... what if you're wrong:
He writes that Terri Schiavo "demonstrates a number of behaviors that I believe cast a reasonable doubt on the prior diagnosis of PVS." Among these observations, he pinpoints: "Her behavior is frequently context-specific. For example, her facial expression brightens and she smiles in response to the voice of familiar persons such as her parents or her nurses...Several times I witness Terri briefly, albeit inconsistently, laugh in response to a humorous comment someone in the room had made. I did not see her laugh in the absence of someone else's laughter."
Last week, I noted that the Providence Journal editorial page had taken the surprising position that disconnecting healthcare from employment might encourage hiring. Today, I point out over on Anchor Rising that the very same editorial page is advising Massachusetts to pass legislation requiring all employers to... pay for employees' healthcare. Ugh.
I'm increasingly convinced that tying healthcare to employment is just about the worst approach to either:
Other analyses cite the soaring costs of health insurance as a damper on hiring. The best jobs come with health coverage, and employers are reportedly afraid to take on new people for whom they'd have to buy health insurance. And so, rather than add to their personnel, these companies just work the employees they have harder.
This dynamic may partially explain why government-given healthcare jumps to the top of the general list of solutions. A person who doesn't receive a good job because of high health insurance costs to the company is a person who can't afford to buy insurance on his own. It's all or nothing. So, the thinking might go, since it is problematic to get companies to "give" employees coverage, a more-universal entity must "give" it to people: the government.
That, needless to say (on this blog, anyway), presents a whole different range of problems. I'd prefer to work for my money and pay for my own health insurance; others among my fellow citizens apparently differ, and a fair, workable blended solution has not been the subject of extensive public investigation and debate.
John Hawkins mentioned some problems with Tennessee's healthcare system, the other day, that I thought worth noting, since the issue persists in nation-level debates (interior quote from Opinion Journal):
Prescription drug costs alone increased 23% last year, as there are effectively no limits on the number or types of drugs the system will pay for. If a doctor prescribes aspirin, TennCare pays for it. Ditto for antacids for heartburn and other over-the-counter products. If TennCare denies a claim for a drug or any other type of care, an appeal can be filed for next to nothing. Fighting each appeal costs the state as much as $1,600 in legal fees. With 10,000 appeals filed every month, it's often easier and cheaper to pay a claim, regardless of the merits.TennCare is now in worse shape than it was a decade ago. Three of the 11 privately run Managed Care Organizations that insured TennCare patients and administered the program have fallen into receivership. Amid the legal wrangling, Blue Cross Blue Shield all but pulled out of the program. Today the state has assumed all the insurance risk and pays most of the premiums."
So we have a program that only covers "1.3 million of the state's 5.8 million people" & it eats up 1/3 of the state's budget? Yep, that "free" health care is a real deal, isn't it?
Michelle Malkin has a couple of posts on pharmaceuticals that are worth your time to read. In the first, she explains the negotiating approach taken by the Veterans Administration, which John Kerry wants to emulate for Medicare. In essence, the VA makes its purchases all-or-nothing in each submarket of medicine; companies compete for particular slots and become, effectively, the sole providers in their therapeutic classes. The problem with extending this, as Malkin puts it, is as follows:
The picture changes when we're talking about Medicare--a program that covers virtually all 40 million elderly people in the U.S. Medicare is a huge program. No other payer in the U.S. is even close in terms of size. Suppose there were only one Medicare formulary. If a drug company's product were to be excluded from that formulary, it would be a huge blow to the company. There's no question that drug companies would fight desperately to get their products included. It is difficult to overstate the importance of the Medicare market to drug companies. How low would prices go? 20 cents per statin tablet? 10 cents? 5 cents?
As attractive as this might sound, the effect that it produces relates to Malkin's second post:
Why on earth does the U.S. get virtually all of its flu vaccine supply from just two manufacturers? Because only a handful of companies make vaccines for the U.S. market. And why is that? Because federal bulk purchase of vaccines at government-controlled prices has made the U.S. vaccine market a market that few drug companies want to be in.
If there were a single economic principle that I wish more people understood enough to respect in the face of immediate self-interest — especially on the topic of healthcare — this would probably be it: The benefits of collective bargaining and unified administration only outweigh the costs as long as the group is reasonably small compared with the total market. The federal government can administer healthcare for its own employees with relatively little cost or disruption, but Rep. Jim Langevin (D-RI) is dreaming to suggest that the system can just be expanded to cover everybody.
Langevin can talk about health insurance providers' shouldering their "fair share of the burden," but having to take a more free, creative, and mature approach to medical policy is one of the burdens of being the United States of America. Socialist healthcare in smaller nations is inadvisable for its own reasons, but the practice avoids being globally catastrophic only because of U.S. resistance to it. The smaller nations are akin to the VA or to the Federal Employee Health Benefits Program, only on the larger scale of the worldwide market.
Medical care is an easy issue on which politicians can stretch their demagoguery legs, but it would be an historic mistake for too many citizens to be taken in by it. Those of us who fear that the lure will prove too powerful can only argue against it and pray that deadly experience is not the only teacher that Americans will follow. The entire world would suffer for our lunge after a mirage.
I love this beginning (emphasis added):
At three laboratories here, separated by a taxi ride of no more than 10 or 15 minutes, the world of stem cell research can be captured in all its complexity, promise and diversity.One of the labs focuses on cells taken from human embryos, another on cells from mice and fish, and a third from stem cells that have mysteriously survived in the adult body long after their original mission is over.
Those are the first two paragraphs of a piece by Gina Kolata in the New York Times. Upon my reading the blockquote that Glenn Reynolds reprinted for his readers, two thoughts came quickly to mind: 1) that the existence of adult stem cell research had finally been acknowledged by the mainstream media, and 2) that Kolata's facts about it disagreed with what I had previously thought to be the case:
One idea, the focus of about half the nation's stem cell research, involves studying stem cells that are naturally present in adults. Researchers have found such cells in a variety of tissues and organs and say they seem to be a part of the body's normal repair mechanism. There are no ethical issues in studying these cells, but the problem is in putting them to work to treat diseases. So far, no one has succeeded. ...As the two lines of research proceed along parallel paths, researchers say it is far too soon to bet on which, if either, will yield cures first. "It's not either-or," said Dr. Diana Bianchi, chief of the division of medical genetics at Tufts New England Medical Center in Boston.
In line with the version of reality that I'd heard several times elsewhere, Wesley Smith described back in May some reasons why Kolata's assertions just aren't true. I suppose one could argue that Kolata's language implies cures already put into practice and available to the public, in which case she'd be right (technically), but anybody who had read only the her article would certainly be surprised to come across these tidbits:
The FDA has allowed a human trial to proceed that will use bone-marrow stem cells to treat severe heart disease. The experiment will be conducted at Texas Heart Institute in Houston. This approach has already safely improved heart function in 14 patients in Brazil, as reported in the medical journal Circulation ...Dennis Turner of southern California was the first human patient known to have been treated by his own brain stem cells for Parkinson's. It is now a few years post treatment and his Parkinson's — which by now was expected to have substantially disabled him — has instead gone into substantial remission. Turner has been able to reduce his medications and rarely experiences significant symptoms of his disease.
Reading a bit farther into Kolata's piece, however, one notes that, although she's acknowledged that adult stem cells are found in "a variety of tissues and organs," she muddies the discussion terribly with the researcher whom she introduces as supposedly representing the adult branch of stem cell experimentation, Dr. Diana Bianchi:
But then she discovered that the fetal cells do not disappear when a pregnancy ends. Instead, they remain in a woman's body for decades, perhaps indefinitely. And if a woman's tissues or organs are injured, fetal cells from her baby migrate there, divide and turn into the needed cell type, be it thyroid or liver, intestine or gallbladder, cervix or spleen.
That's not what most people consider to be "adult stem cell research." Indeed, Bianchi isn't even sure that the cells that she's chasing are stem cells. In other words, these three labs hardly capture the stem cell debate "in all its complexity, promise and diversity." And I can't deny that the assertion that they do has the feel of deliberate distortion. So, although that huge swath of Americans who get their information only from mainstream sources might now be aware that such a thing as adult stem cell research exists (the apparent taboo having been broken), their conception of it is entirely wrong.
I wonder how much more difficult that will make it for conservative legislators to convince their constituents that embryonic stem cell research isn't the way to go.
ADDENDUM:
In posting Kolata's piece, Prof. Reynolds writes something that strikes me as odd:
And, since I don't believe that life begins at conception, the embryonic aspect doesn't bother me much either.
Then when does it begin? It's been awhile since I've taken any biology classes, but as far as I know, it's indisputable fact that an individual human being's life begins at conception. I can understand the argument that an embryo isn't sentient or fulfilled or some other sort of life, even if I disagree about the practical difference that the adjective makes, but it's clearly life — self-contained human life — isn't it, professor?
Since the American Bar Association's attempt to force its not-so-nuanced worldview on the rest of the country has come up, this would seem worth noting:
In order to permit Catholic and other faith-based health-care providers to remain religious while serving critical public functions, state and federal legislators have often provided "conscience" protection that permits religious-based health-care providers to opt out of programs or treatment that they find objectionable. For example, even though they often treat patients receiving Medicare or Medicaid, religious-based hospitals are permitted by federal law not to provide abortion services or referrals.It is this core exercise of religious conscience — and the government's accommodation of it — that the ABA finds so objectionable. Citing studies with titles such as "When Religion Compromises Women's Health Care: A Case Study of a Catholic Managed Health Care Organization," the ABA argues that the religious practices of Catholic health-care providers, both individual and institutional, deny needed health services and information to patients, especially women. Its singles out certain Catholic health care-providers, such as Fidelis Care New York, a Catholic health-care system that provides Medicaid services to the residents of 33 New York counties — services that might otherwise not be available were it not for the faith-based outreach. What crime has Fidelis committed that merits the attention of the nation's bar association? It refuses to provide certain "family planning services" to its patients or refer patients for such services — services that contravene the core teachings of the Catholic faith.
David Gratzer suggests that the direction of healthcare in this country may be turning:
Given Maryland's tight budget situation, though, Sabatini needed to be imaginative — and frugal. First and foremost, Sabatini wanted to encourage businesses to buy insurance, making the option more attractive by making it more affordable. At the heart of his reform package was a simple idea: cut regulations. Insurance companies, he reasoned, ought to be able to offer small employers an inexpensive, no-frills health policy. Small business may fret the price of a Cadillac plan, but what about a Honda? Add to the mix malpractice reform and a crackdown on fraud, and he believes that more Marylanders will be insured. It's a bold agenda, and just last month Sabatini's efforts bore fruit when both chambers of the legislature approved a bill allowing no-frills insurance.
One can only hope that what we're seeing is the beginning of a shake-up of thinking, of some new ideas being put into play. Local AM talk host Dan Yorke was just talking about a new tax break suggested by the governor of Rhode Island, Don Carceiri that would introduce tax breaks whereby families earning less than $75,000 per year could deduct a certain amount of medical expenses that aren't covered by insurance, such as co-pays.
Yorke was focusing on the income cap (which apparently rules him out), and the governor has phrased the proposal in terms of helping people. But I wonder if the strategy mightn't count as a small side-door reform. Mostly the shift is psychological, putting the focus on healthcare as a personal expense, giving a relatively high limit for which to shoot ($1,500), considering the specific expenses included. Again, as a reform, it's miniscule, but it could betoken a change in attitude.
In fact, these two reforms made me realize that I haven't really been thinking about my contribution to the healthcare that I get through my part-time employer. This month, I started attempting to track every penny that we spend, but somehow, it hadn't even occurred to me to include taxes and healthcare in my pie graph. Now that I've done so, I see that health insurance, alone, amounts to about 10%, which, for a two-income family, is almost a full week of work for one person.
Short of finding an employer with a better program, there's not much I can reasonably do to minimize this deducted wedge from my wages. If healthcare were akin to every other cost of living, I could decide that the vision care program, for example, isn't worth the expense. If consumers were granted the ability to make such decisions more easily and directly, providers would have reason to price for incentive.
Granted, I'm predisposed to make these connections, and other people, upon making them, will conclude that somebody else ought to pick up the tab, but one oughtn't underestimate the power of new perspective.
It's hard to understand why anybody would oppose socialized, government-run, universal healthcare when Rep. Jim Langevin (D-RI) puts it like this:
At the crux of any meaningful health-care reform must be a commitment from the government to act in the best interest of its citizens. A national template for this type of coverage already exists: the Federal Employee Health Benefits Program (FEHBP). It manages health insurance for more than 8 million federal employees, retirees and dependents. This program, composed of private insurance carriers, is administered by the federal government, which assumes responsibility for approving or disapproving carriers, negotiating benefit and rate changes, and auditing carriers' operations under the law.With administrative costs of less than 1 percent (compared with private-sector costs that can reach 30 percent), and a below-average annual premium increase, the government can offer a wide variety of choices and protections to its employees.
The system is funded by the taxpayers.
On second thought, how anybody can conclude from the political system and healthcare situation in Rhode Island that what is needed is further regulation and a government-run healthcare monopoly is beyond me. For some reason, this style of thinking seems to be related to that which believes that a system managing healthcare for 2.8% of the population — paid for by the other 97.2% — could simply be expanded to cover everybody.
Hey, if everybody's going to pay for everybody's healthcare, why not just insist that everybody pays for their own? That 1% (or whatever) administrative fee must be a powerful policy incentive...
Paul Craddick emailed me a link to an article by Dale Steinreich that gives some of the background for understanding the mess that healthcare has become. It's worth a few minutes, if you've any interest in the topic. Apart from the history lesson, Steinreich offers the following suggestions:
A first step toward genuine health freedom would be an elimination of all federal restrictions on supply and demand factors in medical markets. This means no more millions of dollars in federal subsidies to hospitals to train fewer doctors, and the abolition of Medicare and Medicaid. Medicare and Medicaid have only worsened the problems in the health-care sector by adopting Blues-type practices which have in turn encouraged an over-consumption of health care services among the poor and elderly.Beyond this point free-market health-care reform becomes a tricky matter since some of the most oppressive restrictions (physician and hospital licensure, restrictions on midwives and pharmacists) have been enacted at the state level. It would be a violation of states' rights to advocate that the federal government override these restrictions.
Steinreich is understandably frustrated by public apathy. That's the difficult part of balancing reasonable policies on specific issues with democratic principles. It's a shame, though, that he ends on the sour note of slurring the public for its ignorance. Coming up with a policy is the (relatively) easy part; convincing others why it's better than one crafted by politicians, special interests, and demagogues is the challenge, and it's much more easily met with optimism.
For better or worse, articles and blog posts about healthcare issues are now blinking on my radar. This hit the other day:
When Chuck O'Brien visits his doctor, they talk about his aches and pains, his heart problems and his diet, but never about his health insurance. That's because Dr. Vern Cherewatenko is one of a small but growing number of physicians across the country who are dumping complicated insurance contracts in favor of cash.Is this the health care wave of the future? Probably not, experts say. Most people are content with monthly premiums and $10 copays; nine out of 10 doctors contract with managed-care companies. But cash-only medicine is becoming an increasingly attractive option for doctors frustrated by red tape and for the 43 million Americans who lack health insurance. ...
He started a group called SimpleCare to spread the gospel of cash-only medicine. The organization steers patients to doctors who offer cash discounts, and gives technical and moral support to doctors who want to start cutting their ties to insurance. Membership has grown to 22,000 patient members and 1,500 doctors. Some reject all insurance and take only cash, while others continue to accept insurance while offering discounts of 15 percent to 50 percent for cash-paying patients.
Independent of SimpleCare, doctors in California, Colorado, Minnesota, Texas, Mississippi and other states have also quit the insurance game. Some tired of the paperwork and administrative expenses. Some wanted to spend more time with patients without managed care bean-counters peering over their shoulders. The patients who pay cash range from poor to wealthy, with most in the blue-collar middle.
To build on my still-blurry view of a solution, a pay-at-the-door component might do much to revivify the medical profession for both doctors and patients. Some basic coverage for calamities and expensive procedures would be mandatory — perhaps with some sort of minimum coverage, such as one free checkup per year — and everything else would be paid on a cash basis.
That might open up an area of competitive differentiation for insurers, which could offer additional free visits and the like to attract subscribers. It would certainly open up the options that doctors would have in designing their practices. If they can receive more income per visit, and therefore spend more time with patients, who knows but some might offer house calls for slightly higher fees.
This might be the PR basis for building consensus behind healthcare reform laws. The possibilities of a liberated system beyond the stifling shelter of insurance are manifold and tremendously appealing, with powerful and comforting imagery to draw from our cultural past.
Even people with high thresholds for tedium will have topics that cause their eyes to gloss over. For me, healthcare is just such a topic; even when I have a direct interest in figuring something out, words and phrases like "premium" and "primary care" do to my comprehension what staring at the sun does to my vision. For all I know, that's a deliberate accomplishment of the folks who run the industry. There are more than enough complicating elements, however, that no corporate conspiracy to bore is required.
For one thing, I've a somewhat latent hypochondria, and unpleasant notions linger everywhere in discussion of health coverage and treatment. It's also emotionally difficult to work up righteousness in defense of professionals — doctors — who move out of state because the low-end of the salary range has dropped 15% to $105,000. Doctors provide a valuable service, of course, requiring a tremendous degree of investment and devotion. Moreover, one can hardly fault folks for working in neighboring states where the money is better. I'm merely suggesting that the dollar amounts in question are high enough that the average person will slip into cry-me-a-river mode.
But then the complexity of the issue kicks in. Financially speaking, insurance companies hardly qualify for sympathy. Doctors, at least, directly provide their crucial service, whereas most people don't know, really, what the purpose of filtering all medical costs through insurers might be.
These matters could all be straightened out in the public mind, however, if it weren't for the involvement of the government. Andrew Morse put it well in an email that he sent me offering some answer to my confusion about the reason any large group of people couldn't negotiate health insurance rates: Our system "combines the compassion of raw capitalism with the efficiency of bureaucratic socialism." Here's part of his explanation:
insurance sold through employers legally insulates insurers from the consequences of their decisions. This is an unintended consequence of a federal law called ERISA - The Employee Retirement Income Security Act of 1974. Under ERISA, when insurance is sold through employers, damages from lawsuits over denied claims cannot include costs (such as death) incurred because treatment was delayed; they can only cover the cost of treatment. Also under ERISA, states cannot regulate HMOs any more stringently than federal government can.
That last part raises further problems, because states can regulate the businesses that are compelled to offer health benefits to their employees. However, as Sydney Smith explains, another layer of big-pocketed folks slip out of the regulatory constraints, which then become nooses to those who remain:
The small business, (as well as the individual) insurance market is a tightly regulated one, and it's regulated by fifty different states with fifty different sets of rules and mandates. A large employer or a union -- and the insurance companies that insure them -- can get around the byzantine maze of regulations and mandates by providing self-funded insurance programs to their employees. Self-insured programs are exempt from state regulations and mandates. Because the large, self-insured businesses and unions turn the money for their insurance programs over to traditional insurance companies to administer, the self-funded programs are just like any other insurance policy -- except that the premiums are cheaper and the risk is assumed by the company. It is an option that small businesses just can not afford. As a result, small businesses and their employees have less choice since they are limited only to insurance companies willing to comply with whatever state regulations may apply in their area. And they pay higher premiums to cover state mandates for care.
Smith notes that one potential solution, the Small Business Health and Fairness Act of 2003, is currently stuck in the Senate. It would allow "small businesses to purchase insurance across state lines through their professional and trade associations." While this sounds like a reasonable, quick bandage on the part of the problem deriving from over-compassionate state governments, it would seem likely to tighten that noose on those who can't slip out through the new opening and to add a further layer of complexity to the issue. In the long run, there may be no other factor that is more important to avoid. As Morse noted in his email:
No one is really sure about how to unravel the tangle of laws, regulations, and precedents that allow insurance companies to restrict the choices of the insured. Because the problem has become such an incomprehensible mess, a lot of people are buying into the idea that the poor quality of health insurance has been created by inevitable socio-economic globalizing forces, and that the only way average citizens can protect themselves is to support a government takeover of healthcare.
The answer that's beginning to take shape beyond my thoroughly glazed eyes is exactly the opposite. Paul Craddick makes a good initial suggestion:
What to do?Not National Health Insurance;
Not piecemeal tinkering around the edges of the current "system";
Not laissez-faire in health care;Rather, mandatory, private, health Insurance - "universal coverage in exchange for universal responsibility."
That, it seems to me, might be the American way to create a universal health plan. It puts the onus on the individual, while providing for his well-being. Think of auto insurance if everybody were born with a car. Like auto insurance, more companies would spring up with varying products tailored to differing priorities; right now the underlying customer priorities are those of the companies negotiating the rates. Also like auto insurance, interested and relevant groups could pick up rate negotiation, as AAA and some companies already do for auto. Churches, for example, could secure group discounts — even offering a charitable component for those who cannot afford the premiums.
Employees might benefit from companies' newfound need to develop other ways to attract and keep employees, once risking temporary unemployment is no longer to risk one's life. Salaries would surely go up. For the companies' benefit, they would no longer have to administer a large program outside of their competencies, and human resources departments could save time now devoted to attempts to comprehend and explain the mind-numbing ins and outs of a system whose critical offering enables a complicated delivery that leaves many going without care and services that would improve their lives — and that they may not know they're already paying for.
I can't believe I've never seen this point made or thought to make it:
Yes, free flow of labor and capital are both important. ... But the major problem we have in the US is that there is no free flow of labor because health insurance is tied to the job. If health insurance were sheared off from employment, so many people would strike out on their own, establishing new businesses, and the economy would be rejuvenated.
I've been only temporarily employed for a few years now (not counting freelancing and odd jobs), and for a while I was a few hours per week under the minimum to gain health insurance benefits. Looking around, I discovered that there isn't really any area of life other than the workplace through which to secure it. Perhaps there's some aspect to the entire system that I haven't noticed, but I still don't understand why any large group (a Church, say) couldn't combine to negotiate health benefits for members.
At any rate, now that I'm working enough hours to gain the benefit, I can absolutely attest that it adds some unquantifiable degree of disincentive to risk leaving. (That's not to say that doing so is an immediate desire of mine, but one continually thinks about options.)
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