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The CBO Cudgel

By Fester:

The CBO has scored the HELP committee's full healtcare bill. The bill is the complete vision of what Senators Kennedy and Dodd want to do and it includes a reasonably strong public option, Medicaid expansion, comparative effectiveness research and an employer mandate. The goal is to expand coverage by a significant margin and introduce significant and well backed competition in regional health insurance markets that are overwhelmingly quasi-monopolosistic or duopolistic.

The CBO previously scored a partial version of the HELP framework that did not have the public option or the employer mandate in it. That partial scoring produced estimated costs of about 1 trillion dollars but with a significant portion of the population still uncovered. The marginal increase in coverage per dollar over the next decade was not good.

The new scoring of the bill that takes into account the actual coverage expansion and cost control measures is pretty damn impressive. From the AP:

The plan carries a 10-year price tag of slightly over $600 billion, and would lead toward an estimated 97 percent of all Americans having coverage, according to the Congressional Budget Office

Not a bad deal at all if we can get 97% coverage in even if there is a reasonable argument that the CBO score is a bit low as made by Jonathan Cohn. The real value of this CBO score with the complete HELP framework including the public option and the employer mandate is that it is a cudgel against the 'centrist' Democrats who don't want the public option overtly because it is 'too expensive' and potentially because it is a threat to major local employers and campaign contributors of regionally dominant health insurance providers. The public option is the best means of cost control and doing without it means a weaker bill for significantly more cost.

The Drunken Scotsman

By Steve Hynd

My homeland has always had a reputation as a boozing nation. In fact, alongside our likewise hard-drinking cousins the Irish, the joke is that without alcohol we would have conquered the world. And we had a good stab at it even so, as the engine room of the British Empoire and originators of many of the ideas that ended up in the U.S. Constitution and Bill of Rights as a light for the world.

But alcohol has always been Scotland's bane, it's escape from social and economic deprivation that caused more poverty and heartache in return. Never more so than in recent years when it has fuelled a kife-and-yobs subculture which has seen violence soar to ignominious world-record levels (although murder rates are still lower than America's proving that guns don't kill people but they certainly help a lot). Moreover, when teens rebel against their elders they rarely err on the side of abstinence, and so Scotland has a problem with hard drugs which is a direct consequence of its drinking culture too.

So, a new study has been published which claims to show that, after taking into account road deaths and cancers caused by hard boozing, Scotland's drinking problem accounts for better than one in twenty of all deaths. That's one death every three hours and far higher, almost double, what earlier estimates had said. There are calls for the political parties to put aside their usual partisan sniping and take concrete action - including price fixing.

Dr Peter Terry, chairman of the British Medical Association Scotland, urged political parties to unite behind the SNP government's plans for minimum pricing to combat alcohol abuse.

Speaking at the BMA's annual conference, he said: "We must first stop the year-on-year increase in alcohol-related illness.

"The minority SNP government has proposed some quite radical legislative suggestions to tackle this problem, including a minimum unit price. In Scotland this suggestion will require the support of MSPs from the other political parties.

"I implore them to put party differences aside and provide that support. They, and the Scottish people they represent, must address the exponentially growing problem of alcohol-related disease in all its forms and the only proven way to do that is to include legislation on the price of alcohol as part of that strategy."

Labour spokesperson Cathy Jamieson endorsed Dr Terry's call for political unity.

She said: "We need a national consensus to tackle Scotland's hard-drinking culture involving all of our political parties, health organisations, the police and the industry itself. Labour has suggested a ban on billboards advertising alcohol near schools and a mandatory code of practice for retailers, but we will look seriously at any credible proposals from any source that will reduce the level of problem drinking in Scotland."

Tory health spokesperson Mary Scanlon warned the government should not rely on pricing as a "single tool solution".

The aim with such a price fixing policy would be to set the unit price high enough to deter, but not so high as to create a black market demand. Increasing the price would most effect young drinkers, who are most likely to binge-drink and suffer a higher than average number of alcohol-related deaths. But the Tories are also right that existing legislation, like that against licensed stores selling to under-age drinkers, is more often observed by breaking it than not.

Scotland has always had a drink problem, but now it is being forced to admit the true severity of that problem. One death every three hours in a population of about 5.5 million. Yet Scotland isn't that much more of a boozy culture than, say, Texas where I now live - and Texas' drunk-driving limits and enforcement are a joke by Scottish standards for just one example. Scotlands rude awakening should be an alarm call for others too.

Disappointment Doesn't Cover It

Commentary By Ron Beasley

To say I'm disappointed in Barack Obama is an understatement.  I'm beginning to think he has no ideology at all only a lust for political power.  He has chosen to not prosecute or even investigate the criminal wrong doings of the Bush/Cheney cabal and in fact in too many cases continued down the same path.  As we have reported here over and over his AF/Pak policy would make Bush and Cheney proud.  He had the opportunity to take on Wall Street and the over inflated financial industry and failed to do so.  He is making one mistake that George W. Bush never made - he's deferring to Congress and the US Congress can't really be trusted to do anything right.

And now we are seeing all of this at work in health care reform.  Katrina Vanden Heuvel:

God I hope David Broder is wrong. "The President has told visitors," the Washington Post columnist wrote last week, "that he would rather have 70 votes in the Senate for a bill that gives him 85 percent of what he wants rather than a 100 percent satisfactory bill that passes 52-48."

There is a reason the United States has two political parties, they have different ideologies.  This is not new - it's the same ideological conflict that John Adams and Thomas Jefferson were having over 200 years ago but as times changed it became even more pronounced.  I think that both Adams and Jefferson opposed an American royalty/oligarchy.  But oligarchs we have had and when they came to power the results have consistently been catastrophic.  The oligarchs are driven by greed for both power and money.  They gained control of the country in the early 20th century and the result was the Great Depression.  It took an FDR to set things straight and things went pretty well until 1981 when Ronald Reagan and the oligarchs once again took charge.  Once again the result was a massive failure of the economy.  The oligarchs and their political allies the Republicans suffered massive losses in 2006 and 2008.  Unfortunately Barack Obama is no FDR. 

The Republicans claim that the health insurance industry won't be able to compete with a public plan.  That's probably true since as Fester pointed out here  they have no competition in most markets now and as Josh Marshall explains this little fact gets little attention.  Seventy two percent of Americans support a public plan and that includes fifty percent of the Republicans.  But what do we get from the Obama administration?  This:

In an emailed statement to Bloomberg News, Health and Human Services Secretary Kathleen Sebelius said she’s open to the idea of dropping a public health insurance option in favor of a medical-insurance cooperative. “You could theoretically design a co-op plan that had the same attributes as a public plan,” Sebelius said.

The leading co-op proposal in the Senate, offered by Sen. Kent Conrad (D-ND), does not share the attributes of a public plan. Instead, Conrad’s proposal would create multiple state or regional non-profits as a competitor to the private insurance market. As Howard Dean has said of this plan: “The co-ops are too small to compete with the big, private insurance companies. They will kill the co-ops completely by undercutting them, using their financial clout to do it.”

Bloomberg’s Al Hunt asked Sebelius, “[If] you’re willing to compromise on your notion of a public plan…what’s non-negotiable?” Sebelius responded that the final bill has to “have a comprehensive approach that lowers costs.

Change?  Not so much - the oligarchs are still in charge.

Write your member of congress and tell them to vote no on any health care reform bill that doesn't include a  strong public plan.  Make it clear to Obama that we demand real change not bipartisan window dressing.

Health Insurance markets by city region

By Fester

States sometimes are excellent units of analysis. Other times they are nearly pointless as a unit of analysis. And occassionnally, the states in question are Delaware or Rhode Island, and thus the distinction between state and any other unit of analysis is pointless as there is nowhere else to look at.

Health Care for America Now (HCAN) has a series of reports that looks at market concention of major health insurers within each state. The basic findings show that a fifth of the states are have a near monopoly of private insurance, and even more states have effective duopolies. However these reports suffer from a serious flaw in the larger states. They are using the state as a unit of analysis despite the fact that the health insurance market in Austin is quite different than the health insurance market providers in El-Paso, and the insurers for Pittsburgh consider Philadelphia to be out of area and out of network while Philadelphia insurers have the same judgement on medical service providers in Pittsburgh.

Using the state as a unit of analysis leads one to conclude that Pennsylvania has a reasonably competetive private insurance market. There are three major providers (Aetna, Highmark Blue Cross and Blue Shield and Indpendence BCBS) and then numerous smaller providers including a few other Blue Cross and Blue Shield affiliates. The Pennsylvania private provider health insurance market has a Gini co-efficient of less than .30 which indicates on first glance a reasonably competetive market.

Highmark BCBS is the Pittsburgh area Blue Cross insurer while Independence BCBS is the Philadelphia area provider. I, as a resident of Greater Pittsburgh, can not use the large, bulk purchasing power of Independence BCBS to bargain against Highmark for a better premium or rating. Pittsburgh and Philadelphia are different markets despite the fact that we are in the same state. The HCAN report for large states does not recognize that the critical unit of analysis is not the state but the metropolitan area.

If one examines metropolitan statistical areas as the relevant unit of analysis for states with multiple MSAs, than I would wager that the Pittsburgh experience with one dominant provider in the form of Highmark, a decent size secondary provider in UPMC and a scattering of smaller providers would be the norm or it could even be better than most other regions. This is despite reports that Highmark had over half the total health insurance market in Western Pennsylvania (including areas outside of the Pittsburgh MSA) in 2008.

Busting non-natural monopolies and duopolies should lead to improvements in cost, services provided or both.

Health Care and Rationing

Commentary by Ron Beasley

The New York Times reports, correctly, that there is little hope for "bipartisan" health care reform.  There may be a few who oppose a public plan for ideological reasons but the reality is the Republicans don't want to give the Democrats a victory on this because they know it will be popular.  In spite of the ads they may run they know that public health care is popular in Canada, Great Britain, France, Spain and everywhere else.  It is the third rail of politics in Canada and Europe and even the conservatives in those countries know not to touch it.  We saw what happened when George W. Bush tried to mess with Social Security, the third rail of American politics. 

We hear that a government run health plan will result in health care rationing. That's true but what they fail to mention is that we have that now. The reason the that the anti government plan marketing is not having any impact is that both those that have health insurance and those who don't know that we already have rationing. I have had two friends and one relative who have probably died before they should have because of rationing. Yes, they all had insurance but physician requests for diagnostic tests were rejected by private insurance companies until it was too late.

And there is another form of rationing – the preexisting condition of being between 55 and 65 years old. I will return to this later.

And then we have Medicare. Medicare will approve about anything and health care providers know that. See what a Texas town can teach us about health care in the New Yorker. To make matters worse these procedures are often not even in the best interest of the patient. I will give you a personal example.

My 86 year old mother is in really good health but had started to be short of breath. They ran some diagnostic tests and discovered she had a bad heart valve. She was referred to a cardiologist who was ready to split her chest open and replace the valve. I asked him several questions:

1. She is in relatively good health now – following the surgery will she ever recover to be as good as she was before? The answer was probably not!

2. I told the doctor that I heard that being on a heart lung machine can have a negative impact on memory and asked him if that was true. The answer was yes, especially in older people.

3. The next question was what will happen if the valve is not replaced? The answer was the shortness of breath may gradually get worse.

4. I asked him if it were his mother would he suggest the surgery? The answer was NO!

The bottom line is they were going to perform a procedure that would cost 50 thousand plus dollars that would have left my mother worse off after the surgery because Medicare would pay for it.

At 63 years of age I cannot get health insurance at any price. I am denied procedures that could keep me alive for another 20 or 30 years while Medicare pays for procedures that add little or even have negative impacts on the health of the patient. That's rationing and foolish.

There is health care rationing now and there will be rationing in any new system. Society simply can't afford to give everyone the care they might desire. So what is required is intelligent rationing. Will it be perfect?  The answer is no but it needs to be better than what we have now. That means that any government health plan needs to do a better job of of deciding which procedures are truly worth while. I would still feel better about a plan where profit was the major driving force even though it might not be perfect.

Rescission and the health insurance industry

by Jay McDonough

Rescission.  You know, like rescinding, or making void.  Sounds so urbane, doesn't it?  But, in fact, rescission is the private health insurance industries name for their practice of canceling the insurance of sick policy holders in order to maximize the company's profits. Not so urbane now, huh?

A recent investigation by the House Subcommittee on Oversight and Investigations found, in the last five years,  WellPoint Inc., UnitedHealth Group and Assurant Inc. canceled coverage for more than 20,000 people to avoid paying more than $300M in claims

The report also noted that specific conditions were targeted for rescission.  Policyholders with breast cancer, lymphoma and more than 1,000 other conditions were specifically targeted and insurance company employees were praised in their performance appraisals for their efficiency at canceling the policies of customers with expensive illnesses.

Following Robin Beaton's testimony last week before the House Oversight and Investigations subcommittee, the CEO's of WellPoint, UnitedHealth Group and Assurant appeared as well. 

Late in the hearing, (Rep Bart) Stupak, the committee chairman, put the executives on the spot. Stupak asked each of them whether he would at least commit his company to immediately stop rescissions except where they could show "intentional fraud."

The answer from all three executives:

"No."

Former Cigna senior executive Wendell Potter, in testimony yesterday before the Senate Committee on Commerce, Science, and Transportation, testified that insurance companies practice rescission to protect the company's bottom line.

“Potter, who has more than 20 years of experience working in public relations for insurance companies Cigna and Humana, said companies routinely drop seriously ill policyholders so they can meet “Wall Street’s relentless profit expectations,’” Potter told the hearing, according to ABC News. (Link)

Free markets are terrific vehicles for pulling the cost out of flat screen televisions and keeping the price of milk in check.  But, somethings terribly wrong if private health insurance providers strategies for playing in the free market include profit maximization, not by streamlining sytems and reducing administrative costs, but by employing corporate policy to deny legitimate coverage to their policyholders.

The real health care rationing

by Jay McDonough

That the GOP positioning on health care reform is dishonest may be expected.  It's politics after all.  What's more infuriating is that a number of Democrats will join Republicans to likely defeat any real and substantive changes to our completely screwed up heath care system. 

Sadly, it seems more and more likely that, at the end of this big debate on health care reform, Americans will have a system that looks an awful lot like the current system; still managed by big, private insurance companies that have made oh so sincere public pledges to cut costs and insure more people.  And Congress will, no doubt, pat themselves on the back for all the heavy lifting they've done to reform the system.  No debate on single payer.  No public plan.  Essentially, business as usual with some tough love (more love, less tough) for the private insurers.

What gets lost in the whole debate in Congress are the private stories of the American health care system.  

How about this?  A quarter of American households are struggling to pay their health insurance premiums.  Or this; 40% of Americans expect to delay health care treatments this summer.  Or this; nearly 20% of American households reported postponing or delaying health care over the past year.  (Note: an interesting statistic from the survey indicates the group least likely to be delaying heath care treatments are those born prior to 1946.  In other words, Medicare patients.  In other words, the recipients of a single payer approach to health care.)

It may be popular for health care opponents in Congress to express their faux concern over health care rationing that would come with government involvement, but one need only look at the current system to see that rationing is already occurring.

And when members of Congress come on TV and refer to the American health care system as the greatest in the world and warn of the dangers of allowing the government to step in and act as an arbiter in health care decisions, think about Robin Beaton.

The real tragedy is that Ms. Beaton's story isn't unique.  The real tragedy is that Congress will likely pass a health care reform package that is more about appeasing private insurance companies, fighting dumb old political battles than it is about Robin Beaton.  Or you.  Or me.

Some Health Care Reform Light

Commentary By Ron Beasley

Is it possible that the Democrats may be listening to the American People?

Democrats May Unite On Public Health Plan

 Emboldened by polls that show public backing for a government health insurance plan, Democrats are moving to make it a politically defining issue in the debate over the future of medical care.

Behind-the-scenes attempts to get a deal with Republicans on nonprofit co-ops as an alternative to a public plan have led only to frustration, complains a key Democrat. He and his colleagues may have to go it alone, said Sen. Chuck Schumer.

The co-ops were seen as perhaps the last hope for compromise on a contentious issue that threatens any remaining prospects of bipartisan support for President Obama's sweeping plan to remake the health care system.

"I don't think I could say with a straight face that this (co-op proposal) is at all close to a nationwide public option," Schumer, D-N.Y., told The Associated Press on Sunday. "Right now, this co-op idea doesn't come close to satisfying anyone who wants a public plan."

This is perhaps the first hopeful sign we have seen for several weeks.  Are we beyond the quixotic foolishness of bipartisanship?  The American people voted for change and the Republicans won't move beyond the same old failed policies.  The health care oligarchs and their friends in congress and the media can't even come up with new arguments and for the most part their old arguments are the same ones that people experience with the for profit insurance companies.  Do you want government bureaucrats making your health care decisions?  It's better than insurance company bureaucrats who make money when the deny care. 

People to Lawmakers

Commentary By Ron Beasley

In Poll, Wide Support for Government-Run Health

 

Americans overwhelmingly support substantial changes to the health care system and are strongly behind one of the most contentious proposals Congress is considering, a government-run insurance plan to compete with private insurers, according to the latest New York Times/CBS News poll.

This is the second poll in the last few days that showed overwhelming support for a public plan.  The NBC/WSJ poll showed that 76% thought the inclusion of a public plan was very important.  And note that even half of the Republicans support a public plan. 

Lawmakers will have to decide if the will of the people or the money from the health insurance oligarchs will make reelection more likely.  These numbers won't have any impact on the conservatives but moderate Republicans and Democrats should take note.

The Oligarchs Are Winning

Commentary By Ron Beasley

Health Care reform is threatened and if we don't see major health care reform the Obama presidency will be a failure.  Robert Reich has some advice:

Momentum for universal health care is slowing dramatically on Capitol Hill. Moderates are worried, Republicans are digging in, and the medical-industrial complex is firing up its lobbying and propaganda machine.

[.....]

If you want to save universal health care, you must do several things, and soon:

And what does he need to do?

1. Go to the nation

2. Be LBJ. So far, Lyndon Johnson has been the only president to defeat American Medical Association and the rest of the medical-industrial complex.

3.  Forget the Republicans. Forget bipartisanship.

4.  Insist on a real public option. It's the lynchpin of universal health care.

5. Demand that taxes be raised on the wealthy to ensure that all Americans get affordable health care.

6.  Put everything else on hold. As important as they are, your other agenda items -- financial reform, home mortgage mitigation, cap-and-trade legislation -- pale in significance relative to universal health care.

 

 And Ezra Klein also had some good advice - Listen to the polls.

 

The public option is considered important by 76% of Americans.  Without a public option any plan will be a failure and Obama and the Democrats will pay the price and the Oligarchs will win.