Tom, Welcome to the Lake.

Merrill, Thank you for Hosting today’s Book Salon.

Welcome to Firedoglake!

From T. R. Reid;

hi, merrill, and Happy Hallowe’en, everybody! I’m delighted to be here to talk about my book, and the goal of universal coverage at reasonable cost.

Hi Tom,
You traveled all over the world trying out different health care systems. We know the U.S. ranks near the bottom in terms of performance and satisfaction. Which one would you say worked the best, and why?

Hello Mr. Reid! Your book is an important work and I learned a lot from reading it.

I’d like to ask the following question:

“In your interview with Joan McCarter over at Daily Kos, you said that the current proposals for health reform in Congress were just ‘tinkering at the margins’ of the health care system. Can you elaborate on why that is?”

Which one worked the best? I’d say there are a dozen or more health care systems in rich countries that are working well. If a country covers everybody, provides fair access to all, maintains high quality standards, and keeps costs under control, that’s a success in my book. And many met that standard.
As a patient, a husband, and a father, I liked the British system. The doctor came to our house, usually within a couple of hours, and there were no bills. The care was just as good as we get in the u.s. The Japanese system also worked well for our family; and in japan, you have the definite plus that, when the nurse calls your name in the waiting room, she says ‘Could the highly honorable mr. reid please come forward?’ you’ve gotta like that.

Tom, Merrill,
How do you think the vote will go in the Senate this coming week?

Yes, we were very pleased by our medical experience in Japan, too. But I’ll let you move on to the health care reform question posed by khin . . . I think we may spend a lot of time talking about the health care reform bills this evening.

Thanks for being here. I saw the former Prime Minister of Singapore on Charlie Rose about a week ago, and he just shook his head and said in so many words that the US is just not dealing with the problem of health care reform.

Is there a buzz in other countries about the obtuseness of America and the “collateral damage” of its own citizenry in terms of health care profiteering?

I’m not yet done with the book, but the clarity with which it is written is wonderful. The opening chapters lay out the four big issues every system has to wrestle with (coverage, quality, cost, and choice), and do a very good job of introducing the basic vocabulary of the discussion.

The U.S. has the most expensive and the most unfair system in the developed world. Both of these problems stem from our failure to provide univ ersal coverage.
This may seem counter-intuitive, but universal coverage is not only fairer, it’s also cheaper. All the countries that cover everybody spend vastly less on health care than we do. That’s not a coincidence. Auniversal system has a)the economic clout and b) the political will to impose tough cost controls. Unless everybody is in the system, you get the constant cost-shifting and protection of inefficiencies that are standard in the U.S.
Another issue with our system is that much of the payment system (insurance) is for-profit. All the other countries, even those that rely on private health insurance companies, have determined that the payment has to be non-profit. This is a key distinction. providers (docs, hospitals, etc.) can make a profit. But other countries see a basic conflict between paying for people’s medical care and paying a profit to investors. But none of the pending bills in Congress deals with this concern.

I’m a poor political prognosticator. I think it will pass with some watered down version of the public plan. I also don’t think Republicans will be able to hang together to sustain a filibuster. All the attention has been on the Democrats ability to get to 60 votes to end one. But I think a handful of moderate Rs will say, I’m going to vote no, but I don’t want to be seen as an obstructionist. But I may be too optimistic.

hi tom, thanks for coming to talk about your book. i just got it, after hearing you speak (via podcast), but haven’t read it yet.

But other nations have one thing in common that America doesn’t have. Most foreign countries start from the moral imperative that health care is a right. Everyone has to be covered by the national system, whatever it is. “Having made that decision, the other nations have organized health care systems to meet that fundamental moral goal,” he writes near the end of his journey. “If the United States made the same moral choice to provide universal coverage, then we, too could design a fair, efficient, and high-quality health care system for all Americans.”

we seem to have a weird disconnect going on, where democrats will sometimes talk about health care as a human right and the need for universal healthcare… and then go on propose policies that divert massive amounts of money to corporate donors and are not universal. but they still use the human rights / universal argument as justification for the policies they propose. makes me crazy. in your travels and research, did you come across any other countries that had that kind of a disconnect?

yeah, other countries love to denounce the US for its “cruel”, “ruthless,” and costly system. In our debate, the bad word is “Socialized Medicine.” In other countries, the bogeyman to be avoided at all costs is “US-style medicine.”
They all enjoy a smug superiority to our country when it comes to health care. if we ever fixed our system, that would be one less thing they’d have to sneer at.

Mr Reid,

This Jon Walker, health care writer here at FDL. Recently, I’ve been trying to draw attention to the dangerous lack of sufficient risk adjustment mechanism on the new exchange. The Dutch which should be the closest model have spend a lot of time and effort on this issue. Do you think it is one of the biggest problems with the current reform plan and if not what did you think is?

Well, we know they will pass some bill. And the Democrats will declare victory. And any of the bills now pending would improve our system.
Maybe you can explain to me the difference between a “robust” and a “weak” public option. To me, a strong option is one that’s available to everybody (as the Obama 2008 website promised in the campaign last year. That would provide real competition for private insurers. But I think all the proposals for a pub. opt. limit it to a small %age of Americans. To me, that’s weak.

In watching the twin debates in DC over health care reform and financial market reform, this passage from the book really stood out (p. 31):

For those Americans who are uninsured or underinsured, any bout with illness can be terrifying on two levels. In addition to the risk of disability or death due to the disease, there’s the risk of financial ruin due to the medical and pharmaceutical bills. This is a uniquely American problem. When I was traveling the world on my quest, I asked the health ministry of each country how many citizens had declared bankruptcy in the past year because of medical bills. Generally, the officials responded to this question with a look of astonishment, as if I had asked how many flying saucers from mars landed in this ministry’s parking lot last week. How many people go bankrupt because of medical bills? In Britain, zero. In France, zero. In Japan, Germany, the Netherlands, Canada, Switzerland: zero. In the United States, according to a joint study by Harvard Law School and Harvard Medical School, the annual figure is around 700,000.

In a system that treats health care as a commodity rather than a right, these kinds of numbers are only to be expected. Sadly, many of the same forces that are twisting the health care system are also twisting the financial system — and in both cases getting in the way of substantive reform.

Its not universal access to the public plan that is necessary. A strong public option would have the power to negotiate prices, say no to expensive and ineffective care, and have the flexibility to encourage more cost-effective and effective forms of delivery — like encouraging its members to move into group plans staffed by salaried physicians.

i argue in the book that designing a nation’s health care system is, at bottom, a moral decision. If a country makes the moral commitment to cover everybody, you can design a system that does it. All the other rich countries have done so. The major flaw in our debate this year, i think, is that we have not made the moral decision to cover everybody. The best of the pending bills would leave 19 million of us uninsured.
I agree with you. If politicians are going to invoke the moral argument, they should produce a system that covers everybody.

Welcome Mssrs. Reid and Goozner. T.R.’s book recently got a lot of publicity being quoted (or misquoted) by Sen. Conrad. What do you have to say about the way he characterized your findings, and what core principle did he get right or get wrong?

Yeah, but if it only covers 5% of the people in a state, docs can opt out of the public system. In my relatively upscale neighborhood of Denver, many docs put up signs saying they won’t accept Medicare rate. They’ll do the same to a pub. option if the loss of business isn’t great. The more people you get into the system, the more pricing power it has.

One of the dilemmas health care reform advocates face is how to confront/respond to the current Senate and House bills. One argument is that they’re vastly better than what we have — e.g., 30 million more people covered, a $$ trillion extracted to help pay for more coverage and lost of other stuff. On the other side is the missing universal moral imperative, the bailout of the for-profit industry, mandates without sufficient subsidies, etc.

Where do you come out on that balance? Or another way to ask the question:

Which of the reforms in these bills are worth preserving, as foundations for something better, and which are steps backwards?

Considering the fiscal crisis in the US, single payer medicare for all would have been renewing and sustainable, a miraculous and sane answer, but the symbiotic campaign finance union at the hip between our reps and corporate lobbies throws out that solution.

Which is a better system in this country, Medicare or the Vets Plan? I know with the vets plan there are not protections for big Pharma and it was not mucked with by Bushco in 2003 like Medicare with the Advantage stuff.

How did other countries like Canada and Japan abort the profit-sucking of the corporations and nationalize?

Far be it from me to criticize Kent Conrad. He read my book, and then he bought copies for all the Dems on the Finance Committee. A discerning reader, for sure.
Sen. Conrad noticed, accurately, the parts of my book on rich countries that cover everybody using private providers and private insurance. He didn’t mention the significant regulation of insurers in those countries that force them to cover everybody, pay every claim, and hold their admin. costs down to about 5%. But he’s an intelligent man; of course he recognizes that we need much more regulation of private insurers if we’re going to rely on them to cover everybody.

From the post:

Let me finish this introduction by highlighting one other important message in his book, which deserves special attention because it has been largely overlooked or dismissed in this year’s debate. Unlike far too many health care pundits, he learns through his visits to other countries about the close connection between universal coverage, disease prevention and overall population health. In our non-system, people shift insurers with every change in jobs and they eventually wind up in a government program — Medicare — when they hit their medically high-cost years. That means private insurers have no incentive to keep people well. Prevention is an extra cost whose benefits will be reaped by a different insurer.

That last sentence captures the perverse effect of financial incentives in our current system. And Merrill’s right: this has indeed been largely overlooked and dismissed.

Tom, what do you see as the biggest obstacle to shifting the incentive structures in favor of prevention?

Health care should be regarded as a civil and human right.

The 45,000 people prematurely dying each year from inadequate health care. Why didn’t that have more of an impact on Congress and Prez and media? I guess that’s pretty much rhetorical.

I really liked your interview on Fresh Air.

When are you going to appear on the Sean Hannity Show?
The Bill O’Reilly Show?
Have you been asked to be a guest on the Glenn Beck Show?
How about Rush Limbaugh?
Has your PR team contacted the Mark Levine show so you can be booked as a guest? When will you be on Neil Boortz?
When can I hear you on Laura Ingraham? How about some of the regional ones like the SF based Lee Rodgers show or Brian Sussman on KSFO?

These are the top radio shows in the country. They are the voice of the people who are spreading healthcare myths. When they play a commercial for a drug that commercial can’t lie. Yet the hosts can repeat lies and myths with impunity.

Have you trained a team of people to call into the shows that allow calls to argue with the hosts and call them on their health care myths? Who is in charge of doing that? Which PR team is pushing back on all the lies on talk radio?

I meant to say earlier than it has to be open to everyone. Yes, some doctors will choose not to participate. But a public plan option that delivers better and lower cost care will attract families, especially low- and moderate-income families without adequate workplace coverage. And I think most physicians will have no problems going where the customers are.

In those countries with private insurers, you say they have to “pay every claim,” but of course, some entity has to screen claims for bogus, unnecessary, or dangerous practices — or even choices that are far too costly when equally effective but cheaper remedies are available. Is that the job of the private insurers, or is there some state mechanism to do that that interacts with the insurers? How is this problem solved?

Welcome, the Highly Honorable Mr. Reid!

I like how, in pages 34-44, you demolish the various myths about why health care costs more in the US than anywhere else — the doctor-salary myth, the trial-lawyer myth, etc. — and focus right on the two biggest factors:

1) The US is the ONLY developed country that relies on profit-making health insurance companies to pay for essential and elective care, and

2) The complex maze of regulations and rules resulting from this.

Scarecrow, you hit on the core question. If I had found another rich democracy with a system like that envisioned in the Baucus Bill, I would not have declared it a success. The pending bills in Congress won’t cover everybody, and won’t do much to control costs.
But if we make insurers cover everybody, and eliminate their current caps on benefits, and end the reprehensible practice of cancelling coverage when people get sick, that’s a big gain. If we had a medicare review commission with some clout (a la Britain’s NICE), we’d be in much better shape than we are today. And to make those reforms work, we need a mandate on everybody to have health insurance. So the current bills are definitely better than what we’ve got.
in the end, i’d be inclined to vote for the pending bills, on the priviso that they represent only a first step toward universal coverage at reasonable cost.

thanks for your reply. my next question is about something i heard you say in a podcast (*) — that you thought the obama administration was using the public option as a bargaining tool with the insurance industry to get them to agree to regulations like guaranteed issue and community rating. is that how you still see it? could you expand on your views of the political dynamics and negotiations of the obama administration with various industry groups, especially insurance industry?

* note: (sorry i forgot which talk or interview it was, would have to go back and re-listen to them all to find it)

Mr. Reid, I noticed in your book that you categorized France’s system as a “Bismarck model.” However, as far as I know, France has national health insurance. (Paul Krugman seems to agree.)

So, why not put France in the national health insurance model category?

One thing you might want to look into is the possibility that the health insurance companies’ financial positions aren’t as strong as claimed.

Our own Masaccio recently pointed out the odd prominence of “goodwill” — an intangible asset — on the balance sheets of several insurance giants. If these companies go under, the likelihood is that their stockholders are going to be utterly screwed.

But if we make insurers cover everybody, and eliminate their current caps on benefits, and end the reprehensible practice of cancelling coverage when people get sick, that’s a big gain

we had pretty close to this in MA prior to our 2006 reform (when mandates were instituted). why do we have to have mandates, especially in states with lousy regulatory oversight?

Preventive care: I argue in the book that preventive medicine saves lives and reduces suffering. But it’s expensive, and often the return on investment doesn’t come for decades. So a system needs an economic incentive to pay now.
if everybody is covered by a unified system, then the payers (gov’t or insurance) have an incentive to keep people healthy. In my book, I say the Britain is the world champ at preventive care, because the nhs has an incentive; it has to cover everybody cradle to grave.
in our system, the avg. insurance customer stays with one insurer less than six year. The insurance company, facing the need to pay quarterly dividends, has no incentive to keep its customers healthy; by the time they get sick, the cost will go to another company, or medicare.
To set our incentives right, we need to put everybody into a unified system. But that seems to be a non-starter in our political world.

I think making health care coverage “portable”, that is, can be carried with you if you leave a job and travel to a new one. If you lose your job you don’t have to fall through the cracks and go through the trauma of being uninsured or economically burdened with high priced temp insurance, and then when you get another job you won’t have to go through the Rube Goldfarbian transitioning to new coverage with new rules, and new networks and doctors. No wonder administrative overhead takes 30 cents per dollar. And the exec compensation. Helmsley of UnitedHealth makes $57,000 a day. And now that insurance will be mandated… how much MORE will he be making?

Anyway, it would be freeing to be less codependent with your employer in terms of your health care needs. And less dependent on the economic vulnerabilities of the company.

Do you not fear channeling so much more money (and importantly government subsidies) to for-profit insurance companies will just increase their huge political power. It is hard enough to try to beat them now, with huge Democratic majority and the moral imperative to insure everyone and fix their worst practices.

If the Baucus bill passes I do not look forward to the next health care reform fight when the private insurance companies are 20% bigger, feasting on government subsidies and with a government created captive costumer base.

Tom,
I want to pick up on your answer to Scarecrow that suggested we’d be a lot better off with something like NICE in the U.S. Why do arguments about rationing care get so much traction here, and do you think progressives made a mistake this year by not focusing more attention on cost control?

It seems that another common feature of the national systems you describe in the book (or those covered in the Frontline piece), is the principle that everyone contributes to the costs of system based on ability to pay — a progressive principle applied to payroll taxation and/or allocation of subsidies for premiums.

Our system seems to be ad hoc, with lots of different approaches, depending on whether you are in the employer-baed system, the individual/small group markets, government insurance etc. I don’t see the Congress doing much to move towards some universal principle. Any thoughts on the current bills?

The French system was designed on the Bismarck Model, and still has 14 private insurance companies. But the government has taken over more and more responsibility for basic coverage. So most med. bills in France are divided among the gov’t., the private insurers, and the patient’s co-pay.
You’re right: it’s a mixed system.

The current debate on healthcare reform has not been about health, care, or reform. Nor has it been a debate. It has been from the start about money and how to divvy it up among various large corporations. And that quite simply is all.

I’m looking forward to reading your book, based on this chat and the interviews you’ve given. I read a BBC story in which the reporter criticized us for an adolescent culture which is giving us an adolescent discussion on health care. Too right.

Did you by any chance work with Hale Champion at the Kaiser Family Foundation?

To set our incentives right, we need to put everybody into a unified system. But that seems to be a non-starter in our political world.

So let’s look at the incentives in the political world.

Keeping PhRMA, AHIP, and other big players in the current system happy brings campaign cash to their friends in DC, and voting against their interests sends that same cash to their challengers.

On the other hand, someone who takes a strong moral stand against the stereotypical big heartless corporate bully can earn praise and support that all the campaign cash on K Street couldn’t buy.

Who do you think are the most effective moral voices on health care in Congress right now? How about outside of Congress?

I’m not asking who have the loudest voices that can grab headlines and get their faces out there. I want to know who are the most effective ones in terms of making their case and persuading others.

In every country, the notion of cutting of care to somebody’s grandma is pretty explosive. So rationing of health care is unpopular everywhere.
But, as you know, all countries ration health care, including the U.S. No system can afford to pay for everything modern medicine can do. Our insurers make millions of rationing decisions every week; just read the terms and conditions of your policy (if your employer makes them available) and you’ll find lots of rationing, right here in the US. When us insurers deny a claim for some doctor or procedure or drug, they can always point to the language in the terms and conditions to justify the denial. That is rationing of care.
US pols who oppose any particular health care reform routinely call it “rationing.” It’s a powerful argument. But guess what? politicians in all the other countries use the same argument to fight changes they don’t like. And since every nation is in a battle to deal with rising costs, there’s a lot so-called rationing going on everywhere.

i’d be inclined to vote for the pending bills, on the priviso that they represent only a first step toward universal coverage at reasonable cost.

i am sitting on the fence now (but leaning towards advocating towards defeating the bills — depending of course on their final form).

the big reasons for the direction i’m leaning are that it doesn’t look like a “first step.”

1. the 19 million (or whatever the number is) that don’t get coverage are probably among the most politically weak. that means that finding the political will to move to universality may be harder than it is now.

2. the way it’s set up is divided by class, with medicare for the poorest, subsidies for the next group and so on. this is designed to undermined social solidarity because we’re not all in the same plan. it also means that the political will to have each of these plans run well will vary greatly across plans. i am a big fan of aligning interests — so the interests of well off are more closely aligned with the poorest and sickest of us.

3. if the *weak* public option fails (ends up being an expensive dumping ground for the sick that private insurance doesn’t want to cover), we are giving opponents a way to win the “i told you so” follow on debate with “the gov is not capable of running health insurance in competition with private companies.” that may put a stake through the heart not only of a more “robust” public option, but also of single payer type solutions.

4. mandates increase the power of private insurance in the system, potentially making future regulation etc politically more difficult.

of course, on the other side, i don’t want to deny even incremental improvements to anyone.

…..

do you have a critique of any of my points to help me get off the fence?

Why do arguments about rationing care get so much traction here,

Who is making those arguments? When you look at the person who is making those arguments you see why they are doing it and why. This is about Fear and they use the fear to stop change.

Here is a clip of Brian Sussman on KSFO yelling at Doctor who was questioning the practices of a insurance company that was trying to cut people off for Crohn’s disease. WMA link MP3 link

Sussman’s advertisers include Kaiser Permamente. Note how he points out that there are program for people and nobody in America has to go with out heath care and you can also buy any health care you want if you need it.

Ah the irony. In between reading through the responses, how many of us are answering the doorbells — trick or treat! — and then feeding really bad candy tonight to children?

How much do our guests attribute successful health outcomes in other countries to better eating/exercise habits/diets, etc?

Great question.

Mommy –
I relied extensively on the Kaiser Family Foundation; could not have done this without them.
This week I was on a panel discussion run by the New Statesman in London, about the major issues facing health care systems in the US and the UK. At the end, we all agreed that the US would love to have the problems facing the British NHS. They cover everybody, they have (somewhat) better medical outcomes, and they spend half as much as we do. on that panel, there was a lot of “Why can’t the Americans get this right?” i shoulod note that the uk health minister, Andy Burnham, was diplomatic, and found things to praise in our system.

So how do we get to rational rationing, where ineffective care gets eliminated. Is it possible to people to understand that demanding the health care system pay for a $10,000-per-month cancer drug that extends life for six weeks and makes you miserable for the last six months of your life just isn’t worth paying for?

appreciate, selise, have been searching for more guidance on single payer websites … and with Kucinich whammy and Weiner HR676 promise in House being reneged by Nancy … is Sanders still putting his bill forward in Senate?

Hugh — I agree with you that our debate this year has been off-track from the start. This always happens; we get so hung up on insurance company reimbursement rates and hospital company profit levels that we lose track of the goal –which ought to be universal coverage at reasonable cost.
i think the president’s basic argument: “if you have good insurance, don’t worry, nothing will change,” was a mistake. That makes the whole issue selfish: Worry about your own situation, and don’t pay attention to the millions without coverage, or the employers paying far too much to keep a healthy work force. i’ve always felt that “We’re all in this together” was a more powerful argument. That’s the argument that led to universal coverage in the other rich democracies.

Mr. Reid, I liked how your book talks about how Taiwan made a transition to national health insurance after the opposition party’s policies were adopted by the more dominant party as their own. Do you think that a similar process driven by upstart politicians could be possible in the United States, or are there too many differences?

I’m not TR, but I did want to note that if the health insurance industry’s financial state is as weak as their reliance on packing their balance sheets with intangibles would seem to indicate, it might be that even a weak public option really would finish them off and pave the way for single-payer, as the Republicans keep yammering.

One of the things that the Christian right has focused on in this story is turning Hospice and end of life care into forcing Grandma to die. They see it as a principled stand against euthanasia. So instead of “death with dignity” they offer “pain for profits”. As boy in my church they talked about “offering it (suffering) up to Jesus”.

Suffering is GOOD for you! If it also helps someone make money, all the better! American Capitalism! Weeeeee!

What did you think of Michael Moore’s SICKO movie?

   How to get to a reasonable rationing system? I talk about some of them in my book.For me, the best model is the UK’s NICE. Its decisions apply to everybody. It is a democratic body, more or less; if you hate NICE’s decisions, you can vote the gov’t. out of office. And it is totally transparent. When I showed up, a foreign journalist, they took me in and showed me the files on every decision.
Rationing is easier if everybody is in the system. in the UK, for example, if NICE decides not to provide Herceptin B to a 92-year-old cancer patient, she may die. But at least we know the money saved will go to help some other sick person. maybe me. In the US, if WellPoint decides not to cover some costly drug, the money saved goes in the pockets of WellPoint’s execs and investors. That makes the decision harder to swallow.

i didn’t include the issue of the kucinich amendment, but that really is THE central issue for me right now. if the bill includes a path to state (or better yet, regional) based single payer i’d be FAR less likely to oppose it.

That’s a great answer Tom. I’ll let you move on to other questions.

a po that is a dumping ground for the people private insurance doesn’t want to cover would be a boon to their bottom lines, especially if combined with a mandate. that is part of my thinking on my point #4.

and one of the reason why i think a weak po is WORSE than no po at all. (obviously a strong po, something akin to hacker’s original proposal circa 2001/2007, would be a different story).

yes, in Taiwan, the liberal out-of-power party jumped on universal health care as a political cause. When the conservative pro-business nationalist party saw how popular this was, the conservatives embraced the idea as well. it was actually the pro-business party that gave Taiwan its single-payer universal system.
When I wrote that, I had hopes that the same dynamic could happen here. But our pro-business party made the decision to oppose universal coverage. And our liberal party couldn’t get all its own people to support a plan. So the Taiwan political situation was not replicated here. it’s a shame, in my view.

that would be me. if i disappear for a few minutes, it’s only hand out unhealthy candy to the neighborhood kids. *g*

By the way Mr. Reid: I was very serious with my question and if your PR people (overloaded I know) want to do a little guerrilla PR they could alert you to when some of these people are talking about heath care, lying about other countries programs or when they have guests from the industry misrepresenting other countries plans and then you can call in.

When the producer/call screener doesn’t put you on the show or puts you off (Please call back to pitch your book during business hours.) then do a post about the lies you wanted to address and how they were afraid to talk to you about it. You “win” the conversation.

Hacker’s plan got hacked immediately, 129 million covered quickly scaled down to 10 million covered? Hmmmmm. So that is what they are calling compromising these days?

As a matter of fact, i’m serving trick-and-treaters while answering these questions.
life style plays a huge role in national health. There’s a whole chapter about it in my book. But I don’t accept the notion (advance regularly by the WSJournal edit. page) that the the only problem with American health care is that we eat too much, and have too much violence.
on lifestyle issues, I’d say the US comes in about the middle of the developed countries. We are fatter; we may exercise less; we have a lot more stress than European countries that mandate five weeks of vacation per year. But, other countries have higher rates of smoking and drinking than the US. As Merrill can attest, the Japanese have more stress in their lives than we do; the government there sends out letters at the New Year pleading with people to take more vacations.

Tom,
You may be responding to another thread, in which case, feel free to put this new one on the backburner. But do you have any thoughts about how to wean American physicians from the fee-for-service model and get them to accept being salaried? The VA, Kaiser Permanente and the Mayo Clinic are great examples of how salaried physicians deliver higher quality, more affordable care. Dr. Arnold Relman, former editor of the New England Journal of Medicine, says we will never have universal, affordable care until we go to the salaried physician model. Why do physicians in other countries find it acceptable, but so few do so here?

Ok, last question from me, then I’m out.

Some people (like Atul Gawande in the New Yorker) say that much of the problem with the US health care system isn’t insurance per se, because there’s a lot of overtreatment and useless services on the provider side. Do you think that changes to the insurance system can deal with this issue, or do we have to pass laws that directly change the way providers work?

Thanks for your answers.

Japan also has a word for dropping dead from overwork.

In Silicon Valley there was (is) a macho culture of “If you aren’t here on Saturday don’t bother coming in on Sunday.” that was deading. I was at the end of a whip’s end of a whip and the pressure was intense. The number one use of health care for my company (comprised mostly of young men and women) was mental health. I asked why we couldn’t have more coverage (we had to pay 50 percent plus limited number of visits) was, and I quote, “If we offered better mental health care to everyone, everyone would use it!” And they saw that as a BAD thing!

And hospice is a very popular program…both medicare & medicaid. Gives comfort and support to the dying and their families. The misrepresentations have been cruel and almost delusional.

you know, I feel like I’ve done every talk show known to man on this Endless Book Tour. I’ve done several conservative radio and TV talk shows, including Fox.
The hosts generally take the WSjournal line that we have the best health care in the world; that’s why Arab shieks fly to the Mayo Clinic. on Fox, i keep meeting Canadians who say they got a bum diagnosis at home and had to come to the US to pay for treatment out-of-pocket. (Actually, it’s a tiny number of Canadians; I keep finding the same 4 people on US talk shows.) And my answer is that the big problem with our system is that tens of millions can’t go to the Mayo Clinic, or any clinic.
one of the standard complainst from callers to the shows is that a public option would be unfair to private insurers, because it would have lower prices and better benefits. And I say: lower prices and better benefits are the goals. Why complain about a system that provides them?

Tom, I’m a pastor who also writes here at FDL on occasion, and your comments about this being a moral issue obviously resonate with me. But as spocko noted @56, the voices on the Christian Right have a much different take on this than progressive clergy like myself.

I know that some religious groups have tried speaking out on this, but either they are not effective at speaking beyond their own community or they are being ignored by the media who would rather talk about the politics of death panels, Olympia Snowe, and Joe Lieberman.

If the moral issue is at the heart of this, in your opinion, who are the best at making that moral argument in a way that gets noticed and paid attention to?

Is there any way to fight the “mandatory” requirement? Having people lose their jobs in this economy or have parttime jobs, and then getting “criminalized” for not being able to afford insurance and heftily fined is certainly blaming the victim in this double standard economy.

i want to deal with this one. As Dr. Gawande has pointed out, there are huge diferences in the amount that medicare pays per patient from one county to the next. The source for this info is the famous Dartmouth Atlas, a powerful record of overbilling and overtreatment. We know which counties and which hospitals are billing too much. The data are there.
But the Dartmouth studies began 20 years ago. Medicare knows about them, and Congress knows. Yet nobody has done anything to reign in the inefficient hospitals. Why? Sheer politics. The local Congressperson protects the wasteful hospitals in her district. (in many towns the hospital is the biggest employer).
Your question, and the Dartmouth data, point up a flaw in my thesis. My book argues that universal coverage saves money, because it provides a strong impetus for cost control. But if our political system continues to protect wasteful docs and hospitals, we can’t get the cost control we need.

What about fraud not only on the part of insurance companies, but also on the part of citizens and health care providers? Is this a big issue in other countries? How do we deal with that here.

I have had dental offices during an emergency when I am doubled over in pain and need a root canal, whatever, or going to a therapy office a while back, and having someone explain a twisted, well you send this to me and then I send this to them, or vice versa, so we get over on the insurance. And they are reluctant to admit to cheating and when questioned they get exasperated, that you are not colluding automatically with the game.

It is like a guilt-free, getting over game and it is part of the problem, though the corporate profiteering is probably the biggest problem, granted. But even with accident insurance, etc., and disability, etc. there seems not much of an honor system. People get bitter about the high costs, so sometimes they want to get theirs. If you can get away with it, you get away with it. So those lacking in integrity overload the system with more costs and raise premiums, etc.

Peterr: sorry for my brusque answer to your earlier question. I hit the delete key by mistake somewhere along the way.
Some faith groups have been right at the front of the fight for universal coverage. We’re all obliged to care for the least of our brethren. But others are sitting this one out. My own archbishop in the Denver Diocese, Charles Chaput, has urged us to oppose all the reform bills in Congress, on grounds that they’re not tough enough on abortion.
I’m struck with the contrast to Europe. I know you’ve heard the argument that Europe is a “post-religious” society. Nobody goes to church or temple any more. Fewer believe. And yet, European countries provide life-saving health care for everybody, while the church-going usa leaves tens of millions outside the door. Which society is truer to Judeo-Christian principles?

Libby,
There are a lot of good economic arguments for requiring mandatory insurance . . . everyone is in the risk pool, it avoids free riders showing up to buy insurance the moment they get sick, etc. But you have hit the nail on the head: if we’re going to maintain 170 million people on private insurance plans provided by their employers, why do we then give employers who don’t provide their workers with insurance an almost free pass (the penalties in the reform bills are minuscule), and instead put the whammy on the workers? It’s the Achilles heel of the reform bills, and could come back to haunt Democrats.

Sorry, Tom. Had to take off my moderator’s hat because this is an issue I feel strongly about. I’ve always thought that the necessary corollary to “you can keep what you have (from your employer)” is “every employer must provide it.”

Sigh. I know you don’t like to be combative, but if you know they are going to bring up that line please think about how to destory their BS. (and believe me, I know how hard it is to argue with these people )
A couple of suggestions that might seem counter intutive. Instead of responding right way to their claim Ask them for some statistics to back up their “Arab Shieks” meme, the the source of the claim or the name of these Sheiks. (that often stumps them and by asking a questions makes them think and puts them on the defensive.)
Second: Ask them what their definition of “best health care in the world” is and what it does and doesn’t include. (They will probably leave off things like care for immigrants, extended life etc.) then ask them “Are you Christian?” That is another thing that throws them. These are just methods that I’ve used (and trained others to use) in these kind of discussions.

With the callers? Ask them a question before you answer, “Do you or a close relative work for the health insurance companies, or PR firm hired by one?” That is always fun. I happen to know that there ARE people who are doing this who work in the industry, some are doing it on their own without being paid, but others are being paid to call in. They know who butters their bread.

Please forgive me if I come off as know it all or harsh with my suggestions. I know all too well that the environment you are in is like and I want to help you in all the ways I can.

The VA is modeled on the British NHS system; gov’t-owned hospitals provide free care, with no bills. Medicare is the Canadian system; private docs and hospitals, public payment.
I’ve used both.
I’ve had good care in the VA for my bum shoulder (and for another minor injury from my Navy days). But you wait for care, and there’s no choice. You get which orthopedist happens to be open when your time comes, even if another doc saw you last time. And, generally, you can only get this care in a VA facility.
medicare, in contrast, lets you go to just about any doctor or hospital. Depending on your plan, you may get a bill, and it’s not always predictable how much the bill is going to be.
I think, because of the broader choice of providers, Medicare is a better system than the VA.
For our current debate, the relevant point is that medicare and the va are both better systems than the privare ins. market. If the private sector really provided better coverage, wouldn’t the veterans and seniors be clamoring to switch to private insurance? In fact, veterans and seniors would destroy the career of any politician who suggested switching them to us-style private insurance.

i completely agree that the dartmouth data needs to be followed up, but there may be some serious design flaws with the analysis which imo need to be addressed before basing policy on it. or perhaps you already know about this question and can lay it to rest?

here is a blog posting on the issue (please don’t be distracted by the funny cat and snark, there are good links):

http://www.correntewire.com/resurrecting_treatment_histories_dead_patients_study_design_should_be_laid_rest

As you look at the current bills — are there two or three key measures or provisions that you’d most like to see improved/fixed? Where should activists be focused on the next month?

Appreciate that exploration, Merrill.

Not a problem. There’s a bunch of us tossing out questions and only one of you to toss out answers.

Good observation with regard to Europe. I’ll have to remember that one in my conversation with other clergy colleagues.

I’m Lutheran (ELCA) in the Kansas City area, but follow the news in the Catholic community fairly closely. When it comes to religion and politics, the Catholics have a fairly good shot at getting the media to pay attention. As for Chaput, my prayers are with you. You have Chaput in Denver, and the RCs here in Kansas City have Naumann and Finn. None of them deal well with shades of gray, and everything seems to come back to abortion.

Thank you, Tom. That explains it so well. That was the sense I was getting from them.

Great question, Scarecrow. Let’s focus our guest author on the current legislation before he signs off for the night.

Yeah, well it was easier for Jesus, a little spit, a little mud, put it on the eyes of some blind guy and voilà, instant cure! Not like today what with the surgery and all, Jesus had it SO easy.

I wonder if Lazarus had to pay his medical bills when he got better?

As we come to the end of this Book Salon,

Tom, Thank you for stopping by the Lake and spending the afternoon with us discussing your new book and health care.

Merrill, Thank you very much for Hosting this great Book Salon.

Everyone, this is a very good book about health care, if you haven’t bought a copy yet, here is a link.

Thanks all.

Okay, Tom, I’m hoping you’re going to weigh in with some last thoughts so there can be some last responses about the reform bill. What should activists be focused on over the next month?

The thing is that they’re fighting even a weak PO just as hard as strong POs.

Mandatory health insurance should be seen as a matter of personal responsibility. if you’ve got the money, or a job, you should make provision in case you get sick or get hit by a truck. unless you’re broke, you don’t have the right to put this responsibility on others.
That’s the Republican argument for the individ. mandate. People who could buy insurance, but don’t, are free-riding off the rest of us.
The economists’ argument for the mandate is the nature of insurance pools. you need a bunch of people paying premiums, but not making claims, for any insurance scheme to work. All the people whose house never burns down are paying to provide re-imbursement for the poor guy who does have a fire.
Finally, there’s a simple equity position. The premiums paid by young and healthy people go to pay the claims of those who are old and sick. Young and health people should be willing to pay their premiums, because the one thing that is absolutely certain is, they won’t be young and healthy forever. And then they’ll need to drawn on insurance.

emptywheel is upstairs!
Hung Out to Dry: One Former VP Chief of Staff

hahaha! i’d love to talk with you about that on another thread — i just don’t think it’s so (first of all, we’ve never tested them with the strong po).

Thanks much to both our guests for answering our questions. Great discussion.

To me, that’s more of an argument for paying for health care out of taxes, rather than an individual mandate for employer-based insurance.

The most important goal of any legislation, for moral and practical reasons, should be Universal Coverage. (If this means more profit for insurance companies, so what? If they covered everybody, I wouldn’t grudge them profit.)
I think Washington has given up on universal coverage, because ofthe focus on costs. so I hope activists will push to get the largest coverage possible on any bill. You can remind your reps in Washington that universal coverage saves money. At least, that has been the case in every country that tried it.
Thanks so much, everybody, for tuning in. –trr

Hacker’s plan got hacked immediately, 129 million covered quickly scaled down to 10 million covered? Hmmmmm. So that is what they are calling compromising these days?

hacker’s plan was never on the table (i think it was hidden with single payer).

that pre-compromise is what i call pre-capitulation.

The most important goal of any legislation, for moral and practical reasons, should be Universal Coverage.

amen.

thank you for your time and for your book. happy halloween!

thanks Tom and Merrill and Bev et al. for a great salon, once again!