Yesterday I appeared on a four-person health care panel that was televised in New Hampshire. The panel included a conservative who surprised me by arguing that the difference between the progressive candidates’ proposals for health care reform and the conservatives’ position on health care just isn’t that great.
Looking at the candidates’ proposals, I disagreed. Put simply, the conservatives would like to make government smaller. They want to “outsource” many of government’s jobs to the private sector. They tried to privatize Social Security, and they have partially succeeded in privatizing Medicare by paying private insurers a steep premium to take care of seniors under Medicare Advantage. (See my post about the high cost of the program here).
Finally, the vote on SCHIP split along conservative/ progressive lines, with conservatives voting against expanding SCHIP. As President Bush explained, more funding for SCHIP would expand the government’s role in our health care system.
The progressives who voted for SCHIP believed that government should
expand, as needed, to provide a safety net for its citizens. If the
market cannot provide affordable, high quality health care for all
Americans, then the government must step in.
Then last night, Barack Obama won the Iowa caucuses , and I listened to
his message of unity: ”We came together as Democrats, as Republicans
and independents, to stand up and say we are one nation . . .”
Without question, it’s an appealing message. But is it true? Or are
there important philosophical differences that divide us? When it
comes to health care, I tend to think that those differences must be
addressed. Glossing over them won’t make them go away.
There are certainly significant differences between conservatives and liberals (or “progressives” if you prefer). My problem with “politics as usual,” though, is that each side tends to emphasize their differences rather than their similarities.
At heart I think a lot of well-meaning and intelligent people on both the left and the right really do want much of the same things — a prosperous economy, staunch defense of national interests within our borders, better education systems , and yes, a good, affordable health care system — but have sharp disagreement about how to get there.
Though it is somewhat stereotypical, the obvious difference is that the right tends to put its faith in “the free market” and the left tends to put its faith in government.
At first glance these seem like they are necessarily contradictory. But are they? There are plenty of examples of successful public-private partnerships in other areas that show it doesn’t have to be either/or, and perhaps even that either/or isn’t the best way anyway. And I think it’s very likely that if there is any sweeping reform, absent a Democratic takeover of the White House and 60 seats in the Senate, neither side will get almost everything they want.
Still the Republicans and the Democrats do what Republicans and Democrats do — become entrenched and intractable, blame the other party, decide that if they can’t get all of what they want, nothing will get done.
I think Americans — not specifically Republicans, not specifically Democrats, not specifically conservatives, not specifically liberals — deserve better than that. Rather than start the debate by keying on what separates us, how about considering what unites us?
For starters, the right needs to stop talking about “socialized” medicine. Few on the left are talking about taking private hospitals into government and making doctors government employees. Few are seriously proposing a complete government takeover of all aspects of health care, which is what real “socialized medicine” would be. Most liberal “plans” mostly focus on how to pay for universal coverage and, to some degree, get insurance companies out of the game or with a reduced role.
Of course, in an election year, all we’ll be hearing about is how we’re different. We’ll hear more about what policy divides us than about what unites us (especially in primary season). Focus on differences, IMO, and you breed an immediate environment of distrust and cynicism. That’s what politics of the last decade have brought us, and in increasing doses.
My belief -I thinked backed by polls- is that the conservatives and republicans are out of touch with most Americans on health care reform.
They will again dregde up the old-wornout scaremongering and jingoistic tactics such as “socialized medicine” and “limited choice” and “waiting times for elective surgery” but to no avail. These bogymen won’t fly in 2008.
Health care reform’s time has arrived and the Republicans have misread a huge issue which could cost them the election.(Possible third party candidate -still pending?)
And it’s NOT just the uninsured but rather extends way beyond that. Just ask your co-workers and neighbors about their hospital experiences,their battles with insurance companies over coverage and bills and their increasing monthly health insurance premiums.
American are tired of paying more for less. Or even worse a health care system that harms.
Dr.Rick Lippin
http://medicalcrises.blogspot.com
There are really two pieces to the healthcare reform debate – how to achieve (or at least approach) universal coverage and how to drive medical cost growth down toward the growth rate in nominal dollar GDP.
Even among the leading Democratic presidential contenders there is a significant difference regarding the need for and the desirability of a mandate. Both John Edwards and Senator Clinton support a mandate and Senator Obama does not (except for children). The downside of a mandate is that it means much higher costs (either premiums or taxes or both) for young, healthy people relative to what they pay now.
It is important to note that people who receive health insurance through an employer are paying for it indirectly in the form of lower wages as Shannon Brownlee points out in her book: Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. Alternatively, if a young person were required to contribute up to 6.5% of income toward the cost of insurance with an additional 6.5% of payroll contributed by employers who do not provide health insurance, that equals 13% of income ($6,500 for a $50,000 earner) for a product that, as a group, young people are likely to use very little of. That said, it is important for them to have catastrophic coverage so they don’t become free riders on the rest of society if they are in a serious accident or are diagnosed with cancer. So, a reasonable compromise might be to have a different definition of minimum credible coverage for people under 40 that would allow them to purchase much less expensive high deductible health insurance. Massachusetts already does this for 19-26 year Olds.
When Republicans use the term “socialized medicine,” I think they really mean socialized insurance (taxpayer funding) as compared to something like the UK’s National Health Service which really is socialized medicine. As a general principle, however, I do think that Republicans are more likely to favor or trust market solutions whenever possible while Democrats are more likely to favor government solutions.
With respect to controlling costs, as I’ve written before, I think the fundamental problem is that none of the major interest groups are willing to give up any money or power in the short run in exchange for a better, more cost-effective and sustainable healthcare system in the long run. My wish list of contributions from the different interest groups is as follows:
Consumers / Patients – Give up the tax preference currently given to employer provided healthcare and accept reductions in other taxes to insure revenue neutrality for the federal government.
Doctors – Accept competition where appropriate, like mini-clinics staffed by NP’s and PA’s in retail stores. Embrace price and quality transparency as well as P4P. Work with your medical specialty societies to develop performance metrics that you can live with. Work to reduce regional differences in practice patterns.
Hospitals – Embrace price and quality transparency. Work with appropriate regulatory authorities to downsize or close unneeded capacity in markets with too many beds. Work to reduce regional differences in practice patterns.
Drug and Device Manufacturers – Device manufacturers should eliminate confidentiality agreements that prohibit hospitals from disclosing to other hospitals how much they pay for devices. Drug companies should support comparative effectiveness research and reduce direct to consumer advertising.
Lawyers – Support Health Courts or some other approach to settling medical disputes to replace the current jury system that often results in unpredictable verdicts driven by emotion which, in turn, encourages doctors to drive up costs by practicing defensive medicine. Malpractice reform lends itself to state level experimentation and innovation.
Insurers – Eliminate confidentiality agreements that prohibit doctors and hospitals from disclosing actual insurer reimbursement rates. Streamline and simplify your offerings. Continue to develop your recent advances in real time claims adjudication.
Government – Fund comparative effectiveness research. Provide financial assistance for implementation of electronic medical records, especially in hospitals. Develop programs to significantly increase the percentage of the population that has a living will or advance directive for healthcare. Require hospitals to honor advance directives and provide appropriate legal protections if relatives threaten to sue if the hospital doesn’t ignore a directive to provide comfort care only and do everything possible to keep the patient alive instead. Conversely, if the hospital provides treatment that the patient did not want as expressed in the living will, it should not be paid for that treatment.
The bottom line is that every interest group needs to make a meaningful contribution toward sensible reform. The old line: Don’t tax you, don’t tax me, tax that fella behind the tree won’t cut it.
“Are there important philosophical differences that divide us?”
Yep. But not everyone is afraid of compromise. Do you not find it significant that Obama is the only major Democratic contender who is against health insurance mandates?
To me, it suggests that rank and file voters are not as ideologically rigid as some policy wonks I can think of.
Tim, Ric, Barry, and Catron–
Thanks for your comments.
First on the whole issue of Obama and mandates: Obama sent a health care representative to the New Hampshire event where I served on a panel last week. During the two- hour panel discussion, I had the opportunity to ask the Obama rep a direct question. Here is the question, and her response:
MM: “I have interviewed David Cutler, Obama’s chief health care adviser and have read what Obama has said about mandates.
“It’s my understanding that Obama believes that we should first let people sign up for insurance voluntarily, but if that doesn’t work, we do have to get everyone into the tent. And so he has said that if voluntary enrollment doesn’t work, he will impose mandates.
“Is that correct?”
Obama Rep: “Yes that is correct. If he has to, he’ll impose mandates.”
The Obama rep. also said it was more of a “philosophical difference” about how to go about getting signed up.
But the three leading Democratic candidates agree that everyone has to be signed up, or else you can’t expect insurers to offer guaranteed issue. (Guaranteeing to offer healthcare insurance to everyone in a given community at the same price whether they are young or old, sick or healthy.)
Obama has been reluctant to say that he would mandate insurance from the beginning because much of his constituency is young. (In Iowa he took the under 30 vote 5 to 1). And he know that many young, relatively affluent people who wouldn’t be eligble for subsidies don’t want to have to buy comprehensive insurance.
But he also knows we can’t afford to cover everyone without an enormous (unaffordable) tax hike– unless those healthy, relatively affluent twenty-somethings contribute their money to the pool
.
Now, turning to your specific comments:
Tim:
First, I agree that you can have a successful public sector/private sector partnership in many areas–including healthcare.
What many people don’t realize is that most European countries don’t have a single-payor or pure public-sector healthcare system. They have a combination of public sector and private sector involvement.
BUT –and this is important– the private sector is very heavily regulated in terms of what it can charge, what it must offer, etc.
And unfortunately, in this country, conservatives are quite staunchly opposed to government regualation of the private sector. (This, despite the fact that dereugulation has led to huge problems in many sectors: energy, the airelines, etc.)
I’m afraid that over the last 25 years or so an ideological gap between conservatives and liberals (or progressives) has widened:
Conservatives put “individual freedom” at the top of their list of priorities. This includes the right to amass as much wealth as you can by charging as much as the market will bear (regardless of whether you are selling life-saving drugs or non-essential luxury goods), and paying as little in taxes as possible, while accmulating and preserving that wealth.
As a result wealth has become more and more concentrated in the hands of a few.
Freedom also means freedom from government regulation which is why, during the conservatives; reign under Reagan, Bush and Bush, our envirnomental laws have been gutted, the FDA has been encouraged to rubber-stamp any product that comes down the pike (leading ultimately to an unprecedented number of drugs and devices being withdrawn from the market, often causing injury to thousands of people); the SEC was encouraged to ignore corporate fraud (which helped to fuel the stock market bubble).
Freedom also means free speech–even if the speech contains lies. Thus, drugmakers are allowed to advertise directly to the consumer–telling the public that Vioxx, for example, is the best pain-killer for everyone, even while hiding what they know about the risks of Vioxx.
.
Lberals (or progressives–these days, the two terms seem to be used interchangebly) put Equality ahead of Individual Freedom. They take a more collective view of things and realize that a democracy’s freedom isn’t worth much if you are hobbled by a poor education, poor health, poor nuitrition and all of the other disadvantages that go along with having the bad luck of been born into poverty.
Liberals believe that public schools should not be funded with property taxes (which assures that the schools in the wealthiest communities where property values are highest will have gymnasiums, playgrounds, much higher-paid teachers and principals, libraries filled with books, a band, and perhaps even music and art classes while schools in poor neighborhoods lack even basic materials– textbooks, paper, crayons, pens, pencils, a rug on the floor. (The teachers buy most of these things out of their own pockets, and make do without required textbooks).
They also don’t have gymns or playgrounds–so their students get little exericse. The schools are filthy (mouse droppings, cockroaches, windows that don’t open, terrible air quality, a very high percentage of respiratory illness among students and a high percentage of miscarriages among teachers) and, of course, very large classes (up to 27 with one teacher and no teacher’s aid in the primary grades.)
Poor schools need more funding than schools in wealthier neighborhoods if only to pay teachers more to attract the best teachers to schools where kids are likely to be growing up in chaotic environments, and are much harder to teach.
Providing adequate funding would mean funding schools through progressive local and state income taxes rather than property taxes–somethign that conservatives oppose.
Equality also means equal access to health care. That would mean paying doctors just as much to treat a Medicaid patient as you pay them to tread a Medicare patient. (Niko has written about how the low pay for doctors who treat Mediciad patients is rooted in racism–and how few specialists will take Medicaid patients.)
This would mean raising FICA taxes on our paychecks in order to provide more fudnng for CMS (which oversees Medicare and Medicaid).
Equal access to health care would mean expanding crowded inner-city hospitals where patients lie on cots in the hallways and building more community clinics in inner cities, while limiting the number of surburban hospitals with waterfalls, whirlpools, etc.
Equality would mean building more low-income and mixed-income subsidized housing in middle-class and upper-middle-class neighborhoods (where air quality is normal) and fewer tax breaks for developers putting up luxury condos.
Equality would mean more full scholarships to college based on income as well as achievement in high school and fewer interest-free loans to upper-middle-class and upper-class parents so that they can continue buying a new SUV every third year.
Equality would mean full scholarships to med school, based on need, to students willing to work in areas where doctors are needed after they graduate. (This might mean that black and Hispanic people would be just as likely to get a pain-killer in the ER as white people. –Did you see the recent story on this?)
I could go on. But I won’t. I promise. The point is that, in general, conservatives want to
re-distribute wealth upward–which is what we have been doing for thelast 25 years. Thus, the gaps between the poor, the upper-middle-class and the uppper-class have been widening each year.
Meanwhile, progressives want to redistribute wealth downward.
The vote on SCHIP tells you what you need to know about how hard it is to persuade conservatives to think collectively, even when it comes to healthcare for poor children and their parents.
Dr. Rick– You are right: middle-class and upper-middle-class Americans who have been in the hospital lately or have had a major medical bill and a battle wtih their insurer are unhappy with our health care system.
But most people are not sick. So, unlike doctors, they really have no idea what is going on. They have employer-sponsored insurance, pay only about 1/4 of the cost (I’m writing a post on this for Monday), and aside from routine doctor’s visits don’t have an opportunity to test that insurance, or our health care system.
This is why the polls all show that they say, yes, they want universal coverage, but no, they don’t want to pay more in taxes to pay for it. . .
I agree that the conservatives have completely missed the boat on healthcare. But if the leading Democratic candidates, Obama appears the least concerned about healthcare. He has the vaguest plan and many political analysts suggest that healthcare just isn’t a top priority with him. (This doesn’t mean he would make a bad president: healthcare is not the only issue to vote on. So please, if you’re an.Obama supporter, understand I am not knocking Obama, just stating a fact.)
Yet he won in Iowa. This does not mean that he has the nomination sewn up. But it does mean that in Iowa, healthcare was not a top priority. Iowans thought Hillary was best on healthcare, but younger Iowans didn’t vote for her.
She got a majority only among Iowans over 65, who voted for her 2 to 1. People over 65 tend ot have had a brush with our healthcare system. . . )
Monday, I’ll put up a post about why healthcare isn’t as pressing an issue in Iowa–or New Hampshire. These two states have suprisingly high-quality, low-cost health care.
Barry–
I completely agree that if we are going to have meaningful national health care reform, everyone has to give up something.
Though I’d suggest that the for-profit corporations need to give up a bit more than you propose. (They don’t need double-digit earnings growth; they shouldn’t be growth stocks. They should be steady companies, that pay modest, but reliable dividends and doing pretty well in good times and bad–like old-fashioned utilities. Like utilities they are in the “necessities” business.
Catron–
As I noted above, Obama really isn’t “against” mandates. He just wants to try voluntary enrollment first. And who knows, maybe he could inspire many young people to sign up for insurance, and only have to “mandate” a a small percentage into the system at the end.
Along the lines of “choice,” or illusion of choice, “rugged individualism,” conservative ethic, etc., read the post below (parts I and II); not lengthy or difficult reads. They always stuck with me, and thought they were insightful and provocative. You will see what I mean. Gets to what Maggie was referring to below in a laser like way.
http://healthaffairs.org/blog/2007/10/16/us-health-care-international-scholars-experience-our-system-what-they-found/
Maggie et al
I continue to be wary and uneasy about both Clinton and Obama’s commitment to achieving far-reaching reforms. It will take a combination of skilled negotiation, grassroots mobilization, and a willingness to fight for the health system reforms that so many Americans desperately need. Obam’s feel-good rhetoric about “bringing the different players together” ignores the reality of what monied interests will do to protect their share of the healthcare spending pie.
As Maggie points out the reforms we need include serious gov’t regulation, and I’d add the creation a viable public insurance option for all (individuals and employers) for starters.
To my mind Edwards’ is clearly the most outspoken and committed to taking on the monied interests who repeatedly block these kinds of reform efforts.
How can voters ever sort out where Obama and Clinton are on this issue? Even is they believe in the reforms stated above and plan to fight for them, how can that be reconciled with the fact that Clinton and Obama are accepting HUGE sums of money in campaign contributions from the folks who comprise the healthcare industrial complex (drug co’s, insurance co’s, medical supplies and device co’s, for-profit hospital and rehab. chains, etc).
What do we make of this from Obama?:
The New York Times
January 5, 2008
The Democratic Debate in New Hampshire (transcript)
Sen. Barack Obama: I have been entirely consistent in my position on
health care. What I said, and I have said on the campaign trail this
time, is if I were designing a system from scratch, I would set up a
single-payer system because we could gain enormous efficiencies from
it. Our medical care costs twice as much per capita as any other
advanced nation. But what I’ve also said is that given that half of
the people are getting already employer-based health care, that it
would be impractical for us to do so…
http://www.nytimes.com/2008/01/05/us/politics/05text-ddebate.html?
ref=politics&pagewanted=all
Brad and Anne–
Thanks for your comments.
Brad–very interesting article. It’s true that in this country freedom of choice often means that you are free to choose–if you can afford it.
Anne–I agree that Obama’s feel-good rhetoric about bringing the players together is not very convicing. The players (in the for-profit health care industry) have an enormous financial stake in continuing to make the double-digit profits that they have been making.
They are not going to graciously give up anything. They are going to fight tooth and nail. And that means twisting the arms of every Congressman who is beholden to them.
I don’t know what to say about the campaign contributions that Clinton and Obama have accepted except to note that virtually every politician in this country has taken campaign contributions from corporations that clearly want something in return.
In our system, the only politicians who can afford to run for office without taking corporate money are very, very wealthy.
I’m glad that someone like Bloomberg is beholden to fewer people, but clearly we don’t want to limit our leaders to multi-millionaires and billionaires.
The only solution, I think, would be to make running for office in the U.S. much, much less expensive by:
–limiting campaign periods to, say, six months;
— banning all paid televison advertising. This is the biggest expense in most elections and I don’t think people learn much from these spots. TV ads may create “name recognition,” but do we really want people voting for someone simply because they recognize his name and like the way he looked for a couple of minutes on TV?
–during the campaign, television would be limited to debates among the candidates, with the time donated, free, by the networks.
No doubt there would be first amendment objections to these ideas, but other countries manage to limit the cost of elections and still have “free speech.”
Going back to Hillary and Obama–will the contributions influence how they would negotiate with the health care industry if elected? I just don’t know.
I do agree that Edwards is much more forthright in identifying for-profit corporations as a large part of the problem.
Finally, I’m not so bothered by Obama’s statement on single-payer. It’s true that the majority of people now have employer-based insurance and, more importantly, like what they have. This does make it “impractical” to try to switch to pure single-payer at this point (though down the road people might choose single payer.)
Maggie – of course you’re right about some of the features of our broken politics in the U.S. – thanks for listing some ideas for reform.
The League of Women VOters for years has been working for free air time for candidates, I think.
The League is very saavy on HC Reform and the MA LWV is an ardent adovocate for streamlined single payer financing HC reform.
Maggie, you didn’t list campaign finance reform in your comment – is it a given?
When I give talks about advocacy work for health system reform I usually try to mention campaign finance as a big part of the solution for both restoring democracy to our politics and also as a lynchpin for achieving almost any progressive policy reform that places the interests and needs of ordinary people ahead of monied and corporate-driven interests.
I wasn’t “bothered” by Obama’s remarks about single payer, and I, too, agree that getting from here to there (meaning nat’l health insurance in the form of improved Medicare For All as an option for everyone) will take intermediary steps. But WE MUST HEAD DOWN A REASONABLE PATH TO GET TO FUNDAMENTAL REFORMS.
Sorry to “yell”, but I deeply believe that the MA plan that others on the state and nat’l level seem poised to follow, that mandates purchase of private insurance under threat of punative financial penalties, takes us down a very tortured, wasteful, and dangerous path. We’re already living it here in MA.
My question about Obama’s remarks was more wondering how far is he willing to go to fight for the reforms that are needed to bring the people of the U.S. a humane and cost effective healthcare system?