Presidential Health Care Summit Re-Cap

Yesterday was the big day. The President’s Health Care Summit. I know this because I watched history unfold for a mind-numbing six-and-one-half hours….and because as I fell asleep last night C-SPAN was showing highlights like they thought they were Sportscenter. To keep it interesting, I flipped back and forth between CNN and C-SPAN. Actually, I didn’t watch so much as I listened while doing other things around the house, like working with the data for my dissertation research. Before you give me too much credit for multi-tasking, let me just say that it was easy, because I heard absolutely nothing new from either side.

Here’s my print-version dramatization of what transpired:

Pres. Obama: Thank you, everybody for coming. As I said before and I will say it again, I didn’t decide to take on the issue of health reform because it was good politics. I did it because it’s in the best interests of the American people. I want to talk today about the areas where we agree–and there are many–and then really take a long, hard look at the areas where we disagree so that we can find a way forward that works for everybody.

Camera cuts away from the President, and John Boehner looks like someone killed his puppy.

Important Republican #1: Thank you, Mr. President. You’re right. There a lot of things we agree on. What we don’t agree on is how to go about achieving those things. So, in effect, we disagree over the things on which we agree. It’s a philosophical difference. The American people have spoken. They want us to start over. We want us to start over. You don’t want us to start over. I think we can all agree on that. I hope you’ll agree.

Pres. Obama: Those are some important points.

Important Democrat #1: Mr. President, the country needs health reform. [Insert substantive proof of the need for reform here.] That should not be the case in America. Our Republican friends say they want reform, but they have done nothing to move the country in that direction. In fact, [cite horrible CBO scores of Republican reform plans here], while the CBO has consistently scored both the House and Senate bills as greatly reducing the deficit over the next decade. If that’s not enough, we’ve [refer to one of the many elements of the bills that are actually borrowed from Republican ideas] and they still won’t support it.

Pres. Obama: These are all fair points.

John McCain: Back room deals. Kick-backs. Pork barrel spending. Shady politics. Mr. President, we both pledged to be open and accountable during the campaign.

Pres. Obama: The campaign’s over, John.

Both sides toss talking points back and forth and make appeals in the names of people they know who have fallen ill and struggled with health insurance and health care they needed. Those stories usually go one of two ways.

Democratic version: “I know Miss Edna Mae Parker–a 47 year old woman from Springfield–who just last year got diagnosed with debilitating disease syndrome. Her husband lost his job, they lost their insurance, and she died because of it.”

Republican version: “My friend, Robert Johnson, who has no health insurance, suffered from chest pains last June and went to the hospital emergency room where he was able to get the care he needed without any problem. He’s alive and well today, because we have the best health care in the world here in America.”

At the end of the day, nothing had changed. Reconciliation’s still the way forward for the Democrats, and I wasted a few hours of my day. The only high points for me came when I recognized a couple of people in the room who I’ve met (Rep. Jim Cooper) or know personally (Jeanne Lambrew). Otherwise, it was the same old song and dance. But, be honest, did you really expect anything else?

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"Government-Run" Health Care

I don’t like the pejorative use of certain words, especially when they’re so incorrectly applied. Today, allow me to vent about the phrase “government-run” health care. Obviously, this phrase is used to evoke a knee-jerk response in people who are opposed to the government running anything. But what does it actually mean? Clearly, there are some cases where government-run is a more fitting description than others.

In the context of health care, there are two main concerns: financing and delivery. In a place like England, the National Health Service both finances health care and by owning the hospitals and paying the physicians on salary, mostly controls the delivery of care as well. That’s about as close as you can get to “government-run.” Still, the actual provision of care occurs between doctors and patients. It isn’t as if there’s a government bureaucrat in the exam room weighing in on treatment decisions–although there is a panel called NICE that makes some cost-benefit decisions that many on this side of the pond would frown upon. Still, they outlive us, so I’m not quite sure what we’re afraid of.

Then, there’s Canada, which people like to lump in with England as being “socialized.” Or, as Wyatt Cenac of the Daily Show recently said, Americans don’t want to become “Nazi Germany, or Nazi Russia, or Nazi Canada.” In Canada, the financing of health care is a government affair, but the delivery is purely private. In many respects, it is no different from the U.S. Medicare program.

Which brings me to the United States. What exactly do people mean when they say Congress is proposing a government-run system? Well, based on my knowledge of what’s in the bills, they can’t mean a government owned delivery system, and they can’t mean much in the way of a government financed system, because there’s not much that would change from where we are today in that respect. Sure, there would be new subsidies, but we’re not talking about Medicare for all. By and large, the private employer-based system would remain intact. So I really don’t see how anything more than partially government-financed can be applied appropriately as a label for the proposed reforms.

Let me put it to you this way: Suppose it’s your birthday. If your Grandma sends you a gift in the mail, that’s Grandma-run. You had next to no say in what you received, where it came from, or how it was paid for. Now, let’s assume she sent you a card with a check in it instead. That’s Grandma-financed. You can choose to spend those resources anywhere you see fit. Of the two, I prefer the latter option. Of course, I suppose I could just buy myself my own gift, but where’s the fun in that?

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National Health Expenditures Update

The newest numbers on U.S. national health expenditures are out in Health Affairs. In 2008, the estimated tab came to a little more than $2.3 Trillion. I really have very little concept of just how much money that actually is. I mean, how many McDonald’s Happy Meals could you buy with that? The answer is a whopping 780 Billion. That’s a lot of hamburgers, fries, and little plastic toys. In fact, it’s enough to provide one happy meal a day to every person on the planet for about 4 months. It’s almost enough to buy 1 of every 10 Americans a new Porsche 911 every year. The apples to oranges comparisons could go on forever. The bottom line is, while spending growth seems to have slowed, we still spend an insane amount on health care.

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Right. Because It’s So Simple Now…

The big health care summit happens tomorrow. Literally dozens of Americans will be glued to their televisions to watch it. The President has released a plan–which is basically a guide for the House and Senate to push reform through using reconciliation–and it strikes a pretty fair balance between the two chambers’ bills. I’ll be writing up a more detailed overview of that later. But before tomorrow’s pow-wow, I wanted–no, needed–to vent a bit.

It seems that a lot of people are threatened by the idea that they will lose their freedom, pay more themselves so that “the other guy” can have coverage, and generally suffer horribly at the hands of the socialicommunazis (because all three things are synonymous if you didn’t pay attention in–or attend–school) who will institute “government-run” health care. I get that people are afraid of change, that they are distrustful of government, that they are inherently individualistic. These things are understandable. I happen to think that the hyperbolic assaults on reform aren’t really necessary, though. You can state your position without fearmongering. Honestly, sometimes I think Rush Limbaugh is just a big, fat, blinding light for a nation full of moths. Okay, I’m getting off track. See, I told you I needed to vent. **Breathe, Brad. Breathe.**

Here’s my beef: The health care system we have now my have familiarity going for it, but it is no walk in the park. The things people claim reform would mean losing are things we don’t really have anyway. Look at it this way….

Insurance is regulated by the individual states. As a consequence entry into the market is limited, and insurers are not very competitive. (As an aside, permitting the sale of insurance across state lines is only a good idea if there is a single national standard put in place to prevent all insurers from heading to a state with lax standards. And when you do this, it’s called “The Exchange.”) So, where you decide to live often limits you to just a handful of insurers right off the bat. Are you free to move elsewhere? Maybe. If you can find work.

Speaking of work, that’s how most of us get our insurance–through our employers. They have people working in human resources who may or may not have much experience in selecting employee benefits. Doesn’t matter. You get the choices they offer you. Don’t like it? Switch careers. Oh, wait. I forgot that no one’s hiring in the recession. Just try not to get sick, okay?

Say you live in Georgia, and the three largest insurers (who enjoy 85% market share) are Blue Cross Blue Shield, United Healthcare, and CIGNA (this is just an example). You’re down to three companies. You work for Delta Airlines. They offer you a CIGNA PPO–either basic or plus–so you really get just two options. Three if you think you can afford to buy non-group coverage. Four if you count being uninsured. Now let’s say you work for a small employer who doesn’t offer benefits. Your options just got severely limited.

All of these restrictions are just on access to an insurance product. They don’t even begin to touch on the fact that the value of the products may differ substantially. They don’t get into the fact that group-insurance is a much better deal than non-group insurance (with its smaller risk pool). Paying a higher premium because you smoke cigarettes makes sense, but why should what you pay for insurance have anything to do with where you happen to work?

By my own admission, this post is devolving. It is truly a rant. There are too many things for me to address them all in a few hundred or even a few thousand words. My overarching point, lest it be lost in the shuffle, is that people who are worried about the complexities of–and the limitations threatened by–“government-run” health care are ill informed of the current system’s complexities and limitations. Otherwise, they would see that much of what’s on the table would simplify the system and give consumers more–not fewer–options.

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Digging Into the Dartmouth Atlas

In case you’re not familiar with it, the Dartmouth Atlas of Health Care is a decades long project started by Dr. John Wennberg to explore small area (i.e., regional) variation in health care utilization, spending, and the like. You can find out more about them here. They’re the folks behind a lot of studies that you might have read about in the popular press, with the basic premise that there’s a wide range of variation in utilization and spending that isn’t easily explained.

In a recent article, Daniel Gottlieb and colleagues find that these regional differences in spending are primarily affected not–as many people thought–by differences in prices, but rather by differences in utilization rates. One has to assume that those differences in utilization are driven by the intersection of different patient populations and different physician practice patterns, but how much of the difference is justified and how much is wasteful has yet to be quantified.

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The Paradox of Employer-Based Health Insurance

A solid majority of Americans receive their health care through their or their spouse’s employer, and for the most part, people are pretty happy with that setup. I’ll put aside for a moment that most people don’t know whether or not they are right to be happy about it–they typically don’t know how generous their coverage is or how much it really costs–and I’ll focus instead on the origin of the employer-based system and the paradox that it presents to those who strongly support the status quo.

Believe it or not, we didn’t always have employer-based health insurance in this country. As a matter of fact, it’s a relatively new invention. It began back during World War II, when the government instituted wage freezes because of the limited supply of available workers, but chose to exclude the provision of benefits from these freezes–and made them tax-free. Competition, like water, seeks its own level, and employers began to use health insurance benefits to attract workers, leading to the system we know today. You can read a succinct account of this here. You can also read Paul Starr’s The Social Transformation of American Medicine, but it will take you much longer to get through.

Unintended consequences are a given in the policy world, and our accidental employer-based system is no different. Besides, there’s evidence that group plans are a better deal than individual plans, because of the more efficient pooling of risk that they entail. Of course, that same principle would favor a universal single-payer plan over the patchwork we have now, but that’s a different post.

There’s an inherent paradox that those who support the employer-based system most strongly must subscribe to given its tax-free nature. Most opponents of reform, you see, would agree with these three statements: “We need less government taxation.” “I don’t want the government providing benefits to people.” “People in this country who work hard deserve to get ahead and people who are lazy shouldn’t get handouts.”

The problem is that, while the tax-exemption of employer-based health insurance certainly aligns with the first and third statements, it flies in the face of the second one. By making health insurance benefits tax-free, the government is effectively subsidizing the coverage of everyone with job-based insurance, including the wealthy. In fact, because they are in a higher tax bracket, the wealthier people catch a bigger break from Uncle Sam.

So champions of the status quo clearly favor less taxation more than they oppose the idea of government giving handouts to people–at least so long as they’re the ones getting the handouts. Otherwise, why not move to making employer-based insurance fully taxable? That would realign incentives “in a quick hurry” to use a good Southern phrase. Some people have raised this idea, but you’ll notice it has very little traction. The closest we’ve come is the targeted tax on “Cadillac plans.”

If we can’t afford to subsidize the purchase of coverage for those who have none, why should we continue subsidizing the purchase of coverage for those who have something already? People should adhere to their principles more stringently, if you ask me. If you don’t believe in government handouts, stop accepting them for yourself, and start paying taxes on all of your compensation. After all, you’ve earned it.

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Why C-SPAN?

The White House Health Care Summit is coming up in just a few days. The President has just released his own plan for reform and the GOP has agreed to attend. Best of all, the event will be televised live………on C-SPAN. It’s that last point that gets me down.

Your average person doesn’t watch C-SPAN. They’re not going to camp out in front of their television to watch this half day long event unfold live. That means that all that most people are going to get are the few snippets the media decides to show them–complete with their own framing of the issue. The story MSNBC tells folks will be quite different from the one heard over at FOX News, which is funny since only one set of actual events will have occurred.

I realize the networks don’t want to devote such precious air time (and ad revenue) to covering the summit. After all, episodes of All My Children and Judge Joe Brown are far more important than the future of the American health care system. Still, I wish they would give people as many opportunities as possible to tune in on the mainstream channels. The stay at home moms and dads might actually watch for a bit and have some things cleared up. In fact, I daresay that–looking at the effect of Tiger Woods’ televised contrition speech on the stock market–even folks who are working on February 25th would tune in if the event were targeted more to the mainstream and less to the wonks.

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Who Supports Health Care Reform?

When it comes to health care reform, chances are pretty good that you either support it or you don’t. Not too many people fall into the “indifferent” camp these days. Chances are even better that you have seen a poll–from one source or another–that shows that the American people either do or do not support health care reform.

The fact that the polls aren’t all in agreement–or even something closely resembling it–underscores a very important point: polling is a highly variable method of collecting information. While some polls are more methodologically rigorous than others, all polling efforts are subject to a variety of biases that can alter their findings.

For instance, how the questions are asked can change a person’s response, even if the underlying point is the same in each case. So, too, can the length of the poll. People get bored easily, become impatient, and are more likely to answer hurriedly towards the end of a poll that is too long. Sometimes people don’t really even understand what they’re being asked. How can we really trust their responses in those cases?

Keep in mind that this has nothing to do with the margin of error polls typically report. That figure is simply an indication that the poll was conducted in a small sample of the population, and that the laws of statistics help us to project from the sample onto the larger population, but only within a given range of accuracy. If a poll is biased, it is simply biased, and its findings then fall anywhere from less accurate to meaningless.

David Brady and Daniel Kessler conducted a study that attempted to cut through the murkiness of the polling data. How did they do it? By conducting a survey, of course. But what they found was both predictable and fascinating. On the predictable side, people who were older, higher income, and Republican were less likely to support health care reform. On the fascinating side, income was the strongest predictor of support for health care reform. The authors write:

“[First,] the difference in support between a respondent in the top versus the bottom income bracket (more than $100,000 annual household income versus less than $25,000) is significantly greater than the difference between a Republican and a Democrat. In addition, income (and party affiliation) are much more important determinants of support than age, although older and middle-aged Americans are less supportive of reform than younger Americans. Second, the negative effects of income on support for reform start early in the income distribution. Depending on the reform, respondents with family incomes from $25,000–$50,000 are 19.7 to 21.6 percentage points less likely to support reform than those with family incomes under $25,000. Increasing income beyond $25,000–$50,000 reduces support for reform, but at a declining rate.”

My take on their findings is simple: People are inherently white-knuckled and short-sighted. People with higher incomes feel more secure in their own right and simultaneously more threatened by the idea that reform means they will be forced to pay for those who have less. The fight over health care reform has less to do with political philosophies and differences of opinion over the role of government and more to do with greedy, selfish, self-centered people with an everyone for themselves attitude. If it didn’t, income wouldn’t be so negatively correlated with support for reform. That’s the white-knuckled part–holding on to what’s “theirs” for all they’re worth.

The short-sighted part is that people fail to realize two very important things. First, that they may fall victim to misfortune and may suddenly find themselves without the incomes they now enjoy. In need of health care, but without the means to obtain it, they will suddenly be at the mercy of a public that doesn’t care to lend them a hand. In an eye-opening moment of clarity, the proverbial shoe will be on the other foot.

But that assumes that some unforeseen circumstances befall the wealthy person. Such an event may never come to pass. Still, there is another way in which people are short-sighted. They miss the point that when the society as a whole is less than whole, all the people suffer in some way. We all shoulder the burden of the costs of uncompensated care, the effects of medical bankruptcies, and denials of insurance coverage through higher premiums, greater business expenses, and the rising cost of all of our goods and services. In short, our economy suffers as the maligned health care system staggers onward. There is a very real cost associated with doing nothing. As Brady and Kessler find, however, the wealthy have yet to feel those effects enough to do something about them.

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The Blair House Summit

I thought I had reached my saturation point on health reform–and that’s pretty bad given that it’s such a huge part of my life–because things seemed to be grinding to a halt ever since Scott Brown came along. Others were a lot more cynical than me, however, proclaiming health reform dead and moving on to anything and everything else. Perhaps I’m just a committed idealist, but I wasn’t ready to let this opportunity slip away, which has proven frustrating given my limited capacity to affect the outcome at this point in my career. If I had Rahm Emanuel on a leash, for example, I’d have made him bite somebody by now.

But alas, there’s a faint glimmer of hope on the horizon, or as Jon Cohn’s metaphor labeled it, a weak but strengthening pulse. That hope is the half-day summit on health reform scheduled to take place at Blair House on February 25th. Now, there’s already been a lot of talk about the event. It’s supposed to be bipartisan, but many GOP leaders were refusing to go unless Congress scrapped both bills it passed last year and agreed to start over. The White House is stressing that the goal is to deal with the substantive issues and reach an agreement on the best way forward. Uwe Reinhardt is skeptical of any effort to solve the health care problem in half a day.

I’m inclined to agree. I don’t think we’ll see any startling new revelations during the summit, but that’s because there aren’t any. People like me–the people who do the research and study the health care sytem–already know what needs to be done. The ideas on the table aren’t those of members of Congress. Sure, they’re the ones who introduce the legislation and vote on it, but they are not experts in the minutia of our health care system. That’s why they have staff who specialize in different substantive areas. But the ideas come from experts in the field. Each member of Congress chooses to listen to those experts or not as they see fit, but what has played out this–and every prior–time around has been one of politics interfering with what needs to get done.

I don’t think the Republicans have any choice but to attend the summit. If they don’t show, they look wholly uncooperative–not even willing to feign the appearance of helping to solve one of America’s biggest problems. That won’t wear well during election season. Strike one. I also don’t think Republicans will offer anything substantively meaningful in the way of health reform proposals that aren’t already in one or both of the bills passed by the House and the Senate. That’s because they have good ideas and bad ideas, and their good ideas have already been included. If they raise their bad ideas, they risk having them exposed for what they are (CBO has already shown that many of their reforms would increase the deficit) all while televised nationwide. Strike two. Then I think that President Obama will clearly demonstrate that the Democrats ideas are the best ones out there on health care, and the Republicans will have little room to disagree. But they will stand in principled opposition, looking foolish in the face of a mountain of evidence collected over many, many years. Strike three.

So, I have hope. I also have hope that the House and Senate are very close to working out their differences and moving forward through reconciliation. And, before I leave you, let me make one other thing perfectly clear. This is not about politics for me. It is about understanding how our system works, where it is broken, and how it needs to be fixed. I appreciate that the reform legislation in Congress includes elements that should have bipartisan support–and would have if this hold thing hadn’t devolved into a political pissing contest. I want to see things get better for the American people, and I believe that this is a step in the right direction. If an entire political party disagrees with that, I don’t want them to tell me how idiotic my ideas are, I want them to offer a better idea on the right way forward.

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Watch Jon Cohn on CNN

Like me, CNN’s Dr. Sanjay Gupta is trying to make health care reform accessible to the American people. Unlike me, he enjoys a noticeable platform for reaching them. One of his first guests was none other than Jonathan Cohn. Hear what he had to say here.

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