Public Option not dead after all! Compromise: State Opt-out?

[I'm Cleo!]

Something that has not been mentioned about the "general welfare" clause is that the federal government simply didn't have the ability to fund far reaching social programs that it does today. We can thank the 16th amendment for that.

There is no bigger danger to a people than giving their government new sources of revenue.

No bigger danger? A government that can arrest and imprison its people without process and hold them beyond the reach of the Writ of Habeas Corpus isn't a bigger danger than a government where duly elected representatives can vote in tax increases? Was the biggest danger to the Iraqi people under Saddam his ability to increase taxes? Really?

To go on a bit of a rant that may or may not have anything to do with what you believe, Figitive Sisyphus, I honestly can't wait for historians to chronicle the development of American conservative thought. It's going to be so interesting to read about how large numbers of people became convinced that civil liberties and the rule of law are not nearly as important as a particular conception of "economic liberty" whereby any capacity to change the present distribution of wealth is viewed as tyranny. I mean, I understand why that particular conception is always "out there" -- I'm sure promoting it pays well -- but the extent to which it's permeated American political life is surprising to me.

Cleo

 

[Cutlass]

Here are 3 articles I read a couple days ago that express different views pretty well. Which you agree with is up to you...

Put Health First With Medicare For All
By RICHARD CARLTON

October 25, 2009

After 30 years of medical practice and countless discussions with other physicians, I believe that the overwhelming majority of doctors have a single overriding priority: They want all patients regardless of their economic means to have access to and to receive the highest level of medical care possible. But patients who come for treatment without health insurance make achieving that goal difficult.

Health insurance is the gateway to access in our medical system. Many doctors spend enormous amounts of time and energy arranging care for patients in need without adequate health or drug coverage insurance. The doctors and their staffs have to work through a piecemeal labyrinth of hospital charity funds, requests for supplies of free samples and applications for various patient assistance programs.

Although I am aware some physicians will not agree with me, they should support apublic option. It is clear, based on professional concerns, that our patients' health requires we support a reform that makes heath care insurance available to all. But, as already noted, I believe most physicians are firmly in this camp.

The problems are who is in control of medical decisions and the feeling of many physicians that they cannot afford further cuts in their reimbursement and more regulations that interfere with their ability to do the best job possible for their patients. Reimbursements are generally lower under Medicare than private insurers. It is also true that Medicare has an array of sometimes intrusive regulations to follow.

But I would propose my fellow physicians consider that their choice is not between health care reform including a public optionand the status quo. President Obama has stated that while he is not wed to a public option,he will insist on two things — universal coverage and cost control. The choice is between a system that includes a public option to compete with private companies and gives a realistic chance, at least, of satisfying both major requirements, or a package without the public option that depends on private insurers to reduce costs.

Does any rational person actually think medical insurance CEOs are going to give up salary and bonuses to achieve cost savings? Does anyone really believe the drug and medical device manufacturers are going to give up profit?

The money will be saved on the backs of our patients through increased cost sharing (familiar with the Medicare Part D doughnut hole?) and through more intrusive medical management of doctors' decisions, along with reduced reimbursements. This will occur while these same corporations are financially benefiting from extending coverage to the 40 million Americans currently without insurance.

Congress now appears to be moving toward a health care package in which a public option would be part of the legislation. Differences between the U.S. House and Senate might result in revisions in the exact workings of a public option, but they are headed in the right direction. Perhaps it would help to name it after something else that is favorably rated by its beneficiaries. I suggest a name I heard somewhere — Medicare For All.

•Richard Carlton, M.D., of South Windsor is an ophthalmologist.

Copyright © 2009, The Hartford Courant

http://www.courant.com/news/opinion/hc-commentarycarlton1025.artoct25,0,521189.story

Government Plan Would Further Shift Costs, Starve Health System
Illustration by Brian Stauffer
By DAVID BRADLEY Retired Senior Vice President Of The Hartford

October 25, 2009

As the health care reform debate focuses on the "public option," it is worthwhile to look at the other government-run health insurance plans, Medicare and Medicaid, to understand the ramifications. The main effect has been on doctors and hospitals — and it has not all been in the public interest.

Government left Medicare and Medicaid in its regular budget. Over time, in an effort to reduce broad budget deficits, it has cut its payment rates to providers to levels that are substantially below-market — rather than challenge doctors who order an MRI when an X-ray will do. Since the costs doctors pay for education, clerical staff and malpractice coverage have risen at much greater rates than inflation, they are not willing or able to live with those lower payment levels for a third of their services.

So providers have charged increasingly higher prices to the private buyers (mainly health insurers) of medical services. Consequently, insurers have to raise their premiums. This is government-induced cost-shifting.

The result of government being the monopoly provider for the elderly and the poor has been the peculiar combination of higher prices and lower net income for doctors and hospitals. And now the higher prices — caused by the government's involvement — are given as the reason to reform the system, using another government-run plan, the "public option," to "keep insurance companies honest."

What would be the outcome of the public option? The president has said it will be run "just like Medicare," which he says means lower administrative costs and no grossly overpaid insurance company CEOs. But Medicare is cheaper because it underpays doctors and hospitals for their services. So the public option will be significantly cheaper than private insurance plans and will grow to dominate the market.

More cost-shifting will occur as the government plan squeezes doctors and hospitals, who will again turn to the still-smaller private sector to fill the gap. Fewer of the best U.S. students will invest 10 years of post-high school studies to become doctors, so the quality of care will deteriorate. And that government-run plan will hasten the journey, begun by Medicare, to a government takeover of health care, putting all hospitals and doctors on the federal budget as expenses.

Health care costs should not be reduced by paying doctors less, unless we also use the power of the government to reduce their costs. Recently, Massachusetts required its citizens to buy insurance (from an insurance company) or pay a tax to the state, and instituted a subsidy to help the poor get coverage. It did not go into the health insurance business. If the federal government instituted that program countrywide, the uninsured problem would be addressed.

In addition, it would reduce one substantial cost health care providers bear now, which is providing free care to many people who are uninsured. And Medicaid could be replaced by this private system and subsidy.

To bring down health care costs further, the government could establish a standard health care card with a person's medical record and a standardized system to record and simultaneously charge insurance for treatments, so that doctors and hospitals could cut their administrative costs.

Second, medical malpractice suits could be brought under the federal court system and federal laws could be passed to institute caps in awards and lawyers' fees. Malpractice insurance is a six-digit annual cost for most doctors and a multimillion-dollar cost for each hospital in America. Half of malpractice costs are lawyers' fees, which is why trial lawyers oppose malpractice reform.

But should we preserve the revenue of lawyers while cutting the income of doctors? Or should it be the other way around? With these cost reductions, hospitals and doctors could be expected to accept lower fees from health insurers.

When a private health insurer disappoints, it can be replaced and ultimately will lose out in the market. Is it better to eliminate them and have the federal government make those choices for all Americans unilaterally? Can we see the inevitable rise in those costs, because the federal government has shown itself to be least likely to disappoint in a coverage decision when it has our taxes as its revenue base?

And when the costs rise, will the government continue to reduce them by underpaying physicians, until the people we have filling those important jobs are not people we want to trust with our lives?

I did not vote for Barack Obama. However, I have been impressed by his intelligence and his demonstrated willingness to change his direction when confronted with new facts. Citizens are seeing that "death panels" are not the facts — higher taxes and mediocre doctors and hospitals are the real facts. I can only hope Barack Obama is again open to change as the people's interest becomes clear.

Copyright © 2009, The Hartford Courant

http://www.courant.com/news/opinion/hc-commentarybradley1025.artoct25,0,7285184.story

Reforms Must Cut Skyrocketing Costs — But Start With Coverage For All
Paul Dolinsky, M.D. Internist; General Practice In West Hartford

October 25, 2009

I have been a primary care doctor in Connecticut for 26 years. Never has the need for health care reform been more apparent.

Everyone should have health care coverage. There is no acceptable excuse to deny health care to any American citizen.

The fear about a "public option" plan or "socialized medicine" seems unfounded. I don't hear many people more than 65 years old asking to scrap Medicare, the biggest public option/socialized medicine program around. Although burdened with excess expenses and far from perfect, Medicare has provided senior citizens with access to health care that is not available to the growing population of uninsured Americans. A public option plan that offers a set of basic coverage items would be a good starting point for Americans who are unlucky enough to be less than 65 years old and without insurance. Although defining a public option plan with "basic" coverage would be challenging, private plans could offer more extensive coverage for individuals or for companies that wish to provide it.

The growing cost of health care must be addressed if a sustainable health care system is to survive. There is plenty of blame to spread around for the rising costs.

Doctors are paid on a fee-for-service basis; the more we do, the more we get paid. The system pays most for procedures; surgeries, scope tests and X-rays, and much less for talking with patients, a thorough examination and thoughtful advice. These incentives promote more expensive testing and procedures, which may not always have the patient's best interest in mind.

Hospitals also compete with one another, often promoting the most lucrative care, which can further raise health care costs.

Although we have an increasing array of effective drug treatments, the prices of branded medicines keep rising, even for medicines that have been on the market for years, making millions of dollars in additional profits for pharmaceutical companies. Direct-to-consumer advertising of prescription medications, while promoting sales, does not encourage the rational use of those treatments.

Patient demands also can drive the cost of unnecessary care, such as CT scans or specialty visits when they may not be warranted. Many times patients tell me, "Doc, I want that test. I don't care what it costs. I've got coverage." If they have some financial responsibility for the testing or treatment, however, they look much more closely at those costs. If they have no insurance at all, they are often forced to abandon critical tests or procedures.

Medical malpractice suits also drive up the cost of care as doctors practice "defensive medicine." Every patient I see can represent a potential lawsuit. I order more tests and consultations and document as much as I can for the possible day I have to defend my actions in court. This is a very inefficient way to protect patients and compensate them when they have a bad outcome from a medical misdeed.

Further, private insurance companies are primarily in business to make money for their shareholders. Some may do an adequate job of paying for health care, but they should not be in the business of delivering health care, a role many insurance companies have adopted.

Medicare, a public plan, does a good job at limiting administrative expenses. A public or not-for-profit option should be strongly considered as an alternative to the traditional profit-driven corporate insurance industry solutions.

What about end of life care? It seems that many people in this country do not accept that we are mortal and death is an inevitable part of the cycle of life. As much as 25 percent of the entire health care budget goes to the care of people in their last year of life.

Much of that care may be appropriate, but we sometimes deliver futile care, with recurrent hospitalizations or expensive treatments with little hope of improving someone's quality of life, although they might live just a few extra weeks.

If we have only a limited amount of money to spend on health care, how should it be rationed? Can we afford to give everyone everything, regardless of the cost or likelihood of success? Fear tactics, such as the recent talk about "death panels," do not allow for rational discussion.

Certainly, we don't want politicians making these decisions. How or should they be made? We need to have this discussion.

We need to change the way health care is delivered in this country so that everyone has access to quality care. If it is to be affordable, changes will need to be made, and change is always difficult.

Copyright © 2009, The Hartford Courant

http://www.courant.com/news/opinion/hc-commentarydolinsky1025.artoct25,0,5800886.story

 

[illram]

Why does the Constitution say it provides for the common defense but only to promote the general welfare? It would seem that if the nationalization of health care (the end result of this policy) is a legitimate function of this government, then it should say so in our laws.

Government subsidized affordable health care is promoting general welfare. Do you disagree?

Is Medicare unconstitutional?

 

[Ayatollah So]

doctors [...] want all patients regardless of their economic means to have access to and to receive the highest level of medical care possible.

Let's scale that back: all patients should have access to a decent level of medical care. If you want the highest level, sign up with a private insurer and buy a Cadillac plan.

The public option should be the Wal-Mart of health insurance. A place to get decent functional stuff for cheap, AND the place where a very large number of people go to get it. The latter feature makes Wal-Mart into something of a monopsony buyer, and that's a feature the public option should share.

Which brings us to the answer to Integral's question - why public option, instead of some random well-intentioned nonprofit in the national market? The name recognition, and the fact that the US govt already has lots of relevant experience with Medicare, will let it hit the ground running and get that quasi-monopsony going.

 

[Fugitive Sisyphus]

No bigger danger? A government that can arrest and imprison its people without process and hold them beyond the reach of the Writ of Habeas Corpus isn't a bigger danger than a government where duly elected representatives can vote in tax increases?

All governments CAN do those things.

Was the biggest danger to the Iraqi people under Saddam his ability to increase taxes? Really?

Actually Saddam probably got his money from oil revenues. Without them he would have had a hard time imposing his will on the Iraqi populous.

To go on a bit of a rant that may or may not have anything to do with what you believe, Figitive Sisyphus, I honestly can't wait for historians to chronicle the development of American conservative thought. It's going to be so interesting to read about how large numbers of people became convinced that civil liberties and the rule of law are not nearly as important as a particular conception of "economic liberty" whereby any capacity to change the present distribution of wealth is viewed as tyranny. I mean, I understand why that particular conception is always "out there" -- I'm sure promoting it pays well -- but the extent to which it's permeated American political life is surprising to me.

Cleo

I personally don't rank "economic liberty" higher than civil liberties and the rule of law. I believe that without any one you can't expect to have the other two. But this has little to do with the point I was trying to make.

1. The amount of power a government has is directly correlated to the amount of money it controls. The more power the government has the more dangerous it is if it falters.

I am not trying to assume your beliefs either but if, for example, you are against the Iraq and/or Afghanistan wars you must realize that without money these wars can't be waged. If the government has limited funds it must spend it on what is most vital and useful which presumably means that the dollars that are taken in are used more efficiently.

2. Government, like other any other organization, becomes dependent on its revenue streams. Unlike other organizations it doesn't have to adapt well to the revenue stream drying up and can tax more, borrow(and tax more later), or even print moneys. Social Security and Medicare are the obvious examples of this.

 

[Bill3000]

1. The amount of power a government has is directly correlated to the amount of money it controls. The more power the government has the more dangerous it is if it falters.

Patently false. The smallest government in the world in terms of government spending as a percent of GDP is Myanmar. I've done the statistics on size of government and dictatorships/democracies and there really isn't much of a correlation at all. How dangerous a government is does not have to be related with how much revenue it has.

 

[I'm Cleo!]

I am not trying to assume your beliefs either but if, for example, you are against the Iraq and/or Afghanistan wars you must realize that without money these wars can't be waged. If the government has limited funds it must spend it on what is most vital and useful which presumably means that the dollars that are taken in are used more efficiently.

But the problem I have with the Iraq War was not that it was funded by tax money, but that it was an impossibly stupid and wasteful idea. I support tax money going towards intelligent and worthwhile ideas. Removing the government's ability to fund its aims is not the way to prevent stupid and wasteful policies.

Cleo

 

[Fugitive Sisyphus]

Patently false. The smallest government in the world in terms of government spending as a percent of GDP is Myanmar. I've done the statistics on size of government and dictatorships/democracies and there really isn't much of a correlation at all. How dangerous a government is does not have to be related with how much revenue it has.

Now imagine they find oil in Myanmar, the proceeds going to the ruling faction in Burma. Is the Myanmar government a bigger, smaller, or the same threat to its people and the rest of the world?

Also you are using a different definition of "dangerous" than I was. The most dangerous nation in the world is without question the United States. The does not mean we are the great Satan but it means the US government can inflict the most harm whether it be foreign or domestic, militarily or economically.

But the problem I have with the Iraq War was not that it was funded by tax money, but that it was an impossibly stupid and wasteful idea. I support tax money going towards intelligent and worthwhile ideas. Removing the government's ability to fund its aims is not the way to prevent stupid and wasteful policies.

Cleo

Well, if China said to the United States "we aren't going to loan you any more money" there would have to be a spending that would have to be cut. Some things that you like and some things you don't like but it would in general be the least important, least desirable, and most wasteful things cut first and dollar for dollar everyone should be happier about the things that are spent on even if they disagree on individual cuts(except the fringe loonies of course ).

 

[Cutlass]

Well, if China said to the United States "we aren't going to loan you any more money" there would have to be a spending that would have to be cut. Some things that you like and some things you don't like but it would in general be the least important, least desirable, and most wasteful things cut first and dollar for dollar everyone should be happier about the things that are spent on even if they disagree on individual cuts(except the fringe loonies of course ).

Bolded part completely ignores how politics work

 

[Fugitive Sisyphus]

Bolded part completely ignores how politics work

Maybe, but I think that politics works like it does currently because there is little pressure to spend wisely.

 

[Karalysia]

Maybe, but I think that politics works like it does currently because there is little pressure to spend wisely.

So you suggest complete global economic collapse as a solution? Which is what would happen if China ever stopped lending to us.

 

[Fugitive Sisyphus]

So you suggest complete global economic collapse as a solution? Which is what would happen if China ever stopped lending to us.

No, but I couldn't think of another way that might result in a serious cut in government spending.

 

[Cutlass]

Maybe, but I think that politics works like it does currently because there is little pressure to spend wisely.

Only true in part. But if you are considering the US recent history, rather than governments generally, then it's more a matter of elected officials having an incentive to spend. But no incentive to not spend. But even at other times the incentive to spend well is weak at best. Dictatorships have horrible records when it comes to well managing public moneys. That's one major reason foreign aid has had such poor results. But in the US, particularly recently, it is management that has been abandoned. Of course there is always things like earmarks and pork. But there's a lot of money to be saved simply running things well. Yet elected officials gain no real benefits from doing that these days. So it does not get done. Instead when faced with a budget squeeze they propose slashing programs the other party supports. Not programs that are wasteful or have no real value to society.

The problem when you artificially cap what a government can spend, is that when that government has to spend more, it can't. And that causes even more harm in the long run.

 

[I'm Cleo!]

Well, if China said to the United States "we aren't going to loan you any more money" there would have to be a spending that would have to be cut. Some things that you like and some things you don't like but it would in general be the least important, least desirable, and most wasteful things cut first and dollar for dollar everyone should be happier about the things that are spent on even if they disagree on individual cuts(except the fringe loonies of course ).

Not necessarily. Eventually you'll reach a point where it's better that the government do the least desirable thing remaining, rather than having the government not do it, and from that point forward, dollar for dollar everyone will get more sad. And that point changes with time and depends on the more broad economic situation.

Cleo

 

[Hygro]

Now imagine they find oil in Myanmar, the proceeds going to the ruling faction in Burma. Is the Myanmar government a bigger, smaller, or the same threat to its people and the rest of the world?

Also you are using a different definition of "dangerous" than I was. The most dangerous nation in the world is without question the United States. The does not mean we are the great Satan but it means the US government can inflict the most harm whether it be foreign or domestic, militarily or economically.

Then your entire point is "those with power have more power"

Duh.