Thinking About Health Care Reform, Pt. 1
(July 6, 2009)
OK, now where was I? Oh yes, health care reform.
Finally, a subject I understand well enough to know what things I don’t understand about it. I have lots of questions, and I see several concerns that any reform plan needs to be able to address in a plausibly reassuring manner.
First off, let me say this is a real problem. As a union guy, I’ve negotiated health insurance benefits for a long time. I’ve felt the lash of premium costs rising much faster than inflation. I’ve seen the discomfort of workers having to choose between higher out-of-pocket premium costs and lesser coverage. I’ve seen plans move to $2000 deductibles per person, just to retain some degree of affordability. And I’ve seen workers gradually educated to the hard reality that every dollar for health care is a dollar that isn’t available for salary.
Worst of all, I’ve mediated intra-union generational warfare in its ugliest. Younger workers fight for higher pay instead of driving money into insurance. Middle age workers fight for family coverage so their kids can be insured, while older workers fight for full coverage for employees and spouses only, even as they also try to figure out how to afford retirement pre-Medicare.
So I am not surprised that the pressure for health care reform is coming not only from the 47 million uninsured (whoever they are), but also from middle-class insureds who see the escalating cost of their coverage and wonder how long they can afford it.
But I’ve also been a health care consumer, and here it seems to me the reformers are way off base. I’ve been to doctors, clinics, and hospitals; I’ve had expensive tests and procedures, and I’ve come out alive. More than alive, I’ve come out marveling at the quality of the health care I’ve received. When Michael Moore touts Cuba’s system, or the NY Times’ editorial stable bemoans America’s “broken system”, I wonder what planet these guys are on.
Has anyone with a life-threatening illness ever voluntarily left the US to be treated in Canada or Britain or France?
The US system is the world’s locomotive of medical innovation, whether in new drugs or advanced bio-mechanical treatments.
And this is needs to be a major concern. Any reform needs to be structured so that it will not inhibit innovation and technological advancement.
We all know drug costs are skyrocketing, faster than any other health care cost. So a few years ago, we had a big campaign to follow the Canadian system and to simply set government price controls on drugs, or (better yet) allow us to import price-controlled US-developed drugs from Canada, thereby proposing the shabbiest example of government out-sourcing ever. The proponents got some great political theater out of Lourdes-like bus caravans of the old and sick to Canada, but fortunately the idea got nowhere. US price controls would have upped the Canadian pin-prick into a vampire’s deadly blood-letting for the US drug companies (“Big Pharma”, as some Democratic enemy-targeters like to call them).
Which brings up the biggest question of all. What is driving health-care cost inflation? We need to ask that before we can talk about fixing it.
It appears that two factors are primary. First, as we’ve been discussing, new drugs and technological innovations are pricy. So they are the problem.
But they are also keeping us alive and well to an extent that has never been dreamed of. Diseases that people routinely died from even 20 years ago are now treated easily with drugs. As an example, the Make-A-Wish foundation grants last wishes to children with terminal diseases. They have recently removed leukemia from their list of terminal diseases eligible for last-wishes. Why? Because leukemia, that nightmarish death sentence of the young, is now routinely survived. New drugs, new treatments. How much overall health care cost increase is that worth?
How many middle-aged people do you know who are able to walk because they got new knees? How many grandparents are still alive because of a heart bypass?
Speaking of grandparents brings us to the other principal cost driver. We are getting older – not just individually, but collectively and on average. Every employee group I ever bargained for was getting steadily older. So is America. Partly, this is a result of medical improvements, so there is a positive feedback loop here. Health care lets us get older, older people need more health care.
But is this a problem? What do we want? Less care? Less old people? What?
In a very real sense, health care cost increases cannot be considered inflation. Inflation means paying more for the same product. In health care, we are paying more for steadily improving products and outcomes. Increased longevity is a valuable commodity. Improved mobility and easily cured diseases are a valuable commodity. If we think of them as problems rather than successes, we are headed for some very ugly outcomes. Rationing care is only a bureaucratic term for rationing life.
There are a lot of additional issues to consider. Who exactly are the 47 million uninsured? Whay are they uninsured? How much would it cost to insure them?
We have considerable experience with some government-run and managed health care. Why aren’t we talking more about that?
Medicare appears to be a successful single-payer plan, if you ignore the cost escalation. Is Medicare’s cost explosion simply the result of the phenomena described above – new drugs, aging demographics? Is the problem simply that the Medicare tax hasn’t been raised in years, unlike all other insurance premiums? In otheer words, is Medicare a model or a disaster warning?
The VA (Veterans Administration) is a classic single-payer single-provider plan that should be studied. How is it working?
Medicaid is the current effort to insure those who can’t afford insurance. It seems to be another cost-exploding program. What is driving its costs? How many of the 47 million are or could be covered by Medicaid? Are we looking at re-structuring health care for 300-million Americans when perhaps some Medicaid adjustments would do the trick?
What about tort reform? We don’t hear much about malpractice lawsuits and insurance costs for doctors anymore; is that because we have a Democratic regime, or has the problem gone away? Are malpractice insurance costs and needless tort-defensive testing and procedures a major cost factor? If so, is anyone (except lawyers) ready to defend them as “valuable commodities”?
Obama’s NEA-Style Summit
(February 26, 2009)
I have just read the description of President Obama’s Financial Responsibility Summit (if I got the name right). It was disturbingly familiar.
It was an NEA conference writ large (or at least upscale).
The formula has been painstakingly refined by NEA (and every other outfit besotted by facilitation consultants and best-selling management gurus). It is the meeting format of choice for an organization committed to patronizing and indoctrinating in the guise of consulting.
You start by bringing folks together. The conference leaders then lay out the problem, the parameters, the importance of their input. The call is made: come up with three or five concrete suggestions to fix the problem. Then the break-outs. Either at small tables (usually 8 people at a banquet round table) or in separate rooms (if the budget permits), the small groups share their thoughts on the topic at hand. A staffer stands ready to write down their every thought, usually on a chart board. (What the Chinese Cultural Revolutionaries called “big-character posters”).
When time is up (Obama’s audience was given 2 1/2 hours to fix the economy), the “reporting out” begins. One person from each table stands to share the table’s collective thoughts. The leader thanks them, compliments them for their interesting and constructive ideas, and then dismisses them in an aura of mutual self-congratulation.
Afterwards, the staffers compile a report from the table-posters. In some cases, this report may resemble what the participants actually said. It will certainly mirror what the leader wanted to hear, to the extent that it contains anything beyond trivialities and vague bromides.
In NEA-land, the purpose of such events is threefold.
First, to flatter the participants that they have been seriously consulted.
Second, to keep the participants busy, and to divert complaints and troublous suggestions.
And third, to reinforce the leaders message and convince the participants that they thought of it themselves. This is called “buy-in”.
If the whole thing is done well, the participant never realizes that he has traveled across the country to engage in a two-hour conversation with seven others, with the results to be filtered and scrubbed clean before being printed and filed away.
NEA is good at this. So, apparently, is the new administration.