seventy-four after a battle with cancer. She was founder and national
coordinator of Healthcare-NOW. Over the past five decades, she
worked for Dr. Martin Luther King, Jr., the Southern Christian
Leadership Conference, the Women's International League
for Peace and Freedom, the Center for Constitutional Rights, the
African National Congress, and The Guardian newspaper. Marilyn
Clement appeared on Democracy Now! in 2007 advocating for a
single-payer healthcare system.
Marilyn Clement: "We need healthcare now. People are desperate.
Desperate. And 18,000 people are dying every year, simply for lack of
healthcare coverage of any kind. Think about how many thousands
will die between now and 2012. So we put forward a single-payer
national healthcare system for everybody that would cost a lot less money.
Think about every dollar you spend on healthcare: one-third of it now
goes to the insurance companies for their profits, their administration,
their advertising, their lobbyists. If we take that one-third that we now
spend on spurious--we don't need the insurance companies-- that would
cover literally everybody who is uncovered in the United States for a lot
less money and provide for the kind of system that most of the advanced
countries in the world, enjoy."
http://www.huffingtonpost.com/robert-kuttner/faint-praise_b_249635.html
Faint Praise
As Shakespeare wrote, "Lilies that fester smell far worse than weeds." The
satisfaction of a Rose Garden signing ceremony is not worth it, if the plan
is more thorn than rose.
By Robert Kuttner
American Prospect: August 2, 2009
President Obama wanted health insurance reform in the worst way. And at the
rate things are going, he is likely to get it.
Let's review the bidding -- first the substance, then the politics. America
spends 15 percent of its GDP covering far less than the entire population,
while other wealthy nations cover everyone, more effectively, for about nine
percent. We under-insure tens of millions of others by leaving big loopholes
in what's covered. More than half of Americans who file medical bankruptcy
nominally have insurance.
Why is our system so massively inefficient? Because it is run by and for
private insurers, aided and abetted by for-profit drug companies and
hospitals. Even if we insure more people, as President Obama hopes to, a
fragmented, profit-oriented system dominated by these interests simply
cannot yield the most efficient use of health outlays.
By contrast, a comprehensive system with a national health budget naturally
looks for the most efficient way to spend health dollars. That means much
greater investment in prevention, and in the comprehensive use of proven
treatment protocols for the easy stuff that makes a big difference in
heading off more expensive treatments later on, such as childhood asthma,
high blood pressure, and diabetes. It means a more sensible breakdown of
primary care doctors and specialists. It means not saddling med school grads
with hundreds of thousands of dollars of debt, which turns them into profit
machines rather than healers.
Private health insurers cannot get us to this outcome because they maximize
their profits by targeting the young and the healthy, and avoiding the sick,
the old, and the risky. They invent preposterous concepts such as exclusion
of people with "pre-existing conditions." Hendrik Hertzberg recently
observed that we are all born with a pre-existing condition -- mortality. In
theory, HMOs were supposed to increase prevention and collaboration. But
they rapidly deteriorated into merely a system where large panels of doctors
are approved providers if they accept the HMO's fee schedule, and physicians
are under pressure to cut costs and see ever more patients in ever shorter
appointments if they wish to maintain their incomes.
The "staff model" group practice -- where doctors are salaried and a medical
team of generalists and specialists works in close collaboration -- is our
closest equivalent of national health insurance, but it is being crowded out
by the cherry-picking practices of the insurance industry. The exceptions
invariably provide the best and most efficient care, such as the Cleveland
Clinic and the Mayo Clinic.
The press commentary on the cause and cure of medical inflation has largely
missed the point. The problem is not that "hospitals" and "doctors" in
general make or charge too much money. The problem is feast coexisting with
famine. The current system gives hospitals incentives to target the services
that produce the most reimbursement at the least cost, such as complex
cardiac interventions. So cardiology departments are gold-plated, while
money-losing emergency rooms are threadbare. To make matters worse,
specialty day-surgery hospitals, often owned by doctor- entrepreneurs,
divert profitable patients from hard-pressed local general hospitals.
There is also a misallocation of resources according to medical specialty.
As reimbursements are cut by insurers and by Medicare, primary care doctors
are squeezed; likewise OB/GYNs, psychiatrists, and pediatricians. Meanwhile,
some specialists such as oncologists (who are permitted to personally profit
from the sale of cancer drugs), surgeons, dermatologists, and others, are
still making out just fine. And standard practices and charges wildly vary
by region.
The bottom line is that these structural problems cannot be fixed by what is
likely to be approved by Congress as the Obama plan. Obama hopes that heavy
reliance on new electronic record-keeping can somehow reduce medical
inflation. But this is not where the problem (or the solution) lies --
because the plan builds on the existing insurance industry, with all of its
inefficiencies. The candid Doug Elmendorf, director of the Congressional
Budget Office, recently testified that the design of the Obama approach did
nothing that would fundamentally change the pattern of medical cost
inflation.
Putting the best possible gloss on Obama's approach, its inclusion of a
public option will gradually move more and more people to a Medicare-style
system; its much tougher regulation of private insurers will yield at least
some of the efficiencies that we could get through true national health
insurance, it will ban some of the worst practices such as exclusion for
pre- existing conditions, and its "play-or-pay" feature for employers and
subsidy of the near-poor will bring insurance to most Americans.
That is the best possible outcome. But it is not the likely one. That brings
us to the politics.
President Obama set the terms of this legislative battle by proposing to
work with, not against the insurance and drug industries. That added one
lead weight to his feet. Then he added a second lead weight by trying to
make the affair bipartisan, inviting Republicans to collude to produce an
unacceptably weak plan. (Let's seek what kind of bastard child emerges from
the collaboration between the unreliable Democrat Max Baucus of the Senate
Finance Committee and his Republican counterpart, Chuck Grassley.) Obama
also waited until very late in the game to take his case to the country.
The result? The insurance and drug industry lobbies say they support Obama.
They just happen to oppose all of the details that would make the reform
meaningful. The bill that (barely) cleared the House Energy and Commerce
Committee on Friday keeps alive a somewhat stripped down public option. It
bans exclusions for pre-existing conditions. And it requires employers to
provide at least standard insurance or pay a tax. But the proposed tax is
far less than the cost of the insurance, shifting some costs onto
government. And it remains to be seen whether the remaining teeth in the
House bill can survive what will surely be a weaker Senate bill. The
Democratic Blue Dogs remain sunshine patriots on health reform if there is a
risk of increasing costs to business; and the Republicans have defined
defeat of health reform as a strategy of handing Obama a disabling symbolic
defeat.
Given the partial progress by the House, it seems almost churlish to
criticize Obama for not having set the bar higher in the first place. The
liberal commentariat has bent over backwards to find things in the bill to
like.
The estimable Hertzberg writes, "The American health-care system is bloated,
wasteful, and cruel. Under the health-insurance-reform package now being
bludgeoned into misshapen shape on Capitol Hill, it will still be bloated,
wasteful, and cruel -- but markedly less so." Yes, but the consequence will
be that medical inflation will likely drive us to further cuts in care,
further speed-ups on primary care doctors, and further cost-shifting to
patients and taxpayers.
The New York Times, in another classic of faint praise, editorialized, "It
seems hard to believe that over the long haul the introduction of electronic
medical records will not save substantial money." Actually, it is quite easy
to believe. This editorialist must be extremely healthy. If he or she has
been to the doctor lately, the medical records are already computerized and
"charts" are electronic, not hand written. The problem is not the technology
but the insurer-dominated system in which it reposes.
The behavior of Harry & Louise, the Republicans and Blue Dog Democrats is so
odious that it's hard not to put in a kind word for Obama. Paul Krugman was
never a fan of the Obama approach. His latest column is a general tutorial
on why we should thank government for the fact that health insurance
functions at all. He declines to say anything nice about the Obama bill, but
concludes, very graciously, with more faint praise: "Now Mr. Obama basically
proposes using additional regulation and subsidies to make decent insurance
available to all of us. That's not radical; it's as American as, well,
Medicare."
In my book, Obama's Challenge, I argued that our new president should devote
all his effort in his first year to getting the economy back on track. Then,
armed with the gratitude of the people and an increased majority in
Congress, he should offer a much more robust health reform such as single
payer after the first mid-term election. It would be a huge mistake, I
contended, to tackle the Mount Everest of domestic reform as a novice.
Well, President Obama didn't take my advice (not the first time.) I can only
join my fellow progressive journalists in hoping that something like the
House version of the bill survives. But the likelihood is that whatever
finally makes it through this session of Congress will reinforce and further
bloat the current disaster of a health insurance system rather than
fundamentally changing it. And if the decent elements of the plan are
blocked, Obama should have the courage to pull the bill and take his case to
the people.
As Shakespeare wrote, "Lilies that fester smell far worse than weeds." The
satisfaction of a Rose Garden signing ceremony is not worth it, if the plan
is more thorn than rose.
Robert Kuttner is co-editor of The American Prospect, a senior fellow at
Demos, and author of Obama's Challenge.
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