent.” But now that he is president, Obama has buckled to Republicans and conservative Blue Dog Democrats in pursuit of consensus. My question is if Congress passes a watered-down version of health care that doesn’t truly cover everyone, is the result worth it?

The president has given no hearing to the advocates of a single-payer system and neither has the media.

He also had worked out a deal with the drug manufacturers not to use the federal government’s massive bargaining power to negotiate lower drug prices — although now the White House appears to be having second thoughts.

Single payer works; it is not code for substandard medical care.

Diana Beeson, an American friend from Ohio who now lives in Canada, wrote me that three years ago she was diagnosed with ovarian cancer and received treatment “unrivaled by anything I can imagine even with my fairly decent coverage as a state employee in the U.S.”

“I have had surgery, chemotherapy and closely followed my oncologist and the family doctor of my own choosing. It has not cost me a dime,” she said.

Beeson said she wanted to share her “wonderful experience with health care in Canada.”

The systems in Canada, Britain and France, among others have been much maligned and scapegoated by corporate medicine in the U.S.

It’s understandable why the president has bent over backwards to appease Congress, having studied Hillary Clinton’s failure to touch base with key lawmakers in selling the program she drafted in her years as first lady. Her recommendations died on Capitol Hill, aided by the phony “Harry and Louise” television distractions.

President Obama should lay down markers for real health care reform — meaning we all kick in to a national program instead of fattening the pocketbooks of the insurance financiers.

Instead, the president has given up on Medicare for all, calling single payer “impractical.”

He still has time to do the right thing and nothing to lose.

http://www.sfgate.com/cgi-bin/blogs/nov05election/detail?blogid=14&entry_id=45426

Inside Story on Town Hall Riots: Right-Wing Shock Troops Do Corporate America’s Dirty Work

How the health-care industry, the GOP and one media mogul made common cause with the anti-government fringe.

By Adele M. Stan
Alternet
August 10, 2009

The recent spate of town hall dustups may look like an overnight sensation, but they’ve been years, even decades, in the making.

Since the days in the late 1970s, when the New Right began its takeover of the Republican Party, it has cultivated a militia of white people armed with a grudge against those who brought forth the social changes of the ’60s.

These malcontents have been promised their day of retribution, a day for which they are more than ready. Few seem to understand that they are merely dupes for a corporate agenda that will only worsen the conditions in which they live.

Why, you may ask, would men of power and fame shake the rough, unmanicured hands of gun enthusiasts, conspiracy theorists, gay-haters, misogynists and racists?

Because somebody’s got to do the dirty work. Magnates don’t like to soil their French cuffs, and it’s hard for a bunch of rich guys to garner sympathy for threats to their bottom lines. It’s the classic inside-outside game that the right wing of the GOP has played for the last two decades.

The Health-Care Industry Executive

Imagine you’re an executive at a pharmaceutical company. Your U.S. operations are your cash cow; they earn you wild net profits because, unlike in other industrialized nations, you do not experience the price controls of a government-administered program in which the government negotiates for the best price on prescription drugs and devices.

Along comes a government plan for health-insurance reform that includes a public, government-financed plan. The public option, they call it. As part of the plan, you will be required to negotiate with the government for the price of medications and devices to be distributed within the plan.

Now that could really screw up your massive profit margins. Private plans might then insist on prices more like those the government is getting.

Instead of increasing your profit by double digits in the worst year the economy has seen since the Great Depression, as did an outfit called The Medicines Co., your shareholders may have to settle for profits more in line with the overall growth of the economy. And wouldn’t that just stink?

Meanwhile, polls show a clear majority of Americans–you know, regular Americans, the kind who don’t want to own an AK-47, or who do accept the president’s citizenship status–favor the public option. In fact, in June, CBS News found that majority to be 72 percent.

So, whaddaya do? Well, if your lobbying firm counts former Rep. Dick Armey, R-Texas, as its senior policy adviser, you don’t have do much. Dick will take care of the rest through FreedomWorks, the ostensibly grassroots, nonprofit organization of anti-taxers, cold warriors and affirmative-action opponents, which he chairs.

Need to make it look like regular Americans oppose the health-insurance reform bills now being considered by Congress? Make sure a handful of those angry white people turn up at the town hall meetings now being conducted by members of Congress throughout the country. Make sure they disrupt the meeting and rattle the congressperson.

Capture it all on amateur video and put it up on a faux, amateur-looking Web site, and try to kid the media into thinking there’s a widespread rebellion happening. After all, the media are gonna want that dramatic footage.

The Republican Member of Congress

Now, suppose you’re a Republican member of Congress. Your party got totally throttled in the 2008 election, and if you don’t derail this health care thing, it’s going to be a big win for your Democratic opponents, as millions of underinsured and uninsured Americans finally have some health care coverage–one bright spot in a largely dismal economy.

Meanwhile, you get a lot of your campaign cash from health-care-related industries and from the Wall Street bankers and brokers who want to keep those profits soaring.

A public option is going to stink for you, too. So, while Armey’s army of taxphobes is useful to you, it would be great to get some really hard-core types to further stoke the fires–especially if marshaled by guys who know how to really tar Democrats with racist imagery and slurs of unpatriotic behavior.

That’s where Grassfire.org and its brother networking site, ResistNet, come in. Sen. Jim DeMint, R-S.C., who promised to make health-care reform President Obama’s “Waterloo,” is a big fan. Says so right there on the Grassfire Web site. ResistNet is yet another right-wing hub for organizing the disruption of health-care town hall meetings.

The Media Mogul

Okay, now put on the hat of a media mogul, one who rails against the minimal restrictions the U.S. has on multi-outlet ownership, and one for whom the bottom line is everything. In fact, you actually own the Wall Street Journal.

If you can nip this health care thing in the bud, you could stand in the way of a president who wants to rein in Wall Street’s worse excesses and who may depress the profit margins of health-care companies in which your readers invest with his dastardly public option. What’s a mogul to do?

Why not hire a guy known for riling the discontented to host a show on your cable news channel, and empower him as an organizer? Let him create a little project pegged to fear and nationalism — something, say, like 9/11–through which he mobilizes bands of those aggrieved by the fact of a black president to disrupt town hall meetings.

That’s exactly what Rupert Murdoch did when he hired Glenn Beck to host a Fox News Channel show and to put together a little organizing site called The 9-12 Project.

Although Beck’s stated goal is to bring America back to where it was on Sept. 12, 2001–a nation pulled together in the wake of the terrorist attacks the day before–he draws together only those who embrace the goals of the right.

But his project site is shaped like a social-networking tool, and activists in Florida credit the Tampa 9-12 chapter as turning them out to a town hall they helped turn into a ruckus.

Put these three scenarios together, and you have the phenomenon that has become the summer of the town-hall scuff, a heated season of right-wing disruptions of civic fora.

Add to that an oppressed-white-people narrative that has its roots in the origins of what used to be called the New Right, and you have a confluence of interests ready to elevate to prime-time status a disgruntled and paranoid minority with a penchant for misplaced blame.

FreedomWorks and the K Street Lobbyist

In Washington’s K Street corridor, Dick Armey is a very important man–so important, in fact, that he was scooped up, upon his retirement from Congress, by the lobbying firm DLA Piper.

It’s been widely reported that Piper lobbies on behalf of health-care industry interests, including Bristol-Myers Squibb, but its top health-care-industry client, according to OpenSecrets.org, is The Medicines Co., a small, below-the-radar firm that has paid Armey’s lobbying firm nearly $2.4 million since the beginning of 2008–nearly 15 percent of DLA Piper’s overall lobbying income for the period.

I called The Medicines Co., requesting an interview with someone on staff who could spell out the company’s position on the pending health care bills, and I got back a rather empty, generic statement via e-mail from the company’s public relations firm, FD:

The Medicines Co., a small biotech company, was founded on and continues to follow our mission of saving lives, improving patient outcomes and reducing health care costs. Any suggestion that the Medicines Co. has opposed or retained anyone to oppose the pending health care reform bills is entirely mistaken.

I sent an e-mail back, asking for the company’s position on the health-care bills what it spent $2.4 million to lobby for, and received no response by press time.

The Medicines Co. operates so below the radar that it is not even listed as a member on the Web site of the Pharmaceutical Research and Manufacturer’s Association (PhRMA), which opposes the House bill because it empowers a non-elected panel of experts to oversee cost-containment in public programs.

PhRMA also claims the House plan will raise premiums on senior citizens enrolled in the Medicare prescription drug plan, a plan, as currently construed, largely seen as a giveaway to the pharmaceutical companies.

Last year, The Medicines Co. saw net earnings on its major product, the anti-coagulant Angiomax, increase 17 percent over the course of a single year.

Because of The Medicines Co.’s tight lips, we may never know whether it feels it’s getting its $2.4 million worth out of Piper, or its senior policy analyst, Armey, in his effort to derail health care through the FreedomWorks astroturf site.

Go to the site, and you’ll find a Health Care Action Kit (PDF), complete with talking points and Armey’s “ObamaCare translator” of key terms in the health care discussion, laced with Armey’s own witticisms. There’s even a mock “ObamaCare insurance card” (PDF) you can print out and pass around at town halls. It promises, among other things on a bulletted list, “Rationed health care” and “Anxiety, pain, risk of death.”

At the risk of mixing messages (a big public-relations no-no), Armey also advises health-care protesters to raise their opposition to the energy-reform provision called “cap and trade” in the health-care town halls.

Coincidentally, DLA Piper’s lobbying portfolio includes a number of oil and energy companies.

Then, there are the actual members of FreedomWorks, who leave the most enlightening comments on the Web site:

This, from Constantine Ivanov:

June 27, 2009 — 3:40pm

The problem is that no matter how passionately we are here condemning the socialized (better to say “Socialistisized”) Medicine, “die eisernen Stiefel” (the iron jackboots) of Obamistas are methodically and systematicly destroying the very core of our country.

And I recall German troops who at a steady gait moved as close as 10 miles to Moscow in 1941.

Or, this, from Joe Massana:

June 27, 2009 — 4:00pm

[Obama] and his socilist party are ruining this country … I know that if I was a black man right now, I would be able to get help from the government with my construction business and household bills.

If an entity providing 15 percent of the lobbying income at Armey’s day job took objection to any of this, do you think Armey would be overseeing the FreedomWorks outfit?

DLA Piper also earned $300,000 since early last year lobbying on behalf of the American Council of Life Insurers, which opposes the long-term care provisions in the House bill, which it sees as competition.

Grassfire and ResistNet

The FreedomWorks commenters are tame by comparison with those found on ResistNet, a project of Grassfire.org. Using a social-networking platform, Grassfire claims some 400,000 members who are dedicated to “resisting” the “Democratic agenda,” which, by their lights, includes “open borders” and “taxpayer-funded abortions.”

A 501(c)(4) nonprofit, Grassfire has been named as a “stealth political action committee” by Public Citizen. Its founder and president, Steve Elliott, has held up MoveOn.org as a model for where he would like to take his organization.

ResistNet, has become a major hub for turning out hard-core right-wingers to health-care town hall meetings. The organization took in $1.5 million in 2007 (the most recent year for which information is publicly available).

It’s difficult to find out much of anything about Elliott; he manages to keep a very low profile. But SourceWatch and Public Citizen report that Grassfire is represented by the Washington public relations firm Shirley & Bannister, whose principal is Craig Shirley, the man who gave us the Willie Horton ad of the 1988 presidential election.

Shirley promoted the movie, Stolen Honor, a Swiftboat-style smear piece made about 2004 presidential candidate Sen. John Kerry, D-Mass. Today, Shirley’s clients, according to the Shirley & Bannister Web site, include the National Rifle Association, author Ann Coulter, religious right co-founder Richard Viguerie, and other religious right figures.

But Shirley & Bannister retains ties to GOP establishment figures; its Web site bears an endorsement from William Kristol, who served in the administration of the first George Bush, who happens to be the candidate whose campaign reaped some of its victory from Shirley’s Horton ad.

The firm also promotes the books of former Rep. Joe Scarborough, R-Fla., (now of MSNBC) and former George H.W. Bush speechwriter Peggy Noonan (who promised us a “kinder, gentler nation”) — books published by Rupert Murdoch’s HarperCollins.

The site also lists several other major publishers as clients for the promotion of books by right-wing authors.

I called Shirley & Bannister on Friday morning, asking if Grassfire/ResistNet was its client, since it is not listed on the Web site. I was told that Amy Haas, the person who could answer my question, was on the phone, and would get back to me. She did not.

On its introductory page, Grassfire.org complimentary words from Rep. Mike Pence, R-Ind., and Sen. DeMint.

“Grassfire has done a great job and has done a great service to the American people,” reads the DeMint quote.

Grassfire makes the point often that it will show the president respect and refrain from personal attacks, as ResistNet, which touts a “no tolerance policy” (they can’t say “zero tolerance,” since “Zero” is the nickname by which many of their members call Obama–a play on the first letter of his last name) for “personal attacks, lewd or profane language, or militancy against Barack Obama or others.”

Yet a boxed statement on the opening page of the ResistNet site offers this: Welcome to the online community for patriotic citizens who are opposing the Obama-led socialist agenda …”

ResistNet is full of comments and blog posts that violate its purported “no tolerance” policy, including those calling for social insurrection and even the death of Obama. It promises that such comments will be removed by a moderator, and yet they live on the site for months.

Here’s a comment that appears below a letter one ResistNet member named Joel wrote to his congresswoman:

Comment by RBJ 1 day ago

Joel, I hate to be the one to tell you this, you remember the old saying about “Sticks and stones may break my bones, but words will never hurt me.”

Well that is all that we are doing here, just throwing words at the crowd of Socialist in D.C., aka “D.C.Terrorist”…

As we all know, when words fail, reach over and get a 2 X 4 and get after it. Words don’t hurt, but a good solid A$$ Whooping will get there attention everytime!

Once you have their attention, then you can talk.

Or check out this one, posted by George and Pat Wilkins on Aug. 6, in which they close a long post warning that “the statists will pass socialized medicine in September” by wishing for the death of the president:

Waiting lines will be long, those waiting will find operable conditions be found to be inoperable, Hospice and palliation for comfort will be their fate. Others will die. Why is this being done? back door reparations. I pray that God will strike Obama dead, and all who stand with him they are evil.

And those just two recent examples. Posted on July 2, and still living on the ResistNet site as I write is a video by the Rev. James David Manning, who warns that “white folks are gonna riot in the streets, and I’m gonna join them.” Throughout the video, Manning, an African American, refers to Obama as a “half-breed Mack Daddy”–slang for a kind of megapimp.

Then there’s this charming bit of propaganda, Obama = Hitler (which you can view at the bottom of this story), which dubs video of Obama delivering a speech with the voice of Adolf Hitler, and interposes swastikas and Obama’s campaign logo; Obama is shown wearing a swastika armband; Hitler is shown with the Obama logo as a belt buckle.

Footage of Obama supporters, most of them African American, is run side-by-side with Hitler’s adoring crowds. As Obama waves and moves his mouth, the dub is Hitler yelling, “Sieg Heil!”

The ResistNet site is also peppered with posts touting the birther conspiracy, and other right-wing favorites. After Thursday’s scuffle at the Tampa, Fla., health care town hall, Eric Erikson (cross-posting from RedState) blamed the violence on “SEIU thugs,” an emerging right-wing theme reported earlier by Steve Benen.

I tried to contact Grassfire President Steve Elliott to ask him about the conflict between ResistNet’s “no tolerance” policy and the vitriol I found on his site. I also wanted to find out if there are health-care interests among his donors. Elliott, said Tina, the woman who answered the phone, was traveling, and his spokesman, Ron DeJong, was on vacation. She promised to text Elliott with my contact information, but I never heard back.

Glenn Beck and the 9-12 Project

Which brings us to Glenn Beck. There’s little I can add to what’s been reported (click here for AlterNet’s Tana Ganeva writing on Beck’s racism), except that when I went to the Web site of Beck’s 9-12 Project, another hub of organizing for disrupters of health-care town hall meetings, I found that the comments section had been shut down.

The message left by someone named “Editor” bore no time stamp, only a date: August 6, the date of the infamous Tampa brouhaha at which anti-health-care protesters, according to the St. Petersburg Times, said they had been inspired by Beck and his project.

Each of these organizations have this in common: They’re all promoting a march on Washington for Sept. 12. Others in the mix include TeaPartyExpress.org, and the Our Country Deserves Better PAC, which was founded by Howard Kaloogian in the heat of the presidential campaign.

Kaloogian was the chairman of the “Recall Gray Davis Committee,” which succeeded in unseating the Democratic governor of California. Our Country Deserves Better ran the “Stop Obama” bus tour during the 2008 presidential election, and was faulted by Fact Check.org for airing misleading anti-Obama advertising.

The Inside-Outside Game

The right wing of the GOP has long played this kind of inside-outside game, from the earliest days of the founding of the religious right by Richard Viguerie, Howard Phillips and the late Paul Weyrich. All were veterans of the 1964 Barry Goldwater campaign, and all had experience within the establishment Republican Party.

Viguerie, following a model pioneered by Morris Dees for the 1972 Democratic primary campaign of Sen. George McGovern, D-S.D., harnessed the power of direct-mail solicitations to land Ronald Reagan in the White House. Weyrich founded the Heritage Foundation, which became a fax-generating spin and policy factory for the Reagan administration.

Phillips took the game outside, organizing on-the-ground misanthropes, and eventually founding his own political party, the U.S. Taxpayer’s Party (now the Constitution Party) to exert pressure on the GOP from the outside.

The strategy firmly established the right’s foothold in the GOP, leading to the party’s takeover. Any remnant of the old establishment of the Republican Party was crushed in 1996, when defeated presidential candidate Patrick J. Buchanan, now a MSNBC commentator, threatened to walk the delegates he had won in his primary war against Sen. Bob Dole, R-Kansas, out of the Republican National Convention and into the arms of Phillips’ U.S. Taxpayer Party if the GOP platform did not firmly enough oppose abortion. He also insisted the platform incorporate a host of other right-wing demands, such as a condemnation of the United Nations.

The GOP forked over the writing of its platform to Phyllis Schlafly (another veteran of the Goldwater campaign) and Buchanan’s sister, Bay, and the takeover was complete. The right wing became the Republican establishment.

All of the narratives today embraced by the ResistNet, FreedomWorks and the Glenn Beck crowd find their legs in the one-man clearinghouse that is Howard Phillips.

Through his Conservative Caucus, Phillips disseminated the “birther” theory that Obama is not an American citizen, gave right-wing operative Cliff Kincaid an award for researching Obama’s alleged socialist roots, and for years has railed against “socialized medicine”–even arguing that Medicare is unconstitutional and warning darkly of a time when the government might determine who shall live and who shall die.

“[W]hen the supply of medical care is controlled by politicians and bureaucrats,” Phillips told a 1997 gathering of his Conservative Caucus Foundation, “and the demand for that care exceeds the supply, then individual human beings created in God’s image become price factors in the eyes of medical gatekeepers–they’re not even medical, they’re bureaucratic gatekeepers–who determine medical decisions not on the basis of medical needs, but on the basis of bureaucratic priorities.”

Phillips’ disdain for feminists is palpable, and his language about LGBT people, routinely labeled on his Web site as “perverts,” “homos” and “sodomites” is contemptible. He refers to Planned Parenthood as “Murder Incorporated.”

I called Phillips for comment on this article, but he was en route to Mexico where he has convened a press conference to protest the nonexistent North American Union, another right-wing conspiracy theory. (Rep. Ron Paul, R-Texas, is an invited speaker.)

Phillips advanced the career of Randall Terry, founder of the militant anti-aborton group Operation Rescue. At one point, it seemed that his U.S. Taxpayer’s Party was to Operation Rescue what Sinn Fein is to the Irish Republican Army–the political wing of a movement steeped in violence. (In Terry’s case, the violence was in rhetoric and obstruction designed to incite others to act.)

Conspiracy of Silence

On Aug. 4, Terry, who is seeking to make a comeback with his new organization, Operation Rescue Insurrecta Nex, sent out an e-mail blast urging followers to attend health care town halls convened by members of Congress.

Trotting out the trope the that health-care reform bills provide for taxpayer-funded abortions, he urges his followers:

Stir up some dust!

Be “unreasonable!”

In fact, you might want to be a little noisier and a little more intense than you might normally be.

I put it this way: If you were in danger of being murdered, and I could possibly save you at a town hall meeting, how would you want people to behave in a town hall meeting?

At a July press conference, Terry warned of “random acts of violence” that would occur if the health-care bill passed. There would be violent “reprisals against those deemed guilty,” he said.

Think Terry’s too out on the fringe to matter? Think again. When AlterNet reported that the Supreme Court nomination hearing of Judge Sonia Sotomayor was being disrupted by Terry’s followers, not one Republican senator condemned him by name.

When Terry staged a demonstration outside the White House featuring men in Obama masks “whipping” him, not a distancing word was placed between him and the GOP establishment.

And now he is promulgating the false Republican claim that health-care reform will mean socialized euthanasia for the aged.

Former Alaska Gov. Sarah Palin also has links to Phillips; for seven years, her husband, Todd, claimed membership in the Alaska affiliate of the Constitution Party–the secessionist Alaska Independence Party, whose convention Palin addressed last year via video.

Every other day, it seems, I receive an e-mail from one right-wing organization or another, warning of the grave consequences of health-insurance reform.

The subject line in an e-mail from Human Events magazine screams at me “Grandmas and babies exterminated by Obama ‘health’ plan,” even as another of its e-mails asks, “Obama birth certificate destroyed?” The anti-gay American Family Association warns: “Liberals seek to silence and demonize those who oppose their socialism.”

Tony Perkins of the Family Research Council sent a plea for money to finance a television ad that features an elderly couple complaining of the government’s denial of surgery for the man while financing abortion with taxpayer dollars.

Think these organizations are not the Republican establishment? Consider that the annual Values Voter Summit sponsored by the Family Research Council’s PAC will feature former “moderate” GOP presidential candidate Mitt Romney as a keynote speaker.

In the corridors of Washington’s K Street lobbying offices, in the district offices of Republican members of Congress, and in the executive suite of one singular mogul, the men of power must be well-pleased with themselves, watching YouTube videos of the mayhem they have unleashed on the rest of us. But they may just get their pound of flesh.

AHIP explains why private insurance is a bad deal

The Value of Provider Networks and the Role of Out-of-Network Provider Charges in Rising Health Care Costs

AHIP (America’s Health Insurance Plans)
August 2009
One tool that health insurance plans use to improve quality and make health care more affordable for consumers is the establishment of provider networks.
Some out-of-network providers are charging exorbitant prices — several hundred or even over a thousand percent of the Medicare reimbursement for the same service in the same area. Recent examples: $4,500 for an office visit when Medicare would have paid $134; $14,400 for removal of a gallbladder when Medicare would have paid $656; and $40,000 for a total hip replacement when Medicare would have paid $1,558.
Consumers who are charged exorbitant fees by out-of-network providers incur additional costs because the protection against balance billing generally does not extend to services provided out-of-network. This detracts from the ability of health plans to offer affordable access to out-of-network providers for those consumers who want the advantages of a network, but also maintain the option to go out-of-network if they choose.
Report:
http://www.ahipresearch.org/PDFs/ValueSurvey/AllStatesReport.pdf

And…

New Report Examines Out-of-Network Charges by Some Physicians

AHIP
August 12, 2009
While the issue of how much is appropriate for out-of-network physicians to charge has not been part of health reform discussion to date, this report demonstrates that it needs to be. No mechanism exists to protect patients who seek care out-of-network from receiving bills that are unreasonable and unaffordable.
“As policymakers pursue health care reform, we encourage them to look at how much is being charged for services, particularly since higher charges don’t mean high quality of care,” said AHIP President and CEO Karen Ignagni. “With the nation facing the crushing burden of rising medical costs, all stakeholders should be focusing on constructive ways to bring costs under control.”
Press release:
http://www.ahip.org/content/pressrelease.aspx?docid=28028

As we look at comprehensive health care reform, we really have to ask ourselves just what is it that the private insurance plans are providing us in exchange for their exorbitantly high administrative costs and the costly administrative burden they place on the health care delivery system?
Risk pooling? Public systems pool risk much more effectively than private plans. In fact, the private insurance industry wastes resources in their efforts to avoid risk. They’re not selling us the equitable risk pooling function that we want, and yet they’re charging us more for their lousy services. We don’t need that.
Managed care? Patients and their health care professionals do not want intrusive administrative managers intervening in their care. The private insurers have received that message and have backed off on the more explicit prohibitions of care. What they have not backed off on is selling us ever more of their wasteful, expensive managed care administrative services that are no longer particularly effective in moderating health care costs increases. They are perpetuating their unwanted intrusions, and they are charging us more for that. We don’t need that either.
So what service are they providing us? They have instituted private sector price controls by establishing contracts with hospitals, laboratories, health care professionals and other sectors of the health care delivery system. Their report released this week confirms that this is an important function. Prices set by the health care industry are much higher than prices dictated by the health insurance industry. If you think health insurance premiums are high now, just think of what they would have been without the private sector price controls applied to the contracted networks of providers.
Of course, there are trade offs. It is very expensive to provide the administrative services of both the insurers and the providers that are necessary to establish and manage these contracts. More dollars are diverted from actual health care to pay for these administrative excesses. A more perverse trade off is that patients are denied their free choice of health care professionals, hospitals, and laboratories since they must choose from the limited in-network panels provided by the insurers. They are limiting our choices, and they are charging us more for these unwanted services. Who wants that?
There is one more trade off that has left a gigantic, gaping hole in the private insurance model of health care financing. There are many legitimate reasons why an individual may receive care from out-of-network providers. When the private insurers do not have contracts with these out-of-network physicians and hospitals, they have no ability to dictate private sector prices. If the private insurers pay the full out-of-network fees, in-network providers will cancel their contracts and then demand the same prices, thus driving up our insurance premiums. If the insurers do not pay these high out-of-network fees, the patient is stuck with them. This is one of the reasons that individuals with “good” insurance end up in bankruptcy due to medical debt.
The timing of this AHIP report is no accident. Congress and the administration have now agreed that individuals will be required to purchase private health plans, perhaps with the additional option of a private model plan that is public in name only. Since the insurers have agreed to provide coverage for everyone not covered by other public and private plans, and since they will continue to use contracted provider networks (PPO, POS, and HMO), they understand that a solution to the high prices of out-of-network providers will have to be provided.
What is their solution? Although it appears only between the lines, their proposal is really not that subtle. “Out-of-network providers are charging exorbitant prices.” AHIP places the entire blame on those who refuse to sign their contracts. “No mechanism exists to protect patients who seek care out-of-network from receiving bills that are unreasonable and unaffordable.” AHIP obviously is calling for a mechanism to control the prices of providers with whom the insurers have no contract.
Lacking the ability to enforce private market contracts that were never agreed to, there is only one other entity that can provide a price-control mechanism. Jumping out from the space between the lines of their report, that entity is obviously the government – yes, the GOVERNMENT! AHIP is implicitly supporting government price controls for health care. But then that isn’t such a foreign concept for them. For decades, they’ve been using price controls through their own private bureaucracies.
So the only service they are providing is a profoundly expensive, administratively wasteful set of fragmented, restricted networks of providers that fall short of controlling prices throughout the system, and for that we have to give up our choice of health care professionals and facilities, not to mention giving up more of our money.
What if we got rid of the private insurers and had the government do it instead? Our experience with Medicare should give us an idea of how that might work. The administrative waste in the Medicare program is much less than that of the private plans. The additional administrative burden placed on the health care delivery system would be reduced dramatically since the providers would have to deal with only one payer and one set of rules. Not only would all risks be pooled together into a single pool, that pool would be funded much more equitably based on ability to pay. Since virtually all physicians and hospitals would participate in the program, patient choice would be almost unlimited, including the right to choose an integrated health system, if so desired.
Just like the private plans, Medicare has established prices for those contracting with the program. But what about those providers who do not have contracts? These are like the providers over whom the private insurers have no control. Well, Medicare is a government program. As such they dictate the prices, with slight adjustments, for non-contracted providers. The only way a physician can charge a Medicare patient the full list price is to refuse to bill Medicare for any patient at all for a minimum of two years, and to have this patient sign an agreement that he or she likewise will not try to collect from Medicare.
So we already have the heavy hand of government administering price controls. But isn’t that what AHIP is not so subtly advocating? GOVERNMENT PRICE CONTROLS for those providers who refuse to sign their private insurance contracts! If the government is going to control prices anyway, then why would we need or even want the private insurance contracts?
BusinessWeek’s statement this past week that the health insurers have already won should not be accepted as a given, but should be considered a challenge to us to demand, in loud and clear terms, the reform that we need. Let’s make it a very hot August for our representatives in Congress, but let’s make our message effective by being polite while we generate heat.

AHIP explains why private insurance is a bad deal

The Value of Provider Networks and the Role of Out-of-Network Provider Charges in Rising Health Care Costs

AHIP (America’s Health Insurance Plans)
August 2009

One tool that health insurance plans use to improve quality and make health care more affordable for consumers is the establishment of provider networks.

Some out-of-network providers are charging exorbitant prices — several hundred or even over a thousand percent of the Medicare reimbursement for the same service in the same area. Recent examples: $4,500 for an office visit when Medicare would have paid $134; $14,400 for removal of a gallbladder when Medicare would have paid $656; and $40,000 for a total hip replacement when Medicare would have paid $1,558.

Consumers who are charged exorbitant fees by out-of-network providers incur additional costs because the protection against balance billing generally does not extend to services provided out-of-network. This detracts from the ability of health plans to offer affordable access to out-of-network providers for those consumers who want the advantages of a network, but also maintain the option to go out-of-network if they choose.

Report:
http://www.ahipresearch.org/PDFs/ValueSurvey/AllStatesReport.pdf

And…

New Report Examines Out-of-Network Charges by Some Physicians

AHIP
August 12, 2009

While the issue of how much is appropriate for out-of-network physicians to charge has not been part of health reform discussion to date, this report demonstrates that it needs to be. No mechanism exists to protect patients who seek care out-of-network from receiving bills that are unreasonable and unaffordable.

“As policymakers pursue health care reform, we encourage them to look at how much is being charged for services, particularly since higher charges don’t mean high quality of care,” said AHIP President and CEO Karen Ignagni. “With the nation facing the crushing burden of rising medical costs, all stakeholders should be focusing on constructive ways to bring costs under control.”

Press release:
http://www.ahip.org/content/pressrelease.aspx?docid=28028

Comment:

By Don McCanne, MD

As we look at comprehensive health care reform, we really have to ask ourselves just what is it that the private insurance plans are providing us in exchange for their exorbitantly high administrative costs and the costly administrative burden they place on the health care delivery system?

Risk pooling? Public systems pool risk much more effectively than private plans. In fact, the private insurance industry wastes resources in their efforts to avoid risk. They’re not selling us the equitable risk pooling function that we want, and yet they’re charging us more for their lousy services. We don’t need that.

Managed care? Patients and their health care professionals do not want intrusive administrative managers intervening in their care. The private insurers have received that message and have backed off on the more explicit prohibitions of care. What they have not backed off on is selling us ever more of their wasteful, expensive managed care administrative services that are no longer particularly effective in moderating health care costs increases. They are perpetuating their unwanted intrusions, and they are charging us more for that. We don’t need that either.

So what service are they providing us? They have instituted private sector price controls by establishing contracts with hospitals, laboratories, health care professionals and other sectors of the health care delivery system. Their report released this week confirms that this is an important function. Prices set by the health care industry are much higher than prices dictated by the health insurance industry. If you think health insurance premiums are high now, just think of what they would have been without the private sector price controls applied to the contracted networks of providers.

Of course, there are trade offs. It is very expensive to provide the administrative services of both the insurers and the providers that are necessary to establish and manage these contracts. More dollars are diverted from actual health care to pay for these administrative excesses. A more perverse trade off is that patients are denied their free choice of health care professionals, hospitals, and laboratories since they must choose from the limited in-network panels provided by the insurers. They are limiting our choices, and they are charging us more for these unwanted services. Who wants that?

There is one more trade off that has left a gigantic, gaping hole in the private insurance model of health care financing. There are many legitimate reasons why an individual may receive care from out-of-network providers. When the private insurers do not have contracts with these out-of-network physicians and hospitals, they have no ability to dictate private sector prices. If the private insurers pay the full out-of-network fees, in-network providers will cancel their contracts and then demand the same prices, thus driving up our insurance premiums. If the insurers do not pay these high out-of-network fees, the patient is stuck with them. This is one of the reasons that individuals with “good” insurance end up in bankruptcy due to medical debt.

The timing of this AHIP report is no accident. Congress and the administration have now agreed that individuals will be required to purchase private health plans, perhaps with the additional option of a private model plan that is public in name only. Since the insurers have agreed to provide coverage for everyone not covered by other public and private plans, and since they will continue to use contracted provider networks (PPO, POS, and HMO), they understand that a solution to the high prices of out-of-network providers will have to be provided.

What is their solution? Although it appears only between the lines, their proposal is really not that subtle. “Out-of-network providers are charging exorbitant prices.” AHIP places the entire blame on those who refuse to sign their contracts. “No mechanism exists to protect patients who seek care out-of-network from receiving bills that are unreasonable and unaffordable.” AHIP obviously is calling for a mechanism to control the prices of providers with whom the insurers have no contract.

Lacking the ability to enforce private market contracts that were never agreed to, there is only one other entity that can provide a price-control mechanism. Jumping out from the space between the lines of their report, that entity is obviously the government – yes, the GOVERNMENT! AHIP is implicitly supporting government price controls for health care. But then that isn’t such a foreign concept for them. For decades, they’ve been using price controls through their own private bureaucracies.

So the only service they are providing is a profoundly expensive, administratively wasteful set of fragmented, restricted networks of providers that fall short of controlling prices throughout the system, and for that we have to give up our choice of health care professionals and facilities, not to mention giving up more of our money.

What if we got rid of the private insurers and had the government do it instead? Our experience with Medicare should give us an idea of how that might work. The administrative waste in the Medicare program is much less than that of the private plans. The additional administrative burden placed on the health care delivery system would be reduced dramatically since the providers would have to deal with only one payer and one set of rules. Not only would all risks be pooled together into a single pool, that pool would be funded much more equitably based on ability to pay. Since virtually all physicians and hospitals would participate in the program, patient choice would be almost unlimited, including the right to choose an integrated health system, if so desired.

Just like the private plans, Medicare has established prices for those contracting with the program. But what about those providers who do not have contracts? These are like the providers over whom the private insurers have no control. Well, Medicare is a government program. As such they dictate the prices, with slight adjustments, for non-contracted providers. The only way a physician can charge a Medicare patient the full list price is to refuse to bill Medicare for any patient at all for a minimum of two years, and to have this patient sign an agreement that he or she likewise will not try to collect from Medicare.

So we already have the heavy hand of government administering price controls. But isn’t that what AHIP is not so subtly advocating? GOVERNMENT PRICE CONTROLS for those providers who refuse to sign their private insurance contracts! If the government is going to control prices anyway, then why would we need or even want the private insurance contracts?

BusinessWeek’s statement this past week that the health insurers have already won should not be accepted as a given, but should be considered a challenge to us to demand, in loud and clear terms, the reform that we need. Let’s make it a very hot August for our representatives in Congress, but let’s make our message effective by being polite while we generate heat.