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2. 1. It does not solve the problem. We never had a health care crisis,we had a health care COST crisis. There may be some things in the bill that address some cost but does not bring down cost effectively because they did not start out working on the true problem.
   2. The mandate placed on individual citizens is inherently wrong. Unconstitutional or other wise,it’s unethical to Mandate the purchase especially without bringing the cost down first. see 1. The group of people who will be negatively affected by this the most are the very people tit is supposed to help POOR people,primarily working poor,poverty level wage earners will now be forced to buy inadequate insurance that won’t include dental or optical(not comprehensive as advertised),or face a tax penalty-fine. They are promised aid,but most working poor make just enough to be en-eligible for other subsidies,so this will probably be the case with this as well.
   All in favor,pat your self on the back for sticking it to low poverty level income workers.
   3. a more ethical approach would have been to just readjust the eligibility for medicaid. example make medicaid optional enrollment for any citizen making less than $20,000 a year. regardless of age,gender race,orientation,religion. Fix medicaid/medicare flaws,
   Allow insurance companies to sell across state line,co-op policies for various groups( all the Cashiers in the country could get on a nationwide cashier plan.
   4. If they want to help working poor,consult working poor instead of consulting higher income segments.
   they don’t have to stop there, that would just be a place to start. I’m all for making Affordable health care AVAILABLE for everyone,but I think it can be done in a way that would not infringe on the right of persons choosing not to participate. They have social med in other countries,but they don’t fine you if you don’t utilize the system(extremely high tax rates not withstanding). They rushed to much before coming up with real solutions.
   They(the fed gov.) could have done a couple things quickly to help some in drastic dire need,like some type of stop-gap emergency medical relief fund to save people from dying,then then they could have come back to working on practical long term solutions.
   I really don’t like the mandate. To me the Individual Mandate is the worst part,and it is contrary to the often discussed “public option”. there is a huge difference between “optional” and “mandatory”.
   The car insurance comparison is terrible,weak at best.
   Many states still allow persons to be self-insured,
   and owning a car is optional, it’s a choice,having a placenta isn’t. It leads one to believe it is just another federal government quagmire with allot of negative side effects that while causing a tremendous amount of social hostility and unrest.

3. “Thus private insurance could deliver Medicare for the same, worst case scenerio, or slightly less, maybe 5-10%.”
   Is that all!? I’d expect at least half for all your defending of private sector insurance. Thanks but I’ll take a public system that has a chance to really give us reductions. Medicare is stuck paying the going rate set by the private sector – which we know is unsustainable.
   “After you passed Medicare now 19% of seniors are on Medicaid and very few can afford to pay their own medical expenses.”
   If that’s true (not even close to provable), but funny, that’s not true for single-pay countries, it’s because Medicare has been a cash cow for private healthcare (other than PCPs) and a success for private healthcare lobbyists, not to mention the AARP.
   “You think Medicare expenditures aren’t increasing?”
   If FICA Medicare went up the 6%-10% compounded yearly increases that private health premiums are there’d be screaming demand to cut costs. But those increases are added to the deficit cause it’s easy and passed on to company plans that shield the insured – you’re all delusional. Talk to people in the individual market not privelaged enough to get an employer or government to pay their health costs – you’ll see the truth about this system’s complete failure.

4. “On Nate’s insurance company and how it’s different from other insurers: Nate works for an alternative insurance company in an alternative universe.”
   Your most intelligent retort yet Maggie. Hey if you don’t have facts on your side I rather you try humor then just making them up like you usually do.
   And FYI I don’t work for I own. There are those of us who actually get out and solve problems, myself, and those of us who stay home and write fiction, thank you for your contribution.

5. margalit & Peter
   Thanks for your comment
   We’re no longer making medical breakthroughs that extend overall life expectancy.
   Relatively inexpensive medications plus lifestyle changes have made death by heart disease rarer, but that just means that you’re more likely to die of cancer–or Alzheimer’s.
   We are very, very far from anything like a cure for Alzheimers. As palliative care specialist Dr. Diane Meier points out, with all of this “innovation” we are simply “saving” ourselves to die of some form of dementia.
   In my boomer generatoin, and more people will find that their bodies outlive their minds. There are worse things than dying
   Some see struggling for an extra few months as heroic.
   Others see it as folly and wince at the sight of a mature adult, flailing about, screaming No, No, NO, not ME!. I’ll pay anything! I have plenty of money! I was my mother’s favorite son! You don’t understand, I can’t die!!
   Accepting death is a sign of growing old gracefully, accepting aging and death as part of life, part of nature is a sign of maturity, and I think, of having lived a good life. I know two people–one in his late 70s, one in his 90s, who have lived very full lives and are not afraid of dying. Each of them has had a brush with death. (Though they are concerned about what a hospital might put them through before they die.) I also know a man who was philosphical about dying when in his 70s. (He was a diabetic, had lost his eyesight, and endured amputations of his toes.) In the hospital, the doctors “brought him back.” He was very very angry. “What the F… is this!” he shouted. Luckily, his daughter stood up for him, refused to let the doctors put him on dialysis (even though the doctor shouted at her) and he managed to die a few days later.
   Read the story in the NY Times magazine a few weeks ago about “What Broke My Father’s Heart.”– See the end of the story, and how the mother handled her own mortaltiy–with extraodinary grace and dignity.
   Also, biological science is beginning to make it clear that in terms of life expectancy, affluent Americans are close to a natural limit. It’s not possible to push life expectancy to 120, making it the “new 100.”
   Ssee the opening chapters of Nortin Hadler’s book “Worried Sick.”
   Nor would we want to live that long. See Gulliver’s Travel’s and the people he meets who never die . . . .They just age, and age, and age.
   Sorry to go on at such length. But this is such an important subject.
   On Nate’s insurance company and how it’s different from other insurers: Nate works for an alternative insurance company in an alternative universe.
   Peter– Yes, legislators are forced to play “hide the ball” with taxes. To be fair only a very few other countires have found a different way to fund public pensions and they are much, much smaller, which makes it much, much easier.
   In any case, Social Security is not in trouble. With just a couple of very small fixes, it will be solvent for a very long time. And the fixes don’t have to come immediately.

6. Peter, Maggie, Matt any other liberals here want to argue Medicare saved seniors from dependence like it was claimed to pass Medicare?
   A central rationale offered to the public for the bills that became Medicare was that they would enable people to “avoid dependence” in old age. In fact it was a bogus rationale that served as a key form of transaction-cost augmentation used to secure the bill’s passage. That this rationale was not believed by the bills’ authors in HEW is clearly indicated by Celebrezze’s acknowledgments above regarding the omission of coverage for catastrophic illness. Nonetheless, government officials’ repeated assertions that Medicare would “avoid dependence” made it more difficult for voters to understand that dependence in old age would not be forestalled by these measures, thereby diminishing resistance to the bills.
   Above is why the liberal argument about the tea party being against government but taking Medicare is such dishonest BS. They paid for it alreadyt and wouldn’t get a refund to replace it and they would lose their SS they already paid for.
   Senator Gordon Allott (R., Colo.) described it to the Senate as a “program of ‘Robin Hood in reverse'” that showed “complete disregard for need in disbursement” and represented a “giant step” toward making “every citizen as dependent as possible on his Government for his every need” (U.S. Cong. Rec.-Senate 8 July 1965: 15935).
   When Rep. Albert Ullman (D., Ore.) cited allegations that the “public is somehow being hoodwinked” and “being misled” and asked HEW’s Wilbur Cohen about the degree to which the public misunderstood the program, Cohen stated that “we do recognize this problem and I think it has been complicated by the use of the term ‘medicare’ which is an erroneous term when applied to this program” (U.S. House Hearings 1965: 104). Although government officials sometimes expressed dismay about this public misimpression, the misinformation nonetheless fueled support for passage of a bill they strongly supported.

7. “7-8K really, for a 65+ year old probably with pre-existing? At what deductible and co-pay?”
   Peter you really are simple sometimes. What do you think the average spending per Medicare beneficiary is per year? Add admin and retention you have your insurance premium. Private insurance delivers the exact same medicare benefits, there is your second answer, slightly less then Medicare does. They also do it minus the 10% fraud rate. Thus private insurance could deliver Medicare for the same, worst case scenerio, or slightly less, maybe 5-10%.
   ” Private insurance does what Medicare can’t and that is raise rates by compounded % each year”
   You think Medicare expenditures aren’t increasing? They just don’t publish it as a rate so simple minded people who can’t be bothered to look up facts before shoting out the mouth never know. They also cut reimbursements and shift cost to keep their increases down.
   “How would your grandma get her Medicare paid if the wealthy could get their Medicare taxes back?”
   Prior to liberals like you, who fail basic math, passing Medicare Grandma didn’t need ANY help paying her medical bills. 87% of seniors where able to pay 100% of their own medical expenses till death. After you passed Medicare now 19% of seniors are on Medicaid and very few can afford to pay their own medical expenses. Thank you Peter and Democrats for solving a problem that didn’t exist and creating a much bigger one in the process.
   “You think I defend that?”
   Peter your the one who asked why seniors don’t cancel Medicare and buy their own coverage. If you knew the answer and agree with it why did you ask?
   Your original question made as much sense as asking why humans don’t get rid of cars and flap our wings. While the solution is praticle and makes sense it is not possible. For all intents and purposes Americans are forced into Medicare and don’t have the option to opt out.

8. “So instead of getting a subsidized plan at 1200 you would have to pay 7-8K, private insurance does deliver Medicare cheaper then medicare does so it would cost less.”
   7-8K really, for a 65+ year old probably with pre-existing? At what deductible and co-pay? And who could afford that on a pension anyway? If I had my way we’d all be on individual plans, single-pay would happen so fast in this market insurance companies wouldn’t know what hit them. Private insurance does what Medicare can’t and that is raise rates by compounded % each year – anybody can do that and make money especially without giving anything back in return, except of course higher deductibles and co-pays. You also don’t get your public school taxes back when you use a private school – it’s part of what little social solidarity exists in this country, at least for now. How would your grandma get her Medicare paid if the wealthy could get their Medicare taxes back?
   “You also seemed to not want to address the fact the federal government takes away your SS benefits, why was that left out?”
   You think I defend that? In fact I don’t agree with any use-specific tax being used for general fund purposes. But since voters hate any tax and especially tax increases, legislators are forced to play hide the ball with taxes to dishonest balance budgets. If you don’t like how elected reps balance budgets talk to voters who think services should be free, at least for them. As I’ve said before, Americans really do like taxes, just other peoples.

9. careful Peter you can’t say things like that on left leaning blogs. Or financial ones either. Medicare taxes are to pay for current enrollee’s Medicare coverage. Paying your Medicare Tax in now way entitles or promises you future benefits.
   I personally think it should but if it did then uncle sam would have another 100 trillion of debt on his books and be insolvant by all measures.
   Medicare Part A is free to enrollees, they pay nothoing for it. Medicacre Part B is $90 or what ever current price is. C/MA is usually free, and D varies. A benefit package that if priced would cost 8K plus per year in fact goes for $1200. That is why it is such a steal.
   Regarding the fallacy of your argument. If you waived Medicare you would not get your taxes returned to you. So instead of getting a subsidized plan at 1200 you would have to pay 7-8K, private insurance does deliver Medicare cheaper then medicare does so it would cost less.
   You also seemed to not want to address the fact the federal government takes away your SS benefits, why was that left out?

10. No Nate, it’s not free, it’s been paid for out of their pay checks and is also paid from their taxes. But I guess that for “free” insureds will accept some hassels dealing with Meducare. The reason they don’t use private insurance is they couldn’t afford the rates even with your assertions that private insurance is so effecient and cost effective. Even during their working life most got their paid for insurance from their employer.

11. I don’t know Peter maybe it has something to do with them taking away your social security?
    Y&ou really need a 10 second rule Peter, think for 10 seconds before you make stupid responces. You will also see if you read that I never once said it was a bad deal for insured. In fact it is an incredible deal at the time you actually become an insured seeing as how you don’t pay for it. Free is always a good deal even when it is wasteful of other people’s money.

12. I guess if Medicare was such a bad deal for insured as Nate says then they could just pay for and use private insurance. I wonder why 65s+ don’t do that?

13. United and Anthem can get away with charging $40 PEPM maybe a little more. For what that includes it is still a bargin compared to Medicare. When you actually do the math Medicare spends roughly $23 directly on administration, another $10-$15 indirectly through CMS and other agencies that contribute to its administration and then loses $58 PEPM to fraud. Total that is $91 compared to $40-$50 for private insurance. Private insurance includes far better customer service and websites, disease management, wellness, and many other services that medicare does not. To say that is unnecessary high is just partisian propoganda.
    Private insurance could easily pay claims like Medicare, FYI want to know how much your customer service call volume drops when you just pay everything!, and eliminate all the frills and end up just like Medicare, what has that gained? Less service and higher total cost.
    People that don’t know what they are talking about like to compare the $23 and $40+ and say see how much more efficient Medicare is, and just pretend the rest of the equation doesn’t matter.

14. Nate, just a general question: are your practices and efficiencies representative of all private insurers, or are they just representative of your company? In other words, should I extrapolate from your $20 overhead to say that UHC’s is the same? And isn’t a TPA somewhat different than actually selling insurance?

15. “As you well know, cherry-picking is and has continued to be be a problem in the individual market, ”
    No I don’t know, I sell insurance and don’t beleive there is cherry picking. Based on what knowledge do you claim there is cherry picking and how do you define cherry picking? If your going to claim charging someone that is sick a higher rate them someone that is healthy then by your defining of the word there is, by normal definition there is not. It is an illegal pratice and hasn’t been around for years.

16. “I realize you talk to a lot of people about buying insurance, but Gallup is in the business of doing surveys in a scientific wa. It’s track record is pretty good.”
    Says who? I just tore apart a gallap poll last week, There is nothing scientific about what they do. They push a political agenda and try to pretend they can support it with fact. I’m in the business of selling insurance, the people I work with every day are in the business of selling insurance. The brokers I work with and myself quote and sell a multitude many times more people then gallap polls. By any scientific measure my direct results are more valid and substbatial then their telephone poll.
    Further you don’t seem to grasp the difference between polling on who buys something and making the unscitific leap to claiming those that don’t buy do so becuase of affordability. It’s a subjective measure and one they don’t even ask in their poll.
    You can’t produce a single study to back up anything your claiming here. Until you show me a study breaking down the personal income and expenditures of the uninsured you can’t beging to claim they can’t afford it. I’ll challenge you to even define affordability. Does someone that forgoes $80 a month insurance premium but has a $130 a month cell phone bill qualify as non affordable?
    I have 10 times the information on these people that Gallop does, if anything is anecdotal it is their 5 minute survey over the phone. Did Gallop see the car they drove? Did Gallop see how they were dressed?
    You can’t dismiss facts for your partisan gain.
    ” For young people in the bottom third (earning under $24,000) subsidies will make insurance extremely affordable”
    I thought all these were going to be covered under their parents plan? In which case the only subsidy is from business.
    “To a degree, I share your concern about gov’t demonizing insurers. Or, put it this way, I think gov’t should also be taking a very hard look at drug-makers, hospitals and some specialists over-charging and selling ineffective products and treatments.”
    Here is a crazy idea, since government is the most inefficient and expensive plan in the entire world how about they start by demonizing themselves? Maybe after they clean up their own plan they can cast dispeersion on everyone else?
    “That said, while insurers’ profit margins are relatively low, their administrative expenses are unncessarily high.”
    By what measure do you make this claim? I charge $20 PEPM to administer a self funded plan. Medicare directly spends about $23.33 per member. My plans have a fraud rate under 1%, Medicare and Medicaid are around 10%. If your going to make these wild baseless claims start backing them up. You can’t produce a single measure by which Medicare is more efficient then me except wasting money.
    The problem is you on the left make these wild claims and are never held responsible to back them up. You feed the distortion and blame that leads people to case blame in the wrong place and thus nothing ever gets fixed.
    “Government is going to continue to press insurers to find ways to economize and to show they are offering value for their premiums.”
    ” (We can’t afford to keep the the for-profit insurance industry going if it can’t provide value .)”
    Not true at all, we can’t afford to keep public healthplans going unless they learn to control cost and fraud like private insurance plans do. The crisis in healthcare is not in private plans, its the trillions of unfunded prmoises in public plans.
    Let me fill in some missing history, this is exactly what Ted Kennedy said when he created HMOs, then when they did exactly what congress wanted them to, they turned on them. You cheer United now but 2 years when someone supposedly will die without a cardionet you will demonize them for not covering them. That is exactly what the left and trial lawyers did 10 years ago.

17. “The only way to change American attitudes about death is through a very long process of education.”
    Yes, but do we really want to do that? What would have happened to all the innovations and advances in medicine if people weren’t willing to fight for an extra couple of months at a time? Who is going to invest time and money in initial breakthrough therapies, if people are just fine with dying whenever? Without those initial clumsy beginnings, there is nothing to build on and there will be no major improvements. There will be no transplants today if the original organ recipients wouldn’t have been interested in clinging to dear life for a few more weeks. Same for cancer, heart disease and almost every other ailment. Maybe those folks that run the huge bills for no apparent benefit to themselves are inadvertently contributing to the well being of future generations more than us cowards who would rather go quickly. Just a thought…

18. Everyone, j.d. & Nate
    Everyone- My reply to Cato’s reponse is now up on http://www.healthbeatblog.org
    j.d. Sorry– started to reply to you and then got lost in my reply to Barry.
    To a degree, I share your concern about gov’t demonizing insurers. Or, put it this way, I think gov’t should also be taking a very hard look at drug-makers, hospitals and some specialists over-charging and selling ineffective products and treatments.
    But you need to understand: the public likes to hear about gov’t squeezing insurers. It doeosn’t like to hear about gov’t pushing hospitals, device-makers etc. to offer better value. Medicare will do it, but Obama is not going to appear on TV threatening brand-name hospitals.
    Of course, insurance is so expenisive in large part because U.S. healthcare is so expensive.At bottom, that’s the bigger problem.
    That said, while insurers’ profit margins are relatively low, their administrative expenses are unncessarily high.
    And insurers are saying that under reform, they can cut those costs (partiallly because they won’t be underwriting and cherry-picking.) Blue Cross of N.C. recently announced it plans to cut $200 million of admnistrative costs from a budget of $1 billion by 2014. That’s a 20 percent reduction.
    They also said they plan to “enter into some tough negotations with hospitals.”
    In Oklahoma, Health Services Corp the parent company for Blue Cross and Blue Shield by “consolidating marketing operations” in the SouthWest.
    Meanwhile, in California, Aetna asked for a 19 percent rate hike for tens of thousands of customers– then, when the state began to take a close look at the numbers, Aetna admitted that it made a mistake (human error) and would have to re-do the numbers. They dont’ need a 19% hike after all, they admitted.
    All of this suggests that there is room for voluntary cutting on the part of insurers. It’s good that they’re reacting to Obama’s bully pulpit; we can’t afford waste in any sector of our medical/industrial complex.
    Meanwhile, some insurers are getting tough with hospitals and device-makers. For example: “CardioNet Inc. said Wednesday that UnitedHealth, one of the largest health insurers, will not cover CardioNet’s wireless heart-monitoring devices.
    CardioNet said UnitedHealth Group Inc. is maintaining its view that ;outpatient cardiovascular telemetry is unproven for managing cardiac arrhythmias.’ The decision comes about a year after a Medicare administrator slashed reimbursement rates for CardioNet’s products and similar devices. That caused health insurers to lower their rates.
    UnitedHealth, the largest publicly traded health insurer based on revenue, is seen as a bellwether for the industry.”
    Note that UnitedHealth was following Medicare’s lead.
    Cardionet was disappointed that Medicare did not include its wireless devices in Medicare’s 2010 fee schedule.
    Government is going to continue to press insurers to find ways to economize and to show they are offering value for their premiums. (We can’t afford to keep the the for-profit insurance industry going if it can’t provide value .) And the public likes to hear that gov’t is pressing insurers.
    But–and this is important– govt will also be pressing hospitals to lower fees , and device-makers and drug-makers to lower prices. Medicare is already cutting fees for some servcies like diagnostic testing and preventable hospital readmissions. In Rhode Island the Insurance Commissioner is capping how much insurers can pay hospitals. . .Medicare has indicated that next year, it will cut oncologists fees.
    Still Washington needs to be aware that when the public hears that government cutting fees for health care providers, device-makers and drugs, this is much less popular. Americans fear that they won’t be cutting the products and servcies they want.
    They are reluctant to believe that their hospitals are over-charging.
    So Obama will make fewer big speeches about hospitals, drug-makers and device-makers. But quietly, Medicare will be cutting spending and insisting on better value for its dollars. And private insurers will continue to follow Medicare’s lead.
    Ultimatley, over time, the public will see that health care will not suffer. Lower prices, greater efficiency and higher qualitly go hand in hand.
    Nate–
    About why young people don’t buy insurance:
    The notion that young people forego insurance not because they don’t think they need it but because they can’t afford it comes from a Gallup poll of 30,000 young people.
    I realize you talk to a lot of people about buying insurance, but Gallup is in the business of doing surveys in a scientific wa. It’s track record is pretty good.
    Their surveys are more credible than anyone’s anecdotal experience. They show that young people are most likley to have insurance if they have a higher income. This doesn’t necessairly mean its cheap. It’s interesting that young people in poor health are least likely to have insurance because they can’t afford it even though they need it. Young people in good health are most likely to buy insurance, even if they aren’t in great need of having insurance (86% of those earning over $45,000 in good health.) For young people in the bottom third (earning under $24,000) subsidies will make insurance extremely affordable and for those earnign $24,000 to $45,000 it will be much more affordable. Look at tables of subsidies

19. Margalit,
    On the issue of charging more for insurance for those who want heroics, we would need to know just how much more than, say, standard Medicare we’re talking about. It might be a lot less than you think.
    Feeding tubes, for example, might be used primarily in a nursing home setting where the payer is either Medicaid or the patient’s family. Paying extra for insurance is irrelevant here because there is no insurance premium in connection with either Medicaid or self-payment. In the hospital setting, we would need to define just what heroics are. In the end, the insurance surcharge for those who want heroics could be surprisingly affordable. We just don’t know without further study. Even if it were an obstacle, it could be dealt with by means testing.

20. j.d.
    On gov’t demonizing insurers . .
    Barry– Here’s the difference between the U.S. and other countires: in the U.S. the belief that one should fight death is an ungrained part of the culture.
    It’s all tied up with the degree to which we value the individual and invidualism (the loss of an unique indivudal is a tragedy, even though he will be replaced by children and grandchildren); a pioneer spirit (fighting to survive no matter what–Indian attacks, blizzards, near starvation–useful when settling the West); a less than philosphical attitude toward the fact that life is finite, that we’re part of nature, dust to dust . .
    I’ve heard Dr. Peter Schroeder talk about this pointing to surveys that show that when Americans are told that they have a fatal disease, they go for a second opinion. They are simply not willing to accept the fact that they are going to die. There must be a cure.
    When Europeans are told they are suffering from a fatal disease, they don’t go for a second opinion. He does a wonderful job of an Englishman going home to his wife and saying “Well, Martha, I guess this is it. It was a good life, wasn’t it? Now let’s sit down, have a spot of tea, and plan the funeral.”
    This is what I mean by having a philosophical attitude toward death (and life.)
    What all of this means is that, in Canada, if you give a relative the choices Peter was given–keep her comfortable or send her to the hospital for life-saving/extending intervention, a Canadian family is much more likely to choose “keep her comfortable.”
    An American family is much more likely to say “do everyting.”
    In Canada, it would cost the family nothing to say “do everything.” This isn’t about money. They just accept the fact that, at a certain point, everyone dies.
    As Peter indicates, it’s not that other countries don’t offer patients
    The only way to change American attitudes about death is through a very long process of education. Palliative care leaders are the people to lead that process. But it’s not going to happen in 10 years or 20. It would take one or two generations. In the U.S.you have thte added problem that minority famlies often fear that white doctors are too quick to declare them dead. (A doctor in South Carolina told me a terrible story about a young African American man who was in an auto accident, and declared dead at the scene. It was only after he was in the morgue that he sat up . . .
    This, of course, is an extreme case, but we know that minority cancer patients are much more likely to die than white cancer patients–even when both are hospitalized. Minority patients who have been in an acccident are more more likely to die than white patients. This may well be because they were in poorer health in the first place. But we also have evidence about disparities in care.
    All of this complicates who you can trust to make end-of-life decisions aside from the patient himself.
    As Margalit says this is not a call that doctors have the moral authority to make. And this is not a call that most doctors want to make. They are trained to save lives. Palliative care specialists, and those who work in hospices are trained to face death; patients and famlies are much more likely to trust them.
    It’s also worth noting that in Europe, discussions of end-of-life care rarely money or how much it will cost the state to keep a dying patient alive. And they always stress patient autonomy, and the patient’s beliefs and values. One recent European forum on heath care emphasized: “any discussion of forgoing treatment is a sensitive issue that must be tailored to the patient’s particular needs and values.”
    The don’t have clear protocols on when to let patients go.
    There have been quite a few studies of end-of-life care for Muslims in Europe, emphasizing that hospitals and doctors must be senstive to cultural and religious differences when treating Muslim patients.
    In many European countires doctors are very reluctant to withdraw food or water. Euthanasia is allowed only in two European countires. (Denmark and the Netherlands.)

21. Barry, the default protocol is of course important and maybe even appropriate. However, if we ask folks to pay more in premiums for heroic measures, there will be two default protocols (at the very least), one for the rich and one for the rest of us, which means the insurance card would have to be consulted before any protocol is attempted. I have a problem with that.
    And to the feeding tube issue, I would expect modern medicine to be capable of providing something better than death by slow starvation, if the patient so chooses. It makes a lot of people uneasy, not just Maggie. Maybe more people would have advanced directives if the specter of being silently tortured to death would be removed. If we decide to let the patient choose, then truly let the patient choose. With all due respect to doctors’ moral dilemma, this is not a call they should be entitled to make.

22. Peter – That’s helpful. Thanks. However, I wonder what they would do if the patient could no longer communicate, was no longer mentally competent to make care decisions and/or had no relative or other surrogate to make decisions on his or her behalf. What is the default protocol that is applied under these circumstances? Is it “do everything” like in the U.S., apply common sense depending on circumstances, or just keep the patient comfortable and don’t attempt any heroics? Along the same lines, would DNR and DNI orders be part of the normal standard of care in the absence of instructions to the contrary?

23. “It would be interesting to see to what extent, if any, their protocols differ from ours.”
    Barry, I have direct experience with Canada’s system as my aged mother with dimentia was in a government subsidized nursing home. The “protocol” was that family members were given a set of options as to end of life for the nursing home to follow, from send her to hospital for life saving/extending intervention, to keep her in the home and comfortable, but take no extra-ordinary efforts. From discussions with my mother I chose the “keep her comfortable” option, which did not mean that curable infections were not treated. At no time did they check her insurance coverage for any indication that she might qualify for unlimited extra efforts.

24. We might also simply consider studying how good, sound medical practice as it relates to the big four end of life conditions (Alzheimer’s, dementia, cancer and CHF) is defined and applied in Germany, France, the Scandinavian countries, the UK and Canada. In the case of the first two conditions, patients are most likely to die in nursing homes while in the other two, they are more likely to die in a hospital. It would be interesting to see to what extent, if any, their protocols differ from ours. I suspect we might learn something useful though I also think we would probably need some changes in our litigation system if we wanted to embrace some of their presumably less aggressive / more conservative approaches.

25. Maggie,
    As I think you know, I’m all for both palliative care consults and hospice care where appropriate. As a general statement, I think a less aggressive approach to end of life care, along with the relatively low amounts of litigation and fraud in the system, are all areas where I would like to see the U.S. be more like Europe and Canada.
    I’ll offer one comment about religion. When I think about religious freedom, respect for religion, and the separation of church and state, I think of the following: We have the freedom to worship as we choose in our own church, synagogue, mosque, temple, shrine, etc. We have the freedom to send our children to religious schools while we are still obligated to pay property and other taxes to support public schools. We have the right to not be discriminated against when seeking employment, housing, etc. What all of these have in common is that they don’t place demands of any consequence on taxpayer resources. If we practiced end of life care less aggressively like they do in other developed countries, I don’t think it is reasonable to expect access to taxpayer resources to pay for expensive, futile care based on a religious conviction if and when it is generally not made available to most of the population unless they can self-pay.

26. Margalit, Barry, Barry & Nate, Nate
    Margalit–YOu are right; the premutations are infinite.
    Barry–
    I’ve talked to palliative care specailist Dr. Diane Meier about this. She says that in a great many cases we just don’t know who is going to die–and who is going to walk out of the ICU and go home. And she has seen many, many more seriously ill patients that either you or I.
    From what I’ve read, it’s easiest to tell when cancer patients are near death. Much harder in most other cases, including heart disease.
    And palliative care is not for dying patients. It’s for patients who might or might not be dying, but are seriously ill and often in great pain. Hospice care is for dying patients.
    On the feeding tube: research shows that patients who have had the feeding tube removed and yet still survived report feeling that they were starving to death.
    I have a living will that calls for no feeding tube, but I admit, this does make me a little uneasy.
    On directives: very often they do little or no good because they don’t fit the actual situation. Being seriously ill or dying is just much, much messier than a standard form can capture.
    This is why I so strongly favor having a palliative care team talk to to patients who are seriously ill at the time, explain options so that the patient can decide as the situation evolves. This is the sort of thing that is best decided on a case-by-case basis, by the patient if at all possible, or, if he/she isn’t capable of making the decision, by a designated relative or close friend.
    If patients have a chance to talk to a palliative care doctor and psychologist specially trained to talk to patients about dying, I think you would be suprised to find how many would accept death–and would reject further pain and suffering with very little hope of recovery.
    As for having people who want “everything possible” pay more for health insurance, this means that the wealthy would have that option, while middle-class people would not.
    As I’ve discussed in the past, in some religions, hanging for as long as possible is terribly important. Human beings are not supposed to make decisions about when we die. How do you tell a very religious lower-middle-class person (or her son) that they don’t have the option of “everyhing possible” to the very end simply because they didn’t have enough money to pay a higher premium?
    Nate & Barry–
    I agree no. 2 on Barry’s list makes a great deal of sense.
    Nate–
    On my credibility, you might want to check out Michael Cannon’s responoe to my reply to Cato on the Cato website. I actually have quite a bit of credibility among knowledgable people who disagree with me.
    Long before we had health IT, we had medical research and medical evidence.
    That medical evidence told us that certain treatments were very risky and not effective.
    Yet, as I pointed out in the post, for-profit insurers continued to cover them because they feared losing market share. Vioxx is the classic case: Kaisier, the Mayo Clinic and the VA all took Vioxx out of their formularly a year before the manufacturer was forced to pull it from the market. The information about risk was out there, in peer-reviewed medical journals. For-profit insurers ignored it.
    The same is true of bone-marrow transplants for breast cancer patients. . .
    Nate:
    In response to your July 20, 8:29 a.m. comment
    As you well know, cherry-picking is and has continued to be be a problem in the individual market, not in the large group employer-based market where so many employers self-insure.
    I was going to respond to the rest of your comment, but when I read it to the end, I discovered that, once again, you resort to personal attack.

27. Margalit,
    I don’t think it’s as complicated as you suggest. While doctors cannot predict precisely when someone will die, they usually have a pretty good idea when the end is approaching. We already have established criteria for when a patient is a potential candidate for hospice care though some of them live a surprisingly long time. We know when and under what circumstances a palliative care consultation is appropriate. If we had a default protocol that called for no heroic measures for people near the end of life and no reasonable prospects for recovery, what I perceive that means is no feeding tube or ventilator and no surgical interventions. For late stage cancer patients who have not responded to one or two or three chemotherapy regimens, it means we stop treatments but we do our best to keep the patient comfortable and as pain free as possible. It would probably be useful, however, if some of the doctors weighed in on this instead of us (non-physicians) going back and forth.

28. Barry,
    While I do understand and on a personal level agree with the general notion, I have no idea how you begin to codify end of life, and you will need to do that if you want to charge more or establish accepted protocols for various situations.
    What does Alzheimer’s mean? Advanced Alzheimer’s? How advanced? Is there an age component, say 89? How about 88? What if a person with terminal cancer gets hit by a bus? How terminal? What if it’s a kid? What if there are 10% chances of remission? 5%? The number of permutations is as infinite as the resources are finite. And what does “finite resources” mean? 20% GDP? 19%? A certain national deficit? A minimum level of profit for providers and payers?
    I have not the slightest idea how to do this and maintain a semblance of humanity.

29. Margalit,
    I think what’s needed is for a new societal consensus to evolve with respect to what constitutes good, sound medical practice in end of life situations in the absence of a living will, advance directive or surrogate empowered to make healthcare decisions on the patient’s behalf if the patient is unable to make his/her own decisions. Since a large percentage of end of life situations involve patients with Alzheimer’s, dementia, cancer or congestive heart failure, the medical specialty societies whose members treat those diseases should have a key voice. The role for state or federal legislators would be to enact legislation that protects doctors, hospitals and other providers from lawsuits if they follow such new guidelines that provide for anything less than “do everything.” As I’ve said many times, resources are finite and we can’t afford to give patients and their families anything and everything they might want no matter how futile or expensive. Moreover, as I suggested in my prior comment, people who specifically want heroic measures employed should pay more for their health insurance.

30. Barry, are you suggesting in #3 that Congress or the states should pass legislation regarding medical protocols in end of life, or perceived end of life, situations? Or am I misunderstanding?

31. Everyone: The Cato Institute’s Michael Cannon has replied to my post on the Cato Insitute’s website here http://www.cato-at-liberty.org/2010/07/19/obamacare-is-unpopular-a-response-to-maggie-mahar/
    It’s an extremely civil,even gracious reply.
    Unfortunately, their website doesn’t have a space for comments, so I’m responding to their reply on http://www.healthbeatblog.org– my response will be up later this afternoon.
    Will be back to reply to comments here later.

32. Blah, blah, blah. Repeal? No need.
    Everyone knows you don’t repeal free money once it starts going out the door. And everyone knows the people who get the free money like the program that gives it to them.
    Conservatives (the real ones, the ones who oppose free money) know this, and liberals (the real ones, those whose religion is getting free money for more people) know this.
    So OF COURSE the new health bureaucracy is popular with Democratic voters, because it will give them more free money than they have to pay. And of course it will grow more popular over time.
    You NEVER repeal the welfare state. All this talk of repealing is just something to keep the people in Republican think tanks employed, just like dreaming up new ways to give away free money keeps the Maggie’s of the world employed.
    You kill or injure the welfare state by doing two things, and only two things: 1. cutting taxes. 2. Create pathways out of the resultant deficit-ridden programs. (In that order.)
    You don’t accept the burden of “figuring out how to pay for it”: you just cut taxes. (Nobody who creates welfare programs actually ever figures out how to pay for them. They are quite certain that “the rich” will pay for them, someday.)
    You don’t apologize for “the deficit”: you cut taxes.
    Because there is one fundamental, unchanging feature of human nature you can count on: statistically, the soul is shaped like a Ponzi molecule. It wants to get more than it gives. The successes of the “progressive” movement exploit this fundamental flaw by creating programs that give more than they take in. (There is no other way to gain their political constituency.) — but the conservative who looks back over history, and out upon the trend of Western democracies, understands
    that the equal and opposite charge on that molecule is the desire to not pay. This desire is the basis for the hope for avoiding the hell-hole of progressive welfare states. And it is a pretty solid hope.
    All of this is to say: there will be progressive “victories”, periodically. Don’t worry about them. Stop talking about them as soon they happen. You can always count on the pendulum to swing back as people see the bill. Because, in the end, it’s just a contest to either feed or starve the fundamental human corruption — “give me your money” — over decades and centuries. Look back at Rome, watch Western Europe.
    So, conservatives: you get power by talking about tax cuts, you cut taxes when you get that power, you let the wonks duel with their graphs and charts, and — did I mention? — you cut taxes.
    You don’t try to figure out all the shifts in the polls, or even one election versus another. The truth is, the same people will vote for contradictory things, in sequence: they’ll vote YES on free money, and then they’ll turn right around and vote YES for a tax cut.
    Endure the first, maximize the second. The rest is just talk.

33. Barry’s 2 should be number 1 on every politician running for office priorities. Personally I think tort reform needs passed but certain people will oppose that. I can’t imagaine anyone but the criminals would mind we eliminate fraudlent billing. The level of fraud in plain sight in miami and other cities is unbelievable. People will register with CMS, bill 40 million then disappear. Years later Medicare will get around to auditing and notice that looks a little fishy by which time any chance to recover the money is gone.
    Something like that doesn’t happen in private insurance. It is also something that could be fixed in a matter of months not years. Makes you wonder by they talk about it for 10 years but never actually do anything.

34. “Innovation? What innovation? For-profit insurers have had 20 to 25 years to learn how to do all of those things–and none have succeeded.”
    I’ll try to be nice but this statement is just partisan ignorance. Al Gore hadn’t even invented the internet 25 years ago, EDI has completely changed the way claims are submitted and processed. The data mining and analysis we do today didn’t exist outside of government 25 years ago. Our ability to compare facilities based not only on price but outcomes wasn’t even technologically possible 10-15 years ago let along 25. Comments like this remind us why you have no creditability outside your partisan circles.
    “As for IT–insurers haven’t helped providers buy IT, even though the insurer would reap much of the savings if Providers used IT in a meaningful way.”
    More ignorance. Carriers can’t have profit margins over 7-10%, if providers reduced claim cost carriers couldn’t pocket that, market forces and competition would reduce it back to historical profit margins. Basic economics 101 you should have learned in high school.
    “insurers put great energy into cherry-picking healthy patients, and recinding policides sold to patients who became sick.”
    Followed by yet more ignorance. It is illegal to cherry pick and hasn’t happened in group in 10+ years. 5000 rescinded policies and most of them meet the new guidelines this is Dogma.
    “The model where the insurer and providers work together seems to work well.”
    Oh really Maggie Partner and BCBS in MA worked well? For who exactly.
    Can’t believe I go away for one day and you get away with posting crap like this. Your knowledge of health insurance and reality should be far better by now. These 2003 lies you keep peddling need to stop.

35. “See Steele’s fairly recent interview with Susan Dentzer in Health Affairs online–it’s very exciting.”
    Maggie – I read that interview in Health Affairs a couple of weeks ago and I was, frankly, disappointed. Geisinger is supposed to be one of the models for the future of care delivery in the U.S. They use electronic records. They have salaried doctors. They have a collegial and collaborative culture. They are also an insurer that covers 30% of their patient population. Yet, according to CEO, Glenn Steele, they have only been able to reduce care costs for their more complex, sicker patients by about 7% from what it would have otherwise been. While 7% is not nothing, it’s a far cry from the 30% to as much as 50% waste widely perceived to permeate our healthcare system.
    Waste is in the eye of the beholder. If it were up to me, I would focus on the following areas:
    1. To reduce defensive medicine, especially expensive diagnostic imaging, I would pass robust tort reform which I define as strong safe harbor protection from lawsuits for doctors who follow evidence based guidelines where they exist. Medical disputes would be decided by judges in specialized health courts instead of juries of ordinary people with no medical expertise.
    2. To combat provider fraud in the Medicare and Medicaid programs, I would require every provider with the authority to bill either program to have a unique numerical identifier as well as an ID card with a picture, a biometric identifier and an address. Both Medicare and Medicaid should be able to track spending by individual providers who either performed or ordered the service, test or procedure or prescribed the drug.
    3. To reduce wasteful end of life care, I would strongly encourage everyone, especially the elderly, to execute living wills or advance directives. I would change the default protocol from do everything because we’re afraid we’ll be sued if we don’t to either apply common sense depending on circumstances or no heroics. People who execute directives that choose heroics should pay more for their health insurance.
    4. Create good, user friendly price and quality transparency tools so both patients and referring doctors can more easily determine who the most cost-effective providers are.
    You will note that it is not within the power of insurers, including Medicare, to change the rules outlined in #1, 2, and 3 above. Only Congress or state legislatures can do that and then the legislation would need to be signed by the president or individual state governors.
    Care does not cost half of what it does in other countries than it does here because insurers are regulated utilities. It cost less because they have a different culture – less litigation, less fraud, less useless and expensive end of life care. Moreover, prices per procedure are lower elsewhere because doctors earn less and they order fewer tests. In short,it has little or nothing to do with insurers including whether they are for profit or non-profit.

36. I dont know why I didnt think about this website. Here is the realclear politics average for polling for the past months about Obamacare. Realclear is unbias and has been a great resource during the elections I have worked on.
    http://www.realclearpolitics.com/epolls/other/obama_and_democrats_health_care_plan-1130.html
    Support for Obamacare has hovered from 35-40. Even has people continued to be more educated about ACA, support has remained the same.
    I really wish I could reply to your entire argument (currently at work) but since you are talking about polling and refuting CATO (who I do not like most of the time), I will isolate my rebuttal to polling data.
    As well, Rass Polling apparently has done more polling about this issue than other polling websites. RealClear combines all polling. Rass Polling does show a gradual decrease; however, I do not think it is fair to attack him a bias because he is conservative. Other polls, as listed by RealClear, show similar numbers.
    Over the next five weeks, support for repeal consistently dropped, while opposition to killing the bill rose.- I do not think this is true by the polling data by realclear.
    Should we point out that less than 20% of people polled by CBS thinks that Obama has actually helped their life get better?

37. margalit–
    Under the reform legislation insurers cannot hike premiums without justifying increases to state regulators. So they won’t be able to hike premiums 30% in order to gain 6%.
    That’s why they’re already beginning to downsize, cutting their administrative costs.

38. Barry and aaron
    Barry–
    You write: “The problem with the minimum MLR is that it is likely to stifle innovation. Suppose, for example, that an insurer develops a more effective way to weed out the high cost doctors and hospitals from its network without sacrificing quality. Suppose it does a better job of fraud mitigation and a better job of getting its members to execute living wills and advance medical directives in order to minimize unwanted futile care at the end of life. . .
    Innovation? What innovation? For-profit insurers have had 20 to 25 years to learn how to do all of those things–and none have succeeded.
    As for IT–insurers haven’t helped providers buy IT, even though the insurer would reap much of the savings if Providers used IT in a meaningful way.
    Non-profits like Kaiser in NOrthern California have learned how to reduce heart disease, help people stop smoking, etc–but no for-profit has been terribly successfuly in these areas. When for-profits decided to stand up to doctors and hospitals and “manage care”–the did it by refusing to pay for expensive care without really trying to figure out what was safe and effective for patients.
    Thus they continued to pay for Vioxx, bone marrow transplants for women with breast cancer and hormone replacement (all dangerous) while refusing to pay for some treatments there were, in fact, effective, though expensive. (Some non-profits stopped coverging Vioxx, bone marrow transplants and hormone replacement much sooner.)
    Rather than investing money and energy in figuring out how to deliver higher quality more affordable care, insurers put great energy into cherry-picking healthy patients, and recinding policides sold to patients who became sick.
    Meanwhile non-profits like Geisinger have attracted excellent doctors willing to work on salary. They’ve been innovating–finding new ways to pay doctors and hospitals (bundled payments) and now Geisinger CEO is talking about setting up a network of accountable care organizations across the nation. This is innovation.
    See Steele’s fairly recent interview with Susan Dentzer in Health Affairs online–it’s very exciting.
    The model where the insurer and providers work together seems to work well. Since every state has to have at least one non-profit, I think we’ll see non-profit accountable care organizations springing up around the country. They may well begin floating blonds and buying up hospitals. If Geisinger wanted to borrow money to buy more hospitals, I would invest. . .
    Tanner is right that health reform aims to turn insurance companies into regulated public utilities.
    This is what private sector insurers are in Europe, and they manage to deliver care that is at least as good, often better than U.S. care for 50% less.
    European countries realize that healthcare is a necessity–like heat and light–and thus insurance companies need to be regulated and ask permission from the govt to raise premiums just as utilities need permission to raise rates.
    aaraon–
    First, I agree that the polls don’t tell us whether healthcare reform will be good for the nation, they just tell us whether people think it will be good.
    I would say it will take ten years before we see the full results of the legislation.
    But I began with the polls because that’s where TAnner began. The big chart on p. 2 of his report is teh Rasmussen chart that I reproduced here. He rests his argument on the notion that “the people” want to repeal health care legislation and “the people” are right. The conservative argument is that President Obama crammed “Obamacare” down our throats, ignoring the will of the people.
    I don’t agree, but I’m going to rebut his argument on his ground, point by point. And in part 1 I’m trying to show that public opposition to the legislation was based on uncertainty and fears (often fear ignited by misinformation.) As people learn more about the bill , we see that opposition is melting, especially among people under 65 who will be most effected by the legislation.
    But of course that doesn’t tell us if it will add to the deficit over the long term, and whether it will be good for the nation.
    But a close reading of the legislation does tell us that reform will not lead to “rationing.” In fact in several places the legislation very specifically states that comparative effectiveness reserach cannot be used to “ration” care or limit benefits.
    Comparative effectiveness reserach will be used to spread informaiton about which treatmetns are most effective for patients who fit a particular profile, however, and the hope is that doctors and hospitals will use that information–and share it with patients– when making decisions. Medicare and the preventive services task force and other groups (for instance the Breast Cancer Coalition) will be putting that information on line so that patients can learn more about what is safe and effective. We know that when patients have more information, they tend to chose less aggressive, less risky and more conservative care.
    I’m also not at all sure as to what you mean by a two-tier system? Would it be something like what we have today–the poor get no care or subpar care under Mediciad while the rich and well-insured are overtreated?
    The legislation is taking a step in the right direction by insisting that Medicaid pay as much as Medicare does for preventive care (Medicaid now pays about 30% less) and by insisting that private insurers pay at least as much as Medicaid when reimbursing community health plans (now they often pay less–community health plans don’t have the clout to demand more.)
    Ultimately, many liberals in Washington would like to see the federal government take over Medicaid and raise standards of care nation-wide.
    Meanwhile generous funding to double the capacity of community health plans, equip them with electronic medical record, etc. will create “medical homes” for a great many low-income and middle-class people. The quality of care at community health plans that meet federal requriments is already very high in many places. (I’m thinking of the plans Dr. Neal Calman runs in and around NYC, for instance.) Accountable care organizatoins like Geisinger offer the same quality of care to low-income and high-income families. This is the direction that we’re heading in: toward evidence-based medicine delivered by teams of health care providers who are collaborating with each other.
    Finally, on the deficit: healthcare did not create the deficit. We had a surplus when President Bush came to the White House. Tax cuts for the wealthy and the wars in the Middle East created the deficit.
    What will happen to the deficit over the next 10 years?
    Will reform add to the deficit? There are so many variables involved here that it is very difficult to know. How much money will reform save? How much waste will Medicare manage to squeeze out of the system? How successful will Medicare be in using financial carrots and sticks to persuade hospitals to reduce errors and infections and pay more attention to patient safety ?(errors and infections are very, very expensive and the latest MedPac report shows that when it comes to patient safety in hosptials, things are getting worse, not better.) How successful will medical homes and accountable care organizations be in managing chronic diseases so that patients don’t end up in the hospital?
    The legislation provides generous loans and scholarships to increase the number of nurses, nurse practioners, physicians’ assistants, primary care doctors etc. They will be working together to lift the quality of prventive care. How successful will they be?
    How much will this save?
    As Medicare and Medicaid move away from paying fee-for-service (encouraging providers to “do more”) and toward rewarding better outcomes, not volume, how much will this save?
    You can see why any estimates of savings as well as the costs of reform is simply a wild guesstimate. CBO greatly underestimated the savings that would come from the last Medicare reform.
    But here’s what we do know: that other countries manage to provide universal coverage that is as good or better than care in the U.S. for 50% less. And we do know that in some regions of this country, and in some medical centers, providers are able to deliver higher quality care much more efficiently, making it much less expensive.
    So we know it can be done.

39. To clarify and amplify my last comment, it’s possible that by pursuing the strategies I outlined, an insurer’s administrative costs could actually rise by 200 or even 300 basis points. However, if the result of that investment were to reduce utilization of healthcare services by 10 percentage points or more without sacrificing quality, it would clearly be a good thing. If half to two thirds of the net savings from lower utilization were passed through in lower premiums, insureds would save money while the innovative insurer would earn a higher profit margin and, presumably, increase its market share. None of that could happen, however, if it had to operate its business to live within the newly established minimum MLR rules. Ah, there are those annoying unintended consequences again.

40. The minimum medical loss ratio is a dumb idea. Profit margins in the health insurance industry are low and the industry is highly competitive. More than 40% of the customers are insured by non-profit entities.
    The problem with the minimum MLR is that it is likely to stifle innovation. Suppose, for example, that an insurer develops a more effective way to weed out the high cost doctors and hospitals from its network without sacrificing quality. Suppose it does a better job of fraud mitigation and a better job of getting its members to execute living wills and advance medical directives in order to minimize unwanted futile care at the end of life. Suppose it did this by investing significantly in information technology and the development of better analytics as well as more aggressive outreach than its competitors. If it drives its MLR below the regulatory minimum and below what its competitors can achieve, it now has to pass the entire savings on to policyholders. Knowing that in advance, it is unlikely to ever make the upfront investments in IT and analytics needed to reduce utilization of healthcare services.
    Rules to establish minimum creditable coverage are reasonable, though I think even these could be waived for those who want a higher deductible and can prove they have either the income or assets to handle it. Minimum MLR rules are stupid and unnecessary.

41. The more Americans learns about the details of the legislation, and how reform will help them and their families, the better they will like it.
    I think that you are right that individuals are gradually coming around to the healthcare reform that was passed last year; however, it does not follow that a) people really know what is in the entire bill b) it is good for the overall healthsystem c)PPACA does not drive the budget into the deepest red ever seen before. Polls are fickled and not reliable. I think the weakest argument you can make for healthcare reform are the polls. Once rationing begins with this new two-tiered model, individuals will dramatically shift away from Obamacare

42. “The rule that they must pay out 85% of premiums in medical reimbursements (to large groups, 80% to small groups) also means that premium increases are less valuable to insurers. If I’m an insurer and I raise premiums for small groups by 10%, I get to keep only 2% of that 10% increase. . .”
    Isn’t this a double edged sword? If I can only keep a small percentage, I would prefer a small percentage of a much larger premium… If the MLR is fixed on the bottom, maybe premium increases should be capped somehow too.

43. neo cons Vikram or the criminal type…I see both all the time:)

44. I would like to believe someone. For that, that person should be able to demonstrate ability to see pros as well cons of their approach. I look forward to see that happen with Maggie and Nate.

45. this is what will happen if we cover smoking cessation under insurance.
    “In 2008, Medicare paid $520 million to Miami-Dade home healthcare agencies for treating diabetic patients — more than what the agency spent in the rest of the country combined, according to federal authorities.”

46. self serving post follows
    ” I hope government will dramatically cut down on accusations of profiteering and see insurers as their enforcers and partners in cost control.”
    How about they actually support self funding for a change, almost absent of insurance profit and by far the most efficient insurance plans in the country. We are still hearing of efforts in DC and some states to kill it off.

47. “First, Cato and others assume that young people will pay the penalty rather than join the pool because they don’t feel they need insurance. It turns out that many young people don’t have insurance not because they think they don’t need it, but becuase they cannot afford it.”
    Can you expand on where this belief comes from or why if it is an opinion you feel this way? As someone that actually sells the insurance I feel I have a pretty good source on why they don’t buy, the person not buying tells me themself. If there is a more accurate source I would like to see what it is. Insurance for most young, especially if it is in a state that doesn’t require maternity, is under $100 per month. That is less then the cell phone bill for the iphone monthly. Insurance is affoirdable but it is not a priority.
    That is in the indivudual market, I also see this in the group market where the young decline even though the cost is under $50 a month. They don’t see it as a good value for the money, seldom is it ever not affordable.
    ” If you look at the wealthiest third of 18 to 29-year-old fully 88% of them have insurance. The share drops sharply as you go down to the middle third and bottom third.”
    Wouldn’t the wealthiest also have the best jobs, those most likely to offer insurance at the lowest cost? This data set also doesn’t allow you to deduct affordability, you would need to know their whole financial picture outside of work to determine what is affordable and what is not.
    “Under reform, the subsidies will make insurance very affordable”
    Strongly disagree with this claim. Young are getting a HUGE cost shift from the old and sick. Correct me if I am wrong but didn’t the new bill limit the spread in premium between young and old to 4 times or something? Long gone are the days of a 20 year old male getting a policy for $60 a month. The new bill also eliminate pre-ex which means total cost will skyrocket as the pools become considerably less healthy.
    “and since poor people are sicker than the rest of us, this would bring premiums up.”
    I don’t think this is accurate. Poor insured people use more care then insured wealthier people. The healthy poor just don’t buy insurance so they don’t show up in nay data to measure. If I have very limited means and am healthy I sure aint going to waste it on insurnace. I don’t see how they could have accurtly measured the realitve health of those not in the system.
    “In any case, the expansion of Medicaid won’t cause insurance premiums to rise.”
    This already is inaccurate. As Medicaid cost expands States shift more cost to private plans to offset what they can’t afford. Ohio and many other states already require dependents be covered till age 28-30, this was done specifcially to get disabeled adults off Medicaid and onto private insurance. They also have bed and other taxes that are passed onto private insurance. Medicad expansion has been causing insurance premiums to rise for the past 5 years and will continue to cause them to rise in the future.
    “The rule that they must pay out 85% of premiums in medical reimbursements (to large groups, 80% to small groups) also means that premium increases are less valuable to insurers. If I’m an insurer and I raise premiums for small groups by 10%, I get to keep only 2% of that 10% increase. . .”
    This is inaccurate, it assume most carriers already aren’t at or near 80-85% loss ratios. Rate increases will be just as beneficial to carriers going forward if not more. Right now of the 20-25% admin cost brokers are getting 8-10, after taxes carriers are only left with 7-12% under reform and getting rid of brokers they most likly will actually have a higher proportion then before meaning they would benefit more from rate increases.
    “Helping people to quit smoking is a public good.”
    No disagreement there at all, but using insurance to pay for it is still a terrible idea. Tax smokers to pay for the cost of smoking and do it outside insurance.
    Lets look at the other side of GA any willing provider law. Everyone on the left is talking about the 33% of waste and how if we get rid of that we can pay for unicorns for every school kid and solve every other problem in the world. What if Northeast Georgia Cancer Care of Athens is the worst praticing provider in GA?
    “Insurance Commissioner John W. Oxendine. “More doctors mean more choice for patients, and I think it’s clear that’s the intent of the any-willing-provider law.”
    Commiss doesn’t seem to make any allowance for denial due to pratice paterns. It seems any provider willing to accept the reimbursement level must be allowed in. Wouldn’t the worst most unethical providers be the most willing to take any reimbursement since they are crooks any ways? This is an example of poor regualtion driving up cost because regualtors don’t see the full picture. How does an insurer avoid bad providers under any willing provider??

48. Margalit,
    I totally agree that anyone should be wary about health insurance that doesn’t include any oncologists. My point wasn’t that insurers do this (I don’t know of any that do), but that they pay attention to relative attractiveness for cancer. An insurer may very well knowingly limit its number of oncologists so that their plans don’t become known as the best place for cancer patients to go. Now, that should change in the new world of risk-adjusted premium for Medicare and Medicaid. It won’t change, and in fact may be accentuated, in the products on the exchanges that appear in 2014.
    Maggie:
    I’m worried about how increased government scrutiny of insurer premium hikes will play out. The best case scenario is that state or federal governments are hard on large hikes and tell insurers to go back to the drawing board, but don’t go out of their way to demonize the insurers and in fact back them when insurers do the only things they can do to keep premiums under control (including, first and foremost, reduce rates for providers and pharma.). The fact remains that insurer margins are now and have always been lower than most industries, so I hope government will dramatically cut down on accusations of profiteering and see insurers as their enforcers and partners in cost control.
    My nightmare scenario is that government keeps going to the well on this tried and true bit of profiteering demagoguery, and fights insurers when they enact utilization controls, network reductions and most of all fee schedule reductions. If that happens, we’ll have a far uglier, stupider and less effective period of transition to a lower medical cost trend. It will cost the nation hundreds of billions of dollars to score a few cheap political points. Right now I’m not optimistic, but I’m not a full-blown pessimist either, yet.

49. stop smoking help, Nate
    In addition to a national compaign funded with tax dollars, I think insurers should cover nicotine patches much as they cover aspirin for people suffering from heart disease, or artifical knees for people whose joints are going. (Often, the bad knee can be traced back to playing sports; one could argue that the athelete is to blame because he wasn’t more careful about running on hard surfaces or whatever. We’re all guilty of doing something self-destructive, even if it’s only worrying too much, or working too hard. . . Let’s stop blaming the victim and focus on creating a healthier society. )

50. stop smoking help, Nate-
    Yes, nicotine is an addictive drug–much more addicitve than many other drugs. As Stop Smoking no doubt knows, most people who begin drinking don’t become alcholics; they are able to have one or two drinks and stop. The vast majority of people who begin smoking aren’t able to have 1 or 2 or even 5 cigarettes a day.
    Quitting smoking is often compared to quitting cocaine.
    It’s that addictive.
    In the 1960s we had a national campaign to get people to quit smoking. I remember see movies featuring diseased lungs in junior high. No doubt the campaign was expensive, but it waas hugely successful. A great many upper-middle-class and middle-class kids of my generation never started smoking. By the time I went to college, smokers were in the minority. (It was a private college– mainlyl upper-middle class and upper-class students.)
    Today, the vast majority of smokers come from low-income, less well educated households. A significant share suffer from one or more psychological diseases: depression, anxiety, etc. (Google “Steve Schroeder” for exact numbers.) Smoking is a form of self-medication.
    Once smoking became a problem that, to a large degree, was confined to the poor, we stopped spending large amounts of public money on anti-smoking campaigns or smoking cessation clinics.
    In the 1990s, however, smoking increased among all teens–except black teens. (For some reason, black culture seems to have rejected smoking as a white person’s disease.) This rise in smoking among white teens has attracted attention, and could lead to another National Anti-Smoking campaign, funded with taxpayer’s dollars.
    Yes, smokers die earlier. How much money we do or dont’ save if we reduce the number of smokers depends on what eventually kills people who quit (or never started.) If they die of Alzheimer’s, that’s very expensive. If they’re struck down by liver cancer (fast-moving, no cure) that’s a relatively cheap death.
    I have no idea how to calculate cost or savings, and absolutely no interest.
    Helping people to quit smoking is a public good.

51. Margalit, Nate–
    I have read articles suggesting that under reform some insurers will try to avoid cancer patients by having few oncologists in their network–a subtler from of cherry-picking.
    But insofar as that happens, both patients and oncologists will protest, and regulations and laws will be revised. For instance, see this ruling:
    “Blue Cross Blue Shield Healthcare Plan of Georgia must allow Northeast Georgia Cancer Care of Athens to participate in its health maintenance organization network, according to statements issued April 7 by the state’s Dept. of Insurance.
    “I’m sure consumers want to see more doctors in their health networks, not fewer,” said Insurance Commissioner John W. Oxendine. “More doctors mean more choice for patients, and I think it’s clear that’s the intent of the any-willing-provider law.”
    “The state’s any-willing-provider law, much like those in many other states, grants doctors and health care providers licensed to practice and in good standing the right to become health insurance participants. But the law did not necessarily require an HMO to take in any physician who wanted to join it. Oxendine’s ruling was the first time a regulator said it did.”
    Undoubtedly, some insurers will try to “game the system” in various ways and both regulators and Congress will have to revise the rules and the law as problems crop up. It won’t be too hard to spot what’s going on; if oncologists or other specialists are excluded from networks, they’ll let us know.

52. jd–
    Yes, the figure 2 is a joke. Luckily, when I was at Barron’s I did a lot of work on charts, collaborating with the person in our art dept. who did charts. (Barron’s readers LOVED charts and I like them too. If done right, they can be very informative.)
    I’ve actually been working on a post on whether premiums will rise. There are many variables involved . . .
    First, Cato and others assume that young people will pay the penalty rather than join the pool because they don’t feel they need insurance. It turns out that many young people don’t have insurance not because they think they don’t need it, but becuase they cannot afford it. If you look at the wealthiest third of 18 to 29-year-old fully 88% of them have insurance. The share drops sharply as you go down to the middle third and bottom third.
    Under reform, the subsidies will make insurance very affordable for the bottom third and pretty affordable for the middle third. Moreover, under reform many 20-somethings will be getting insurance through their parent’s employer–and their parents can pay the extra premiums with before-tax dollars, making it a very attractive deal.
    This suggests that we’ll have more young people in the pool than many predicted; because they use less care, this will bring premiums down.
    OF course many of the uninsured are poor, and since poor people are sicker than the rest of us, this would bring premiums up. But, the poorest (and presumably sickest) won’t be in the pool with everyone else–as Medicaid expands, they’ll be going into Medicaid. (We’ll have to pay for Medicaid with taxes, of course, and ultimately, I think we’ll make it a federal program. The states can’t afford it. To fund it, this administration is likely to continue to raise taxes for the wealthy–capital gains taxes, inheritance taxes are at historically low levels.
    In any case, the expansion of Medicaid won’t cause insurance premiums to rise.
    You are right that insurers will be cutting admnistrative expenses because they will no longer be charging sick peolple more. In fact insurers have already begun cutting expenses–layoffs in many places.
    The rule that they must pay out 85% of premiums in medical reimbursements (to large groups, 80% to small groups) also means that premium increases are less valuable to insurers. If I’m an insurer and I raise premiums for small groups by 10%, I get to keep only 2% of that 10% increase. . .
    And state regulators are begin to take a very close look at requests for premium increases; I think that regulation will be tough in many states. No one likes insurers. A governor who doesn’t take a tough stance will be risking his political future.
    Some states will be tougher than others, and I think we’ll see sharp differences in premiums in different states. Also, in some states (like California) more people with pre-existing conditions who have been denied insurance in the past will be joining the pool, while in other states (like Minnesota) a much larger percentage of the population already has insurance.
    Finally, Medicare is already beginning to cut spending on tests and re-admissions, and private insurers have indicated they will follow Medicare’s lead. As Medicare changes how it pays (paying for quality rather than volume) private insurers will adopt Medicare’s reforms.
    There are many unknowns. For instance, how much care will the newly insured Want? We know that the newly insured will Need quite a bit of care, in part because many are poor. But needing care and going for care are two different things. Of course we should do everything we can to deliver needed care to poor people. But I’m just not convinced that low-income diabetics will be as eager to engage in chronic disease management as higher-income, better educated diabetics.
    Most people don’t enjoy going to the doctor, undergoing tests and procedures, etc. so they may not consume as much medical care as projections suggest. You can look at Massachusetts as a model, but it’s a unique state–much wealthier than most, higher levels of better education, significantly more liberal . . .
    Bottom line– there is much waste in the system, many places to save, as well as many unknowns about the cost of universal coverage. But there is every reason to believe that we can put a lid on healthcare inflation. We did it in the 1990s.

53. Okay, this is my last posting. I forgot the last point you made about the National Cessation Program. That sounds like a great idea. However, you say we, the taxpayer, should not pay for a penny of it. I guess I didn’t make my point clear last time, we’re already paying for it, in spades. Why not take some of that money that we’re already paying and use it to fund a program.
    Also, smokers who are addicted suffer from a chronic illness – nicotine addiction. It’s not like they can just quit as easily as they started. Anyone who has been addicted can tell you how hard it is to stop, hence the definition of clinical addiction. It is beyond their control, which is hard for us nonsmokers to comprehend. We think “the lousy smoker did it to himself”, and to a point, that’s true. But just because we don’t understand it, doesn’t make it less real for those who suffer from it, and believe me, they suffer. Much like depression or other psych. illnesses. Many don’t want to pay for mental illness because it’s all in their mind. But we’ve come to understand it and thus, we help fund support and treatment for it.
    Will we ever get to that point with nicotine addiction?

54. This is my first such debate, so please pardon me if I reply one more time – no disrespect meant.
    So your best argument for the most important part of the wonkish debate is that you’d rather people die from one disease because it’s “cheaper” than people living longer where they might contract some other worse disease which costs more to manage? Do you know how much 10 ER visits per year, daily chronic breathing treatments, oxygen, pulmonary rehab, pulmonary testing, blood work, radiological workups, pneumonia admits, antibiotics, LTAC admissions, ICU days, invasive and non-invasive ventilator support, comorbidity disease management, etc. costs a COPD patient every year? Now multiply that by 20 years. I can’t imagine it is that much less than your prostate cancer patient. I averaged about 35 patients per day that had smoking related illnesses in the hospital and maybe only 1-2 per week with prostate cancer. Plus, 90% of all lung cancers are related to smoking. So there’s your chemo and radiation cost.
    Also, so you would rather us practice reactive medical care than preventive medicine? It’s a risky proposition to continue with healthcare that only treats disease rather than trying to prevent disease. That’s why I came up with my website. I was tired of being reactive only, I wanted to do something proactive for a change.
    With regards to your fraud argument, fraud is everywhere. As long as there are dirtbags in this world, people will try to defraud us. How different is that than the San Diego physicians who self prescribe hundreds of prescription pain relievers and then dole them out to athletes at a $$. Should we outlaw the ability for physicians to prescribe medications? No, that would be ridiculous. Point is, rules can be written to limit fraud, not prevent it altogether.
    Regardless of which side of the argument you find yourself, this is yet another great example of how well intentioned people have seemingly wonderful ideas, but they can be argued to the point of “give-up”. So we continue to stand pat because we’ve all got tired head. Like Dr. Jones said, we continue to get angry, care falls off and hospitals look for ways to squeeze more out of the orange (which sets up yet more ideal situations for fraud, as people become desperate).
    I think we’d both agree, we can’t just stand pat. Something has to be done. The question is, can we get beyond the arguments?

55. tcoyote–
    First,
    If the popularity of repeal isn’t important to Tanner’s argument, then why did he chooose to put the Rasmussen chart on page 2 of his report and say that Republicans will make repeal the “centerpiece” of their campaigns this fall?
    I agree that the legislation will not be repealed. And this means that by pushing the idea, Republicans will be hurting themselves.
    My larger point is that over time, as voters learn more about what is in the bill, support for reform is growing.
    Here’s the newest numbers I’ve seen: Wed., Bloomberg released a poll showing that 61 percent of respondents don’t have any interest in repealing the health care legislation that Congress passed earlier this year (47 percent want to see how it works, 14 percent say it should be left alone).
    Igor Volsky adds: “Just 37 percent want the bill repealed (as is the wish of the Republican leadership).
    The numbers underscore increasing public approval of the health care reform law. It also illustrates the potential dangers the Republican caucus assumes by make the repeal agenda a major plank of its campaign platform.”
    The fact that so much of the opposition to the legislation comes from seniors also is interesting. Conservatives have done a good job of making seniors fear that reform will be funded in part by cutting Medicare benefits. In fact, the funding will come from cutting Medicare waste: reducing hospital errors, paying for outcomes instead of volume, etc. Meanwhile, Medicare benefits will be expanded insofar as preventive services wil become available without co-pays and dedcuibles.
    As seniors see this, their feelings about reform are likely to soften.
    Also, conservatives and some doctors have been trying to scare seniors by saying that docs will stop taking Medicare patients. In fact, Medicare is not cutting docs reimbursements across the board; unlike most American workers, they’re receiving a small raise.
    And the Medicare Payment Advisory Commission has just come out with a new report showing that, in 2009, that when compared to privately insured individuals, Medicare patients report “as good or better ability to get timely appointments with physicians” and they also report having an easier time finding a new physicain than privately insured patients. Both groups report more difficulty finding a primary care doc, though 88% of Medicare beneficiaries report that finding a new primary care doc was “no problem” or “only a small problem.”
    As my associate Naomi Freundliche pointed out on http://www.healthbeatblog.org, large numbers of doctors are NOT dropping Medicare patients or refusing to take new patients. The idea that docs in Texas were “boycotting Medicare” made headlines, but when you look at the numbers you discover that just “two hundred doctors are opting out of Medicare in Texas–really just a drop in the bucket: There are nearly 60,000 non-federal physicians practicing in the state already.” (Naomis’ post is cross-posted on TCHB here https://thehealthcareblog.com/the_health_care_blog/2010/06/are-doctors-really-boycotting-medicare.html
    As Medicare patients realize this,they’ll be less fearful of reform. And I think Berwick will be extremely effective when it comes to communicating with seniors.
    This is important because as support for reform grows, it will become increasingly difficult for Congressional conservatives to weaken the legislation.
    As for the argument that reform will add to the deficit–I’ll get to that when I get to that part of the report. Here, let me just repeat: Projecting costs and savings 10 years out is impossible. There are too many variables involved. As CBO explains “A wide range of changes could occur—in people’s health, in the sources and extent of their insurance coverage, and in the delivery of medical care—that are almost impossible to predict but that could have a significant effect on federal health care spending, both under the legislation and under prior law.”
    I’m glad you acknowledge that the “unfunded mandate of MMA, which, along with the Iraq war, started us down the path to insolvency under George Bush . . .”
    I’m not sure why you think that the Republicans would set better fiscal policy when/if they regain control; the leadership of the party really hasn’t changed.
    There is also a serious question about Republicans re-gaining control. By moving so far to the right, they are turning themselves into a minority party.
    And Obama remains surprisingly popular despite a recession, the fact that the real unemployment rate remains over 10%, and that we’re mired in two unwinnable wars . . . Over the next 2 1/2 years, I expect he will manage to create jobs, and that we will begin withdrawing from the Middle East (which is all that most Americans want–few expect we can “win”.)
    I expect he’ll tackle the deficit through a combination of continuing to raise taxes for the wealthy and Medicare reform–which is already beginning.
    Even if Obama loses support, I’m not at all convinced that Republicans could win by running another conservative candidate. Yet the leadership of the party seems determined to steer to the right. I still can’t quite believe that they gave Harry Reid the great gift of Sharon Angle as his opponent. (Reid was supposed to have no chance; he’s ahead by 7 points in latest poll.)
    Looking ahead, there are reasons to believe that President Obama’s election may mark the beginning of a long run of Democratic victories, in part thanks to shifting demographics: “A new report by Ruy Teix­eira (co-author of The Emerg­ing Demo­c­ra­tic Major­ity) argues that huge demo­graphic shifts in the United States will see ‘the Demo­c­ra­tic Party become even more dom­i­nated by the emerg­ing con­stituen­cies that gave Barack Obama his his­toric 2008 vic­tory, while the Repub­li­can party will be forced to move to the cen­ter to com­pete for these con­stituen­cies. As a result, mod­ern con­ser­vatism is likely to lose its dom­i­nant place in the GOP.”
    I don’t know whether Democrats will be able to hang onto the House this Fall, but if Republicans continue to present themselves as the party of No, Dems might hold the House. But I’m less concerned with which party dominates than how many conservatives win vs. true moderates and liberals.
    .

56. Hospitals are closing, care is deteriorating, doctors are angry, hospital administrators are desperate. The Cato report is spot on.

57. the added tabacco tax later would be an insurance premium tax, not just another tax that disappears once it hits the states, we all know how well that turned out

58. If nothing else bev should be happy to see some wonkish debate.
    “One case of cardiovascular disease, COPD, and lung CA will cost the insurance company more than the cessation aid cost for probably more than 500 people.”
    True, but if you’re going to make the cost argument, 15 years of continued living then dying from a protracted battle with prostate cancer cost 100 times more than COPD. Dying early from smoking actually saves money in the long run. Not that I advocate spiking cigs, more than they already are, with poison to kill them off but you are not saving me money by doing this, in fact your costing me considerably more.
    “Not every smoker will take advantage of the benefit.”
    True, if it is a required benefit even some non smokers will though. This is the type of benefit medicare fraud loves, high volume, no accountability, no risk to member. Steal a HICN you could bill 3-4 of these a year for 10 years.
    “Cessation aids have very low success rates, so it’s important for those who want to stop, to be able to keep trying with no hinderances. It takes the avg. smoker 7 attempts before they finally quit. Why not make it as easy as possible for them to try?”
    Because it is my money they are wasting every time they fail. When you waste someone else’s money your motivation is not nearly that if you are spending your own.
    “Although, it doesn’t sound very conservative to mandate insurance companies pick up the nominal expense, it is very fiscally responsible in the big picture.”
    I disagree, it is a terribly inefficient and fraud prone way to achieve little to no added benefit.
    5 and 6 can be accomplished without opening it up to fraud and a 20% insurance add on. I would start by pointing out the word, what risk are you insuring against with smoking cessation aids? The person smokes, this is known. It will take 7+ tries and most still won’t stop, this is not an insurable item and there is nothing conservative about trying to make other people pay for someone else’s shortcomings and weaknesses.
    Don’t take this as I am against smoking cessation aids. Insurance is just the worst possible way to accomplish this. Off the top of my head I would say a national smoking cessation program would be far more efficient. No premium taxes, claim paying, broker fees, fraudulent providers etc. Fund it 100% with a new tobacco tax, non smokers shouldn’t be funding a penny of this. People get to choose as many and as often from the approved treatments at no cost besides what they pay in additional taxes. Direct from the manufacturer delivered through the agency to track who is using what and outcomes. This will also reduce fraud. A couple years after it starts I would add a tobacco tax to all smokers equal to the cost of treating smoking related illness. Anyone actively in a program trying to quite would get a waiver.
    I just cut the cost of the program to a quarter or less, eliminated cost to taxpayers and non smokers, and would likely achieve much better results.

59. Nate: I wrote an article about why it’s not a bad idea for insurance to pay for the out-of-pocket cost for smoking cessation aids. Here are the highlights.
    1. Smoking is the most expensive preventable healthcare cost in the world. One case of cardiovascular disease, COPD, and lung CA will cost the insurance company more than the cessation aid cost for probably more than 500 people.
    2. Not every smoker will take advantage of the benefit.
    3. Cessation aids have very low success rates, so it’s important for those who want to stop, to be able to keep trying with no hinderances. It takes the avg. smoker 7 attempts before they finally quit. Why not make it as easy as possible for them to try?
    4. Although, it doesn’t sound very conservative to mandate insurance companies pick up the nominal expense, it is very fiscally responsible in the big picture.
    5. One role of government, it can be argued, is to look out for the little guy, who is poorly educated. Studies show that those with less education are more likely to smoke. So why not use this to help the little guy who doesn’t know better. Again, you’re taking one of his excuses away. That is another conservative plank – help people so they can make better decisions.
    6. I am tired of paying higher medicare taxes for the > $90 billion in direct medical expenses to treat smoker’s diseases. I’d rather pay $1 billion for cessation aids and lets say only $50 billion for those direct medical expenses. That’s outside the box, medical reform. Another conservative idea.

60. So “only” 53% of voters in the latest Rasmussen poll favor repealing the law. Perhaps in the next one, it will “only” be half. Sounds like the thing is still pretty damned unpopular to me.
    This was the least important part of Tanner’s argument- the political part, and a waste of Maggie’s and our time. The important parts are that it was absolutely misrepresented to voters as deficit neutral, and whether we’ll actually be able to afford to implement it.
    The law isn’t going to be repealed. There is simply too much “puppies and ice cream” in the health reform bill. The real question will be what the Republicans do with it when they regain control of things and begin actually setting fiscal priorities. On top of the unfunded mandate of MMA, which, along with the Iraq war, started us down the path to insolvency under George Bush, the federal budget saturnalia Obama has thrown is coming to an end. Where we go next- where we really need to put our scarce resources- is the next great budget battle.

61. “BTW – I too believe insurance should cover the out-of-pocket expense for FDA approved cessation aids”
    Why? This is where I think people suffer a huge disconnect between what sounds simple on paper and what makes sense big picture. By paying for this via insurance you just tacked 20% onto the price tax. What have you gained by adding 20% and having insurance pay for it? And that isn’t even the expensive part of your fallacy. If it is now “free” from your insurance company the individual has nothing at stake. Providers will push it on everyone rather they smoke or not and people will try one day then throw the rest in the medicine cabinet.
    You could easily increase spending on cessation aids 50-100% with no improvement in outcomes. cessation aids cost a fraction of an actual smoking habit, if they can afford to smoke they can afford their own cessation aids.
    ” the analyses do not look at the cost of a particular benefit set before and after reform for the average person who must use the individual market for insurance”
    How do you define benefit cost? If you are referring to what XYZ insurance will pay for a vision exam it might stay flat or drop with the increased volumn. If you are talking how much XYZ will charge in premium for a vision exam it not only will skyrockets but already has. The average premium in existance today, we can’t project for premiums that don’t exist, will double in 5 years for sure. Your removing the remaining few personal cost controls, capping out of pocket and deductibles, creating an endless benefit to providers, remove annual and lifetime caps, giving coverage away to the sickest people without any controls, and promising to cover just about everything, trials. The premium cost of benefits for those curretently covered are going to inflate like no time in history.

62. Maggie,
    In your rebuttal I figure you plan to include Figure 2 on page 6. That’s a doozy of misinformation.
    Just from the perspective of intellectual cleanliness, creating a chart which shows “possible” premium increases from various sources and then giving point estimates rather than ranges is, well, unclean. As far as RAND was concerned, there were lots of “possibilities” other than 17%. I haven’t read the RAND study, but if they gave a standard 95% confidence interval you could have used those values as well and been just as correct in stating “possible” outcomes according to RAND. Tanner’s approach is especially indefensible for the CAHI estimate, which was a range from 75% to 95%, yet the figure only shows the 95% top end. A work of political hackery.
    The bigger problem is that this chart misleads by looking only at the individuals who have insurance right now in the individual market. This conveniently excludes those who could not get insurance or for whom the cost was too high due to pre-existing conditions. The cost of coverage for them will go down substantially.
    These studies easily can mislead people (as Tanner is doing deliberately here) into thinking that everyone’s costs will go up by 17% or more.
    To put it another way, the analyses do not look at the cost of a particular benefit set before and after reform for the average person who must use the individual market for insurance (including the currently uninsured who don’t have access to group insurance, Medicare or Medicaid). From what I’ve read, the average cost of a given benefit set will go down after reform. This makes sense for several reasons: reduced administrative cost through guaranteed issue and elimination of underwriting, as well as greater efficiencies of scale.

63. jd, I am all for free gym memberships and wellness programs, but even a 100% healthy person would (or should) think twice before getting a plan with no oncologists, or other expensive specialists. Previously very healthy folks are diagnosed with cancer every day. After all it is supposed to be an insurance plan, for all those unforeseen horrors.
    BTW, I think every office building or factory or whatever should be mandated by code to have an appropriately sized exercise facility. Just like they must have bathrooms or fire safety.

64. Margalit, that quote about relocating to the top floor of a building with no elevator is a howler. I suppose the insurance company will also eliminate its customer service by phone and internet just to stick it to the infirm. But the remarks about offering wellness programs and not offering oncologists are a bit more serious.
    Insurers definitely look at how attractive their specialty networks and benefits are compared to competitors and don’t want their benefits+network combination to be too attractive, in order not to set off an actuarial death spiral. There is nothing new about that, of course; it’s been happening for years.
    The wellness program point is actually one I’m willing to defend. Why shouldn’t an insurer make a big effort to create attractive wellness programs for its members? I think this is right on many levels:
    1. The healthy get the least out of their health insurance. This enhances fairness by giving them something tangible in return for the premium they pay.
    2. To the extent the wellness programs work, they lower health care costs, which is a win-win outcome.
    3. Health insurers need to compete and differentiate on something. Wellness is a much better place to do this than is, say, risk selection through making health benefits more difficult to access.
    4. An obese diabetic who hates the thought of exercise or self-control isn’t pushed out of a health plan with a strong wellness benefit. It just means that a small (1%?) proportion of the premium is going to pay for these things that other people do take advantage of, perhaps lowering that diabetic’s premiums in the long run anyway.

65. I’m on page 24, reading about “Growing the Nanny State” and I just learned that requiring restaurants to post calorie counts on menus “represent[s] yet another blow against individual responsibility” and this in itself is the sole reason for the growth of the Nanny State because there’s nothing else other than restaurants in this section.

66. Thanks. Looks like I have some “light reading” to do.
    BTW – I too believe insurance should cover the out-of-pocket expense for FDA approved cessation aids (including counseling). There was a nice article in the Sacramento Bee about that not too long ago.
    Think what our healthcare system would be like if we took the $194 billion/yr in direct/indirect costs associated with smoking related illness and put them somewhere else. As a respiratory therapist, I wouldn’t mind it at all.

67. Nate, it’s from page 6 of the CATO paper that Maggie is discussing here – right column, one paragraph before last….

68. did you make this up margalit or did this actually come from somewhere? Not saying we don’t trust you but if your going to post attacking quotes, some context and sourcing is nice.
    Curious who actually visits their insurance company? just trying to establish some relavancy.

69. Here is some comical relief regarding insurers strategies to avoid people with pre-existing conditions:
    “… or they can locate their offices on the top floor of a building with no elevator; or provide free health club memberships while failing to include any oncologists in their network.”
    I guess they could also make their ID cards become invisible when exposed to light….

70. “But what matters is what percentage of ALL Americans (and particuarly Americans who vote–which is the group Rasmussen tries to capture) favor repeal or oppose repeal.”
    This is correct, and if your going to claim 42% of ALL americans oppose repeal based on a poll of 1000 people I want to know the D/R ratio of those 1000 people. If you call 500 D and 500 R and got a 42% opposition that is completly differnt then calling 800 D and 200 R and only getting a 42% opposition to repeal. I spent a good 20 minutes looking for this info for the gallup poll and am pretty certain they didn’t ask the question and their poll oversampled Dems.
    If your asking how many people like apple pie we don’t need this info, any poll asking a hyper-politial question like for or ahgainst repeal of healthcare reform that doesn’t ask this question and prominently provide the internals is not journalistically quotable. We don’t need a poll to tell us how the dailyKos feels about HCR. If they can’t prove they are a scientif poll they shouldn’t be quoted like one.
    “And if public sentiment continues to move against repeal, even Republicans will back away from the idea.”
    And this is exactly why liberals publish inaccurate polls that sample Dems 12% higher then Reps. Its not fact its propoganda. They are trying to trick people into thinking the public wants to give it a chance, it is 100% false. All accurate polls show HRC losing popularity.

71. stop smoking help–
    I totallly agree with your English teacher. That’s why I include so many links in my post–as evidence. Gallup polls are generally considered to be objective. They call a random sample of people and have been doing this for a long, long time. As I noted, some people think Rasmussen polls lean to the right, and that Kaiser polls lean to the left (as an organization it’s a fair guess that Kaiser favors reform.)
    That’s why I included all three: Gallup, Rasmussen, Kaiser. When they all agree on the general trend (moving away from favoring repeal), that’s telling.
    I don’t realize you had a smoking cessation website. That isn’t “rinky-dink”!
    The single thing we could do that would lower premature deaths in this country–and improve overall health–would be to help people stop smoking.
    I’m very glad that, under reform, new insurance plans will not charge co-pays or deductibles for smoking cessation counseling. I wish we would also put the cost of patches and smoking cessation drugs on a sliding scale based on income so that everyone could afford them.
    Summaries of reform: For a readable summary of reform that is arranged as a time line telling you what happens in 2010, what happens in 2011, etc. see this Commonwealth Fund timeline. It goes into quite a bit of detail and is very readable: http://www.commonwealthfund.org/Content/Publications/Other/2010/Timeline-for-Health-Care-Reform-Implementation.aspx
    Kaiser offers an even more detailed summary. It may be more detailed than you want, but it’s well-organized into sections like “individual mandate”
    and “tax changes related to health reform” so that you can read the sections that interest you. You’ll find it here: http://www.kff.org/healthreform/upload/8061.pdf

72. Nate–
    Yes, Democrats and liberals are more enthusiastic about reform than conservatives and Republicans.
    This is a very well-known fact.
    If you want a break-down by party, all you have to do is click on the link I gave you to the Gallup poll which includes a table showing that in June:
    17% of Republicans thought the reform legislation was a “good thing”–up from 10% in April.
    Among Independents, 43% saw it as a good thing, roughly teh same as in April (41%)
    Among Democrats, 76% saw it as a good thing, down slightly from April (81%)
    Margin of error +/- 4 percent.
    So the increase in Republicans favoring reform is statistically significant, the drop in Democrats just barely significant. Other Gallup polls tell us that some Democrats dont’ like the bill becauase they feel it didn’t go far enough. They want single payer or a public option.
    But what matters is what percentage of ALL Americans (and particuarly Americans who vote–which is the group Rasmussen tries to capture) favor repeal or oppose repeal.
    This will have an effect on how the Republicans and conservatives fare in the elections this fall. If they continue to push for repeal, this will factor into whether voters vote for them or against them.
    It seems that the majority either favor or reform or want to see how it works out. They may well be alarmed by conservatives who want to repeal or replace it.
    And if public sentiment continues to move against repeal, even Republicans will back away from the idea.
    They would like to win elections in November even more than they would like to repeal the bill.

73. I don’t have a problem with anyone’s political leanings. I just wanted to point out how things are phrased and how they can be interpreted by us readers and commenters.
    I just like to challenge people (and what they believe) by making them see how their perspectives may color their approach to a given topic. Are they being unbiased? Are they taking an open mind with them or are they already closed. Don’t get me wrong, I do it all the time too.
    I guess I’ll pull the curtain back a little and say I’m more conservative than liberal. I don’t like change unless, as my 5th grade English teacher told me, you can back it up with objective data. Make your point, but be prepared to back it up.
    That’s why I started my website. It’s unbiased, literature-based smoking cessation information. I don’t promise anything or make outrageous claims. I know these blogs cover much bigger issues than my rinky-dink website. I have really come to enjoy the “lively banter” and information given here and on other blogs.
    So I can better understand these issues, is there a place that has the reform legislation posted? And when I say posted, I mean where a political novice (like myself) can actually read and hope to understand most of the high points without someone else telling me what I’m reading? I’ve looked without a lot of success. Thanks!

74. “Similarly, picking the one poll out of 17 weeks of polling that strongly supports your argument is misleading. This isn’t a matter of opinion–it’s a fact.
    Note that I showed you all 17 weeks”
    Why don’t you show the sampling spread between Dems and Repubs? If a poll claims there is a 12% spread when there is not then the liberal position will appear to be more popular. IN FACT, and this really is a fact, Amoungst a representive slice of the US population it is less popular. Amoung liberals it has much higher popularity but that isn’t what your claiming. I took Matt and you to task for this last week. Your knowingly using a bias poll to project opinions on the public at large that only apply to liberals.
    If you really want to be transparent and have your opinions respected then share the data that matters and that is poll internals.
    Read this from your gallop poll;
    “Samples are weighted on the basis of gender, age, race, education, region and phone lines.”
    As far as we know Gallop called 1014 names of the DNC contributor list. And you hold this up as honesty?

75. stop somking help–
    Good to hear from you.
    I have to disagree that “nobody knows whether statistics are right.” It’s always worth analyzing statistics. In her comment, Margalit, for example, makes a good catch.
    And there is such a thing as “true” and “untrue.”
    For instance, it’s just not true to say :”reform legislation remains deeply unpopular.” This statement implies that it’s just as unpopular as it was in March–and that’s not what the polls show. It would be far more accurate to say “some Americans remain strongly opposed to reform legislation, but the percent who want to see it repealed has fallen since March.”
    Also, picking one outlier poll from May to demonstrate that “63%” of the public wants the legislation repealed is misleading.
    On the other hand, some things are a matter of opinion.
    The report says that reform will redistribute income from people earning over $348,000 to people earning $18,000 to $55,000. This is true.
    Is it a good thing? That’s a matter of opinion and depends on what you call one’s “angle”–i.e. their political perspective.
    I’m completely happy to identify myself liberal and to say that I look at these things from a liberal perspective. I think it’s a good thing to redistribute income downward because we have been redistributing income upward for nearly 3 decades. It’s time to right the balance–that’s an opinion.
    But that doesn’t mean that everything is a matter of opinion or perspective. 2 + 2 equals 4, not 5.
    To say that slightly more than 35% of Mass. citizens who remain uninsured between 18 and 25 –and not putting the number in context (only 3.7% of the population remains uninsured)– is a classic case of using numbers to distort the truth. 35 percent sounds like a lot of people. As Maragalit points out 35% of 3.7% is not a lot of people. The overwhelming majority of young peole in Mass. are part of the pool.
    Similarly, picking the one poll out of 17 weeks of polling that strongly supports your argument is misleading. This isn’t a matter of opinion–it’s a fact.
    Note that I showed you all 17 weeks– including the weeks where it looked as if support for repeal might be rising. That’s called putting the numbers in context rather than cherry-picking them. That’s the way statistics should be presented. Again, not a matter of opinion, it’s a fact.
    So my analysis will be a combination of opinion and fact. I’ll true to make it clear when I’m offering an opinion –for instance some people say the Rasmussen polls are biased, but others say they they are “generally reliable.” So I decided to go with the Rasmussen polls, at least as the first example, and to quote the Rasmussen pollsters analyzing their own data–talking about the trend through June, etc.

76. Truth-seeker, Peter,Margalit
    Truth-Seeker– I’m not sure how you think reform is “screwing doctors.” Medicare just hiked fees, across the board (by a small amount, but still it’s an increase.) Berwick, the new head of CMS, is liked and respected by physicians. He’s not a bureaucrat, he’s a doctors’ doctor.
    Maybe you fear that reform will screw doctors at some point in the future. If so, I think you’re in for a pleasant surprise. Reform is going to reward a great many good doctors by paying them to talk to and listen to patients.
    Peter:
    Yes, you’re entirely right– without reform, we’ll definitely add to the deficit.
    With reform, it’s quite certain that we’ll see significant savings under reform. We just don’t know how much– too many variables involved.
    But we do know that roughly 33% of health care dollars are wasted. In order to “break the curve” of health care spending, we need to reduce spending by 5% to 6% a year. That means eliminating only about one-fifth of the waste.
    We know it can be done. For about 5 years in the 1990s, health care care inflation dropped sharply and spending as a percent of GDP remained flat. This is because private insurers were making a serious effort to contain costs under “managed care.”
    Unfortunately, they did this in a ham-handed way, focusing on costs rather than the effectiveness of treatment. Sometimes the refused to pay for ineffective, futile treatments, but sometimes they refused to pay for treatments that might have helped the patient.
    Under reform, comparative-effectivness research will serve as the guide to what we pay for. (Note I say guide.) Private insurers won’t be making the decisions. Though, in insofar as Medicare trims waste, they will follow Medicare’s example.
    Medicare is already beginning to address waste by limiting payments for tests done in the doctor’s office. (Reserarch shows that when doctors buy or lease a million dollars worth of testing equipment they do twice as many tests in order to pay for it.)
    Medicare is also refusing to pay for an excessive number of
    preventable readmissions. In response, the American Hospitalist Society is already working on redisigning what happens when patients are admitted, and when they are discharged to make sure that they or a caregiver has clear information about what meds they should be taking, to make sure they have a follow-up appointment with a doctor, to make sure that they’re not leaving the hospital with a hospital-acquired infection. . .
    In other words, hospitals (and hospitalists) are going to be workign to try to eliminate waste in this area. The financial stick is making hospitals aware of the problem. Too many patients “bounce back” within a couple of months.
    Similarly, Medicare is going to be looking at hospital infection rates, and ultimately, publishing them. This is likely to make hospital administrators begin to pay much more attention to doing all of the things they can to reduce infections. The Insitute for Healthcare Improvement and others have demonstrated that it is possible to cut infection rates sharply.
    Private insurers will follow Medicare’s lead–they just want Medicare to provide political cover.
    And it’s already happening. See this story from Bloomberg: ” CardioNet Inc. said Wednesday that UnitedHealth, one of the largest health insurers, will not cover CardioNet’s wireless heart-monitoring devices.
    CardioNet said UnitedHealth Group Inc. is maintaining its view that “outpatient cardiovascular telemetry is unproven for managing cardiac arrhythmias.” The decision comes about a year after a Medicare administrator slashed reimbursement rates for CardioNet’s products and similar devices. That caused health insurers to lower their rates.”
    In addition Medicare will be chaging how it pays for care–paying for quality, not volume, as they move away from fee-for-service and reward providers for better outcomes. Private Insurers will follow suit.
    The reform legislation provides funding to double the capacity of community health centers, many of which will be open after hours. This provides a much less expensive, more patient-centered alernative to the emergency room; they goal is to siphon off the patients who now get their care at ERs and redirect them to community cencers staffed by a combination of doctors, nurse practioners and physicians’ assistants. These centers will become medical homes–and provideres will be paid extra for providing that home.
    All of this is bound to lead to savings– we just don’t know how much.
    But everyone is going to be more cost-conscious–including insurers. They will no longer be able to pay whatever a hospital or a drug-maker demands and pass the cost along in the form of higher premiums. States are already beginning to block premium increases, insisting on proof that they’re necessary. And since insurers will have to pay out 85% of premiums for medical expenses (when covering large groups, 80% when covering small groups) jacking up premiums won’t do them that much good. If they raise premiums 10%, they get to keep only 1.5% to 2% of the increase–they rest must be paid out in reimbursements or they have to refund customers.
    Health care reform is going to put a lid on health care inflation in many different ways.
    Margalit–
    Good catch.
    It’s worth reading the report just to become familiar with how conservatives distort numbers, and make things up out of whole cloth. That’s why I’m taking the time to deconstuct the whole report.
    The Century Foundation hopes that when people consider quoting the Cato report they’ll also take a look at our report (we’ll be putting my posts together in one document) as a way of fact-checking.

77. Hard to avoid personal bias in this argument, regardless of where you come from. Maggie is already going to analyze and rebutt, which tells me she doesn’t agree with it and will be approaching from her angle. Not that it’s a bad thing, we all do it.
    Opinions and statistics are like politicians. We all have them representing us, but nobody knows if they’re right.

78. As doctors get screwed more, the costs go higher. Go figure.

79. CORREX
    Forgot to label this diatribe as a “fact.” Instead of proof of political narrow-mindedness.
    Somewhere, Geo. Orwell is LOL.
    See you Nov. 2. That’s the only poll that matters. Unless the Chinese Commies cut off OWE-bama’s spending, like they did with the Greek Commies.

80. “Tanner seems sure: the legislation will add to the deficit, he asserts, and force insurance premiums higher.”
    I agree with this unless costs are reduced, but not “reforming” the cost/payment system will “add to the deficit” as well. How much higher will premiums go than their historical 6% – 10% compounded increases per year without “reform”? But if the legislation had done any significant reduction of costs (cutting prices/procedures) CATO would be screaming government take-over.
    “Moreover, he stamps the legislation “unjust”: it would turn private insurance companies into regulated “public utilities,” forcing them to insure sick people,”
    Imagine, actually providing healthcare coverage to “sick people”, how un-American. No self respecting private insurance company can make money providing coverage to people that are actually sick.
    “while “redistributing income” from families earning “over $348,000” to families earning “$18,000 to $55,000.””
    I guess “redistributing” income from those earning $18,000 to $55,000 to those earning over $348,000″ is much fairer.
    “Ultimately, he argues, reform represents yet another step toward turning the U.S. into a “Nanny State.””
    Seems Wall Street likes a “Nanny State”.

81. I am only on page 4 of the 52 page report and already learning new tricks… Here is how you “game” statistics:
    “Slightly more than 35 percent of that state’s [Massachusetts] remaining uninsured are between the ages of 18 and 25”
    “Before the mandate, those between the ages of 18 and 25 made up roughly 30 percent of the uninsured, suggesting that the young(and presumably healthier) are less likely to comply with the mandate.”
    “…this does not bode well for the national plan.”
    The latest uninsured figure in MA that I am aware of is 3.7%. Of those, 35%-30%(“roughly”)=5%(“roughly”) more are young and healthy, as compared to the situation before the mandate to buy coverage.
    5% of 3.7% is 0.185%, or 12,198 people out of 6,593,587 in MA. This is within the margin of error for “roughly” and “bodes” absolutely nothing.
    Not sure I want to read more, but I will anyway. It’s just campaign propaganda.

82. The Act will result in many hospitals going bankrupt, the number depending on the degree of gaming of the system by insurers, employers, and individuals. Premiums have already leapt to the sky. Maggie, wake up, that report is accurate and it has nothing to do with polls.