Inkwell: Authors and Artists

    
Or, for that matter, that the government will turn out to be hollow
and collapse a la Enron...

As far as political currency, just got a mailer from John Russo,
Oakland City Attorney running for Assembly, and he's promising he'll
fight for SP.  And Dellums is running for mayor on the theme.  What's
with that?
  

    
That's a reasonable scenario, Jonathan.

Keta, Dellums and Russo are signs of an important ingredient here: 
States and localities are beginning to see that they can do smoething 
about this - not everything, but something. 

There is movement afoot in Congress to pre-empt state and local laws 
like those in Masachusetts. I think it would be a very interesting 
political test of how far the SP idea has cmoe.
  

    
We certainly have the best Congress money can buy.
  

    
So, what shape should a Single Payer system take? If you just say, "The 
government pays for health care out of tax revenues," you still haven't 
said how the government pays - and the differences make a difference. 
Let's look at some alternatives:

o   The government simply pays a flat yearly budget for each 
institution, and a salary and overhead costs for each practitioner.

o   The government pays established amounts per covered life - your 
institution or practice does the healthcare for X number of people (of Y 
ages and conditions), you get Z dollars. (In a twist on this one, people 
are assigned to their local institution. If someone assigned to your 
institution has to, or chooses to, go elsewhere for treatment, you have 
to pay for that treatment out of your budget - so you have lots of 
incentive to provide the best treatment so that your customers don't 
wander elsewhere. This is the Iranian system, designed for the Shah by a 
professor at Carnegie Mellon, and still in place.)

o   The government pays established amounts per medical act (i.e. extend 
Medicare to everyone).

o   The government pays insurance companies to insure people for 
healthcare.

o   The government funds medical savings accounts for people, with which 
they can buy private insurance, buy into high-deductible plans and leave 
the rest in the MSA to pay for everyday medical needs, or any 
combination of things, as long as it is medically related. If you are 
diagnosed with a condition (e.g. MS, AIDS . . .) that will require large 
amounts of healthcare for a long period of time, you are shifted into a 
Medicare-style program that pays for everything.

In any of these, you could have the government program be the only one 
allowed (as Canada did until now), or you could allow private 
funding to run in parallel, for people who can afford something more - 
and you could have private insurance be a tax-deductible business 
expense, or not.

The first three of these funding schemes wipe out the healthcare 
insurance industry, and so are less politically feasible. 

Each of these funding styles has different incentives for the providers 
and for the consumers to control use and costs. Anything that is fully 
covered tends to increase: the prices go up, and people use more.

So what shape?
  

    
just curious --- where would gatekeepers/decisionmakers over
who gets what kind of treatment fit into any of these schemes?
have heard anecdotally about all kinds of things
NOT covered by the uk and canadian systems --- stuff i would
put under the category of 'care' (physical therapy; better
wheelchairs; etc etc) rather than 'immediate medical
intervention' (stithces for a gash in the head)
rationing of healthcare? any input on oregon's attempts
at rationing healthcare?
  

    
We would probably get a solution to the healthcare situation sooner if
congress was denied the benefits that they voted for themselves, and
had to sink or swim like the rest of us.
  

    
>>if congress was denied the benefits that they voted for themselves

yep
  

    
Except of course that they generally are wealthy individuals, and we
generally are not.  That makes basic emapathy and equity a little tougher.
The pressure of a situation where not to suipport a strong national 
health plan would be political suicide is what's needed, in my
opinion.

The hardest political task may be to get the populace to believe it's 
possible and to detect and reject phony decoy proposals that are sure to
surface with a whole lot of dollars behind them.
  

    
Gail speaks sooth.

>gatekeepers

#1-3: Government, as the CMS (Center for Medicare and Medicaid
Services) does today for Medicare and Medicaid.

#4 (gov pays for private insurance): Probably insurance companies

#5 (gov funds MSAs): mostly the individual consumer, except the gov
would decide who qualifies for the hardship stuff

Most countries have the government be the gatekeeper, which is why in
most countries the actual management of healthcare (not just payment)
is a constant political issue, while it is not in the United States.
  

    
it's interesting, in that medicare -is- our sp, but
- one is advised to get medigap insurance, which only makes up
for what is cobvered by medicare but
- there is tons of stuff not covered by medicare.
and of course the stuff not covered adds up.

i dont know what the other SP systems (western europe minus
the uk; japan) do in these matters...
.
  

    

Joe, this has been such a rich conversation, with so much to explore. I feel
like we've hardly gotten started, yet it's been two weeks since you first
joined us.

Thank you, Joe, for sharing your time and expertise with us, and thank you,
Andrea, for being such an excellent moderator. Though our viritual spotlight
has turned to a new discussion, this topic will remain open for further
comments indefinitely. So if you're able to stick around, please know you're
more than welcome.

Thanks!
  

    
Yes, thanks, Joe and Andrea; it's been great.

How great? Robin writes in e-mail to say she's joining the Well to
participate. She also says:

"Hello.  My name is Robin Podolsky, and I work for State Senator Sheila
Kuehl, who has authored legislation, SB 840, that will bring single
payer healthcare to California.  Under the terms of the bill, each
resident of the state would be insured with comprehensive benefits
(medical, dental, vision, hospitalization, etc); California would
negotiate bulk rates for prescription drugs and durable medical
equipment, such as wheelchairs; and we would each retain the right to
choose our own doctor.  The state would oversee claims and
reimbursement.  This would lower the percentage of the healthcare budget
now spent on administrative costs from about 30% to less than 5%, while
leaving doctors, hospitals and pharmacies in business for themselves as
they are now.  The bill passed the State Senate and Assembly Health
committees last year and is making its way through the Senate again.

I am very excited to see this issue taken up here and look forward to
participating in the discussion."
  

    
Wow. I wonder what the chances of that passing are, Imagine that you 
are an executive for United or Aetna. Here is a bill that proposes to 
take away your largest market. What would you do?
  

    
Bribery.  Failing that, murder for hire.
  

    
There you go again. one thing your solutions would do is overlaod the 
already overloaded ERs.

Here is an article from the Economist reviewing Michael Porter's new 
book "Redefining Healthcare," which argues that 1) competitive forces 
used so far in healthcare have been 'introduced piecemeal, in 
incoherent and counter-productive ways that lead to perverse incentives 
and worse outcomes: "health-care competition is not focused on 
delivering value for patients."' But 2)  'a redirection of competition 
from the level of health plans, doctors, clinics and hospitals, to 
competition "at the level of medical conditions, which is all but 
absent" could bring quality up and costs down.

http://www.economist.com/business/globalexecutive/reading/
displaystory.cfm?story_id=6999160

I have not read the book yet. I have the book right here. It is one of 
several that I am to write an essay on for Strategy + Business over the 
summer. I must say that as far as I understand the book, I agree with 
Porter - and I also see no conflict between competition in the 
marketplace and a single-payer system (as I said in the article that 
framed this conversation). But I am less sanguine that the powerful 
forces looking to make money from healthcare could let the necessary 
reforms come through that would shape the competition around bringing 
true value to the customer. Those forces are having a fine time with the 
present system skimming off the value for themselves, and would surely 
strive to skew any reforms to benefit them even more, at the cost of any 
benefit to the individual consumer or the society as a whole.
  

    
My solutions would only overload the morgue.  Just buy another fridge
or two and you're fine.
  

    
Thanks <bbear>!  Great thinking!
  

    
"Wow. I wonder what the chances of that passing are, Imagine that you 
are an executive for United or Aetna. Here is a bill that proposes to 
take away your largest market. What would you do?"

Well, all of us are still alive and unharmed--and this bill that
wasn't supposed to make it out of its first committee is alive and well
also.  Thing is, almost any business that now offers health benefits
(most of the large ones) would save money due to this
bill--corporations, like individuals would be assessed on the basis of
means, not what a monopolized industry could squeeze out of them.  As
to small businesses--the benefits/pension crisis doesn't only threaten
big corps like GM--if they fail and their workers lose jobs, every dry
cleaner, hair dresser and realtor who depends on them loses income too.
 Further, the costs of underinsurance drain small businesses in ways
that are hard to measure--lost hours, lost efficiency, low morale, etc;
in addition to ways that can be measured, such as higher local fees
from governments that need to pay for their own benefits packages.

So, it's not even us vs. big business--it's a certain kind of big
insurance vs. everyone else.  Companies like Kaiser, on the other hand,
would do great with our bill.  They could negotiate a yearly budget
that would allow them to provide healthcare efficiently without
dangerous corner-cutting.

 
  

    
A personal note. What a diconnect. It is hard to keep this discussion
going because in open discussion the consensus comes to single payer
and then what more is there to say. 

Meantime my housemate was sitting at the dinning room table in tears
yesterday because she has no insurance and routine medical tests, yes
all those recommended tests that save money in the long-run are going
to cost her $500 which she is hard pressed to come up with. As an
uninsured person she has had years of people implying that her lack of
insurance is due to a lack of motivation, drive, will to get ahead and
essentially her own fault. 
  

    

That absolutely sucks, jhaskett. It makes me so angry.
  

    
Meanwhile, I had to take my stepson to Kaiser yesterday evening for a
cat-scratch that had gotten infected. Got through to an actual human
advice nurse (as opposed to an automated AI go - to - the - Emergency
Room, telephone button decision tree like at Amerigroup). She had all
his records available electronically, was able to hunt me up an
appointment at the nearest urgent - care facility and send them a note
electronically that I couldn't find his Kaiser card (no problem).
Waited 15 minutes at the urgent care facility got to see a doctor who,
again, had all Sebastian's records online, got a prescription filled at
the inhouse pharmacy and got home in like 1 hour and 45 minutes. 

Saved Kaiser a boatload of money by A) not deferring treatment until
the infection was severe because of fear of costs and B) not going to
the emergency room. 

This could be everybody. 
  

    
Time to take some of these ideas to a more political venue. 

Two new websites reported in today's Washington Post both of which aim
at boosting progressive/democratic idea generation. 

www.democracyjournal.com
www.thedemocraticstrategist.org/premiere/

Democracy Journal has an article illustrating how the deductability of
coporate health insurance amounts to a govt. subsidy of the current
broken healthcare system. 

These are the kinds of policy forums in which single-payer needs to
presented and support for it solidified so that it becomes part of the
Democratic party idea bank. 

For those who don't like Dems I would be happy to know where an
althernative forum exists to present this idea with any viability to
the Repubs, or a policy alternative that provides the potential for
100% coverage for all Americans, at equivalent high standards and low
costs. 
  

    
S.F. unveils universal health care plan - Yahoo! News

http://news.yahoo.com/s/ap/20060621/ap_on_he_me/san_francisco_health_care

A better model than Massachussetts?
  

    
The next part of this discussion is how to get there.  The recent
Massachusetts legislation is flawed in many ways and may not work
ultimately because its compromise was caving to the insurance and drug
industries.  As long as the model is to accommodate these profit making
entities as they wish, no real change can happen. 

BUT! If the discussion in the media, in legislatures can ever get
framed properly, it might include: 
1--Access to health care is as important to our economy and democracy
is access to education.  Why do we not treat it the same way?
2--Access to health care for all will go farther to ensure our general
wellbeing by better controlling communicable diseases.  Think of
another flu outbreak, SARS, and so on.