Inkwell: Authors and Artists

    
>How did we get in this situation, with employers considered responsible 
for healthcare insurance?

I believe that, like Kaiser, it started as a response to WWII, with 
employers coming out of the Depression, suddenly scrambling for workers, 
and employing many women for the first time (and women are and always 
have been the gatekeepers of healthcare for the family) 
but constrained by wage controls from offering higher wages - so they 
offered other things, including healthcare insurance. After WWII, unions 
were very strong, and demanded that this precedent be expanded and 
reinforced. 

There were efforts under Truman and Eisenhower to offer federal 
healthcare coverage for all. Republican Eisenhower was actually the 
first to offer a bill - written by Peter Drucker, who would go on to 
become one of the nation's top business strategists. The bill went 
nowhere.

Johnson tried again, but eventually decided to scale it back to cover 
only the populations that needed it the most - the elderly, the poor, 
and the disabled. And despite its many problems, it must be said that 
the Medicare/Medicaid package has been remarkably successful at 
expanding healthcare for those populations. It is one of the main 
reasons why we have such a burgeoning elderly population today, compared 
to 40 years ago.
  

    
>What's in it for providers? Why is the AMA opposed?

I think largely for historical reasons. Most doctors are small 
business people, either independent, or in small-to-medium corporations 
which they own as partners. Even Doctor Eshleman (whose participation 
here, by the way, I particularly welcome) is a part owner of a rather 
large for-profit medical corporation. Small business people do not like 
government interference. And single-payer is associated in almost 
everyone's mind with government control. In the current situation, 
thought, doctors have lost a great deal of their power to the insurers, 
so dealing with one controller might be a lot easier than dealing with 
many.
  

    
But single payer need not mean centralized bureaucratic control. Suppose 
that we left the present system intact, with these differences: 
Healthcare insurance is no longer a tax deductible business expense, for 
anyone (which means, of course, that most employers would stop offering 
it for most employees). Take the tax revenues gained, and give them back 
to the people in the form of funded medical savings accounts and a 
basic, government-backed catastrophic healthcare insurance program. If 
you have the money, and want healthcare with better guarantees, and 
access to the high-pockets specialists or whatever, fine, you pay for 
the insurance with after-tax dollars. But everybody is covered and, 
because the money is in MSAs, there is still competition among providers 
and insurers for those dollars - and not particularly any more 
government control than there is now.
  

    
I find this conversation particularly interesting in part because of a
term paper I did for a history of medicine course at UC Berkeley.  I
took advantage of a large collection of Kaiser papers at the Bancroft
library to study the history of the Kaiser system.  I remember
astonishment at the vehemence of the reaction to Kaiser--the very idea
of the HMO was decried as socialist, if not outright communist, by the
AMA and politicians of both major parties alike.  

Today I find something equally astonishing:  the incredible number of
capable people who are working in health care not delivering care, but
tending to coverage issues--former nurses reviewing charts to see that
they're compliant with insurer requirements, and on the other side,
insurance industry people spending time trying not to pay for services.
 That's a huge, huge waste of money and human capital.  And what I see
in the hospital is only the tip of the iceberg.
  

    
In the 1950s Kaiser doctors were excluded from membership in
California county medical societies--just part of the McCarthyite
hysteria of the time.

BTW, highly recommended is the May 18 issue of the New England Journal
of Medicine, which arrived in my mailbox today.  There are two lead
articles about the Massachusetts plan for universal coverage.

A few factoids from the articles:

*Public opinion polls now show that a majority of Democrats,
Republicans,and Independents favor universal health care coverage.

*in 2004, per capita health care expenditures were $6,280 (16%of the
GDP)

*in 2005, the average [I think they mean "mean"] monthly cost of
coverage through job-based health insurance was $335 for an individual
and $907 for a family.

The Massacusetts plan, in brief:

*requires everyone who can afford it, to buy health insurance

*assesses business a charge of $295 per employee per annum if they do
not already offer a health insurance plan   This money is earmarked to
subsidize insurance for those who cannot otherwise afford it.

* extends Masscare (their version of Medicaid) to children in families
with incomes up to 300% of the Federal poverty standard or about $60K
per year.

*Extends the same to indiviudals with incomes up to 100% of the
poverty standard

*gives subsidies to individuals with incomes between 100 and 300% of
the poverty level.

Will it work?  Let's hope so.  

The mandate that those who can must buy insurance is very similar to
what Switzerland requires of its citizens.  In Switzerland, citizens
purchase a basic package from private insurers who are restricted in
how much they can charge.  In return ,these private insurers can sell
all sorts of supplemental plans (Botox benefits and the like) to those
who can afford them.  

Massachusetts will make sure that people buy insurance by checking
their coverage at state income tax filing time.  If they haven't
purchased insurance by then, they will be assessed a penalty.

Finally, I think the power of the AMA is overrated, especially in
layman's mind.  Patients often ask me what the AMA's policy is about
particular therapies, assuming such policies exist.  They don't. 

Certainly the conservative elements of the AMA come in to play in the
debate over medical economics, but the AMA is no longer any sort of
king-maker.
  

    
Alan, I'm also appreciating your participation here, and was also
happy to see Dr. Diane drop in. 

I don't think that the AMA is the political juggernaut it may once
have been (heavy on the maybe there), but I do think that organized
physician opposition to single payer concepts could and should be a
concern. 

One interesting thing I turned up is the AMPAC pattern of political
contributions, described in the links below: 

<http://www.opensecrets.org/orgs/summary.asp?ID=D000000068>

<http://content.nejm.org/cgi/content/short/330/1/32>

I do not, however, want to see this discussion derailed onto a siding,
so I'll drop this at this point , and leave the links for anyone
interested in knowing more. 
  

    
I want to thank you for the summary of the Massachussetts plan, as
well, Alan.  It will be very interesting to see not only the
anticipated impacts and outcomes, but also the unintended ones. 

I wonder if this kind of mandate could be a bridging step toward the
goal of a single payer system.
  

    
Slippage.

The New England Journal stuff is 14 years old...Interesting, though. 

Organized physician *support* is also very necessary.  One problem
with the Clintons' plan was that Hillary and her brain trust went off
to private meetings and drew up a plan with almost no input from
physicians in the trenches.  That process pissed a lot of people off,
me included! Without much organized support, it was easy for the
insurance industry (not the AMA) to roll out the Harry and Louise
campaign and shoot the whole thing down.  

Massachusttsis aiming for 90-95% coverage per the articles I
mentioned.
  

    
The Open Secrets link updates the twelve year old study, fwiw. And
it's rather interesting that no one seems to have analyzed those
donations in detail since, especially in light of the tobacco issue.

I agree that one of the mistakes made by the Clintons et al was the
perceived secrecy around the development of the plan, although I can
understand why the myriad political pressures on the process led them
that way. 

No new paradigm or plan is going to succeed without early and intense
stakeholder involvement. 

Along that line, I'd like to go back to go back to a point that Diane
made about the amount of time spent on coverage issues now. 

One of the major traits of the health care reimbursement morass is its
opacity. I spent a lot of time professionally working with coding and
reimbursement problems, and I now have a casual sideline in EOB
interpretation for friends and family.

Translating payor-beneficiary communication has become a sort of
subspecialty of its own. From the provider end, it has become
increasingly difficult for even trained, educated, professionals to
understand what the insurers are telling them, and what is actual
policy requirement vs. what is interpretation. 

In the opinions of a lot of people in the field that I've worked with,
there are too many medical/treatment/discharge decisions being made by
bureaucrats, rather than by health care professionals. 

Could a single payer system do something similar to what the IRS has
attempted: revolutionize communication between all parties by
conducting it in plain English? Could the rules be simplified such that
they are understandable to all? 
  

    
Sure, why not?  If everyone had the same basic insurance policy and if
there were limits on what was covered (medicine is an enterprise where
demand always outstrips supply, and a good deal of the demand is
unnecessary)it should be possible to describe things simply.  

And I have to say, one of the nice things about being a Kaiser doc is
that never in almost 20 years has any bureaucrat ever attempted to
trump my medical decisions.  Disagreement among colleagues?  Sure. 
Limits on the formulary?  Yes. We don't automatically cover every new
blockbuster drug.  But no medication has ever been denied if there was
no alternative.
  

    
A great topic and gratifying in that observations and comments
reinforce and enlarge my own thoughts about the matter.

In a previous life, I had contact with public health officials for
some developed and some less developed countries.  A consistent view I
got was that the major health problems were due to individual choices. 
When I protested that this cannot be true where there is poverty, I
was assured that even where choices were severly limited, bad choices
were made.  

If there is some truth to this, will single-payor offer a better way
to attack the problem of bad life choices by individuals?  How do
existing single-payor systems attempt to get at the problem?  
  

    
Thanks for the summary of the Mass. plan, <doctore>. The politics and
other factors of our situation show that this is the kind of solution
we can expect -cobbled together, not radical, not sidelining the
insurance companies or employers, but at least covering most people.

The opacity of the current system is, of course, unnecessary. If
insurance companies found it in their interests to be transparent and
helpful, that's what they would be. It is not in their interest to be
truly trnsparent or helpful.
  

    
Robert, public health officials who say that health status is merely
the result of individual bad choices are merely reflecting the
prejudices of their class. There is extensive and well-documented
literature showing that, while some health problems are due to choices,
those choices are heavily influenced by socioeconomic class, and
opportunity. In brief, those people are healthiest who have the most
feeling of control over their lives. The entire global "healthier
communities" movement is built around this notion. 
  

    
I think we'd find that the number of people who have not made bad
choices in some aspect of their lives to be quite small.

I agree with much of what you're saying, Joe, but as you know, don't
think we should carry the insurance companies like a millstone around
our next for all eternity just because they employ a very large number
of people.  People used to say that all sorts of economic disasters
would ensue if we ended child labor.  We've muddled throught somehow.
  

    
Patricia Zentara writes:


Hi, Joe and all!
.
Am just a first time guest.I have been
interested in The Well for years..
.
I seem to get that Americans have
a "Drive-through" syndrome for
instant gratification...to very complex
issues.
.
I am not referring to anyone here
because I am more than weary at what
I have seen In newsgroups and in the media......
The desire to lay blame on any entity.
Honest discourse seems lacking and
pervasive. And when one takes a stand
...the reward is not positve.
.
I observe there are many "trips" and anyone not in line with us must
be wrong.
.
My own, limited, point of view is that
our society has been raised to believe
that life is fair...it is anything but.
.
So...re; Medical Insurance?
We got here I think,because we have given up on~or never searched
alternative methods of healh care for openers. And if we find out we
have to pay for it...my goodness..what upsets occur!
.
The money we spend on the latest
technological toys/cars..vacations takes precedence over heath care, .
I stay away from MD's and I am not
young...I think the Medicare D does
promise.... too much for some and it
does work for others.So far, it works
for me.
.
What I am trying to say is that we
should seek new and more creative
ways to care for ourselves and others.
.
I do think President Kennedy was right
on point when he said:
"Ask not what your country can do for
you~ ask what you can do for your
country"...
.
I hope I can do something to make a
difference in some way to this world. 
.
Peace to all~
Patricia Zentara
Lodi, California
  

    
Wonderful discussion, and thanks to everybody.

I had back-to-back experiences with the Japanese and the American
healthcare systems (same injury).  The Japanese, for about $85,
diagnosed and recommended action (which would've cost more than $85,
but even so...)

When I got back to NYC, I got the same diagnosis, had the surgery,
yadda yadda.  What utterly flummoxed me was that the Japanese had taken
all the particulars down in Kanji on  electronic notepads: diagnosis,
X-rays, therapy, all ended up in a databank.

In NYC, a guy young enough to have grown up on videogames took the
same info into 1932-style three-ring binders by hand.  Same old
questions--allergies, previous surgeries, etc.  This is at a hospital
where I'd had a 25-year history of whatever allergies to medicine,
anesthesia. and so forth.  At this point I was livid (and in real pain)
and read him the riot act. 

A few weeks later, when I'd recovered my equanimity, I emailed a pal
at Columbia-Pres who is in medical informatics, about why there was
such a difference JUST IN INFORMATION TECHNOLOGIES, whose
implementation saves a lot when it's done right.

Same answer: we need a single-payer system to reconcile all the
gazillions of little doc- and hospital- and insurance-operated systems
extant.

When, oh Lord?
  

    
>reconcile all the gazillions of little doc- and hospital- and
insurance-operated systems extant.<

Standardized record systems offer economies and other benefits, no
doubt.  My experience in developing similar systems to describe medical
device function and mal-function made me concerned that the zeal to
categorize for ease of data handling may gloss over some unique
aspects. I remember one MD saying "The patient can have as many
diseases as he damn well pleases". Certainly, any record system can
miss information. Standardized coding appropriate for data handling
will help characterize a population of patients to the systems benefit.
Individual patients, however, may find that their particular
combination of health problems and issues may not be well-reflected
when placed in predetermined categories. 

As usual, the devil is in the detail
  

    
>There is extensive and well-documented literature showing that, while
some health problems are due to choices, those choices are heavily
influenced by socioeconomic class, and opportunity.<

Joe, I'm certain that public-health officials everywhere would agree
with you but the point was that major health problems result from
choices that individuals are free to make even where choice is limited
by such things as class and opportunity.  Further, we see people that
are highly advantaged having health problems due to choices made. 

The "healthier communities" you note sounds like a positive step to
get the peer group to support the individual to make better choices.  
  

    
>we need a single-payer system to reconcile all the
 gazillions of little doc- and hospital- and insurance-operated systems
 extant.

The need for information transparency is not a argument for a 
single-payer system. It is an argument for industry data-transfer 
standards, which already exist, and are spreadng with the slow spread of 
digitization through the industry. For an example, just look at the 
credit card industry: credit cards are issued and administrated by 
thousands of independent institutions around the world, yet they 
communicate their informatino seemlessly, instantaneously, 
accurately. One could easily imagine a single-payer system with munged 
information standards that prevented prompt and accurate communications 
between, for instance, different government programs, or between clinical 
and administrative sides, or between different types of providers.

For me, the relationship of information technology to the single-payer 
question is that both are about the quality and efficiency of the basic 
transactions of healthcare. Healthcare that is not only digitized by 
automated and networked would be hundreds of times more 
transaction-efficient and high quality than today's healthcare. And a 
healthcare that replaced an insurance sector that adds no value with a 
simple and universal flow-through payment system would also greatly 
reduce transaction costs.
  

    
>major health problems result from
 choices that individuals are free to make even where choice is limited
 by such things as class and opportunity

This is true, but in ways that are so limited as to be useless in making 
public policy judgments. Fetal alcohol syndrome, for instance, results 
from the mother's poor choices. And those choices are heavily 
modulated by socioeconomic status, as well as by population genetics. 
So? Knowing that does nothing for the child, or for the society that 
must deal with the child's many developmental problems, and which will 
eventually be burdened with an adult that is less educable, productive 
and socially useful. The suggestion here is that looking at healthcare 
as a unified social good that we provide for ourselves as a society, 
rather than a private good, is more likely to provide comprehensive 
social and medical answers to such problems.

The best book I have encountered on this subject Is "Why Are Some People 
Healthy And Others Not," by Evans et al.

For a quick but deep intro to this subject, here is an interview I did 
with Fraser Mustard: http://www.imaginewhatif.com/Pages/Mustard.html

Please forgive the "broken" look of the page. It's a part of my web site 
I have not cleaned up yet.

More writing on the subject (from back when I was doing a lot of it) is 
available at http://www.well.com/~bbear/hc_articles.html
  

    
Joe, I take your point that a transparent and efficient IT system
isn't *necessarily* an argument for a single-payer.  And in today's
news, we hear that some functionary at the VA managed to get burgled of
a CD that had more than 25 million veterans' records and SS numbers. 
In a healthcare system, that would be just swell.  (Not that the
private sector with its gazillions of independent operators has had a
much better record of guarding privacy.)

Interesting that, in your view, the insurance sector adds no value.  A
strong statement.  I'm willing to believe it on faith, but can you say
more?
  

    
Thanks to all of you for the excellent questions. 

Joe, can you speak to HIPAA standards, digitization and the protection
of patient confidentiality? How might a single payer system impact or
be influenced by the need to protect those records as we move into
digital records and transmittal?
  

    
Joe, thanks for the link to the Fraser Mustard interview.
  

    
> Interesting that, in your view, the insurance sector adds no value.  A
 strong statement.  I'm willing to believe it on faith, but can you say
 more?

The reason that we have insurance is to spread risk - to turn what would 
have been rare but financially catastrophic into a regular, calculable 
cost of doing business. The risk is spread across time and across 
populations. 

Three points: 1) Healthcare does not really fit that model. A few people 
require almost no healthcare - they grow up relatively disease-free, 
then get hit by a bus or blown up in Iraq. Sad, but not much cost to the 
system. A few people need huge amounts of healthcare for long periods of 
time - people with MS, AIDS, and so forth. Most of us need varying 
amounts, increasing as we age, then relatively large amounts as we fight 
our inevitable death. This is not a good model on which to attempt to 
spread risk, and becomes less so as we manage to extend the elderly 
stage of life. When healthcare insurance, even living past 65 was a 
relatively rare event - 3% of the population in the 1940s.

2) Insurance companies are increasingly using their vast informatino 
structures to narrowly target populations with special offerings which 
in effect avoid spreading risk.

3) It poorly serves the health of the population to have some people 
covered and some not. When people avoid healthcare because they cannot 
afford it, they tend to spread more communicable disease vectors.

So for poorly spreading risk, and aggregating customers to strong-arm 
costs downwards, insurance companies take 25% of the healthcare dollar.
  

    
> HIPAA standards . . . digitization . . . privacy . . . single payer

I am not sure that these are not completely separate issues, except for 
this: the vast amount of information that insurance companies have 
isused constantly, in every way legally available to them, to separate 
out the "outliers" and deny them coverage in one way or another. In a 
single-payer system, the worry would go away.