The Health Care Working Group has asked for input, and I thought I’d make this a front-page post, instead of posting this in the comments of the below thread. I will try to be brief but comprehensive. (If you’re looking for more information on the new law, see our interview with Health Care for All’s John McDonough here.)
First, the generalities:
- Everyone should be able to get health care. Health care is a matter of human dignity. I’m not interested in discussing whether it’s a “right” or not; it seems obvious that depriving someone of health care for whatever reason is cruel and inhuman — as well as economically destructive.
- Any health care solution must address health, much less health care, and certainly not simply health insurance. (The goal of “universal insurance” invites mischief from those who would sell “insurance” but withhold actual care. Eyes on the prize.)
The new health care law is an important step forward in that:
- many thousands of people are now insured that weren’t before;
- Insurance for small businesses and individuals has been pooled, resulting in lower premiums;
- Other benefits, such as dental and eyeglasses, have been restored for many who need them.
It is severely flawed in that:
- You cannot simply force people to buy insurance at whatever price, and say you’ve brought “universal coverage”. For lower-income folks, the personal mandate threatens to exacerbate the already-crushing cost of living in Massachusetts. The Patrick administration should refer to GBIO’s research as to what is realistically affordable for whom — and what is not.
- Even if some people are deemed not to be required to buy unaffordable insurance, what happens to them? The law leaves them in a new “doughnut hole”: Not eligible for subsidy (or enough subsidy), and unable to afford insurance. Gov. Patrick should entertain expanding the subsidy levels.
- The “minimum creditable coverage” products being contemplated only aggravate the problem by covering less at prices that are still not affordable for many people.
- The financial picture of the law is quite precarious, even in the near term.
- If the law supposedly represents a three-legged stool of
- personal responsibility
- state responsibility, and
- employer responsibility
… the third leg is a good bit shorter than the rest; $295/year/employee is a free ride, not an imposition of responsibility or an incentive to do the right thing. Furthermore, requiring a degree of employer responsibility enjoys broad public support. Should the financing of the health care law run into trouble, this should be the first place that Gov. Patrick looks.
Furthermore, the new law doesn’t address health care costs in any signficant way.
- The system of incentives in the health care system needs to be addressed, aggressively. Providers currently have few or no economic incentives to provide health; the incentives are legion to sell products and services in a situation of inelastic demand and low information: As patients, we don’t really know what we need or what we’re getting, but we’ll pay any price for it.
- In response to this, we need absolutely rock-solid care-quality research, including independent, thorough evaluations of the effectiveness of prescription drugs, to actively combat marketing flim-flam from the extremely aggressive pharmaceutical industry. A thoroughly independent, empowered new Massachusetts Health Research Office could set the tone for the nation, much less our Commonwealth; and help save taxpayers and health plans billions. (Here’s the kind of thing they could do.)
- (UPDATE:) The state should regulate how much of a health care premium must be spent on care: The Globe has suggested 90%. Yes, that’s intrusive to insurers. Tough luck. It’s long past time to unlock the box that our premiums go into.
- Massachusetts should standardize fully-interoperable electronic medical records.
- Health Care for All promises a report on controlling health care costs soon. Their recommendations should be considered carefully.
In conclusion: Bolstered by his own victory and public opinion polls, Gov. Patrick should feel free to reshape the new law in a much more equitable way. The free market in health care has thus far failed to provide quality and access at reasonable costs. Furthermore, special-interest politics have created a law that places a hugely disproportionate burden on private citizens and the government, allowing non-insuring employers to externalize their costs on the rest of us. That’s neither fair nor sustainable.
For the time being, we shouldn’t be afraid of regulating the insurance market rather strictly, imposing efficiencies from above, for instance, with regard to the cost of paperwork. The state must also take a leading role in providing transparent information that makes the market function more efficiently. Reward success; take out the trash. Measures to address costs will doubtless require political boldness: That money’s going somewhere, and whoever’s getting it is bound to complain, loudly. This will doubtless include well-financed corporate interests from within and without the state. But we mustn’t let the health care sector continue to hold the rest of the economy hostage. Get ready for a fight.
(I can’t imagine that I’ve included everything — please hold forth in the comments.)
It might be worth taking a long look at the Oregon approach to cost containment, and defining basic levels of service. As I understand it, the Oregon Health Services Commission meets every year to create a priorized list of health services, ranking from most to least important to the entire population. That group holds hearing around the state to get input. The legislature then decides how far down the list to pay for services, but it cannot rearrange the priorities.
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What I like about this approach is that it looks at insurance from a public health standpoint. It creates incentives for providers and others to contain costs, so that procedures will be covered. It works from a utilitarian analysis of the greatest good for the greatest number.
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There are certainly critics of the system, especially those with conditions that fall below the line for public funding. Their stories make for weepy news items. However, a large number of people seem to be getting their basic needs covered, and the rationing of health care occurs in a rational way.
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Oregon List Overview
Somebody please correct me if I’m wrong.
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Only if WE”RE ALL in the same boat together does rational rationing really work. We need to do it but we have a moral obligation to do it right.
I believe it does just apply to Medicaid, although I think Oregon has expanded the number of eligible people as a result of this approach.
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The more I think about health care and health insurance, the more I think we’re all becoming poor people. My employer’s cost for health insurance for a family of 3 or more is more than $18,000 per year (HMO Blue). I offered the Oregon model less for its specifics than for its approach. It raises the question of what kind of health care is a basic human right. How much coverage should be universal, and how much should we deal with differently? In a universe that doesn’t have an infinite number of health care dollars, how do we collectively decide what health care all of us deserve? I would really like to see the new Mass. law work, and to do it, I think we’ll need to make some hard choices. I’d love to be wrong, but if we have to make choices, I’d like them to be public health driven, rather than determined by arcane insurance company rules.
for 3 items I feel obligated to challenge in brief, for now:
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and
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Important potints to raise, all, but I disagree with where you go on each of them. I hope this discussion, and the HC WG Report, will benefit from a forthright dialogue. Not much time now, but for a start:
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1. If you believe everyone should be able to get HC as a matter of human dignity, doesn’t that lead to affirming it as a right with some legal standing so you can actually move health policy goals beyond rhetoric (“I/We believe that”) to a binding framework to achieve actual policy that fulfills that goal? (such as a constitutional guarantee to health care being one way to make something a legal “right”.) There certainly is a convincing argument built on overwhelming evidence that in addition to being the right thing to do, a true universal health program is the smart thing to do ecomonically.
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2. Re “market function”. Hold up there, please. Health Care just DOES NOT FUNCTION AS A MARKET. And that kind of thinking and policy approach leads to hurting us physically (folks being maimed, permanently disabled, and others dying b/c they can’t afford the commercial product of private health insurance) and huyrts us economically (look what a largely “market-driven” treatment of HC as gotten us in the way of absurdly and obscenely high health costs in MA and the nation). I can’t get all the links to post now, but, please, somebody help out on this one and put some in your comment. It was 15 or 20 years ago that I went to hear Barney Frank talk on this very topic at CCB, and he made this very argument, and made it quite convincingly (no surprise), as do countless other extremely smart and well informed people.
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Understanding that HC does not function as a market is why Barney along with 6 out of our state’s 8 members of congress, incl’g mine -Mike Capuano, yea!- have endorsed HR 676 to establish a National Health Insurance Program to create a public funding mechanism for universal health insurance coverage and a coherrent system for privately delivered care. A national health progam that is, of all things, accountable to the American people.
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We can lead the way in this direction on the state level by re-tooling the recent health reform law into something more akin to HR 676’s more sensible, humane, and economically prudent approach. The Massachusetts Health Care Trust bill will be re-filed soon. Stay tuned, and in the meantime you can get on board to support it , please.
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and finally
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3. No disrespect, Charley, but “the fight” for meaningful health reform has been raging for many a year. A wonderful man, Bernard Lown, who is also a doc and a founding member of the Alliance to Defend Health Care who is now in his 80’s, talks about being part of “the fight” for universal health care reform starting in medical school! And this fight/struggle/movement building has always included the emphasis on creating a true HEALTH CARE SYSTEM in place of the “disease-cure” model that dominates at present.
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Lastly and very sincerely, thanks so much for your post that thoughtfully raises so many imporant elements that beg for wider discussion. A great new resource on Massachsuetts health reform now exists and I am happy to be able to say that it is enjoyable, as well as informative, to use. It is free and available to all at this link Have a look and come back here to make comments, please.
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Civic engagement at a peak. Here on BMG. Thanks again.
If I understand your position, and I’m pretty sure I do, you just want to scrap Chapter 58 and go Universal.
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I just don’t see how that’s politically possible, even if, you’re 100% right.
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Don’t you think Chapter 58 has to be given a chance to succeed or fail prior to scrapping?
I’m up to answering adequately in a blog comment at this time.
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I wish the HC work group mtg held at Dimock health center on 12/4 had been taped, because I think my public comments there would go a long way to answering your question here.
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Maybe you and I could chat sometime. Let me know by email if you’d like to do that. The same invitation goes out to others, including HC work group members.
Good to get your perspective in here, too. I wanted to write about what is immediately going to be on Gov. Patrick’s plate, since he has said he’s going to try to make Ch. 58 work. So I went from that assumption.
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In response to your points:
1. I support the constitutional guarantee to health care. I think that would strengthen whatever legislative solution we have. I just wanted to head off what I see as an unproductive semantic debate as to whether it’s a “right” or not. Who cares? You gotta have it, as a matter of human decency.
2. Sure, health care functions as a market, but a really weird, screwed-up one with largely misunderstood incentives. Even single-payer systems function as markets — just not as “free markets”. But to function efficiently, they need reliable and widespread information just as much as putatively “free” markets.
3. My reference to the “fight” refers to the ongoing implementation of Chapter 58. I’m not under any illusion about how long folks have been fighting for this.
Letter to the Editor in today’s Globe on the issue of state HC reform. I would like to submit this as formal input to the HC working group:
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written by Ben Day, Exec Driector of MassCare (of which I am a member who just happened to ride to Worcester today with Ben and a local doc for a half-day MassCare mtg. Oh the joys of Saturdays…)
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“Health system is what ails us, not city workers
The Boston Globe, December 9, 2006
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IN YOUR Nov. 30 editorial “Hale workers, sick cities,” the Globe implies that Boston employees enjoy Cadillac health coverage while taxpayers foot the bill and receive eroded, Yugo municipal service in return. The Globe proposes making city workers pay more and merging with the state employee health pool as “obvious” ways to control costs.
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For the past two years the City of Boston has ranked sixth among the top employers in the state whose workers have had to receive public health assistance: In 2006 more than 1,500 Boston employees and 1,000 of their children relied on Medicaid or the Free Care Pool. This makes the city a worse offender than all but five other large employers in the state. Are these the workers onto whose backs the Globe is proposing to shift healthcare costs?
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The state, like Boston, has seen healthcare premiums for its workers skyrocket. Boston’s crisis is representative of a national trend faced by governments, businesses, and individuals. The problem is rooted in our healthcare system. Making healthcare a basic right that you don’t receive through the workplace has effectively controlled costs and provided universal access to every other developed nation in the world. It’s time for Massachusetts to have hale workers and hale cities.
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BENJAMIN DAY
Jamaica Plain
The writer is executive director of Mass-Care, a nonprofit that tries to win single payer healthcare for Massachusetts.
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© Copyright 2006 Globe Newspaper Company.
Chapter 58 passed with the good intention to provide the uninsured with health coverage. But just saying that we want everyone covered will not cause it to happen. The present system is too expensive. We need to reduce the cost of health plans before we can offer (or force people to buy) these plans to the uninsure.
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It is time to have the political courage to require that there will be bulk buying of drugs (maybe even from Canada), that there must be a cap on administration costs and that there will be uniform billing.
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Also it is absolutely absurd to allow bad employers to pay only $295 per year for plans that are running $7,000 to $12,000.
Hi Charley and Commenters – thanks for posting such thoughtful and extensive reviews of the health care issues facing the Patrick administration.
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When we look at the state subsidy component of the bill, which offers some form of financial aid to individuals up to 300% of poverty, it’s important to be aware that many similar bills have been passed in other states, some less ambitious and others much more ambitious than the Massachusetts plan. None of these laws have been able to reduce the percentage of the population that is uninsured – much less approach universal health coverage – which does not mean that they aren’t working, but just that the health care crisis is moving faster than the public health programs trying to catch up with it.
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The Washington Basic Health Plan way back in 1987 tried to subsidize health insurance for all residents up to 200% of the poverty line. But there was a funding shortfall early on, and presently enrollment is capped at 125,000 with another 400,000 or so eligible but unenrolled.
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The most important example, Tennessee’s TennCare, attempted to subsidize insurance up to 400% of the poverty line, and actually succeeded in enrolling 400,000 uninsured people under the TennCare expansion. However, when you look at the whole population, while the rate of uninsured dropped from 14.7% to 11.2% following the first year of implementation, the very next year the uninsurance rate jumped right back up to 16.4% and has stayed there. Last year, one out of every four Tennesseeans under 65 were enrolled in Medicaid – an unprecedented level of public support – and yet a single year of the normal progression of the health care crisis was enough to wipe out the gains of the country’s largest public health care expansion.
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Even here in Massachusetts, a massive MassHealth expansion added over 300,000 uninsured residents to the public rolls, reducing the uninsurance rate here for several years. But just two or three years later, we were back to where we started, and the uninsurance rate in Massachusetts has actually risen much more steeply than the national average in the last two decades, and we have lost more ground even than Texas or Florida (with the highest percentages of their population lacking insurance).
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The basic lesson is that even massive expansions of public health insurance programs are not able to even make steps towards universal coverage, and it is disingenuous to pitch them as such – although every such bill ever passed is covered by the media as a universal health care initiative. What they actually represent, are vitally important damage control measures for the uninsured. We need to support these efforts, but we also need to work towards truly universal, comprehensive coverage – and incremental expansions can’t get us there.
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We face even more of a challenge in Massachusetts because our incremental expansion bill doesn’t even attempt to control costs. Most similar bills in the past have been premised on reinvesting savings or generating new revenues of some sort – either from moving medicaid recipients into managed care plans, or from new tobacco taxes. But Chapter 58 contains shockingly little financial framework to support its mostly worthy exterior. But this, nonetheless, will put Chapter 58 firmly in the tradition of previous incremental expansions, all of which run up against budget limitations before they can make an enduring dent in the uninsurance rate.
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The individual mandate on the other hand represents to me an extremely disturbing trend in health care reform. The “personal responsibility” rhetoric springs from the attack on welfare – recall that the Personal Responsibility Act was one of the ten platforms of Newt Gingrich’s “Contract with America.” (Read AFL-CIO President John Sweeney’s original [ press release http://www.aflcio.or… ] criticizing the bill, expressing shock that Massachusetts would take a page from the Gingrich playbook.) Personal responsibility has been adapted for the health care realm in the shape of High-Deductible Health Plans and HSAs (for private insurance), Medicaid reforms that attempt to force enrollees to abide by “personally responsible” behavior or lose their benefits (for public insurance), and individual mandates (for the uninsured). Although sometimes couched in progressive terms as if only the well-off with discretionary income to spare will be affected, the measure in reality targets the lower middle-class, which is increasingly affected by uninsurance and underinsurance because they are less and less able to afford it.
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There is a whole body of research showing that the American middle-class is increasingly shouldering unsustainable levels of debt, and is losing its capacity to save and weather financial disruptions (spells of unemployment, unexpected costs, etc.) See the report [ Middle Class in Turmoil http://www.americanp… ] by the Center for American Progress for some truly disturbing figures about the financial insecurity of the middle 60% of Americans.
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I would offer the brief correction that the merging of the non-group and small group markets will not “lower premiums” – it will lower premiums for the non-group market (individuals), but raise premiums for the small-group market.
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The $56 billion question then is how do we control health care costs in Massachusetts? Most of the measures that states have turned to in the past have had limited or no success. We know that single payer systems are vastly more efficient, and they are the only systems with a track record of achieving universal health care (there are no counter examples in the history of the planet, thus far). This might seem like a difficult political struggle, but it beats struggling for reforms that don’t work.
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Many of the smaller steps that Charley mentions in his initial post I believe point towards single payer in that they attempt to consolidate and streamline health care financing, taking some of the rough edges off of our fragmented, immensely wasteful system.
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Senators Steve Tolman and Bruce Tarr have a bill, for example, that would bring a uniform billing mechanism to all insurers and providers in Massachusetts.
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Senator Pat Jehlen has a bill that would, as Charley describes, impose a limit on how much insurance companies can waste on overhead expenses, so that a higher percentage of our premium dollar would actually go towards care.
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And Senator Montigny has in the past sponsored a bill for bulk purchasing of pharmaceuticals.
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It’s unclear how much cost savings we could actually get from such measures – they would be steps in the right direction, and they deserve far more attention than they have received in the public eye. But there is really no substitute for the single payer option, which allows for global budgeting – the golden arrow of cost control.
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We have a saying in the single payer movement that hails from David Lloyd George: “You can’t cross a chasm in small steps.” But you can of course try to keep from falling in until you’re ready for the leap!
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(All of this information on the new health care law and more can be found in Mass-Care’s new powerpoint presentation on Chapter 58, available by [ clicking here http://www.masscare…. ].