On the Contrary

The magic word in the health care debate is “the public option”.  But does anybody really know what that means?  I doubt it, so lets examine it.  You have heard Medicare for people under 65.  Well that is not quite right.  Medicare is free and was and is paid for by your and others contributions.  I probably have insurance closest to what they are talking about.  I am a retired federal worker so the government offers a multitude of programs from various health providers and they subsidize my monthly costs along with the ability to negotiate very good rates.  Oh yeah, their administrative costs are minute compared to the insurance industry’s. Those that would qualify for the government program would get roughly the same program and the subsidy would be dependent on your ability to pay.  But it must take all comers and all the policies are not priced based upon the status of your health.

Now there are a couple of things to notice here.  First and foremost, there is no government bureaucrat between my health care provider and me.  The badly misused term in this discussion, and I should say prejudicial term is “government provided health care”.  The government does not provide the health care; they pay for it, or in my case subsidize it.  My health care is provided by a private health care provider who negotiates with the government for one price to provide the benefits I selected.  I select my plan and that plan and its benefits are charged to the government and my contribution is billed to me every month by the government.  It is very small compared to what most people pay for private insurance.

Second, who qualifies for the government plan?  The present options being considered in Congress have only a very small segment of the poor who will get these benefits.  So just how is this going to help small business or others who need a real choice?  How will this small segment, estimated at 10% of our population who will actually have access to a public option provide real competition to the insurance companies?  Why shouldn’t everyone have that choice?  That one is beyond me.  Additionally, the plan the President favors, because he thinks it is politically expedient, is one that will not go into effect unless some sort of trigger mechanism activates it.  This one is destined to failure.  It might be the most politically feasible among the dinosaurs who rule in Washington, but how long do we have to wait for it to kick in and how can the medical Insurance companies game the system to prevent it from ever happening?  It is truly a bad idea when you consider how many people will die while we dither.

Third there is this idea of “a level playing field”.  Just exactly what does this mean?  Well the industry is concerned that the government can price the same plans that they are providing at significantly less than they can, so they want either the government’s ability to negotiate or the rates they charge limited to provide them a “fair” opportunity.  Now think about this people.  If you end up paying higher rates so that private insurance companies can maintain their profits, that is money that is not going to treat a segment of our population.  The other side of this coin is that if we keep making an artificial level at which private insurers can earn money, where is the incentive for all that innovation that competition is suppose to foster?

So is it any wonder that this whole debate is really being carried out in a fog?  Please define public option and how it works; define who qualifies for it; and please define what you mean by a level playing field.  And within this, let’s not forget what we are trying to do:  Universal coverage at the lowest price without affecting the quality of the care.  Probably the best way forward is Medicare for anyone who wants to buy in.  Cost of the insurance in addition to what you already have withheld from your pay and earnings would be prorated on your ability to pay.  Let the private insurers compete with that.  No leveling, and no restriction of the government’s ability to negotiate.  Small business could then buy their plans directly from Medicare and we are off and running with a dual track system and may the best man/plan win.  You still have competition in that each plan would negotiate with the government or insurance providers for the services they provide and the onus would be on them to find ways to economize.  Additionally the government could partner with some of the providers to come up with innovative ways to reduce costs and increase the quality of care.

But all this is too simple and straightforward when you are trying to maintain the health insurance companies gouging our economy and our future for their well-being.  Just try to keep in mind that these health insurances companies have had years and years to compete and innovate and they did not.  And those second homes and nice cars that all those health insurances executives have are paid for by the 40,000 uninsured Americans who die for lack of insurance every year.  Then the discussion gets fairly simple.

In my mind we are not going to get anything anywhere near what I proposed above and therefore it is destined to fail.  If we do not get that robust public option in the final bill, then I would recommend they vote it down.  Putting a failed plan into effect will just make the next round that much more difficult after thousands have died.  If it isn’t right, then don’t compromise for failure.  Hold out for a real plan that gives us real relief and moves us forward instead of some holding action that could kill reform in the long run.

“The House Republican leader, Representative John A. Boehner of Ohio, said: “House Republicans want to hear what the president has to say, but after the public outcry this August, it’s clear the American people don’t want a new speech. They want a new plan.” Mr. Boehner said the Democrats should scrap their current proposals and start over.” (New York Times)

For once I agree with Representative Boehner.  But I think the new plan he and I have in mind are two very different plans.  Based upon news reports this morning, President Obama is going to pare down his health care plan because of the almost unanimous opposition from the Republicans.  I think they are now compromising to get one Republican vote, and that is Olympia Snow’s.

Here is where the Washington Conventional wisdom comes in and it goes like this:  President Obama and the Democrats needs a health care bill, any bill, or the 2010 elections will be a Republican landslide.  Therefore any bill is okay.  The pundits think that those who say that without a public option they will veto the bill are being foolish, that half a loaf is better than no loaf at all.  Therefore the Democrats need to cave to Republican demands of no government involvement and settle with something that at least gives them rules that don’t let private insurers deny care.  It’s a start and we can get the rest later.

I think this approach would be a disaster for the Democrats and represents old thinking.  First and foremost it would grant the Republicans a win and show that if you put Democrats in power, well, they are powerless, not to mention gutless.  But more important, it is just kicking the can down the road since what you are doing is insuring more, leaving the problem (private insurers) in place, and guaranteeing that the bill will not reduce costs.  It will be judged a failure as will the Democrats who caved in to this approach.  Worse, it does not hold out for a real fix and makes it much more difficult to come back later and really make the changes that are necessary.  “See, there last idea was a bust.” I think settling for just any bill now will be a disaster for the Democrats in 2010 because those of us that voted for real change will be totally disillusioned with this crop of gutless wonders and we are their base.

The best strategy in my mind is to show some courage.  The President could lay out a plan with a public option that might really work.  I am not talking about something that might kick in in a couple of years if (when) the present continues system fails. I am talking about a real public option now.  Then if we can’t get it, don’t compromise to defeat, but raise the ante for next year.  Stand firm on your principals.  As the health care crisis worsens and you convince more people of the disaster that is the present system, the pressure will mount for real reform.  Those morons that have been screaming at town hall meetings will be forced to face reality that their wonderful health care they have is an illusion.  As the prices continue to rise, and their employers drop their plans, they will change their tune.  “Why doesn’t government do something about this?”  It is the only way forward if the Democrats are going to remain a viable party to that other party, the crazies.

A public plan is simply a step forward, but not the answer.  The reason that the Republicans are so against it is that it really is a Trojan Horse.  Once a fully operational public option is working, and assuming it is not structured so that the insurance industry can dump all their high risk enrollees in, it will be much cheaper than private insurance.  The final answer is a single payer system (U.S. Government) totally funded, not by employers and fees, but by our tax base.  The argument is moral.  We are the only industrial country that does not do this.  People deserve good basic health care as a right and we should all pay for it through our tax base.  Really nothing changes except your health care provider bills the federal government, not some for-profit insurance company.

The misconceptions about this approach abound, but here are the big three:

There will be rationing.  The reality is that we have it now in terms of what insurance companies won’t pay for, and denying care to the poor until they are almost dead and then the government pays for their end of life care.  Think of it this way:  If you have $85,000 in your savings account and your 88 year old mom who is slowly dying of congestive heart failure, wants a new hip.  But your two-year old has a defective heart valve and will not live to see six if this is not repaired.  Both operations will cost $85,000, so which would you decide to spend it on?  One reason for the escalating medical costs is that we want to have it all, but we can’t.  Many who have private insurance that are now facing catastrophic medical problems are finding out that their insurance won’t pay either, but not based on a needs evaluation, but on a profit evaluation.

It will cost too much.  In the present reform package, President Obama wants it to be revenue neutral and this is big problem under the present employer based system.  If we assume this is a moral cost, and we all (not just the rich) have to contribute, then this issue goes away except for how much our taxes will rise.  But I think less than you think.  There are so many health care costs hidden in our budgets, from the cost we pay for goods and services, to the very high premiums we pay to insurance companies (and our employers pay) to cover not only ourselves, but all the unreimbursed poor being treated in emergency rooms where health care is the most expensive and is usually too late.  Include in this the 30% that would not be scraped off the top by insurance companies and we will certainly get more care for the same amount of money.

Government medicine is socialized medicine.  What is actually being proposed is that the government become the insurance company under a single payer system, not the medical provider.  This provides the real advantage of the government being able to incentivize more cost effective modes of treatment and billing practices which is where, other than the 30% insurance rake off, the real cost growth is.  This would include a fixed price for each person covered, simplified billing and accounting practices, and the ability to negotiate for lower prices.  Fee for each individual test/procedure just incentivizes profit based upon more tests and procedures which studies have shown do not result in better care or outcomes.

The bottom line is that this system is what the rest of the world does and it works fairly well.  Those who want to hold on to their present system do not yet understand that it will be forever changed and wrenched from their clutches by the ever escalating costs in the present system.  Once they have a medical crisis, the light dawns.  So instead of settling for something that won’t solve the problem, and make the next correction even harder to accomplish, my recommendation is to stand firm and wait until we can get real reform.  Democrats have to learn discipline and long term thinking.  They would stay in power longer if they did.

It feels like the morning after.  We elected a President for change; we have made a pass at a climate bill and a health care bill; we stopped torturing, but still do rendition; we thought we were going to open up our government, but then we are told that the truth will do too much damage and somebody’s morale might he hurt;  and we still have gays being thrown out of the military for being who they are.  We just went through a weekend where we said goodbye to Teddy Kennedy and maybe the last lion to champion liberalism.  Now we face tomorrow and what we know is the people who have no ideas about our future are stifling any change.  And what we know is that the status quo is not acceptable and yet the defenders of that status quo are winning.

If we look at each of the major issues facing us today, there are viable and undeniable arguments for making a change.  There are also some good and viable arguments against some of the specifics of the plans proposed.  But those arguments are being lost in the din of emotionalism run amok.  Instead of having a rational discussion about the pros and cons of the proposed change, we are seeing a barrage of emotional appeals that have no rational basis.  What we have to understand is that these emotional appeals like death panels and the end of Medicare are smoke screens to prevent any change.  What is really going on here is an attempt to change nothing because the big money interests make big money in the present system and frightened little people unable to let the past be the past.  It is a total failure to face reality.  Denial is king.

Let’s take our climate change/energy bill.   There are undeniable (or so one would think) reasons to reduce our dependence on fossil fuel.  These are climate change, the unstoppable growth in the cost of fossil fuels, and that its use transfers much of our wealth to those who hate us.  Those against it deny climate change, and say the last two problems are controlled if we drill baby drill.  None of it is rational.  It is simply hanging on to the status quo assuming the future will be like the past.  If one accepts the proposition that fuel prices will continue to spike, then developing green energy will stimulate an industrial base for our future.  So what is so hard about this?  Money.  Sadly it was chronicled the other day that China was now leading us in green energy because of their government’s investment in its research.  But governments are bad aren’t they?

Now Republicans will hate climate legislation because it requires government intervention into a stagnate industry, therefore bad.  Their fear tactic?  A tax on every citizen and making us uncompetitive.  Democrats in middle America are bought and paid for by the coal industry.  Although we hear the word, “clean coal”, it does not exist.  It destroys the environment to extract it and there is no way yet to remove the carbon dioxide and sequester it.  But middle America gets their energy by coal and there is big money to be lost if we start taxing their pollution to incentivize other forms of competing energy production.  So our wonderful capitalist system (which doesn’t exist) is the biggest hindrance to innovation and change.  It is true that it will put a tax on many forms of energy production, but it is the tax that invests in our future.  The argument should be about how do we expedite our movement to green energy and how best to make it a soft landing for other forms of energy, but the fear tactics will stop anything and it is the product of our energy corporations.

Then of course we have health care.  We have heard the baseless allegations by top Republicans to stifle real debate.  The money train here has been well established by the New York Times, Washington Post, MSNBC, etc.  There are real and substantial arguments against what is presently being proposed and we are not hearing them.  If we had a real debate then a plan would go forward that addresses these issues.  But to have this debate would be to admit that change is necessary in a meaningful way.  Those against health care reform want no debate whatsoever if it impacts negatively the profits of their corporate masters.  Since by necessity this is what real reform will bring, there can be no real reform.

So far it would appear that they are winning as we have seen the less enlightened in our population  come out and scream at Town Hall meetings and listening to our moron media say that there are real concerns out there.  Is it a real concern if you are concerned about something that doesn’t exist and you are ignoring the real problems we are facing?  But shouting matches are good entertainment for small minds and we see that instead of enlightened debate.

So what I see is one party who sees challenges before us and is offering solutions albeit, liberal solutions.  The other party is unwilling to debate these proposed solutions on a rational basis because they do want change.  Therefore rational debate is being stifled by fear and ignorance.  We saw this in the run up to the Iraq war and apparently we have learned nothing.  I fear for this country when a large segment of the population operates with a set of facts that aren’t facts and we are afraid to let go of our past and face our future.

I am still on travel so there will be no report from the vineyard and I still can’t post pictures.  But in the meantime I do turn on the news in the morning and then wonder at what is happening in the world, so here are a couple of nuggets:

• Healthcare Reform – I listened to a reporter on MSNBC report that House Democrats are looking for a way to pay for the package.  Then he said “single payer plan is dead”.  My thought here is then don’t bother.  I can’t figure out what it is that Congress can’t figure out that there is only one way forward.  And in all of this discussion have you heard one informed discussion about how other countries who have universal care have proceeded, the strengths and the weaknesses?  No, but you have heard some wild claims to scare you to hang on to our failing system.  On the money thing, WE ALREADY PAY FOR IT.  It is just hidden in our fees, cost of goods, and our ever increasing insurance costs as the uncovered end up in emergency rooms which is the least cost effective way to pay for their care.  Gut up, understand we all pay for it, and just make it part of the tax base.
• DNA Testing – The Supreme Court in a 5-4 ruling, decided that convicts do not have a right to DNA testing to try to exonerate themselves.  The majority view was that this is a State’s rights issue.  Chief Justice Roberts wrote, “To suddenly constitutionalize this area would short-circuit what looks to be a prompt and considered legislative response.”  So if you live in one of those States who denies you the ability to try to exonerate yourself, this should give you great comfort.  Here is where the statement of nominee Sonia Sototmayer is showing so much wisdom.  She said that her experiences as a Latina woman would give her some insight and understanding that the majority may not understand (I am paraphrasing).  I cannot understand how anyone could believe that allowing the State to deny convicts the right to examine the evidence against them is anything but a lack of life and liberty.  But these guys have never been persecuted by the State and don’t get it.  You might want to ask yourself why States would want to refuse convicts, at their cost, to examine DNA evidence.  Maybe they don’t want to be proved wrong.  Most prosecutors are political positions.  The Constitution was written to protect individual rights and the five that voted against this case think their responsibility is to uphold the legislative process trumps  due process and standing up for the rights of our citizens.
• President’s Popularity – President Obama has taken some hits in popularity lately and it is deserved.  He is trying hard, but as I have written here before, he is taking the middle road and being timid and what we get is compromise to no where.  Where is his and the Democrat’s spine?  Whether it is gay rights, health care, torture, he is just becoming like the rest of them, deciding what is best for us and politically achievable.  Some day I want to be treated like a grown up.  Change is being compromised into more of the same.
• Iran – This is probably one of the most interesting stories about what change is possible.  Watching the brave Persians stand up for having their voice heard has been inspiring.  I think we have handled this well because any perception of U.S. meddling in the Middle East would be counter-productive.  It is also a lesson to us on Iraq and Afghanistan.  Iran is not the monlithic monster invisioned and Muslims will only resolve their problems internally.  Our involvement simply muddies the waters and feeds the fear of an infidel invasion.  The “Supreme Leader” has shown his fallibility and has cast doubt about this regime throughout the world.  Once the seed of change is planted, there is no turning back, just minor setbacks.
• Financial Reform – It is just barely a start.  Note that we are hearing all the usual arguments about government is bad, regulation hurts the economy.  But it wasn’t government that got us into this problem, but the lack of it.  There are tons of arcane details, but the only question you need to consider is whose economy will it hurt?  The bankers or the middle class.  The last eight years have been devastating to the middle class, but who cares, stock prices were up.  The reality is very simple.  In order to have less volatility, the swings in the market have to be smaller.  But we can’t have the wild profiteering that was going on in the financial industry.  So regulation hurts who?  The bankers.  We have nothing yet.

I think it is time for a reality check.  In America we only seem to remember the last problem as long as it personally affects us and then it is forgotten to come back and bite us another day.  Take ex-Vice President Cheney.  Here is the guy who had the memos and intelligence to prove WMD and an Al-Qaeda connection in Iraq and now we are listening to him on the efficacy of torture?  Oh well what can I say?  More importantly have we missed the lessons of our latest problems as things seem to be abating and we have changed nothing,  Here are some things that I think are patently obvious or as one of my math professors used to say, glaringly obvious to the casual observer, but totally being ignored by the mainstream, media or otherwise:
•    Economy – On Tuesday there was an article in the New York Times that the economy might be getting better (Markets Rise on Consumer Optimism).  Simon Johnson in his Baseline Scenario blog noted that “…among the people I talk with on Capitol Hill, there is a very real sense that business is returning to usual; certainly, the lobbyists are out in force, they want what they always want, and it’s hard to see many of them as seriously weakened.”  If this is correct then nothing has really changed and we still have a fundamentally flawed market and banking system.  But I don’t think they have it right.  I think the worst is yet to come.  Those on Wall Street are all patting themselves on the back because the banks haven’t failed, but the U.S. is up to its eyeballs in debt bailing them out and they have not been restructured.  They are still too big to fail which is how we got here in the first place.  Almost every state is facing cutbacks and layoffs.  More and more mortgages are defaulting as people lose their jobs.  I think what we have is that the middle class and working people are continuing to suffer and that suffering is getting worse, while the investment class has been saved from feeling the effects by the bailouts.  As more states tighten their belts and more people get laid off, there is going to be anger like we haven’t seen in a long, long time.  There is a real disconnection between working men and women and our upper classes.  We have corrected nothing and restoring the status quo is a recipe for disaster.
•    Iraq – The reality here is that it is going to get bloody and there is nothing we can or should do.  The “Awakening” is over and the results for the Sunnis were not what was hoped for.  Now we will see a great deal of violence as each party jostles for position in the coming power grab.  This is inevitable and the Iraqis will have to sort this out among themselves if they are ever going to stand on their own two feet.  Delaying our withdrawal will simply delay the inevitable and get us caught up in the middle of their local power politics.  Al-Qaeda will be a minor player and should be of little concern as Iraqis dual for power and control, use Al-Qaeda if it suits their means, and then abandon them when they secure power.
•    Afghanistan – The reality here is this will also get a lot bloodier.  As we step up our efforts to eradicate drugs and empower a very corrupt government, we are going to be in the middle of tribal warfare.  I have mixed emotions here as I see that if we are willing to fight the hard fight, the fight that should have been fought seven years ago (thank you Dick and George), it is going to be another 10-15 years before Afghanistan is stable.  I really wonder if it is worth it.  I guess I would have to say no since if I don’t want to sacrifice my own son for this endeavor, then I cannot justify sacrificing anyone else’s.
•    Health Care – This one is a no-brainer.  Without a single payer, government option, nothing is going to get accomplished.  I have written at length about the business model of health care insurers and nothing is going to fundamentally change that until you take profit out of health insurance (See Health Care Wars and Scare Tactics and Reinventing the Wheel – Universal Health Care).  We need a pared down Medicare plan for everyone as a choice with the ability to add additional services and benefits by piggybacking private insurance.  That really is their only role and the only place where profit makes sense in health care.
•    Energy – I don’t think we are getting anywhere fast on a real energy policy that will change our country in a fundamental way.  As soon as gas prices dropped, our eye was off the ball and the forces of the status quo swiftly reasserted them selves in our choices.  But the reality here is that this is the lull in the storm, but in the meantime we are losing precious time.  The cap and trade bill to reduce our dependence on polluting fuel sources is being watered down by special interests invested in the status quo.  If you are not even going to make a dent, why bother.
•    Infrastructure – On the infrastructure side, there may still be hope if I am right about the economy.  If I am, and the economy will stagnate further and a massive infusion of money this time actually focused on rebuilding our infrastructure is our only hope.  It provides good jobs in the short term, and is a long-term investment in a viable economy in the future.  I am not the only one who sees this no brainer.  See Bob Herbert’s column in the New York Times on Tuesday (Our Crumbling Foundation).

I don’t know about the rest of you, but it seems like we are being lulled asleep again and we are failing to make the big changes that are necessary to really change our direction.  I almost feel like we have lost our momentum for change and the Republicans will be allowed to obstruct any real progress as we lose our sense of urgency.  I hope I am wrong.

Change is so damn hard.  Watching the Health Care Summit was a case in point.  Many of us have been arguing for years that health care system was a disaster waiting to happen, but only now are we going to have a real discussion.  The change that is allowing this discussion is that all the problems we have been pointing out (high cost, poor coverage, poor outcomes) are starting to be felt by our entire population.  Unless you are rich, you are now the recipient of either higher cost for your insurance with lower coverage, or no coverage at all.  Businesses are being priced out of the market providing health care to their employees.

Sadly there is only one answer and I wonder how many years it will take until we finally get there, and that is a single payer system.  Socialized Medicine!  Socialized Medicine!  I hear Rush Limbaugh has already started to beat that drum of fear.  So let’s consider this two part problem; why single payer, and is it socialized medicine, and why is that bad?

Why a single payer system?  Because medicine for profit (private insurers) puts all the incentives on lots of enrollees and few payouts.  Remember that private insurance is primarily not about providing health care, but profit for the owners/stockholders.  So ask yourself how one would do this:  Enrolling healthy people and denying claims.  I won’t belabor the details which I did in my blog Issues – Healthcare.  The reality is that that is how they operate today and their administration costs in this pursuit adds 30% to the cost of medical care delivery.  It has to go.

Now for the really scary part:  Socialized Medicine!  This terrifies everyone because they see some Soviet hospital with limited access and mediocre to poor care delivery.  But that view is a result of our own myopia.  This model is one of the government owning and employing all health care modes of delivery.  This is the model used by the British and, although not one I would recommend, is not the envisioned horror by the Republicans.  One the other hand we have the model of the Japanese where health care delivery systems are maintained in private hands, but there is only one insurer, the government.  There are pros and cons to both these systems, but both do a better job than our system does.  Needless to say there are plenty of other models out there to study if we could just overcome our panic attack at the thought of government provided health care.

So the solution is obvious, but we can’t say it out loud because the Republicans, the people who have kept us in the dark ages, especially the ones with Southern accents, will go ballistic.  President Obama is employing an old management trick right out of Project Management 101.  If you want to bring about real change, invest the opposition in it and instead of letting them sit on the sidelines taking pot shots, have them face the hard choices as part of the process.  If they are part of the solution it is hard to criticize.  My guess on this one is the answer is obvious, but it will take years of iteration to get there because most people can’t just face up to the change required and as we are seeing now, it will take harsh reality to force the inevitable changes.  As some sage person said, politics is the art of possible and for the near term in the political world the possible will be some bastardization of a single payer system and insurers.

Here are a couple of other things that are high on my frustration index:

• Proposition 8 in California that denied gays and lesbians equal rights – California must be proud of itself being led around by the Mormons and the Russian immigrants (top contributors to the Yes on 8).  If you don’t believe in gay marriage, don’t marry a gay.
• Super Majorities for anything but constitutional amendments – With the filibuster in the Senate and the two-thirds requirement for budgets in California, we have handed ourselves over to the radical minority.
• As an adjunct to this, Cuba politics – Two Hispanic Senators. one Democrat, one Republican, sent the budget bill down (keeping it from getting 60 votes) because they want to strip out the loosening of travel and commerce restriction on Cuba.  How long do we have to tolerate these morons?
• Adjusting Mortgage interest rates and principal in bankruptcies – Let’s see, we can do this in any bankruptcy proceeding except for personal bankruptcy.  Don’t you think lenders would be more willing to deal if they faced this possibility?
• Understanding the Economic downturn is global, not local – Until the debt and over valued assets are wrung out of the system, there will be continued bad news.  It is time to bite the bullet and admit that most of the crap Wall Street is selling is worthless and reboot the system.
• Listening to Republicans do nothing but criticize – Next time a Republican says no, ask them what their plan is and ask how they will address our real problems of a lagging middle class and failing infrastructure.  They are all about the status quo because it made them rich.

But change, even when reality tells us everything we having been doing is wrong, is not going to be easy.  Then there are those morons out there (usually wealthy Republicans who don’t want a change to the status quo that has been so good to them) who are now blaming everything on the Obama administration.  This is the ultimate in denial.  I wonder how much longer we have to tolerate these people?