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The real death panel

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As we all know, there are no “death panels” in the actual health care reform bill — that’s a fantasy of Sarah Palin & Co.

But there is a real death panel up and running right now: the U.S. Senate.  NYT:

The Obama administration sent signals on Sunday that it has backed away from its once-firm vision of a government organization to provide for the nation’s 50 million uninsured and is now open to using nonprofit cooperatives instead.  Kathleen Sebelius, the Secretary of Health and Human Services, said on Sunday morning that an additional government insurer is “not the essential element” of the administration’s plan to overhaul the country’s health care system….

[T]he Senate Finance Committee appears to be forming a bipartisan consensus around the idea of nonprofit insurance cooperatives. The health care industry prefers that format, even though many liberal Democrats have argued that cooperatives would not have as much sway over the prices Americans pay for health care.

So the Senate, in effect, is strangling real health care reform in its cradle.  Instead, we’ll get some modest tweaks, which will help, but which probably won’t do what’s necessary to stabilize the system.  Which likely means higher costs, and higher premiums, into the foreseeable future.  Good times, good times.

The real death panel is the Senate.  Pass it on.

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  1. At first blush, health cooperatives sound like a decent alternative, and who knows, maybe they will be. (Though certainly not if they can’t negotiate drug prices.)

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    p>But what really scares me about them is a thing called demutualization. There is a history of member-owned institutions being taken private by management — essentially at the insistence of the financial markets that decry the market “inefficiency” of cooperative ownership — and legally by bribing members with a one-time payoff.

    <

    p>It’s what happened to the majority of customer-owned life insurance companies, after actual life insurance became less profitable than something called “wealth management.” So the safety-net aspect of the industry, available to a broad range of working people, was marginalized in favor of chasing wealthier customers. It’s a frightening precedent for health care.  

  2. That’s huge.

    <

    p>We already have PHARMA supporting the reform because of millions of new potential customers, and now, if public option bites the dust, we have big insurance supporting the reform because of, yep, millions of new customers compelled by law, to be customers.

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    p>Drop the label health reform and just call it the Stimulus for Health Insurance and Tax bill, as in the SHIT Bill, because now it appears to be shaping up to take i) money from employers at 8% of compensation plus ii) a bite from taxpayers and give the sum to PHARMA plus insurance companies.  Right?  I suppose Doctors will get a cut too.

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    p>A federal law requiring all of us to make a deal with the insurance company.  Cue the impassioned libertarian plea…

    <

    p>Seriously, it’s a lame bill WITH the public option.  It’s lame times 10 without it.  Roadkill compared to roadkill after a week in the sun.

      • Which is typical… it’s a big bag of crazy over there.  

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        p>

        HEY————IT AIN’T OVER AT THE FAT LADY AIN”T SINGING (0.00 / 0)

        Stop patting yourself on the back. Now it is time to go for the jugular. You think for one second that these morons in Washington aren’t planning on shanking you? Wake the F#%& up! This is just the beginning. There are many more battles to be fought between now and 11/10. On 12/10 you can pat yourself on the back when we have a reasonable parity in Congress. After Gingrich and company stepped on their dicks and George Bush–I no longer trust anyone in Washington!

        by: Seaworthy @ Sun Aug 16, 2009 at 19:32:51 PM CDT

    • Gays!  Affirmative action!   Sex changes!  Be afraid!

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      p>

      1. Will Affirmative Action quota requirements be a deciding factor in who gets health care services?  

      2. Will ObamaCare cover the cost of sex changes?  As discouraged as I am that nationalized health care may cover abortions – I am equally concerned about federal health care (ObamaCare) covering sex change operations.  I would hate to think that while a man in one room is waiting to see his doctor another man in a room across the hall is getting an addadictomy.  Who will decide which operation has a higher priority?

      3. Will ObamaCare treat gay couples as though they are legally married at the federal level, thus requiring a decision by the Supreme Court to make matters consistent?  Are we opening a can of worms that will somehow contradict current legislation?

    • The answer is a bill that takes a long while in carefully crafting it and making damn sure that the federal government is unable to strong arm anyone. I want zero regulatory power by those morons in Washington ie FANNIE MAE, FREDDIE MAC and the SEC!  Those corrupt and incompetent imbeciles torn everything they touch to SHIT!

  4. but many choose not to read it. The biologics bill which garnered no attention no fan fare passed in favor of the biotech lobby. Waxman wanted 5 years and he settled for 12.

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    p>I am happy about Obama’s latest move here. Medicare doesnt reimburse doctors what it cost to care for medicare patients. The lose money on medicare patients thereby transferring the losses to private pay patients and insurers.

    <

    p>Why does govt think they can pay less than what it costs to care for there mandated programs? Should we lose money on every transaction and just make it up in volume? Real life tells us that if we run deficits we will fail, not so for govt agencies, print more money and laugh.

  5. favor of co-ops?

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    p>I have to say this is one of the most stunning displays of political cowardice I’ve seen in my lifetime.  Ugh.  What a fiasco.  And the thuggish goons who will be celebrating the killing of a public option are likely the ones who would most benefit from it.  Not exactly America’s finest hour.  

  6. at every HMO in America. The fact that the Harry Reid would allow enough Democrats to be peeled off to favor those death panels over keeping people alive and saving money over the long haul is baffling.

  7. How does the public option fix the problem of runaway costs?  

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    p>Here are a couple of links that suggest it doesn’t, because the real problem is aligning incentives and making people responsible for and vested in how much they spend for medical care.  

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    p>http://money.cnn.com/2009/08/1…

    <

    p>http://www.thehealthcareblog.c…

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    p>If we don’t change the way we pay I don’t think its going to matter if the insurance company is Uncle Sam or not (although it will likely significantly impact who pays).

    • jibe with the many European (and Canadian) varieties of health care, where that alignment doesn’t seem to exist to the extent it does in America, yet they have longer expected lifetimes, lower infant mortality rate, and lower total medical bills?

      • But some questions:

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        p>Are the proposals currently on the table essentially the same as the European/Canadian models?  I didn’t think so.

        <

        p>Perhaps those models are better than what we have now but could be improved upon?  I am not advocating for the status quo, which clearly is not working.

        <

        p>Is it reasonable to compare other countries, particularly Europe, to the US?  Immigration, population diversity and density, significant cultural differences (e.g., our amazing fascination with fast food), etc. seem to make such comparisons very difficult.  What do you think?

        • the real problem is aligning incentives and making people responsible for and vested in how much they spend for medical care.

          <

          p>There’s this idea from the right that people treat their own bodies and doctors visits like they would Coca-Cola or Levis.

          <

          p>Even if it cost me nothing out of pocket to go to the doctor, I still wouldn’t go more often than necessary.  After all, I don’t like taking time out of the middle of my day, I don’t like going to/from the doctor’s office, I don’t like filling out forms, I don’t like reading 8 month old Sports Illustrateds, I don’t like sitting in an over-AC’d room with my shirt off on that leather bench, I don’t like tongue depressors or blood pressure armcuffs or a flashlight in my ear.  So, why would I take more of it were it free?

          <

          p>

          <

          p>Now, consider the group of 40M+ who suspect (or know via a doctor) that they need care, but can’t afford it.  Even though they too don’t like to visit the doctor, they’d go… because nobody likes to live in pain, and we all have families who depend on us and love us and we can’t be there for them 100% if our bodies aren’t at 100%.  So, all these people would go to the doctor despite their dislike for the process, but don’t because they can’t afford it.  Now their families suffer.  Their health suffers.  Their jobs suffer.  The fact is, society as a whole suffers.  When the person just can’t take it anymore of the problem gets worse, they go to the ER, costing us all more money.  When they finally become eligible for Medicare, their problems may have become chronic, and now their Medicare benefits will cost the system more resources.

          <

          p>

          <

          p>So my point is simply this: the idea that we need to align incentives to make people responsible is nonsense.  If people won’t quit smoking to avoid the pain and suffering of lung cancer, they aren’t going to quit smoking because they’ll be the ones paying for the medicine.  Same goes for heart problems and obesity, same goes for extreme sports and broken bones.  People already have enough incentive to avoid doctors offices — the ones who don’t have an aligned incentive are insurance companies because they make more money by denying more care.  Medical care ain’t a can of Coke; humans already have hundreds of thousands of years of evolution telling us we don’t like getting sick.

          • I think there is enormous overuse of the current system.  How many people run to the doctor every time they get a cold?  Or their kid gets a cold?  Just because you don’t doesn’t mean it doesn’t happen.  

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            p>So explain to me, how will this insurance reform, which is what the bills are proposing, reign in the cost of providing medical care?  Doctors certainly aren’t the ones that are going to be the gatekeepers on cost.  If not the patient or the doctor, then who?

            • “I think there is enormous overuse of the current system.”

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              p>If you are right, that’d be a significant point in the conversation.  However, what you’ve added here are not even anecdotes, but rather hypothetical anecdotes.

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              p>I’d love to look a cite.  

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              p>BTW, I don’t think I disagree that much with you (hard to know without some specifics), but I also think it’s a lot more complicated than stated.

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              p>With regard to your question ‘how’?  Comparative effectiveness should do a significant job of discouraging unnecessary tests, which probably represents the majority of the ‘over use’ you (don’t) cite.

              • My comment was based on personal experience, observation and common sense.  I have a pretty significant amount of gray hair.  

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                p>Obviously the less you charge for something the more people will use it.  Rational people will, anyway.  And I think we need to assume most people will behave rationally notwithstanding that there are those among us that are killing themselves with tobacco, food, alcohol and drugs.  I can’t see how to make doctors the gatekeepers on cost.  They make more money and reduce their liability exposure by providing more services and prescribing more drugs and tests.  

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                p>I’m not that bright, so please explain what comparative effectiveness is and how this will keep costs down (and why it isn’t currently employed).  

                • … gray hairs aren’t data.  We actually need to fix this problem for our future.  We can’t rely on gray haired anecdotes and common sense.

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                  p>Comparative effectiveness is exactly the kind of thing that finds efficiencies from looking at the data rather than making assumptions based on what is common practice.  

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                  p>Right now we are in a situation where the amount of money spent is a poor predictor of outcomes, as is evidenced by a (now famous among policy wonks)chart:
                  (click on picture for blog-post)

                  <

                  p>Comparative effectiveness is an effort to increase the knowledge base for finding what works to better inform treatment choices and avoid unnecessary.

                  <

                  p>

                  If you reworked all the incentives for doctors tomorrow, they wouldn’t overprescribe as much, but they might not get any better at prescribing care that’s actually of high quality. That sort of transformation requires a whole lot of evidence, which means funding a whole lot of comparative effectiveness research. Currently, that’s not happening, and so a lot of the data comes from medical device manufacturers, pharmaceutical companies, and so forth. It’s not exactly pure and unbiased information. That’s why so many health wonks are so big on things like comparative effectiveness boards. If we spent a couple hundred million a year testing treatments, we’d make it back tenfold in cuts to total health spending.

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                  p>As to your other conundrum: “I can’t see how to make doctors the gatekeepers on cost.”

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                  p>Certainly comparative effectiveness should make physicians better cost controllers, but the systemic problem remaining is that our current system is set up so as to incentivise testing and procedures and not outcomes.  The trick here is to take stock in what’s going on here.  Patients, as consumers of health care, don’t behave like normal consumers of other products.  As patients we listen to our doctors to find out not what we want but what we need.  Our health purchasing decision is informed by the doctor, and not much else.  As with a lot of things, treating health like any other commodity can actually end up with counter-intuitive results:

                  <

                  p>

                  A lucky I-banker who walks into a specialty foods store with corporate credit card heads for the caviar and oysters because caviar and oysters are delicious, and he wants more of them. They are luxury goods, sensual pleasures that we love to experience when finances permit, but understand we can do without when incomes tighten.

                  By contrast, colonoscopies and MRIs aren’t a good time. If I won a $5,000 spending spree from my local bank, I would not rush to for a gastrointestinal check-up, even if it came with a side of general anesthesia. But if my doctors told me I need a colonoscopy or an MRI, I’d get one. Diagnostic tests and medical treatments are not luxury goods. They are necessities. They do not feel like a choice. Which is why some many of us go into debt, take out second mortgages, and draw down savings. Hubbard characterizes the purchase of medical tests as “our decisions,” but that’s inaccurate. They are our doctor’s decisions. We don’t want to make those purchases; we’re informed that we need to make them. Then we try and figure out how to pay for them. But the economics around luxury goods are quite different than the economics around necessary goods; you can’t compare chemotherapy with a sumptuous steak.

                  <

                  p>This means we have to change the system to incentivise outcomes rather than tests and procedures.  The first thing you need to do that is get good data on outcomes (comparative effectiveness).  The next thing you need to do is rework the compensation system.  Unfortunately what we have on the table only gets us part of the way there.

                  <

                  p>

                  Similarly, the bills call for empowering a federal panel to set Medicare rates free of pressure from providers, and for programs to test payment models that emphasize the quality of care instead of the quantity of treatments delivered. But these steps may not be enough to bring about the change that many experts urge — away from a system in which we pay for every MRI or drug infusion on a case-by-case basis, and toward one in which salaried medical professionals are paid to do what it takes to keep us healthy.

                  <

                  p>The part she’s talking about there is the MedPAC provision.  MedPAC is a republican idea.  There is a non-partisan panel of medical technocrats and experts that evaluate Medicare and submit a report to Congress (I think annually) on what should be done to make it better.  The problem is that how ever good the recommendations are, they are muddied (and usually lost) in the political process that is the legislature.  The bill would make passage of MedPAC recommendations automatic unless ‘opposed’ in whole by a joint resolution.

                  <

                  p>Hope all that is illuminating.

                • It’s ok.  I’m pretty sure I’m still able to have an opinion based on experience, am I not?  You are free to agree or disagree, of course.  You seem to fear that someone will be forming policy based on my observations.  I’m thinking that such an occurrence is fairly unlikely.

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                  p>As for the famous chart you posted, does not the second paragraph under it (if you click on it) support my experience based opinion that misaligned incentives lead to overuse of the system?  And the third paragraph under the chart speaks to the concept of comparative effectiveness.  I agree that we should invest some money in better understanding what works and what doesn’t.  However, there will always be a certain amount of trial and error in medicine and I think we need to be careful not to stifle the process that leads ultimately to effective treatment even though we don’t know the shortest path to take when we begin.  

              • … is a problem with over use of emergency medicine for non-emergency care.  Much of that, however, is due to lack of access to general care.  As is often pointed out by conservatives, they’ll treat you in an emergency room (somewhat,… sometimes) even if you have no insurance or GP.

            • because the conservative mindset is that there are hoards of unworthies who completely sponge off of social services.  An entire army of welfare queens, unqualified affirmative action recipients, and entire families who qualify for government health care but instead turn it down and go to the E.R. for a paper cut.  It’s a meme, but it’s supported by anecdotes, not data.

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              p>A friend of a friend who goes to the doctor when he gets a cold is an anecdote.  40 million people without access to affordable health care because they are uninsured is data.

              • You can roll out the C word, head fake, spin move, etc., but ….

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                p>How about an answer to the question:

                <

                p>So explain to me, how will this insurance reform, which is what the bills are proposing, reign in the cost of providing medical care?  

                <

                p>Don’t forget the data.

                • You spew out anecdotes and claims without data, and without economic theory.  When you get called out on it, you want everybody else (see: Mr. Lynne) to do your work for you, and then you just ignore it and move on to the next poster (see: stomv).

                  <

                  p>Nah.  I’m not playing your game of the ostrich with head in the sand assigning homework to all the thoughtful, rational, reasonable bloggers who use teh googlez to actually assemble useful, interesting posts, which you promptly ignore.

                • Say it isn’t so.  I’m crushed.  Five years of therapy down the drain.  

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                  p>Did you read what Mr. Lynne posted?  It actually supports my view.  
                   

              • Here are the first few paragraphs to one of the links I posted above.  Apparently he didn’t get the memo.

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                p>

                I was born into a Berkeley family of Social Democrats-my father studied Swedish economic  policies-then I trained in social-democratic Economics in Scandinavia, before cutting my career teeth in a Norwegian Labor Party think tank. I thereby personify the threat trumpeted by Republicans: the sinister spread of Social Democracy.

                So I am cheering wildly for establishing a federally owned health plan, right? Wrong.

                Not that I’m particular opposed, either: It’s just not a big deal. Either way, new government-run plan or not, there won’t be much impact on our nation’s enormous health care problems.  Our health care dilemmas-high costs, poor access, and mediocre outcomes–stem from much more fundamental issues than who sits on the board of yet another insurance plan.

                These include the perverse incentive structures for key decision makers in the industry, including insurers, providers and patients. Insurers earn money by serving the well rather than the ill who need their assistance most, providers don’t become rich by managing care over time but by medically over-treating the critically sick, and consumers are incented to both stay out of the insurance pool until they’re sick and to seek medical help late.

                 

      • The expected lifetime measure is not indicative of a health care system.  What about lifestyles?  What about culture?  National genetics?  Besides, we’re talking a difference, in some case, of months.  This is statistically meaningless on 75 or 80 year lifespans.

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        p>I’d MUCH rather be here at age 50 than in Canada or Britain.  What are our cancer survival rates?  Cardiac and stroke survivals?  Severe pediatric complications?  Emergency care?  I bet they’re all WAY BETTER here.  People from around the world come here for treatment.  Why is that?

        <

        p>Total lower medical bills?  That’s a sign of lower medical bill, not better health care.  We spend much more per capital on computers than the EU … should we spend less?

        <

        p>Why do Canadians and Brits come to the US for critical care?  Mayo Clinic, MGH, Anderson, Sloan Kettering, Cleveland Clinic …  

        • …some have called for tweaking the language to talk about health insurance reform rather than health care reform.

          <

          p>People come to the United States because we do have the best care in the world, but I wouldn’t be surprised if the coverage aspect is still handled by the patients’ respective home systems.  That being said, I think the quality in other countries sometimes gets a bad rap.  I don’t remember the details, but I seem to recall something about Rudy Giuliani saying he wouldn’t be able to survive his cancer in another country, but this claim was demonstrated to be false.

          <

          p>You and the previous commenter have mentioned culture, which seems to suffer from a split personality.  Fast food is indeed big business, but so are, it seems, various diet and weight loss plans.  I for one have said all along that I’m more willing to be generous with things that go toward prevention.

          • It’s health insurance reform, but the other side, health care, is where we have a cost problem.  How will health insurance reform impact the cost of providing health care?  The links I posted upthread don’t think it will.  I’d love to hear someone articulate how this is supposed to work.

          • cancer survival rates discussed here.  I’ll try to address the others.

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            p>In the meantime, I pose the same question: why do kings, princes, the wealthy, and the privileged come to the US for treatment?

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            p>How come rich American’s don’t go to Toronto, Vancouver, London or Bonn for treatment?

            • Doesn’t really make your point, does it?

              <

              p>How do you know folks don’t go abroad for treatment?

                • Viva la free trade.  

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                  p>Apparently there are a few thousand people per year who take healthcare/tourist vacations and go to another country for a procedure and have that procedure covered by insurance because the procedure is cheaper in the other country.  The practice speaks more toward free trade than it does comparability of systems between countries.

                  <

                  p>The Farra Fawcett example is further to that point. U.S. Government Regulation prevented her from a particular treatment in US so she sought it elsewhere.

                  <

                  p>Irony that the same person who can go thousands of miles to another country for a medical procedure because it’s cheaper can’t also go to another state for health insurance because it’s cheaper.  And that the answer to that dichotomy isn’t to make shopping across state line less regulated, but rather create a Federal Bureau that regulates it more!

  8. Pleeez ..Last time I heard “chills down my leg mathews”  told me it was 40 million David. What happened? did we let another 10 million illegal aliens in last night?  Wouldn’t surprise me  at all.
    Seriously , How Many are actually” uninsured” that is to say EXCLUDING the some 12 or so million that have access but don’t take the time or interest or are perhaps too stupid to even enroll ? Then the somewhere between 28 and 40 MILLION people in the country that are here ILLEGALLY?

    <

    p>What we’re seeing is ” silent majority” finally awakening and they don’t like what they’re seeing. Far left liberals need to get used to the idea that this is  in fact, a Center right country. Check out the poll numbers and get ready for 1994 redux when the liberal left politicians are given the boot in 2010  …ain’t gonna be pretty for the left…watch

    • Two years go, it was 45.7 million. That’s the latest data the Census has. It’s wonderful that you don’t care that those people are falling into bankruptcy or death because the insurance companies have bought our national legislature.

      <

      p>What we’re seeing here is the same old shit from the reactionary crowd. It smells just as bad every time they start flinging it around, and they never bother to clean it up.

  9. The public option is a stinker.  And it’s political trouble for Dems in 2010 even if it doesn’t pass (which would be suicidal.)

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    p>A solid majority of likely voters are against it, and I bet you’ll see Republican congressional challengers running campaigns with “they’ll be back” messages that resonate, winning seats in close districts.

  10. Prior to abandoning the public option, the Administration had cobbled together a strong Baptist and Bootlegger coaltion, with Universal Health Harpies unwittingly teaming with PHARMA.  They appear to have been beaten back by the Tea Parties plus Insurance Companies.  Baptists and Bootleggers in everything!

    <

    p>If the public option is properly dead, the next target ought to be the individual mandate.  Unfortunately, I can think of no monied coalition at this point opposed to the mandate what with Pharma, physicians and insurance on board.

  11. …when you START with a compromise.  If we had single payer as the starting marker the current proposal WOULD be the compromise.

    • A minority of Americans want a public option.  You cannot sell a universal product for all Americans that the majority do not want.  

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      p>The same fate, I predict, will befall GM and Chrysler if the autos they produce are the ones Congress wants and not the American car buyer.

      • I searched the web a bit before responding to this comment to see if I could find a poll question specifically about what people think of a public option, but came up empty.  If you can do better please let us know and post the link. I’ll say right away that generic questions about Obama’s handling of the issue don’t count as people on the disapproving side of that question could include staunch single-payer advocates and those who just don’t think he’s communicating very well.  I need to see “Do you support or oppose the public option currently being discussed?”

        <

        p>That being said, I could not care less about the polls, even as they mostly indicate that the public DOES feel we need an overhaul of some sort.  There are plenty of people who think that the reforms will not effect them and that’s fine because they are correct and should not be counted automatically as opposing.  This is the right thing to do and I accept that the persuasion end needs work.  Elected leaders are supposed to shape public opinion not the other way around.

        <

        p>Not sure what the auto reference was about.  As I recall those companies had problems precisely because they insisted on building vehicles people no longer wanted BEFORE the government got involved.  Besides, I don’t like tha market analogy in this context anyway; for many of us precisely the point is to neutralize the effects of the market on health care.

  12. Any health care system rations care. It’s impossible not to. Resources are limited. Care might be rationed arbitrarily, or by plan, policy, or panel. It is still rationed. That’s just inescapable.

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    p>A thoroughly private system partially hides this fact.

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    p>There’s the illusion that, if one insurer won’t cover something, another one will and one can always switch insurers. But this is pure illusion: if a catastrophic illness strikes you, you’re very lucky if you can retain your current insurer. You won’t be able to afford switching insurers during such crises. It’s not going to happen.

    <

    p>A public system exposes rationing. Instead of being obscured policy it is public policy.

    <

    p>We humans who would all prefer to be immortal and have infinite resources at our disposal do not find this state of affairs comforting.

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