The 1990’s saw an attack on Medicare from the right wing – said Newt Gingrich, the program was “Soviet-style health care, too bureaucratic, too centralized, too dominated by government.” Gingrich is a smart man, but is blinded by ideology. Anyone who can compare private health insurance to government-run and say the latter is “too bureaucratic” is missing the big picture.

The primary thrust these days from the right are HSA’s – health savings accounts. The objective is to counter what insurers call a “moral hazard” – the idea that people use too much health care when it is provided by others. HSA’s force people to save for their own care, making them cautious about spending, thereby making only medically necessary expenditures.

HSA’s are appealing to younger, wealthier people. These people have fewer medical problems, and are attracted to the idea that they can accumulate cash in an IRA-like fashion that could later be converted to an IRA account. But medical costs are like the angel of death hovering over all of us, affecting only a few at a given time. A major medical problem quickly wipes out an HSA, and the owner becomes part of the larger scheme again. The overall thrust of HSA’s is to segregate the population into sick and healthy, forcing larger costs on the sick, negating the benefits of large insurance pools of healthy and unhealthy alike. That’s a moral hazard.

HSA’s face another moral hazard – the fact that financial institutions are drawn to the deposit and fund-management aspects of the program. Their main objective is to build up deposits, but HSA’s also offer opportunity for fees for account processing. As with mutual funds, these fees draw down asset accumulation and income stream over time – a subcommittee of the Senate Finance Committee found that mutual funds on average lose 26% of their accumulation to fees. (Social Security drain: 3%.)

People do tend to spend less on medical costs when they are dependent on HSA’s. The problem is that most of us don’t have a crystal ball, and don’t know what’s important, what is not. HSA’s end to decrease the chance for early detection, meaning later and more expensive treatment of diseases and conditions. Furthermore, poor people are most likely to scrimp on expenditures, meaning that they would, as with the current insurance system, get the short end of the stick.

The above are condensed thoughts from Jill Quadagno and J. Brandon McKelvey from an essay entitled “The Transformation of American Health Insurance”, not available on the web. (The 26%/3% figures come from a Sen Max Baucus aide on the Senate Finance Committee whose name eludes me. He was here in Bozeman to address seniors are part of the Wonderlust program.) Here’s an interesting excerpt:

In the past few years, Congress has enacted measures that have given private insurers a larger role in Medicare, most recently with the Medicare Modernization Act of 2003, which created Medicare Advantage, a private insurance option. There is already evidence that inserting private insurance into a social insurance program exposes beneficiaries to the risk of abuse. The private insurers who run Medicare’s new drug benefit program and offer other private insurance options encouraged by the Bush Administration have used deceptive sales tactics and improperly denied claims to thousands of beneficiaries. The problems include improper termination of coverage for people with HIV and AIDS, huge backlogs of claims and complaints, and a failure to answer telephone calls. In 2007, Medicare imposed more than $770,000 in fines on eleven companies for marketing violations and for failing to notify beneficiaries about changes in costs and benefits in a timely fashion. Many of the marketing abuses occurred in sales of the Medicare Advantage product.

Sounds like we need to deregulate.

But seriously, folks, private insurers and patients are at odds with one another, one seeking health care, the other benefiting only when that care is denied. It’s a system in conflict with itself, and doomed to fail. Yet it is the only one that free-market types can fathom for us.

It is probably best to jettison the free-market types. They are a moral hazard.

More so than Jay, I am troubled by Democratic Party proposals to fix our health care system that are built around the private insurance model. It is contradictory – it says that we fix the problem by spreading the problem around. The private insurance model is the reason why we have 47 million uninsured, millions more underinsured, and seniors, the poor, and children dumped onto government as the insurer of last resort.

Private insurance is a profit-driven model, and as such, has to confine itself to the lowest risk clients they can find. That’s the nature of the beast – it cannot be changed. Health insurance salespeople sift through the rubble looking for profitable clients, screening out the others. My wife and I, with our pre-existing conditions, have been told by agents not even to bother applying, and are sent packing instead to the ultra-expensive Montana health care pool for unprofitable health care clients. (It exists by government mandate – that alone is informative.)

So I am intrigued by Obama’s statements during the campaign, and by the Baucus proposal, that would make it illegal to reject people for insurance based on pre-existing conditions. I’m encouraged by this because it would undermine the private insurance model, and perhaps act as a driving force towards government-sponsored health care. No private insurer can survive if it has to provide insurance to all comers. Their business model is built around rejection of high risks.

Of course, the private insurance people are probalby miles ahead of me here. They might be willing to take on higher risk clients if we help them out – subsidy. That might well be our future – government-subsidized private insurance. That is the most expensive model we could possibly design, complete with all of the waste and extravagance of subsidy coupled with the greed and inefficiency and golden parachutes of the private insurers. It is no solution – it has all of the earmarks of a boondoggle.

The cleanest way to health care is to eliminate insurance pools, and simply provide care to everyone, high and low risk alike. Insurers can find other ways to make a living – an honest living. In other industrialized countries, it works just fine. People in Canada, Great Britain, France and Germany are mostly happy with their systems, far more satisfied than we are with ours. Maybe I’m being overly pessimistic here, but I see big brother private insurer in my future, want him or not. He’s bought his way in, and it will take major surgery to remove him.

Obama is a nice change, but he does not represent major change. That much is readily apparent as we watch him assemble his team with retreads, excluding progressives.

Conservatives often change tactics, but never stripes. Their formula is simple, if not simplistic – Ronald Reagan said “The nine most terrifying words in the English language are: ‘I’m from the government and I’m here to help.'” Conservatives want to make government small and insignificant – so they say. They don’t see much in the way of practical use for it, and believe markets self-regulate and self-correct and that we are all best served by deregulated markets.

When evidence flies in their face, as with the current crisis, they usually find a way to blame government. And when it painfully apparent to most all of us that deregulation of the financial markets has created a massive financial squeeze – a near panic putting us on the brink of depression – conservatives go right along insisting that deregulation is a panacea in other areas too. Like, for instance, heath care.

Merrill Mathews, of the right wing think tank Institute for Policy Innovation as a marvelously innovative solution for our health care crisis: deregulation. But he’s not calling it that. He says it’s merely a different kind of regulation. In his op-ed in yesterday’s Wall Street Journal (McCain is Right on Interstate Health Insurance), Mathews offers up a long-standing right wing cure to health care woes: eliminate the barriers that prevent us from buying health insurance in states where we do not live.

Mr. McCain backs legislation sponsored by Arizona Rep. John Shadegg. Known as the Health Care Choice Act, it would allow individuals living in one state to purchase health insurance being sold to people living in other states. The policy would still have to meet the regulations of the state in which it is being sold, and would be subject to additional federal oversight.

In other words, the McCain-Shadegg reform would allow a person living in New Jersey or New York to buy health insurance that is being sold in and regulated by Pennsylvania or Connecticut. That’s hardly the Wild West of health insurance.

Various states around the union have looked at products offered by health insurers, and found them inadequate, often deceptive. So they have mandated coverages for things like maternity leave, mental illness, addictions, and many other items. The reasons are simple – for one, people gravitate towards the cheapest coverage when they are healthy, and usually under-insure themselves. In addition, many public health problems simply go untreated for lack of coverage. Health insurers want to minimize their financial risk, and so offer a range of coverages that tends to minimize their exposure.

Yes, it is more expensive to cover things than not to cover them, but there are valid public policy reasons for doing so. The insurance model is an inadequate vehicle for public health, so we have attempted to fix its deficiencies though law. Insurers don’t like it – they want to tailor coverages to maximize profits, and would rather not cover things that are highly likely to occur. That’s a guarantee of higher costs.

So addiction and mental illness go untreated, and maternity coverage is restricted to men over age 50. That’s the health insurance model.

Under Mathews plan, state regulations would go out the window, and we would automatically default to the policies of the state with the fewest regulations and cheapest insurance. All of Montana’s thoughtful legislation regarding health care policy would be set aside as our people go to Pennsylvania for their coverage. And insurers would flock to the state with the fewest regulations. Pennsylvania would become the new Delaware. We’d be right back where we started – too little coverage. That’s bad public policy.

Mathews surely knows this, but listen to him:

Mr. Obama opposes interstate sales … he doesn’t believe a market can work in health insurance. He believes it is necessary for the government to look over everybody’s shoulder to make sure patients are getting the care and coverage the government thinks is appropriate at a price the government considers affordable.

…Creating an interstate option for individuals to purchase health insurance doesn’t solve every problem faced by the 45 million Americans who are uninsured. But the choice isn’t between a regulated or unregulated health-insurance market. The choice is between an overregulated market favored by Mr. Obama and a regulated market favored by Mr. McCain that provides more options to help individuals afford health coverage.

So Mr. McCain actually favors a regulated market, and would give it to us by doing de facto deregulation.

I love conservatives – they never change – they don’t adapt. Perhaps they are doomed to extinction.

We are faced with a serious problem, one requiring the full faith and credit of the free market. We need to unleash resources and creativity. That’s what markets do best, right?

The problem is drug-resistant bacteria and diseases that cannot be cured with existing strains of antibiotics. Yet market incentives are perverse. The marketplace is just as often our enemy as our friend.

This is from an article by Jerome Groopman in the New Yorker, Superbugs, August 11/18 issue:

In the past, large pharmaceutical companies were the primary sources of antibiotic research. But many of these companies have abandoned the field. “Eli Lilly and Company developed the first cephalosporins,” Moellering told me, referring to familiar drugs like Keflex. “They developed a huge number of important anti-microbial agents. They had incredible chemistry and incredible research facilities, and, unfortunately, they have completely pulled out of it now. After Squibb merged with Bristol-Myers, they closed their antibacterial program,” he said, as did Abbott, which developed key agents in the past treatment of gram-negative bacteria. A recent assessment of progress in the field, from U.C.L.A., concluded, “FDA approval of new antibacterial agents decreased by 56 per cent over the past 20 years (1998-2002 vs. 1983-1987),” noting that, in the researchers’ projection of future development only six of the five hundred and six drugs currently being developed were new antibacterial agents. Drug companies are looking for blockbuster therapies that must be taken daily for decades, drugs like Lipitor, for high cholesterol, or Zyprexa, for psychiatric disorders, used by millions of people and generating many billions of dollars each year. Antibiotics are used to treat infections, and are therefore prescribed only for days or weeks. (The exception is the use of antibiotics in livestock, which is both a profit-driver and a potential cause of antibiotic resistance.)

If there is a solution to this problem, it will come from the college campuses and the National Institute of Health – government sources. The market is not helping – in fact – is structurally unable to help. This phenomenon is known as “market failure” – the public is disserved by the profit motive. In such situations, government has to intervene to provide for the greater good.

It’s interesting – I realized as I wrote those words that in the past in my exchanges with Dave Budge (a libertarian conservative Republican who at any given time denies affiliation to any of those three schools), he claimed not to grasp the concepts of “market failure” and “greater good”. Ayn Rand herself did not believe in individuals sacrificing to a greater good – that is, she did not think there was any point in people serving anything but their own self-interest. Perhaps libertarianism, a sideshow that has much greater currency in leadership circles than among the general population, is a failed philosophy.

Superbugs are a common problem affecting all of us. Those institutions that profit from the public’s need for drugs have an obligation to step in and help us solve the problem. But they’re not – they’re busy doing the self-interest thing. Rand would be proud.

In an exchange I had with Steve at Rabid Sanity regarding health care, he referred me to two articles that take issue with the current low ranking by World Health Organization of the United States’ health care system against other industrialized countries. We’re 37th. The two articles dispute the rankings, saying they are biased in favor or state-run systems. Our system is not “perfect” one admits, but is probably the best in the world.

The first article is How surveys twist rankings on health care, by Glen Whitman. The problem is, he says, the objectives of the study.

The most obvious bias is that 62.5 percent of their weighting concerns not quality of service but equality. In other words, the rankings are less concerned with the ability of a health system to make sick people better than with the political consideration of achieving equal access and state-controlled funding.

This, he says, is a flaw in the study. The United States is very good at making sick people better – not all sick people, but that’s not the point. A health care system should be measured by its abilities, and not its delivery capacity. That 47 million of us are without insurance? Not an issue. Bias.

The rankings include measures for “health level” and “responsiveness.” “Health level” is their way of saying life expectancy, while “responsiveness” refers to a survey based on “respect for persons” and elements such as speed of service, convenience and choice — yet even in these cases half the overall weighting is determined by considerations of equality. Thus, a country with a poor level of “responsiveness” throughout the population will score higher than a country with a good level in some parts and an excellent level in others.

It’s in the eye of the beholder, I guess. Whitman is a professor of economics, and is not concerned about equality. And he is right: If you only measure the people we actually take care of in this country, we’re the toast of the town.

The second article, Ranking the U.S. Health-Care System, by Jim Peron (for whom it gives no credentials), says pretty much the same thing, but from a doctrinal standpoint. Peron starts off by using the word “socialist” as a pejorative, so it’s not hard to see where he’s going. Referring to a study by the Commonwealth Fund that also ranked the U.S. very low, he says

The Commonwealth Fund marked down the United States partly because “All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefits packages with no cost-sharing by the patients.” Again the American system loses points because it doesn’t provide socialized medicine. And the Times neglected to note that “no cost-sharing” means the people have paid through taxes whether they receive the care or not.

This is a curiosity. The concept of insurance is based on shared risk, no different than coverage of people’s health care through taxation, also a shared-risk system. But Peron presumes that private insurance is a superior model because it is not based on taxation. That’s nothing more than personal bias.

This is priceless:

This issue is not unknown to the Commonwealth Fund. In 1999 it
published The Elderly’s Experiences with Health Care in Five Nations, which found significant delays for “serious surgery.” Only 4 percent of the American seniors reported long waits for serious surgery. The rate was 11 percent in Canada and 13 percent in Britain. For non-serious surgery the differences were more obvious: 7 percent in the United States, 40 percent in Canada, and 51 percent in Britain.

He’s talking about seniors. He doesn’t seem to realize it, but he’s comparing our Medicare, or government-sponsored system that is supported by taxes, with other countries. I’m happy that Medicare is doing well in that regard. It’s a well-run system.

In other areas, Peron simply offers up weak, made-up-on-the-spot excuses.

The United States also lost credit because fewer Americans report having a regular doctor for five years or more. But Americans are more mobile than many other people.CNN reports that Americans move every five years on average.

He does that in other areas as well, as in emergent care wait periods, lack of centralized medical records, and the number of patient complaints. (“But different cultures have different attitudes toward complaining.”)

It’s all illuminating, but not of the relative merits of health care systems. In terms of equality and delivery of care, the U.S. lags far behind other countries. But these articles, and Steve’s post to begin with, shine a light not on study biases, but rather on right wing biases. Yes, we don’t offer care to everyone. We don’t intend to! Yes, our care for the wealthy and well-insured is excellent. Those are the people the system is meant to serve.

The system works as it is intended to work, delivering excellent care to insiders, and poor or no care to outsiders. When we debate conservatives like Steve on this issue, that is the subtext, and the issue we need to highlight. Conservatives are far too caught up in rewarding the financially well-off. In health care, that’s a poor objective. Even if they attain it, they have failed us.

For that reason, they need to step aside and let us “socialists” fix our health care system. It’s long overdue. We have real answers while they offer nothing other than a curtsy to Ayn Rand.

A Livingston, Montana man, Terry, once worked for a small sign company, but the wages were bad, the hours irregular. Still, the company at one time provided health insurance benefits, so the job had its value. But citing rising costs, the company dropped that benefit. Terry was left working for low wages ($12 per hour) and no benefits. He realized he could make more money on his own, but that he would lose the two protections left employed people that are mandated by state law: Workers Compensation insurance, and unemployment benefits.

Terry struck out on his own, and has been hiring himself out for any sort of craftsman’s work in the Livingston area. He bills at a much higher rate than he was paid in wages, and makes enough money to pay his bills. However, health insurance is still out of the question as he and his wife are in their fifties, and premium costs are out of reach. And who knows – at that age, they might have preexisting conditions. They had to go bare – it’s a chance they had to take.

This week Terry had an accident on a job, and broke both of his shoulder blades. He is now laid up, deep in medical debt and has no income to boot.

Soon to come: bankruptcy and tut-tuts that he should have managed his money better.

I’m going to do a left equivalent of a RWCJ* thing here, and link to another left wing blog and repeat what was said over there in hopes that others will do the same, in time producing a cacophony of voices each saying the same thing, thereby lending authority and importance to the insignificant.

But I came upon a sentence in a post about health care at Left in the West, and thought that it did so well what I do so poorly – saying a lot while saying a little.

Missoula doctor Tom Roberts: “Our profit-based system is fundamentally at odds with our valued-based system.”

*Right Wing Circle Jerk

The following is an interview I found interesting, between radio talk-show host Thom Hartmann and Dr. Lewis Mehl-Madrona, the author of Coyote Healing, Miracles in Native Medicine, and a number of other books. He’s a PhD and MD, Professor of Medicine at the University of Saskatchewan College of Medicine, and out on the East Coast practices at Beth Israel Medical Center. He’s also a practicing psychiatrist in Canada.

One thing I’ve noticed over the years is that, when we talk of Canadian medicine here in the United States, we don’t talk to Canadians (unless they are unhappy with that system). So we don’t get personal testimony about what single-payer means to ordinary Canucks. The following interview is limited, but does give some insight.

TH: You have practiced and taught medicine in the United States for the better part of a couple of decades …

LM: It’s been 32 years since I got my MD.

TH: …and you are now teaching and practicing medicine in Canada. Last night 60 Minutes did this amazing piece on a charity called Remote Area Medical that typically goes into third world countries or worse and sets up two and three day emergency medicine clinics for people who have never seen a doctor or are not going to have opportunity to see a doctor, and diagnostic and treatment facilities. And they did this in Knoxville, Tennessee, and people drove from hundreds of miles around and sat freezing in line all night long – they were absolutely overwhelmed. The state of American medical care for anyone who makes less than (fill in the blank) – somewhere between $40 and $70 thousand bucks a year, is not unlike that in a third world country. Or worse. And that’s not the case in Canada. Can you quickly describe for us what it is like in Canada? You teach there, you practice there, you are presumably a consumer of medical services in Canada. What is it like, and what would it take for the United States to make the transition into a Canadian-style system?

LM: Probably the simplest thing is that nobody worries about how we’re going to pay for anything, so as a patient you just go to the doctor and you don’t really worry about how much it costs. You just hand them your card and they bill for it and that’s that. And as a doctor, we’re not really worried about how you’re going to pay for it either. We just do what we think is best and that’s that. What’s amazing going to Canada from the U.S. is that no one ever asks what kind of insurance you have. No one ever questions whether or not you can pay for something. People get what they need. Yes, sometimes they wait for elective surgery, basically because there aren’t enough operating rooms, or sometimes it’s because there are not enough surgeons. But if it’s an emergency, it’s quick. There’s no such thing as what’s called utilization review. When I practiced in the U.S., someone from the U.R. department would come see me every day to try and kick people out of the hospital because they were costing money, or if I wanted to admit somebody to the hospital they would refuse.

TH: You see these shows like House, here in the United States, which is supposed to take place in Princeton Medical Center, and he says “Order an MRI and do a test for this”, and in reality, it would be “Would you please find if the insurance company will pay for an MRI?” It’s such a twisted view of medicine. What we’re seeing in our TV shows is medicine s it’s practiced in Canada or as it’s practiced in Europe, but they’re taking place in the United States. It’s bizarre.

LM: It is. You know, Canada has its problems – we still order too many lab tests, we spend less time with people that we should – it’s less severe than the United States, because in Canada as a family physician you can bill for every fifteen minutes that you spend with a patient, whereas here, as a family physician, you’re “tapped”, and so you can only bill for the first six minutes.

TH: After that the insurance companies won’t pay for it. That’s why the doctors try to get you out of the office as fast as they can, because after six minutes they’re not being paid anymore.

LM: So now, in Canada, if you see people very six minutes you can still make more money than if you see them every fifteen minutes. So, for instance, as a family physician, you would make about forty dollars for a fifteen minute office visit, but if you can do that in six minutes you still make forty dollars. Here you probably make about, I’m guessing, thirty dollars for an office visit, and so if you see them every six minutes you’re still making enough money to pay your overhead. But you can, in Canada, choose to see people every fifteen minutes, or you can see the same person for an hour …

TH And bill for four fifteen minute segments.

LM: That’s right.

TH: So then I can hear conservatives all over America screaming “Oh my God, people who just love to go to the doctor’s office are just going to come in and talk your ear off and I’m going to have to pay for it. It must cost a fortune!”

LM: Let me tell you about that. I’m using an American example, I have a friend in Scottsdale who has what’s called a “concierge’s practice”, and she’s a family physician, and she limits her practice to 250 people, and each of those people pay her $2,000 at the start of each year. They can come see her as much as they want. They can see her as long as they want. They never have to pay another penny. And what she found was that people see her a lot less than she wants them to when they can come as much as they want. And people get tired and they leave before she’s ready to stop the appointment.

TH: So the reality is that this whole myth of the people who want to take advantage of the system because it’s free is nonsense. There may be some small, one-thousandth of one percent of the people – the ones who are compulsive about having surgeries – there is a medical condition there you probably know the name of and I don’t. That’s the exception.

LM: Right. It’s really not a lot of fun to go to the doctor. … And every study that’s been done has shown that if you give people the time they need when they need it, they actually consume less resources over the course of a year. It costs you less to take care of people.

TH: Both because of preventive care and because people generally have better things to do than hang out at the doctor’s office.

LM: Right.

TH: And if the United States was to make this transition to a Canadian-style system, or more European style, a single-payer system, what is it that we would have to change, structurally or psychologically here in the United States in order for that to happen?

LM: People would have to change the idea that they deserve every test immediately, right now. A quick example, I know someone in Anchorage, Alaska, a 54 year old woman who smokes a couple cigarettes a day and doesn’t exercise, has high stress, had chest pain and went to the ER. The logical thing to do would be to make sure she’s not having a heart attack and schedule her for a stress test or a treadmill test where she walks on the treadmill …

TH: To make sure she’s not having a panic attack …

LM: Right. So what happened is she went straight to cardiac cath, a test that costs at least $20,000 …

TH: A cardiac cath is where they put the long tube in the femoral artery and snake it up into the heart and do this all under X rays. And this has a certain rate of death associated with it – nine out of a thousand?

LM: Not death, but some kind of stroke kills nine percent in one study [I think he meant to say that strokes are experienced by 9/10 of one percent of those who are subjected to this procedure.] So here’s a risky procedure that could have caused her many problems that cost $20,000, that really wasn’t necessary, and after she was done she was so grateful to them because they definitively proved that there was nothing wrong with her.

TH: Where instead of a $20,000 very dangerous procedure, they could have done a thirty dollar test – a blood test that would have shown that …

LM: Well, a treadmill test would probably be more like an $800 test, but if you pass your treadmill test, your chances of having a heart attack in the year are minimal.

Mother of four?