Sunday, November 29, 2009

Let the Health Care Debate Begin

So the debate in Congress by the Senate over health care reform is finally about to begin. For those in favor of reform, it has been terribly frustrating to put up with the same tired arguments of “socialized medicine” and “government takeover of health care” from those opposing the Democrats’ proposed bills. It’s one thing to criticize; but the problems faced by those who are unable to obtain affordable health insurance are real. What is the Republican alternative to help these people?

A recent article by conservative columnist and physician Charles Krauthammer
Kill these bills, then do health reform right sounds promising because it at least suggests some alternatives. But do they really solve the problem of the uninsured or are they little more than right-wing talking points?

Of course the reader can read the entire commentary in the link above. But I would like to provide some excerpts with some commentary of my own.
The United States has the best health care in the world -- but because of its inefficiencies, also the most expensive.
The quality of health care in the US is not in question. But it doesn’t matter how good health care is if one cannot get access to it due to lack of insurance. There is no question that we spend far more per capita than other countries that do provide true universal health care. Most importantly, it is only in the US where people die or go bankrupt for lack of coverage. Instead of pretending that the US is the best at everything, we should look to adopt what works in other countries.
The bill is irredeemable. It should not only be defeated. It should be immolated, its ashes scattered over the Senate swimming pool.
The bill even in the eyes of supporters has many flaws. But it least it would end the practice of people being denied coverage for pre-existing conditions or dropped because they got sick and had to file a claim. Do any Republican alternatives even address this?

Then do health care the right way -- one reform at a time, each simple and simplifying, aimed at reducing complexity, arbitrariness and inefficiency.

First, tort reform. This is money -- the low-end estimate is about half a trillion per decade -- wasted in two ways. Part is simply hemorrhaged into the legal system to benefit a few jackpot lawsuit winners and an army of extravagantly rich malpractice lawyers such as John Edwards.
The idea behind tort reform is that if we limit damages that patients can sue for, the cost of malpractice insurance would then go down which would help to make health care more affordable.

But in a paper by Americans for Insurance Reform,
Stable Losses/Unstable Rates they come up with this conclusion:

Specifically, AIR has consistently found that total payouts (by insurance companies) have been stable, tracking the rate of medical inflation, but premiums have not. Rather, premiums that doctors pay rise and fall in sync with the state of the economy, reflecting profitability of the insurance industry, including gains or losses experienced by the insurance industry’s bond and stock market investments.

They explain further:

Insurers make most of their profits from investment income. During years of high interest rates and/or excellent insurer profits, insurance companies engage in fierce competition for premium dollars to invest for maximum return. Insurers severely underprice their policies and insure very poor risks just to get premium dollars to invest. This is known as the “soft” insurance market.

But when investment income decreases — because interest rates drop or the stock market plummets or the cumulative price cuts make profits become unbearably low — the industry responds by sharply increasing premiums and reducing coverage, creating a “hard” insurance market usually degenerating into a “liability insurance crisis.”
So the assertion is that the low interest rates and poorly performing stock market of this last decade has been the main driver of higher malpractice premiums and not an increase in claims. If so, then the main beneficiary of tort reform will be none other than the insurance industry which has been vigorously lobbying for and financing the opposition to health care reform.

Second, even more simple and simplifying, abolish the prohibition against buying health insurance across state lines.

Some states have very few health insurers. Rates are high. So why not allow interstate competition? After all, you can buy oranges across state lines. If you couldn't, oranges would be extremely expensive in Wisconsin, especially in winter.
But health insurance is an extremely complex product that is subject to regulations that each state has established. As explained by in their paper Across State Lines Explained:

Allowing the state laws chosen by the insurance company, rather than the laws of the state where the consumer lives to govern health insurance regulation is what makes this policy so controversial.
But if some states do indeed have high rates because of very few competitors, why don’t other companies become licensed in those states to provide some competition and lower prices now? Maybe it’s at least in part because of the
McCarran-Ferguson Act passed by Congress in 1945 which has granted the health insurance industry an exemption from federal anti-trust laws and captive markets with no curbs on price fixing and other anti-competitive practices. In addition, critcs feel that allowing this competition across state lines may provide for better prices for the young and healthy but would still not address the needs of those who cannot get insurance because of pre-existing conditions.

Third, tax employer-provided health insurance. This is an accrued inefficiency of 65 years, an accident of World War II wage controls. It creates a $250 billion annual loss of federal revenues -- the largest tax break for individuals in the entire federal budget.
My, what would the Tea Partiers who watch Krauthammer on Fox News have to say about this idea to raise taxes? In any event, Krauthammer overstates the amount of savings compared to the
White House Office of Management and Budget which predicts an estimated $155 billion loss in 2010. Even so, it does raise an issue of fairness. Should people who get their health insurance from an employer get a tax subsidy when those who buy insurance on the open market have to use after-tax dollars? (A similar argument can be made for home owners who can write off mortgage interest compared to renters who get no tax break.)

Even so, this would be a tough sell since it would mean a tax increase for the middle class when many of them are already struggling. Repealing the Bush tax cuts for the wealthy who are not struggling would be a better way to help pay for all of this.

Insuring the uninsured is a moral imperative. The problem is that the Democrats have chosen the worst possible method -- a $1 trillion new entitlement of stupefying arbitrariness and inefficiency.

The better choice is targeted measures that attack the inefficiencies of the current system one by one -- tort reform, interstate purchasing and taxing employee benefits. It would take 20 pages to write such a bill, not 2,000 -- and provide the funds to cover the uninsured without wrecking both U.S. health care and the U.S. Treasury.
Insuring the uninsured is a moral imperative. The proposed bill does reek of stupefying arbitrariness and inefficiency. But with the simpler option of single-payer (Medicare for all) not politically feasible, this bill is probably the best we can hope for. Since the Clintons’ attempt at health care reform back in 1993 was blocked, the number of uninsured has skyrocketed during the years of subsequent Republican control of the presidency and Congress. Now that the Democrats are again in the majority and trying to pass health care reform, we again get Republican cries that they can do health care reform better.

So do the Republicans have a better way to do health care reform or are they little more than obstructionists working on behalf of the health care industry as many have charged? For a start, why doesn’t Krauthammer write up his proposed bill so we can all examine and debate its merits or faults? Certainly 20 pages is not a lot to ask of a professional writer. Would the proposed bill truly insure the uninsured (including those with pre-existing conditions) or would it mostly just ignore their existence? Let the debate begin!

Monday, November 23, 2009

The High Cost of Dying

This Sunday, the 60 Minutes story The Cost of Dying raised some crucial issues on the containment of health expenses for Medicare, the single payer health insurance for US citizens over 65.

Last year, Medicare paid $50 billion just for doctor and hospital bills during the last two months of patients' lives - that's more than the budget of the Department of Homeland Security or the Department of Education. And it has been estimated that 20 to 30 percent of these medical expenditures may have had no meaningful impact. Most of the bills are paid for by the federal government with few or no questions asked.

This is entirely different from the horror stories of private insurers denying procedures that have cut short the lives of people who were otherwise young and vital. In this case, we have a government insurance plan whose leniency allows doctors and hospitals to pad the bill by ordering endless procedures on patients without any real benefit in the way of life extension.

Here is one example from the story.

Meredith Snedeker's 85-year-old mother spent her last two months shuttling between a nursing home and community hospital in New Jersey, suffering from advanced heart and liver disease.

Dorothy Glas was a former nurse who had signed a living will expressing her wishes that no extraordinary measures be taken to keep her alive. But that didn't stop a legion of doctors from conducting batteries of tests. "I can't tell you all the tests they took. But I do know that she saw over 13 specialists," Snedeker told Kroft. Asked what kind of specialists, Snedeker said, "Neurological, gastroenterologists. She even saw a psychiatrist because they said she was depressed. And she told the psychiatrist, 'Of course, I'm depressed. I'm dying.'"

When (60 Minutes) reviewed the medical records, (they) discovered that there weren't 13 specialists who attended to her mother: there were 25, each of whom billed Medicare separately. The hospital told 60 Minutes that all the tests were appropriate, and an independent physician said this case was fairly typical. "You think they were running up the bill to make money? Or running up the bill or giving her all these tests because they really thought it might help her? Or to cover their…rear?" Kroft asked.

"Yeah, to cover their rear," Snedeker replied.

Among the tests conducted was a pap smear, which is generally only recommended for much younger women, not an octogenarian who was already dying of liver and heart disease.

Maybe it was both to run up the bill and cover their rears.

I have a personal experience to share here.

It was almost 30 years ago that my father was dying. We planned to have him spend his last days at home but some complications arose that required us to have him taken back to the hospital. Although he was in a coma by then, neither I or my mother wanted him to die alone so we took turns staying by his hospital bed, she during the day and me at night.

For someone who was obviously only a few days away from dying, it was curious to see the parade of doctors who came by all though the night to visit and sign the chart in front of his bed. I didn’t pay it much mind until I saw the bills from the doctors and hospital a month or so later. There was the list of visits and charges from each of those doctors — an incredible number of them who listed visits in the last few days of his life. And to add insult to injury, there were doctor visits listed for one and two days after his death!

When critics of Medicare bring up its financial difficulties, they overlook that since most people don’t die before reaching age 65, the private insurers in effect pass off almost all of the end of life care issues to Medicare. It would certainly make sense to have a discussion about limiting testing and procedures to where a patient can realistically be made better instead of prolonging an inevitable death with no quality of life. But then we would surely get the demagoguery in the form of “death panels” and “pulling the plug on Grandma” that is presently practiced by those demonstrating against health care reform.

Whether we like it or not, to make Medicare financially solvent over the long run, we do have to exert better control over what is being paid out to stop the abuses of those providers who are taking advantage of the present system to pad their profits through either unnecessary procedures or just outright fraud which alone is estimated at about $60 billion a year.

Finally doing something about all of this waste and fraud would go a long way toward our being able to afford health insurance for those millions in the US who have had to go without it.

Tuesday, November 17, 2009

Health Reform Is About People

For all too many of us, discussions on health reform are about how much it will cost along with arguments over political ideology. It’s all too easy to forget about the human suffering that is happening under our noses.

Recently, Rich Stockwell, Senior Producer for the MSNBC show Countdown came up with an idea to set up some free clinics in the states that are the home of conservative Democratic senators who have been opposing health care reform. The idea was to demonstrate how much of a need there was to help the people in these states and perhaps shame these senators into finally supporting health care reform.

Thanks to Countdown along with donations from viewers across the country, the first free clinic was held this Saturday in New Orleans. Senator Mary Landrieu (D-LA) among those opposing reform was invited to attend the clinic but declined.

But Mr. Stockwell did attend and wrote this account of what he saw,
Health Reform's Human Stories which Countdown host Keith Olbermann reads during a video shown of the event. Please check out the compelling video in this link.

It is hard to sum it up better than Stockwell when he wrote of his experience:

Health reform is not about Democrats or Republicans or who can score political points for the next election, it's about people. It's about fairness and justice in a system that knows none. I'd defy even the most hardened capitalist-loving-conservative to do what I did on Saturday and continue to pretend that the system in place right now is working.

I am left with one overwhelming question: what does it say about us as a nation of people who can live in a country so rich and yet allow this to continue?

Sunday, November 8, 2009

Why Baseball Needs More Competitive Balance

This last Wednesday, the New York Yankees won their record 27th World Series championship. For a franchise that has been in existence for 108 years, this means that they have won the World Series, on average once every 4 years. Just as impressive is their total of 40 World Series appearances which averages out to appearing in the World Series on average, 3 out of every 8 years.

Since I didn’t have a rooting interest, I watched the Yankees’ celebration seeing the look of ecstasy on the players’ faces along with their adoring fans. It was living vicariously since I knew that my hometown Pittsburgh Pirates would never likely get to the World Series in my lifetime ever again — certainly not under the present system used in baseball that mostly rewards the teams that are willing and able to spend the most for players. In Pittsburgh, a successful baseball season is now defined as finishing over .500 — which the Pirates have now failed to do over the last 17 seasons with no apparent end in sight.

In any one season, only one team can win it all. But there was always that hope for the losers who say “Wait Till Next Year” when the season starts anew and offers a fresh chance for everybody.

But especially for fans in smaller markets, that hope has vanished. They know that occasionally teams from small markets can get lucky and make the post-season playoffs. But even if they do, that means that the best emerging players will soon be attracted to the teams with the most money to spend so the joy will be short-lived. This happened twice after a pair of improbable World Series victories by the Florida Marlins which were followed by the dismantling of the teams for financial reasons. In effect, we have a system where the small market teams function as a farm team for the larger market teams with deeper pockets.

The Yankees have been notorious for their payrolls that dwarf those of most other teams. So after their victory, there is always the question of whether they won because of things like “character” or whether they are just simply
The best team money could buy.

The Yankees are not a big-market team. They DWARF big-market teams. They are quantitatively different from every other team in baseball and every other team in American sports. They don't just spend more money than every other team. They spend A LOT more money than every other team. The Boston Red Sox spend $50 million more than the Kansas City Royals? Who cares? The Yankees spend $80 million more than the Boston Red Sox.

Because of the more unpredictable nature of baseball games and their short playoff series, the teams with the largest payrolls don’t always win championships. But even so, the fans of smaller market teams know that the best stars will be playing elsewhere since that is where the money is.

In the National Football League which has a salary cap to equalize payrolls, teams succeed because they have better coaching and talent evaluation. And with more competitive balance, more fans in more cities stay interested in their teams throughout the season. In comparison, July in Pittsburgh is not important for the beginning of the baseball pennant race but rather for the start of Steelers’ training camp.

Baseball is the only major sport in America not to have a salary cap and if the powerful Major League Baseball Players Association has their way, there will NEVER be one. They obviously do not want to compromise the earning power of their marquee players. But in taking this stance, the union may well be doing a disservice to the players who play on the smaller market teams. Just like the fans who want to win a championship, these players would also like to have a chance to win a championship one day. There isn’t room for everybody to play for the Yankees and other large market teams.

The larger question is whether this has caused overall interest in the sport to decline. Several generations ago, baseball certainly earned its title in America as The National Pastime and the World Series was one of the most watched TV events of the year. Examining World Series television ratings over the last 25 years however, the percentage share of households watching TV who are tuned in has declined from in the 40s in the 1980s down to the 20s in the 1990s and in this decade mostly in the high teens. In contrast, National Football League Super Bowl television ratings through the years boast share ratings of at least 60% and sometimes 70%. In addition, NBC who presented the latest Super Bowl was able to command a cool $3 million for a 30 second ad.

The MLB All-Star Game has suffered a similar decline over the years and has now has to resort to the pathetic gimmick that the league that wins the All-Star Game gets home field advantage in the upcoming World Series to try and make it compelling enough to watch.

We have seen real life examples of what benefits those on the top of the food chain, e.g. Wall Street, doesn’t do much to benefit those on Main Street who are struggling. A similar case can be made that what benefits the top of the food chain in Major League Baseball, e.g. the Yankees, doesn’t do much to benefit the smaller market franchises that are struggling — which is hurting the overall popularity and health of the game. Of course, there are other issues such as steroid scandals that are turning off fans.

But if Major League Baseball wants to try and recapture the popularity it has lost in recent decades to football, they have to show that if they indeed want to operate 30 franchises, they need to work on offering a quality product with much more competitive balance. It is competitive balance that creates compelling interest in the games. The NFL knows this and has used it to expand its popularity over the years. In many cities, come September, it means the difference between baseball fans following a hot pennant race with their favorite teams — or instead turning to football because their team is hopelessly out of it!

Sunday, November 1, 2009

Can We Talk About Medical Marijuana?

Recently, the controversy around medical marijuana came to the fore again as detailed in U.S. Won't Prosecute in States That Allow Medical Marijuana.

People who use marijuana for medical purposes and those who distribute it to them should not face federal prosecution, provided they act according to state law, the Justice Department said Monday in a directive with far-reaching political and legal implications.

In a
memorandum to federal prosecutors in the 14 states that make some allowance for the use of marijuana for medical purposes, the department said that it was committed to the “efficient and rational use” of its resources and that prosecuting patients and distributors who are in “clear and unambiguous compliance” with state laws did not meet that standard.

The significance of this is that up until now, despite these states legalizing medical marijuana, the federal government still had the right to arrest people for consuming marijuana for any purpose — and did under previous administrations. This reversal under the Obama administration allows these medical users to breathe a sigh of relief.

But despite ample evidence that marijuana has been helpful in easing the suffering of cancer and AIDS patients, the US government continues to include marijuana as a
Schedule I controlled substance which declares that it has no accepted medical use. In keeping with this, the Food and Drug Administration has issued statements that "no sound scientific studies" support the use of marijuana.

What further compounds the aggravation for those supporting the use of medical marijuana is that the federal government is the nation’s
only legal grower of marijuana for medical research. Critics have charged that the government issue marijuana is of too low a quality to conduct serious research and have sought permission to grow their own medical grade marijuana for research purposes but without success.

So basically we have the government taking the position that there are no sound studies to support medical use of marijuana while at the same time doing what they can to restrict any research that may prove them wrong. But what else can we expect from a government that still stubbornly chooses to conduct a “War on Drugs”? In a way, it presents a dilemma for them. Taking a drug away from people who rely on it to relieve their suffering is cruel. But allowing it for medical purposes then opens the door for those who want to use and grow marijuana for recreational purposes which the War on Drugs people obviously don’t want to happen.

A New York Times video,
The Marijuana State shows how twelve years after California voters legalized medical marijuana, it is being exploited as a cash crop and for recreational use so it is felt by many that California has achieved de facto legalization or at least decriminalization of pot. Just to make sure, there are initiatives in California on legislation that would formally legalize pot.

This is why the medical marijuana controversy is inextricably linked with the controversy around its legalization. As long as marijuana remains illegal, it will remain a lucrative crop to grow whether it is by the Mexican drug cartels, or by those in Afghanistan where
eradicated poppy fields have been replaced by marijuana. The legalization and taxing of marijuana could bring a sizable windfall in government revenue at a time when we desperately need it to continue to provide vital services.

Drug Policy Alliance Network sums it all up this way:

Few public policies have compromised public health and undermined our fundamental civil liberties for so long and to such a degree as the war on drugs. The United States is now the world's largest jailer, imprisoning nearly half a million people for drug offenses alone. That's more people than Western Europe, with a bigger population, incarcerates for all offenses. Roughly 1.5 million people are arrested each year for drug law violations - 40% of them just for marijuana possession.

(And in the 36 states that still prohibit medical marijuana) People suffering from cancer, AIDS and other debilitating illnesses are regularly denied access to their medicine or even arrested and prosecuted for using medical marijuana. We can do better.