Senate smothers the life out of health care reform

I shouldn't be surprised. Mark Twain himself once said, "Imagine that you are a senator. Now imagine that you are an idiot. But I repeat myself." (or something like that). Why did I think that the Senate would produce a health care reform bill that would accomplish what President Obama set out to do?

I hope I am wrong in predicting that the Senate will fail to pass meaningful health care reform legislation this year. But here's why I think I'll be proved right:

1. The Republican bloc has chosen to derail health care reform, rather than to work to bring to a vote a package that they could live with. Their motivation can be only short-term political gain, and their act is one of destruction, rather than edification. The Republican bloc is not acting on behalf of American citizens, but on their own political behalf. For that reason, every one of them should be voted out of office at the very next possible chance.
2. Liberal Democrats have been surprisingly willing to compromise, but I suspect that they're tired of (in their eyes) selling out and will soon tire of compromise and will return to demanding more socially inclined legislation, led by their party chairman Howard Dean, who is now publicly calling for the current Senate bill to be thrown out.
3. Joe Lieberman is becoming drunk with the delusion of power, and will insist on his way, which in summary is to defeat any and every idea and amendment offered by the liberal Democrats.

The result will be a compromise that nobody is happy with.

Here's what I would be happy with: a private health care plan chartered and managed by the Office of Personnel Management and priced by market forces. Subsidies will be awarded to purchasers based on their income level. Don't expand Medicaid. Don't offer Medicare to persons aged 55-64. Instead, put all of these folks in the OPM-managed health plan. While ostensibly more expensive than the Medicare and Medicaid options, it would in fact end up being more affordable, because both government insurance plans (Medicare and Medicaid) are priced on misconceptions and are not adjusted by the market.

Without a "semi-public" option, as some are calling this, the private sector will not deliver affordable health plans for the currently uninsured. And without some form of public option, the bill won't pass the Senate.

But, for the sake of argument, let's say the Senate does pull itself together and passes a health care reform bill. Whatever squeaks out of the Senate will be a far cry from what the House generated, and the Conference Committee will have a herculean task pulling a mash-up out of these two disparate pieces of legislation.

President Obama, may I make a suggestion? While the clowns of Congress are performing on the current three-ring circus, bring your staff together in the West Wing and write a Health Care Reform Bill that accomplishes what you set out to do. As soon as the current effort flops, bring your bill to both houses, and commence twisting arms until they break or pull off. You won't have to water it down like the current bills because you'll be able to leverage Congress' failure to empower your negotiating position.

The pundits say that your presidency will live or die by the success or failure of health care reform. Pundits are stupid. They said the same thing about Bill Clinton, and his presidency, though sullied by failing to reform health care, was nonetheless very successful. BUT, if the pundits are right, and health care reform will define your presidency, wouldn't you rather be responsible for what ultimately passes?

First amendment to pass, first to fail

First I must apologize for not having yet read the Senate bill. I've been busy reading the 669 pages of the Federal Register that updates the Medicare outpatient prospective payment system for hospitals for calendar year 2010. Since this piece of executive rulemaking has direct impact on my everyday job, it had to take precedence. It took me a long time to read because I kept it at my bedside. Best sleep I've gotten in years.

The Baltimore Sun reported today that the Senate passed the first amendment to the health care reform bill currently on the floor, that amendment requiring all insurers to cover women's preventative health and screening tests with no copay. I suspect the impetus for this amendment arose from the backlash to the US Preventive Services Task Force's recent publication of relaxed breast cancer screening recommendations in the Journal of the American Medical Association.

Truth is, the amendment, as I understand it, won't really prevent any deleterious changes to insurance coverage arising from such research. What it will do, however, is increase access to diagnostic services, hopefully allowing us to find cancers earlier and thereby decrease mortality from these diseases. At least that's the conventional wisdom. Ironically, what the USPSTF discovered is that screening women in their 40s by mammography doesn't have an impact on breast cancer mortality.

Overall, though, I think it's a good thing to improve access to preventive care and screening. In fact, in my experience, most insurance plans are migrating to coverage of preventive care and early detection and exempting these interventions from patient financial responsibility. The reason: it's good business. Insurance companies have already discovered that they save money by treating disease earlier.

The other amendment - the one that failed - was sponsored by John McCain and attempted to restore funding to Medicare that was being shifted to expand coverage to the 31 million or so uninsured the bill proposes to cover. Those of us on the provider side would have loved for that amendment to pass. It would mean little or no money being taken out of our pockets. It means we're going to have to figure out how to be good business operators, reducing waste and spurring innovation in order to adapt to the significant financial hit we're going to take when the bill passes.

If you look at this from another angle, however, you realize that the provider community isn't losing as much as it initially seems. Even though we'll lose some Medicare reimbursement, we'll offset that by significant reductions in unreimbursed care provided to the uninsured. If the math works out as it should, two-thirds of folks who currently do not have insurance will be covered when the bill passes.

Tonight I'll start reading the Senate Bill, so that I can speak half-way intelligently about it. Don't expect me to be blogging by the weekend. The bill is 2,074 pages. And judging by my experience with the Federal Register, I'll be sleeping like a baby until the New Year comes.

Between the Republicans and Nancy Pelosi, there must be a rational middle!

The Republican Party finally wised up, although perhaps too late, and announced that they will present a Republican alternative to the various, Democratic-driven health care reform plans being pushed through Congress. Perhaps Karl Rove has come out of retirement to advise the party, which heretofore behaved like spoilers, bent only on derailing health care reform without offering something better.

The problem: it has been reported (in the WSJ, of course, and elsewhere) that the Republican alternative won't raise taxes (at least, not on the rich); won't force individuals to purchase insurance or small businesses to cover their employees; won't include a public option to compete with private health plans; won't expand Medicaid or cut Medicare . . . so what exactly are they reforming? It sounds, to the untrained ear, like the Republican version of health care reform is status quo.

On the other extreme, Nancy Pelosi has upped the ante as both houses prepare to pass final versions of their internal bills prior to sending them to conference committee. I suspect that she has proposed her bill as a political maneuver, to give her more leverage when negotiating compromises with the conservative wing. But there are significant problems with Pelosi's proposal; specifically, it costs way too much (over $1 trillion); but it also pays for itself. That's a bad thing because it means a significant increase in taxes on the rich coupled with overly drastic cuts to Medicare in order to balance the budget on reform.

Not that I'm ever going to be in danger of paying the surtax, but a 5% burden added to folks already in the highest tax bracket is an overwhelming shock. I think a 1.5% to 2% surtax would be more palatable.

Pelosi is also in the camp that thinks Medicare is a generous payer, and that there is an abundance of fat to cut out of the system. I'm the first to agree that there is waste and economic profit in various pockets within Medicare, but I don't think there is overall excess. What needs to happen with Medicare is not overall cuts, but rebalancing of payments (e.g., the proposal to shift reimbursement to primary care physicians from specialists).

The System is Working (even if inefficiently)

Liberals and conservatives should take a short vacation from wallowing in fear and panic and take note that the system actually works! Yes, it's a good bit inefficient, and the pendulum swings could be a little less volatile. But overall, our system of government is actually working, with regard to health care reform. Different groups with different perspectives are pushing legislation that benefits them. These proposals are being whittled and reshaped through conflict with other parties who have other needs. After all the head butting and name calling is done, we'll have a final product that resembles what most of us want. Or at least will settle for.

And we'll know when we've arrived at a suitable compromise, because the fringes on either side of the middle will be screaming about the injustice and irresponsibility of final bill. Beware a final bill that is blessed by either the far right or the far left!

Illegals seeking wellness

I should save this for another column, because (1) this one is getting too long; and (2) this is a whole 'nother subject. But I can't let this issue pass without comment. The issue: some conservative Democrats and (do I even need to say it?) most Republicans are concerned that undocumented workers will be able to purchase insurance from the Public Option (even though they are barred from receiving government subsidies).

These congresspersons want to prohibit these "aliens" from purchasing Public Option coverage. Are they crazy? Why would we NOT allow them to PURCHASE insurance? Who cares if it's a government-managed plan, if these undocumented immigrants are paying in full for the coverage? At least, then, when they seek medical attention, it will be paid for with privately paid premiums, rather than tax dollars.

If we refuse to allow these immigrants to purchase insurance, based on some misguided jingoistic principle, when they do require urgent medical care, as eventually some will (remember, many of them do the jobs that are too dangerous, or low paying, or back-breaking, for red-blooded Americans to perform), these undocumented workers will show up in the already strained emergency rooms of our hospitals, and we will treat them, because federal law requires that we treat them (EMTALA . . . we can't turn away true emergencies, regardless of any circumstances, including citizenship and ability to pay). And, because we didn't allow them to purchase insurance, YOU will pay for their care, with your tax dollars (Emergency Medical Assistance, or EMA Medicaid), or with higher prices and higher insurance premiums (cost-shifting by providers to cover uncompensated care).

Not only as a matter of fairness, but also economic common sense, we should enthusiastically allow undocumented aliens to purchase the Public Option plan. If it's a matter of nationalistic principle, then deport them all and "Hire American!" to build houses and buss tables. But if we're going to exploit their work ethic, the least we can do is allow them the opportunity to be healthy.

Is Health Care a Right or a Privilege? A Christian Ethical Perspective

One of the basic sources of conflict in our society regarding the direction that health care reform should take stems from a deep division among our populace as to whether health care is a basic human or civil right. If health care is a right, then government has an obligation to provide it, regardless of the individual's ability to pay for it. If it is a civil right, then this coverage must be extended to all lawful citizens. If it is a human right, then it must also be extended to criminals, non-resident aliens and illegal immigrants.

If, however, we do not have a right to health care, then there is no obligation for the government to provide health services to individuals within our society. There is no obligation to stem infant mortality, or control the spread of communicable diseases, or develop better treatments for cancer. That is not to say that these are not worthwhile goals; merely, that it is not the government's responsibility to provide these benefits. It is up to the market to provide these services if they are profitable, and to charities to provide them otherwise.

It seems that some of the most verbal opponents of government-supported health services are committed, believing Christians. I find this counter-intuitive. I cannot mount a competent secular ethical argument for a human or civil right to health care. But I can make a case from a Christian ethical perspective. And I invite commentary from readers of other religious traditions regarding the ethical imperatives arising from their traditions with respect to health care.

Christianity as a religion grew from Judaic roots, and is founded upon the belief that an historical human being who lived in Palestine around 2,000 years ago, Jesus of Nazareth, was in fact the incarnation (the "fleshing out") of God. Consequently, the words and actions of Jesus are perhaps the most authoritative reference for Christian life and practice. Jesus was crystal clear about the individual's responsibility for the welfare of his/her neighbor. In Luke 4 he quotes from the Hebrew prophet Isaiah to define his mission:

"The Spirit of the Lord is on me,

because he has anointed me
to preach good news to the poor.
He has sent me to proclaim freedom for the prisoners
and recovery of sight for the blind (emphasis added),
to release the oppressed,
to proclaim the year of the Lord's favor."

In chapter 11 of the same book, Jesus tells the story of the Good Samaritan, the man who spent his own money to bind the wounds of an injured man (providing emergency services) and put him up at an inn for his recuperation (hospitalization). Defining this as "neighborly" behavior, Jesus commanded, "Go and do likewise."

There are many, many more examples, but I'll give just one more: In Matthew 25, Jesus describes the final judgement of the nations (Greek ethnos, which means cultures or peoples, the concept of nation state having not yet developed). Those who are judged righteous and rewarded with eternal life are those who carried out specific behaviors, and those who were judged evil and condemned for eternity failed to perform these same behaviors:

"I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I naked and you clothed me, I was sick and you looked after me (emphasis added), I was in prison and you came to visit me."

Jesus goes on to say that whenever we treat the least of our neighbors (i.e. the marginalized of society) in this way, it is as if we are literally caring for him.

At this point, the Christian who is inclined to disagree with me will quote Jesus (John 18) telling Pilate, "My Kingdom is not of this world," and follow this with quotes from Paul (Romans 13: submit yourself to the governing authority) and I Peter (submit yourselves to the king), to make the case that how we live our faith is a separate issue from how the government orders our society. I counter with the consistent message of the Hebrew prophets, and offer this one example from Isaiah 10:

Woe to those who make unjust laws,

to those who issue oppressive decrees,

to deprive the poor of their rights

and withhold justice

from the oppressed of my people,

making widows their prey

and robbing the fatherless.

What will you do on the day of reckoning,

when disaster comes from afar?

To whom will you run for help?

Where will you leave your riches?

When the New Testament was written, the Roman Empire was not a Christian state. In fact, Christians were persecuted and killed by Rome. On top of that, Christians were convinced that the end of the world was near, and therefore they were not concerned with temporal matters like social justice, nor were they in a position to influence these matters.

Israel, on the other hand, was a theocracy of sorts. The King and the Temple cult were inextricably tied. Temple worship was the "state religion." It was in this context that Isaiah prophesied against the religious and political leadership of Jerusalem. This context is more congruent with current American society, which is still not yet post-Christian. Christians who believe the American myth of a country founded on Judeo-Christian principles (and I'm using myth in the technical sense here, NOT as a synonym for fable) are violating their own integrity when they adopt the economic conservative stance that we have no societal or political obligation to provide at least a basic level of health care for our nation's citizens.

I therefore call on Christians to put their money where their mouth is. If we believe the United Sates is a Christian (or Judeo-Christian) nation, then we need to be intellectually and ethically consistent and support a more socialized model of medical care. OR, we need to be honest about what we really believe about the authority of Scripture (or, in this case, the lack thereof).

HCR, once stuck in the mud, is moving down the tracks again

As I predicted in my last column, the Senate Finance version of health care reform will form the core of whatever ultimately passes both houses of congress. The Republican minority attempted to derail reform, only to reveal to the Democrats that they can pass reform without Republican support. The opposition party comes off looking merely obstructionist, with the exception of Olympia Snowe.

The Public Option, once on life support, is making a remarkable recovery. Still in all, I am not a big fan of the public option because it will artificially depress the market. The reason is that supporters of the public option intend to set initial pricing at current Medicare rates, which are already below market value. Many older primary care physicians, whose patients have aged along with them into the Medicare universe, are retiring early because they can't afford to keep their practices operating at the rates Medicare pays. If the public option is implemented at those same rates, physicians will opt out, either immediately, or after trying to make it work for several months.

If this is indeed the turn of events, the public option, rather than tempering the rates charged by commercial insurers for individual and small group plans, will simply devolve into an empty shell, much like the Competitive Acquisition Program that CMS attempted to launch several years ago. For most of you, who have never heard of the CAP, it was an attempt to knock physicians out of the drug reselling business, where oncologists, for instance, earned most of their profits. CMS sought to control costs by enticing a handful of drug distributers to bid for the government's business. These few companies, in turn would have in effect an oligopoly (except without the ability to artificially prop up prices, which is the main purpose of oligopolies). These companies would then develop extensive drug delivery and retailing pipelines, with the oncologists serving as consignment shops.

The drug distribution industry saw the hook in the worm and didn't bite. Neither did the oncologists. The CAP never came to be.

Now here is how the public option can - and should - work: First of all, don't implement the public option right away. Instead, save it and use it as a threatening storm on the horizon, triggering its operation only if the commercial insurance market cannot provide affordable plans to individuals and small groups. Second, if the public option is enacted, set the pricing at 110% to 115% of Medicare rates. That's on the low end of what HMOs will pay for health services, but maybe high enough to entice the most efficient and well-run providers into opting in. From there the market should dictate which way the rates go.

Which brings me to a point regarding Medicare that many folks don't know, and I can't believe I'm about to say this because it'll make me sound like Milton Friedman, God rest his soul:

In a free market, supply and demand are inversely proportional, such that when supply is high and demand is low, prices drop, and vice versa. As the Baby Boomers age into Medicare, the demand for services will rise dramatically. At the same time, we are facing an impending shortage of physicians, as well as most other medical professionals. The result, in a free market economy, would be a significant increase in price commanded for health services.

Medicare works the opposite way. It wants to maintain budget neutrality. CMS, or more accurately, Congress, wants to pay only a certain aggregate amount for health services. So when demand goes up, and quantity supplied increases to meet the demand, Congress will reduce the price paid per unit in order to contain health care costs in the aggregate. What will be the effect of this? More physicians will retire early. Fewer college graduates will enter medical school. Nurses will leave hospital inpatient units in droves. The rate of consolidation in the health care sector will increase.

Medicare and Medicaid beneficiaries will be most vulnerable to these changes, because health care providers will simply stop offering services that are utilized disproportionately by these patients.

Here's a specific prediction: if CMS continues to reduce payments for cancer care - for instance chemotherapy treatments - medical oncologists will stop treating patients in their offices, because they'll lose money on the drugs. They'll begin sending government-insured patients to the hospitals for chemotherapy. However, since hospitals will be hit with a disproportionate number of underpaying patients (the physicians keeping the well-insured patients for themselves), the hospitals will simply shutter their chemotherapy infusion suites. Medicare patients will have to go to the few safety-net hospitals to get their treatments, and they'll have to wait in line, because the demand will far exceed supply.

The same chilling effect will be felt in other sectors of health care where the majority of patients are insured by the government.

Unfortunately, I'm not foretelling a future full of doom. These reductions in services are already occurring. In the large metropolitan market where I work, several community hospitals have already either closed or greatly restricted their outpatient infusion services because they can no longer afford to treat the number of uninsured and underinsured patients seeking chemotherapy at their facilities. And by underinsured, I mean to include Medicaid patients and Medicare patients who don't have a MediGap supplemental policy.

Maybe cancer care is an anomaly. Or maybe it's the canary in the mineshaft.

Senate Finance bill will become the centerpiece of reform

The health care reform bill being crafted in the Senate Finance committee, chaired by Sen. Max Baucus, will become the core of whatever bill ultimately passes both houses of Congress. We will all need to read the bill (I haven't started yet) so that we know for ourselves what the bill puts forth, rather than trusting the pundits to explain it for us.

By now everyone should realize that virtually everyone has an axe to grind when it comes to health care reform. You're not going to get a straight presentation from any major information outlet. So read the bill for yourself.

What I have picked up from reading the Wall Street Journal (still, in my mind, the most objective and accurate reporting on health care reform), as well as other news sources, is that the Finance bill has effectively killed the public option. As I have said before, I think that's a good thing, because the public option was going to start at Medicare payment rates. Most physicians aren't very good businessmen, but those who are will undoubtedly have refused to contract with the public option plan. They are already losing money on Medicare patients and can't afford higher volumes of patients at those payment rates.

Hospitals are even less adept at business than physicians, so most of them probably would have signed on with the public option. The hospital where I work is losing money on Medicare patients. For every dollar we spend to care for a Medicare beneficiary, the government is reimbursing us 90 cents. We can't afford more health insurance plans that pay at Medicare's rates.

Nancy Pelosi and other liberal Democrats will raise cain over the Senate's rejection of the public option, but in the end they will not be able to reverse the direction that Congress is moving.

There is a moderate possibility that the public option will be retained as a "trigger" option; that is, the public option will be retained in reserve and will be activated if the market fails to provide an acceptable level of coverage at a reasonable price for lower income individuals. I would support using the public option as a "poison pill" of sorts. Without the threat of austere action, the players in the health care market will not be sufficiently incentivized to produce the necessary reductions in cost (and economic profit) required to bring health care spending in line.

Let me be so bold as to suggest that you write your senators and ask them to support a delayed public option health plan to be activated only upon the failure of the market to generate the necessary reforms.

The Public Health Insurance Option

The public health insurance option is a component of the House health care reform bill (HC 3200) created to, in the words of the President, keep the insurance companies "honest" by engendering price competition. It has been criticized by some as unfair competition, and others believe it to be creeping socialism.

We don't know, of course, what impact the public option will have. We can be sure that there will be significant unintended consequences arising from the public option if it survives public debate, and currently it looks very much like it will not survive in whatever final form health care reform legislation takes.

The President betrayed his true feelings about the public option when he so quickly signaled, at the first sign of stiff opposition, that he was willing to surrender on that point. Current posturing about the public option is an exercise in backpedaling designed to unruffle the fur of the far left. The Senate bill does not contain a publicly funded, government-sponsored insurance plan, opting instead for non-profit cooperatives, a clear signal that the public option won't survive a Senate vote.

On the outside chance that the public health insurance option does make it into whatever legislation is finally passed, let's review what HR 3200 actually creates.

What's good about the public option:

• The public plan will allow physicians to participate on the same two levels currently seen in the Medicare plan; that is, they can participate as "preferred" providers, who will accept the payment rate as set by the public option plan (analogous to "accepting assignment" in Medicare), or they can sign up as "participating, non-preferred providers," analogous to Medicare participating providers who do not accept assignment. This latter designation allows the non-preferred physician to charge more than what the public option allows, but caps that additional amount, probably at the same rate as Medicare, which is, I believe, 120% of Medicare's rate.
• Physicians will not be forced to participate. There will be an opt-out clause.
• Physician reimbursement will increase at least 1% per year. This is in contrast to Medicare, where physician pay rates have been scheduled to be cut significantly each year, according to a schedule created by Congress years ago, which Congress has overridden every year since.
• Premiums will be set according to actuarial realities; that is, contrary to what many fear, the Commissioner of the plan will be required to charge premiums at rates set to actually cover the cost of providing insurance. This means premiums will not be artificially low, consequently gutting the insurance industry, as well as causing market disequilibrium (artificial supply/demand construct).
• The public option will exist only on the individual health insurance exchange. It will not compete with group health plans. This is good because individual plans are currently priced to favor the insurance companies (oligopoly market, creating economic profit at the expense of the consumer). The public option will move the market toward perfect competition. On the other hand, the group insurance market is probably too fragile to compete with the public option, mostly because employers would leave their current plans in droves to purchase cheaper rates from the government.
  
• Perhaps the best aspect of the public option is that the Commissioner of the plan will have the freedom to experiment with reimbursement mechanisms in order to incentivize improvements in quality and patient outcomes; for instance, increasing reimbursement for primary care physicians who create "medical homes" (that's a whole 'nother blog).

What's wrong with the public option:
Aside from the general caveats, which, prejudiced as they may be, are probably accurate , there are specific problems I can point out. In terms of the general caveats, they are the charges being lobbed at "government-run" health care by its detractors; for instance, the government has a penchant for breaking everything it tries to fix. In attempts to make health care more efficient the government will create layers of bureaucracy, and run the business like a courtroom or a legislature instead of like a business, ironically increasing the cost astronomically rather than saving money. Charges like these are unsubstantiated only because they are predicting a future as yet unrealized. However, the government's track record is dismally clear. Even President Obama himself pointed out that the government-run postal service is imploding while private enterprise mail delivery (FedEx, UPS, DHL) is thriving.

Now onto the specifics:

• The legislation sets initial reimbursement rates at current Medicare rates. The government really believes that Medicare reimbursement is generous. I know because I read the outpatient hospital payment updates published in the Federal Register every year (you think HR 3200 is bad at 1018 pages . . . the proposed 2010 updates to the outpatient prospective payment system was over 1800 pages this year!). But I can tell you that no physician in his/her right mind will accept 100% of Medicare. Most contracts with private insurance plans peg reimbursement as a percentage of Medicare, usually somewhere between 110% and 130%. Why would a provider, who successfully negotiates with Aetna and Blue Cross for, say 115% of Medicare, agree to accept straight Medicare rates from the public option? Unfortunately for the public option, the law creates a provider escape clause, and I predict most providers (at least the good ones with full waiting rooms) will exploit.
• Providers other than physicians (e.g. hospitals, nursing facilities, ambulance companies) have a take-it-or-leave-it reimbursement option: they can agree to accept Medicare rates or they can opt out. Big providers like hospitals are used to taking Medicare rates, and they will generally feel intimidated by the government's market dominance to accept these rates.
• From an economic perspective, setting rates artificially at Medicare reimbursement levels will cause supplier shortages. As I said above, Medicare rates are too low already. In a real free market, suppliers would stop producing if the price was set artificially below the cost of production. In the whacky health care world, we adjust our losses by shifting costs onto our paying customers, in this case, the private health insurance plans. This in turn creates artificially high prices for these customers. Or, another way to look at it is as a hidden tax tacked onto your health insurance premium.
• The plan will truly be run by the government, including the Dept. of Treasury creating a special bank account for the plan. As we said above, the government does not know how to do anything efficiently. It creates additional layers of bureaucracy, and regulatory hurdles, and a slavish devotion to process with complete disregard to outcome. The government would be better off hiring private insurers as contractors to deliver these services, just as they already do with Medicare (NOTE: you may think Medicare is a pure-bred government-run health care plan, but in all actuality, it's only government-funded. CMS pays private companies, like Blue Cross, to administer the program for seniors).
• I am afraid the the most devastating unintended - but certainly not unforeseen - consequence of the public option will be the demise of employer-sponsored group health insurance plans. American industrialists are a creative bunch, getting where they are in part because of their problem-solving skills and their stick-to-it-iveness. Employers will find a way to bump their employees off of group plans and into the individual insurance market, where they will pick up the public option. Let's face it: the dreaded 8% (of payroll) penalty that will be levied against employers who do not provide health insurance to their employees is a BARGAIN compared to the true cost to employers of providing health insurance in the first place. For this reason, if for no other, I would prefer the Senate's solution of creating non-profit coops to compete against the private insurance industry.

The Public Option introduces some good ideas to the health care reform debate, but as a complete package, I am afraid that the dangers outweigh the promises. This is probably a moot point, since I predict the public option will be excised from the final bill.

Don't Crush AEtna!

IN my last blog, I mentioned that the constellation of restrictions placed on for-profit health insurance companies by HR 3200 create the risk of imploding the health insurance industry. Not that the industry doesn't need - and deserve - some regulation! Still and all, for these companies to flourish, they must be able to operate in the marketplace. And investors will flee from their stock if they adjudge that these companies will no longer be able to make a profit.

In addition to the restrictions I discussed in my previous blog; namely, setting limits on out-of-pocket responsibilities for policy purchasers, HR 3200 seeks to create other restrictions on the health insurance industry:

1. Individual policies that aren't grandfathered will have to be offered on the Insurance Exchange, which will be sort of a comparison-shopping website or program where all plans can be compared to one another, much like Medicare Advantage plans can now be compared one to another on the Medicare website. This will engender competition among the plans, driving costs down and reducing variation in the benefits offered. But it will also limit an insurance company's ability to restructure pricing for its product. Overall, however, I think this is a good thing, because individual insurance policies currently are all over the place, with regard to price and quality.
2. Exclusion for pre-existing conditions will be prohibited. I mentioned this in my last post. This is a good thing for the consumer. Of course, for the issuer of the policy, it increases risk and provides no method of escape.
3. Guaranteed renewal of coverage - insurance plans will not be able to drop customers because their risk profile intensified. The only legitimate reason for dropping a customer is non-payment of premiums, and even then, the insurance plan has to notify the client of the impending cancellation and offer a grace period to re-activate coverage. Overall, this is a necessary improvement, since this has been one of the most common ways that insurers have shed themselves of expensive clients.
4. Variation of rates based on age of the insured person is allowed, but limited to a 2:1 ratio; that is, the higher rate for an older client cannot exceed twice the lowest rate for a younger customer. Again, this limits the insurer's ability to minimize its vulnerability to risk.
   
5. Insurers must provide coverage for mental health and substance abuse. Traditionally, insurers have reduced benefits for these two elements within their plans, to reduce their expenses for what many people don't even consider an illness in the first place. I believe this "discrimination" against mental health benefits was a reaction to the unrestrained avarice of the mental health/substance abuse facilities of last decade. I think these facilities learned their lesson . . . at least those that didn't go bankrupt in the ensuing response from insurers to the overutilization of the 1980s and 1990s.
6. The federal government will regulate the allowable medical loss ratio. This is perhaps the biggest threat to the insurance industry. If the government sets, in effect, a ceiling on the profits an insurance company can earn, it will drive investors away from the industry. The medical loss ratio is the percentage of revenue that is paid out in medical claims. If the government sets this amount too high, the profit margin will be erased (there is very little risk that the government will set the ratio too low).
7. Coverage for services can only be restricted based on medical necessity. That means that an insurance plan cannot decide to exclude coverage for a particuar medication or treatment that is FDA approved. If a drug is very expensive and the insurance plan doesn't want to cover it, the plan cannot create a bogus exclusion for the drug. It will have to find a way to provide the drug, because it is medically appropriate. The insurance plan is allowed to use the cost-share (copayment, co-insurance) to reduce demand for the drug or treatment. This is a common form of rationing currently used by the private markets. Ironically, many conservatives are worried about rationing of health care by a "government-run" system; yet this law will outlaw rationing based on anything other than medical appropriateness of the treatment.
8. The government will define a minimum set of services that must be covered. Insurance plans won't like this because they won't have the freedom to exclude certain services in their fine print. This is another trick that individual plans, especially, use to get out of paying for health care.
9. Annual and lifetime benefit maximums will be prohibited. This is another dirty trick used often by individual plans; for instance, the man I wrote about in my last blog whose insurance plan limited coverage for chemotherapy to $1000 per day. Or the patients we've seen with Mega Life policies (a division of United Health Care) that have a $25,000 annual cap, which is typically used up in the first two weeks of catastrophic care.
10. Cost sharing (deductibles, copays, coinsurance) will be limited, and altogether prohibited for preventive care. This increases the financial liability for insurance plans; on the other hand, it incentivizes individuals to seek out preventive care, which is always cheaper than treating late stage illness.

Taken together, these ten elements may very well hobble the private insurance industry, perhaps even erasing any profitability. This would be a big mistake, and I would urge the Secretary of Health and Human Services, who is charged ultimately with the regulation of health insurance plans, to protect the viability of the industry. The game will be played at the margins; that is, all of these changes may be implemented, and if they are implemented to the right degree, they may restrain the insurance industry without destroying it.

If these changes are implemented appropriately, the industry will survive, though not as profitably as it currently exists, and the consumer will be able to purchase a fair and reasonable product. Some plans will go out of business: the ones that need to go out of business. Most of these doomed plans are individual and small group plans - the plans that are poorly regulated today. Plans that charge exhorbitant premiums but end up paying out very little in benefits, through a mixture of exclusions, limitations, caveats and fine print. Plans that routinely drop patients when their loss ratio climbs too high, or exclude coverage for pre-existing conditions, or set unfair coverage limits . . . all these plans will go away. And that is as it should be.

HR 3200, Division A, Title I: What's Right; What's Wrong

Many pundits are talking about the Health Care Reform bill in Congress. Very few people have actually read it, including me. In actuality, there are three bills (not just one) currently wending their way through the two houses of Congress.

The piece of legislation that everyone is talking about is HR 3200. It is the longest, and the most liberal of the bills. So I thought that was a good place to start reading. House of Representatives Bill 3200, the 1,018-page behemoth passed in the House, is composed of three large divisions, each having a number of titles. I have slogged through the first section (Title I) of the first division (Division A), which is about affordable health care choices.

Title I sets out to standardize health insurance plans - both individual plans and group plans. While large group health insurance plans have been more highly regulated, historically, individual and small group plans have been flying under the radar for many years, and this is where I personally see the most abuse of consumers by the insurance industry.

The very first thing HR 3200 does is guarantee your right to maintain your current coverage, as long as you continue paying your premiums. So the plan won't scrap anybody's gold-plated plan already in existence. Or for that matter, if you currently pay for a crappy plan, your right to maintain poor coverage will continue for as long as you pay your premiums.

For people who currently do not have adequate insurance coverage, the bill creates a classification entitled, "Qualified Health Benefits Plans" (QHBP) and then sets out proposed regulations to standardize plans and protect consumers from mechanisms used by the insurance industry to avoid payouts.

Standards Guaranteeing Access to Affordable Coverage: Insurance plans will be limited in how much out of pocket expenses they can foist on their clients. Even then, the deductible limits are generous to the insurance industry, with caps on deductibles of $5,000 per individual and $10,000 per family, adjusted upward for inflation in future years. There will be three levels of QHBPs. The standard plan with the least expensive premium, will be allowed to shift about 30% of total cost of care on the insured. The next level up will be allowed to shift around 15%, and the top, or premium, plan will shift only 5% of total cost on the consumer.

Health plans will not be allowed to drop customers who become too expensive, as long as the customer pays his premiums. Nor will plans be allowed to exclude coverage for pre-existing conditions, nor raise premiums drastically on "high-risk" consumers to drive them out of the plan.

Here's what's good about it: in my line of work I have seen dozens of cancer patients who have lost their insurance because they lost their jobs and their group health benefits. If they were able to afford COBRA payments, their COBRA coverage eventually ran out and they were forced to convert to individual policies or lose insurance coverage altogether. Prior to the Stimulus Package, COBRA was unaffordable for most people, as group health plans were allowed to charge up to around 102% of the premium directly to the individual (the extra 2% or so was to cover the administrative costs incurred by the company). While most companies don't take this extreme option, they still shift most of the premium burden onto the individual, often making insurance unaffordable, especially when the individual is unable to work because of the illness.

When a patient's COBRA is converted to individual insurance (or if the patient was a small business owner or self-employed and already had individual insurance) then all bets are off. Because the protections built into group health regulations don't exist in the individual insurance market.

Individual plans are allowed to increase premiums annually (sometimes more frequently) based on the individual's history of claims. In most states, individual plans are allowed to exclude coverage for pre-existing conditions, often for more than a year, and in a few states indefinitely. Thus, if you were a cancer patient who was dropped from her individual insurance plan, you might attempt to purchase another plan on the open market, only to find that you lived in a state where the insurance company was allowed to exclude your cancer diagnosis for a year. Or forever. Health insurance, at that point, isn't worth the investment, since the main driver of your health expenses - your cancer - won't even be covered by the health plan.

Under the proposed reform to health insurance practices, insurance companies will no longer be allowed to discriminate against consumers based on pre-existing conditions. And premiums, as well as premium increases, will be regulated so insurance companies can't use premiums as a back-door way of firing their expensive patients.

What's bad about it: By itself, the prohibitions against excluding and dropping patients and against charging exhorbitant out-of-pocket rates aren't bad at all, and are prohibitions that the insurance industry can probably absorb. The problem is the number of restrictions that this bill places on insurance companies (and we'll visit more of these restrictions in later posts). Insurance companies are still for-profit businesses, and they have to be able to thrive and pay dividends (or at least grow in value) . If the government increases the regulatory burden on insurance companies to the point that they all become unprofitable, we will face a crisis in the health care financing infrastructure.

Some of my readers believe that the more liberal elements of the Democratic party secretly want this to happen, in order to usher in the Golden Era of the Single Payer Health Care System (or in their minds, the return of Stalinist centralized socialist economy). Well, truth is, some liberal Democrats do want this. But I don't believe President Obama or most of Congress really want to sneak in a single payer healthcare system by decimating the private insurance industry. Doing it in an underhanded way as this would only create chaos and anarchy for a period of time before a "government-run" health care system could rise from the ashes.

No, if this bill triggers an economic crisis in the insurance industry, it won't be because of some dastardly secret plan to destroy the free market. It'll just be the government's uncanny talent for creating more formidable unintended consequences than intended outcomes.

We have a good bit more to cover on Title I of Division A, but I'll save that for another night, as this post is already getting overlong.

Coming up:

Subtitle C—Standards Guaranteeing Access to Essential Benefits - the Health Choices Commission standardizes benefits
Subtitle G—Early Investments - reinsurance plan guaranteed by a $10 billion trust fund provides security for group health plans covering retired employees who are not (yet) eligible for Social Security (or "Rick Waggoner, couldn't you have held on two more years?")
. . . and much more!

Death Panels

Newt Gingrich and Sarah Palin have something in common . . . they both have attacked the end-0f-life planning section of the House's health care reform bill. Newt was more sophisticated in his attacks, refraining from using Sarah's term, "Death Panels," but called it the same in so many words. Sarah really believes it. Newt is too smart to believe it, but too Machiavellian to pass up the opportunity to terrorize the simpler-minded in our country for his own political gain.

Have you read the "Death Panel" clause? It begins on page 424 of the House bill (the version authored by Rep. Dingell, et al.) Before you start hiding your grandparents and your children with Downs Syndrome in the cellar, just take a look at this section of the bill amending Sec. 1861 of the Social Security Act. When you actually read it you'll discover that it is, very simply, an amendment that requires Medicare to pay for "advance planning consultations" not more than every five years.

And what is an advance planning consultation? It's an opportunity for a Medicare beneficiary to sit down with his or her physician and have an honest conversation about what is often inappropriately called "end of life" issues. In fact, these are issues we all face every day, but those of us who are young enough to be in denial about our mortality successfully avoid. They are decisions that every one of us should already be thinking about, in case we get hit by a bus, or get diagnosed with leukemia, or suffer some other trauma or life-threatening disease.

There are several elements to an advance planning consultation. The practitioner educates the patient about these issues, and then the patient asks questions and thinks out loud. The practitioner provides resources to the patient. The patient might make some decisions during the consultation, or he might go home and think about all these issues. The patient is not required to make any decisions regarding end of life care. Here are the things you talk about:

• Advance directives (living wills, durable powers of attorney for health care, etc.)
• What kind of life sustaining treatments you want - or don't want - in the event that you get really sick and you are not able to speak for yourself (you're unconscious or on a ventilator, etc.).
• Health care proxies: the person who will speak on your behalf in the event you can't speak for yourself, to make sure your wishes are carried out.
• Palliative care and hospice. These are not the same thing, by the way. Palliation is treatment that eases your symptoms, like pain management. You can receive palliative care while being aggressively treated, as well as when receiving only supportive care. Hospice is "end of life" care for the terminally ill. It is not euthanasia. It's symptom management when cure is no longer possible, allowing nature to take her course, and death to come naturally.

Is advance planning morbid? In the mind of most people, yes. That's because most people are afraid of death and don't want to think about it. Ever.

I don't have the luxury of living in this denial. In my work, I have seen many people die. I have been in the patient's room a hundred times - in the ICU, in the oncology unit, in the Emergency room. I have seen people die good deaths. They were prepared. They knew they were dying, and so did their families and loved ones. These patients are usually the patients who made these difficult decisions about the end of life. And because they faced the difficult decisions, they were able to die peacefully, surrounded by family, often in prayer, sometimes even singing hymns.

I have also seen patients die horrible deaths. I have seen patients coded over and over again, shocked with defibrillators, their ribs cracked from chest compressions. I have seen patients kept in the dark space between life and death, tethered to ventilators and dialysis machines, with no hope for survival, but trapped by loved ones who can't let go or won't let go. Sometimes they're trapped by the guilt of a survivor who didn't make amends for hurts inflicted long ago. Other times patients are kept in literal purgatory because a husband or wife or adult child has been asked to make a decision - a decision they never before considered - to "withdraw care"; that is, to stop treatment. And he can't. Because it feels like he is actively taking the patient's life.

The common denominator in these terrible deaths is that these patients, and often their physicians, avoided those difficult end-of-life discussions, hoping to escape the necessity. And then the crisis arrives like a thief in the night, leaving them no time to make those decisions.

In the House bill, advance planning consultations are purely voluntary. The patient must request it from the practitioner. All the bill attempted to do was to provide payment to the doctor for taking the time to have these conversations. Because right now, your doctor does not get paid to sit with you for an hour and talk you through these difficult but necessary decisions. And with what Medicare pays your doctor, he or she can't afford to give up six paying patients to spend an hour with you for free. This bill was going to enable your doctor to make time for you.

Alas! Because of intellectually challenged people like Sarah Palin, and morally challenged people like Newt Gingrich, the odds are now that the advance planning consultation clause will be struck from the bill.

Now let me say one more thing about "Death Panels." The purveryors of scare tactics want you to believe that a government-run health care system will ration care, focusing on the brightest and best of society and putting the weak and old to death. Don't you know that this is already happening? And not at the hands of the federal government, but under private health insurance and market driven health care.

When I was a case manager for oncology patients in the hospital, I could not count the number of times I was pressured by an insurance case manager to talk to their beneficiaries about hospice. I would call the insurance company to give them an update on the patient's condition. The nurse on the other end of the line would often say something like this: "Well this patient has cancer. She probably doesn't have long. Why is she getting treatment? Don't you think she should go on hospice? You need to bring up hospice with the patient." Sometimes the patient really was near the end of life. Sometimes the patient had just gotten diagnosed. If the patient's cancer had just recurred, or if it had spread, I was sure to get the hospice "option" pushed onto me.

Let me say this about hospice: it is a wonderful service for somebody who needs it and wants it. But the decision to choose hospice care is a philosophical decision, not an economic one. And it's the patient's decision, not the payer's.

Advance planning consultations - are they Death Panels? Not at all! They are actually Life-giving conversations. Because, in the words of a great prayer, until we are prepared to die, we never really are prepared to live. The issue, friends, is not whether the big bad government is going to take the decision of life an death away from us. The issue is whether we choose to exert control over that decision ourselves. The enemy is not the government, and it isn't even the insurance company. The enemy, in the words of Pogo, is us.

Freedom of Speech and the Responsibility to Listen

At this point I want to depart from my usual theme and talk about this recent phenomenon, driven by a grass-roots conservative movement, where public forums about health care reform are being dirsrupted by an unruly crowd that shouts down the speaker at the podium. Their purpose is to prevent any meaningful discourse from occurring, and to create the impression in the media that there is a groundswell of opposition to health care reform.

First, I find it somewhat ironic that this ultra-conservative group is using tactics made popular by leftist radicals in the 1960s. But more to the point, I'd like to make these observations:

• When a person resorts to yelling and dirsrupting reasonable discourse, it usually means that the person has nothing useful to bring to the discussion. It becomes an indictment, therefore, against conservative forces, who betray that they are "agin" reform, but have nothing better to offer.
• These people were raised in a barn, and their mommas never taught them any manners.
• It's a sad day in the body politic when we cannot have civilized and rational discourse on the issues at hand. It speaks sadly to the deterioration of civilization in our nation.
• It behooves us to engage one another, even with wildly divergent views, in order to find a place where we can meet. Because we can't stay where we are, with regard to health care in this country.
  

Health Care: Right or Privilege?

Part of the reason we find it difficult to have rational discourse on health care reform in this country is that we all speak different languages. What I mean by that is we hold different assumptions and beliefs from which we operate, and therefore we can't figure out why the person who disagrees with us is such an idiot. Well, he or she is probably not an idiot; he or she simply holds a different set of beliefs than we do, causing them to see the world differently.

One of the basic issues that we have to be at least aware of, if not in agreement with, is whether health care is a right or a privilege. If health care is a right, then, ultimately, we have to provide a certain level of health care to everyone, regardless of their ability to pay for it . . . which means government-run health care. If health care is a privilege, or perhaps more accurately, a responsibility, then we can allow the free market to provide financing options for health care and people may choose to purchase coverage or to pay as they go. And if they end up needing more health care than they can afford, they just have to live (or die) with the consequences of their decision (not to buy health insurance).

I happen to think that virtually every American actually agrees on this issue. Virtually everyone I speak with about health care believes the same thing: that he (or she) has a right to health care, but as far as everyone else is concerned, it's a privilege. Even the most die-hard libertarians who rant about being coerced by the government to pay taxes to fund social welfare programs suddenly become very nearly socialist when, for instance, after smoking two packs a day for 30 years, they develop lung cancer, find themselves somehow uninsured, and turn to Medicaid to pay for treatment. I have never seen a free-marketer turn down government-run health care when his own life was on the line.

The truth is that we are schizophrenic about this issue, and our actions betray our confused beliefs. As a nation, we seem to believe that some basic level of health care is a right, as borne out by the Medicare and Medicaid programs, and EMTALA legislation that requires emergency departments to treat patients with life- or limb-threatening illnesses, regardless of their ability to pay.

On the other hand, we also seem to believe health care is a privilege, as evidenced by the different levels of health insurance that we can purchase, or choose not to purchase at all. The fact that 15% of our nation's citizens have no health care coverage, and we as a society tolerate this inequity, is further proof that we consider health care a privilege.

I think we would be best served by putting this issue squarely on the table, and coming to some sort of majority agreement (consensus is impossible in our current environment) as to what level of health care is a civil right, and create the infrastructure for providing that level of care to our citizens. Then, persons who want more than the basic level of health care coverage can choose to purchase additional coverage. In a sense, this is what we already have for the poor and the elderly with Medicaid and Medicare, respectively.

NOW A COROLLARY TO HEALTH CARE AS RIGHT OR PRIVILEGE

Americans, in general, confuse the right to health care with the financing of health care. A popular argument currently being bandied about against reform goes something like this: "I don't want some unelected bureaucrat making my health care decisions for me. That's for my doctor and me to decide."

Here's the problem with that argument: you can already decide for yourself what kind of health care you want. The question is whether you can afford it. If you're worried that you are going to lose the freedom to make your own health care choices under "ObamaCare," you should open your eyes. That train left the station years ago!

The fact is, your freedom of choice has already been limited by the private sector! If you are uninsured you'll discover that you can't afford anything beyond the most basic care. If you are insured you will discover that your insurance company will have the last say on whether they will pay for your choices, in which case, if you choose a plan of action that your insurance company considers medically unnecessary, you're back to the first scenario . . . you're basically uninsured.

Let's use an example from my world - cancer care. Let's say you're a man, and you get diagnosed with prostate cancer. You and your doctor decide together that the best option for you is proton-beam therapy . . . the most expensive form of radiation therapy, available in only a handful of centers. In this case, you'd be lucky if you were the victim of government-run health care (i.e. if you were a Medicare beneficiary) because Medicare pays for proton-beam treatments.

But let's say you decided to purchase the cheapest insurance you could find, with a low monthly premium. You know that the insurance company can charge such a low premium because they make up the difference with high deductibles and copays. At the time you bought the policy, you weren't planning on getting sick, and so you didn't think much about it. You also didn't bother to read the exclusions and conditions and the other fine print.

Now you have prostate cancer. And you want to go to Loma Linda for proton beam therapy. You make the appointment and fly out for the consultation, only to be told that you will have to pay $50,000 (or more) up front because your insurance plan doesn't cover proton beam therapy.

Read this next part very carefully: Your insurance company never said that you could not get proton beam treatments. You are perfectly free to get proton beam treatments if that's what you and your doctor think is best. All your insurance company said is that they aren't going to pay for it. And they don't have to. Because health care, at this level, is a privilege, not a right.

At this point, you might beg or plead or even demand that the good folks at the Loma Linda facility treat you for free, or for a greatly reduced price. But they are not obligated to give you a price cut. Just because you are free to choose this expensive treatment doesn't mean the provider has to give it to you.

So you are free, in theory, to choose whatever health care you and your doctor think is best. But if you can't afford the treatment, are you really free? And if your insurance company refuses to cover the treatment, are you really free?

We are in a place in this country where we can't speak to each other rationally or, for that matter, civilly, about health care reform. And we will never get out of this place until we can find some common ground, or as they say in the music biz, sing from the same sheet of music.

One of first issues with which we have to come to terms is whether we believe there is a basic civil right to a minimum level of health care. If we do, how will we provide that level of care? And if we don't, how will we be able to turn those people away at the Emergency Room door who can't afford to pay?

You get what you pay for . . . NOT

We are not getting value for our health care dollar in the United States.

In 2007, we spent $2.4 trillion on health care, or $7,900 for every man, woman and child in America. That's more than any other country on the globe spent on health care, as a total sum, or as per-capita spending.

To put it another way, we spent 17% of our gross domestic product (GDP) on health care. The GDP is the sum total of all production - in terms of goods and services - generated by our nation's economy. That means for every $1 of wealth that we as a nation created in 2007, 17 cents went to pay medical expenses.

Again, to put our health care spending in perspective, we are spending 4.3 times more on health care than we spend on national defense. And what are we getting for our money? The U.S.A. ranks 50th in the world, according to the CIA, in life expectancy, behind Portugal and just ahead of Albania (our average life expectancy, if you were wondering, is 78.11 years). And at 6.26 deaths per 1,000 live births (again, according to the CIA), we rank 46th in infant mortality -- behind Cuba and just ahead of Croatia.

Let me repeat that, so it sinks in. We spend more than any other nation on earth, per person AND in total, and yet we have Third-World rates of infant mortality and life expectancy. And for all that money we spend, we still leave 46 million people uninsured.

Let's now compare American health care value with some of our neighbors in the community of industrialized nations. These figures come from the Organization for Economic Cooperation and Development: Switzerland spends 10.9% of its GDP on health care, and ranks 16th in the world in infant mortality and 11th in life expectancy.
Germany which spends 10.7% of its GDP on health care, ranks 15th in infant mortality and 32nd in life expectancy. Canada spends 9.7% of its GDP on health care. Canada ranks 36th in the world in infant mortality and 8th in life expectancy.
France spends 9.5%. France ranks 8th in infant mortality and 9th in life expectancy.

The USA spends almost twice as much on health care as these four industrialized nations, yet they all rank higher than we do on these two measures of health. To top it off, all four of these countries provide universal coverage for their citizens. Clearly, we are not getting our money's worth. In future posts to this blog, we'll explore some of the reasons that American health care costs so much but delivers less than promised in terms of value. Right now I mostly want you to realize that it is very possible to spend less on health care and expand coverage to all Americans at the same time.

Are the French smarter than we are? Are the Canadians more efficient? Are the Swiss just hardier people? Do the Germans live healthier lifestyles than we do? The answer to each of these questions is NO! If these nations can do provide universal health care cost-effectively to their citizenry, certainly we Americans can do it at least as well, if not better.

Hidden health care costs

First we need to understand that we are already paying, as a society, all the health care costs - those that are obvious and those that are hidden.
The average Joe (like me) pays for part of the cost of my health insurance, which is heavily subsidized by my employer. So, for instance, I pay around $300 per month for family coverage. My employer pays more than that - probably round $400 a month - to cover my family and me.
In addition to private health insurance, I pay Medicare taxes, which pays for current Medicare beneficiaries to cover their health care costs. There is this huge misconception that Medicare beneficiaries banked their money years ago and are now withdrawing it to pay for their medical expenses. In fact, the money that Medicare beneficiaries are currently spending is the same money that you and I are paying in Medicare taxes today. The average Medicare beneficiary spends every penny he or she has "banked" very early in his/her Medicare career. Their costs are significantly higher than whatever they "socked away."

Now, the hidden taxes.

My health insurance premiums are probably a thousand dollars or two higher than they should be, because hospitals shift costs from uninsured and underinsured patients to those of us who are insured.
Then, I pay state taxes, which go to cover the state's portion of Medicaid expenses. And I pay federal taxes to pay the costs of the federal portion of Medicaid. On top of that, in the county in which I reside, I pay a penny of sales tax to support the charity hospital in my town. So between my own health plan, and the extra costs tacked onto my own health plan, and the Medicaid and Medicare taxes I pay, AND the premiums my employer pays, we are paying, collectively, for my health care and everyone else's.

The fallacy that many people are buying into right now is that the cost of health care is going to skyrocket as a result of health care reform. In fact, the cost is not going to skyrocket at all. Are we are doing is merely naming all the hidden expenses that we are already paying for. If anything, now that we are explicitly naming all the expenses that we are already paying, we can now reduce those expenses by bringing them under control.

Later on, we'll discuss who is paying for what; that is, which sub-groups of folks are paying for health care and which groups aren't. But right now, I'm focusing on how all of us, as a society, are paying the health care costs.

Rational thoughts on health care reform

I have hesitated to start this blog. Who cares what I think about health care reform, anyway? Who am I to opine on the subject? And so I've been sitting on my hands.
Day after day, however, I've been inundated by so many other writers, and pundits, and self-styled experts on health care reform, reporting not facts or statistics, but hysteria, misinformation, or just plain ignorance.
In Journalism School I learned the importance of checking facts, of using corroborating sources, of showing as much objectivity as it is possible for a human to have. That's a lot of work! Who has time for that? I have a life (well, sort of), with real responsibilities, and demands on my time. But then I've been reading and listening to so many so-called journalists who clearly aren't following the responsible route of reporting. From Ann Coulter, who wrote the most inane column on health care and the free market, to the Regular Guys, a couple of syndicated shock jocks who ramble audaciously about completely false concepts such as forced euthanasia in the health care reform bill. Hell, I thought, I'm not any stupider than these guys!

I can't fault Fox News or Clear Channel for airing these morons and allowing them to spread misinformation on the public airwaves. After all, as the parent of a severely developmentally disabled child, I've always been a proponent of hiring the handicapped. But if I'm going to complain, then I have to offer a responsible alternative. So I have decided to jump into the fray with this blog: Miranda Writes about Health Care Reform (if I have to explain the pun in the title, then you should probably stop reading now and turn on Fox News).

What are my qualifications to discuss health care reform? Well, I'm no Uwe Reinhart, but I do have some street cred. I earned an MBA with a concentration in health care in 1999. I have worked for 17 years in a not-for-profit community hospital, concentrating on cancer care. I consume the Wall Street Journal daily - which, by the way, is absolutely the best health care reporting in the country. I have immersed myself in source documents published on the CMS website, making me somewhat of a local expert on government-run health care.

So that's me, and that's why I believe I have something to say about health care reform. In the coming days and weeks, I will talk about different aspects of health care reform, including, but not limited to, the current bills moving through the House and Senate. I'll also talk about concepts that may or may not be included in the current debate, but have been presented and discussed in recent years and hold merit for today's discussion.
I welcome your thoughts, your responses, your disagreements, your ideas. But you have to promise to consider the facts and alternative views before making up your mind. If you've already made up your mind, then don't waste your time reading this, and don't waste space responding.