If You've Lost The Dean Of the Harvard Medical School...

The current legislative package advertised as "health care reform" flunks out of Harvard Medical school:

As the dean of Harvard Medical School I am frequently asked to comment on the health-reform debate. I'd give it a failing grade.

Instead of forthrightly dealing with the fundamental problems, discussion is dominated by rival factions struggling to enact or defeat President Barack Obama's agenda. The rhetoric on both sides is exaggerated and often deceptive. Those of us for whom the central issue is health—not politics—have been left in the lurch. And as controversy heads toward a conclusion in Washington, it appears that the people who favor the legislation are engaged in collective denial.

Our health-care system suffers from problems of cost, access and quality, and needs major reform. Tax policy drives employment-based insurance; this begets overinsurance and drives costs upward while creating inequities for the unemployed and self-employed. A regulatory morass limits innovation. And deep flaws in Medicare and Medicaid drive spending without optimizing care.

Speeches and news reports can lead you to believe that proposed congressional legislation would tackle the problems of cost, access and quality. But that's not true. The various bills do deal with access by expanding Medicaid and mandating subsidized insurance at substantial cost—and thus addresses an important social goal. However, there are no provisions to substantively control the growth of costs or raise the quality of care. So the overall effort will fail to qualify as reform.

A bit of future history - let's imagine that the Democrats get hammered in 2010.  Health care reform then becomes to Obama what welfare reform was to Clinton - something he needs to deliver by 2012 to establish his relevance and ability to deliver on a major promise.

Chastened Dems and fretful Republicans then produce a more modest and sensible bill that looks like real reform.

As one example, I will recycle a notion for pre-existing conditions that avoids the current Dem approach of mandates and penalties:

The Tough Love approach would be to (a) evaluate insurance policies and providers, and (b) legislate that anyone with, for example, a Class One coverage cannot be denied Class One coverage by another insurer at prevailing rates. 

In other words, people only have to pass through the door once; after that first insurance company covers them, they can buy coverage for life from any provider without exclusions for pre-existing conditions.  People who take their chances and don't buy insurance when they are young face the risk of getting the Tough Love message (which will be as tough as that faced by the current uninsured, namely, emergency room and clinic care.)

This approach is similar to open enrollments at companies that offer multiple health care plans with a free switching option once a year.  It is also somewhat like COBRA, but with a much longer horizon. 

However, this approach won't be much help for someone who has lost their job and simply cannot afford to pay health insurance premiums themselves.  Obama originally campaigned on a promise of public assistance without a mandate; that could overlap well with this "Once Covered, Always Eligible" suggestion.

Comments

[Pofarmer]

How about we stop with the legislatin' already?

How about we stop with the controls?

How about we stop with the "govt fixes?"

How about we let the free market WORK??????

Graduate more Dr's.

Build more Clinics.

Provide more health care at a lower cost.

The Capitalist model WORKS!

[Appalled]

TM:

The approach you talk about is already in the law, usually referred to by those in the know as the HIPAA portability provisions. This is why, when you cahange jobs, you don't have to worry about pre-existing conditions if you were covered before you changed jobs.

The problem with HIPAA is that it did not mandate that the coverage be priced reasonably. Which means, if you try to buy individual coverage with a pre-existing condition, you can obtain the policy, but it will be horribly expensive.

The dire fact is that, if you want an affordable health insurance reform, there has to be some variety of mandate, because, otherwise, the people who will get insurance are the ones who know they'll need it.

From a cost standpoint, the best reform is something like a nationalized HSA approach that carves out routine doctor visits from the "high dedutable health plan" component.

[Porchlight]

The dire fact is that, if you want an affordable health insurance reform, there has to be some variety of mandate, because, otherwise, the people who will get insurance are the ones who know they'll need it.

But doesn't the same thing happen with mandates? Some will be able to afford insurance but will choose to buck the mandates, just as they choose not to buy insurance now. Some will claim pure ignorance of the law. Some will want to buy, but won't be able to afford it. And some fraction of those three groups will eventually get sick. Then who pays? We do, just as we always have.

And then there are the people TM mentions who purchase insurance in good faith but for whatever reason end up failing to make payments. If they get sick, who pays? We do.

It seems to me that mandates simply create a different class of uninsured people, as well as creating new costs for prosecuting those who break the mandate law. This is going to be more expensive, not less.

[Pofarmer]

Hold on Appalled, are you saying it's expensive to create a new class of criminals and prosecute them?

[Pofarmer]

I've gotta go back to work before my head explodes.

[anduril]

I like my formatting better: Health 'Reform' Gets a Failing Grade, even at 10:32 am.

[anduril]

heh. my formatting WASN'T so great, last post, was it?

Health 'Reform' Gets a Failing Grade,

[anduril]

Here's the part that had me scratching my head:

Worse, currently proposed federal legislation would undermine any potential for real innovation in insurance and the provision of care. It would do so by overregulating the health-care system in the service of special interests such as insurance companies, hospitals, professional organizations and pharmaceutical companies, rather than the patients who should be our primary concern.

This is all about transforming the US into a socialist state--OK, technically, on the model of the fascist corporate state. Since when was innovation a big selling point for socialism? It's all about convincing the masses that they'll get cradle to grave security--which they won't, but it'll be too late when they find out. I'd like to know for whom the good doctor voted, and when was the last time he was out in public warning about nationalized healthcare. Better late than never?

[verner]

Hi Guys,

Just wanted you all to know, that I've just sent a donation to NASS in Peter's memory for $600.

Good job JOMers!!!!

Smooch Smooch XXXOOO

[Pofarmer]

How did the insurance companies get to be the bogeyman? If they don't do something, they'll be squashed like a bug.

[sylvia]

The other options people like Tom and a lot of Repubs are proposing just don't work for people who don't have a lot of money. They've got their head in the clouds otherwise. I think the public option is the best solution. And pretty much the only solution.

I still don't understand what the big deal is about a public option. We have private for the people in traditional jobs and public for those who aren't. It's just like public school or private school. Private colleges or state colleges. The Post Office or Fed X. Public television or cable TV. City run trash collection or private trash companies. Both provide unique and needed services.

Why should health insurance be any different? We should be able to pick what whatever gosh darn option we want. It's a free country after all. Why should the health insurance companies be coddled when you don't hear the private trash collection companies complaining? It's silly. The health insurance agencies have succeeded in creating hysteria.

[sylvia]

What's NASS?

[Pofarmer]

OH GOOD LORD SYLVIA.

( I know, I said I have to get back to work, and, I do.)

Let's compare private schools to public schools, shall we?

For instance, you pay property taxes that go to fund your local schools. If you choose to send your kids to private schools do you get that money back? Hell no, you get to fund the public schools, get NO services(well, we do get speech and PT through the public schools) and you get to pay the private school tuition. NOW WHO DOES THIS HURT THE MOST? That's right THE POOR. Ho many people could send their kids to a better school if they got the tax money back that was being dumped into the public schools? How many more private schools would there be? Health care would be no different. You will be REQUIRED to pay taxes to support the Pubic "option" and then pay more for private coverage, if it is even available.

Why is this so hard?

(Why am I replying?)

[sylvia]

So you're saying Pofarmer that having public elementary school hurts the poor and that we should only have private schooling.

Yeah okay. See how mnay poor kids end up going to school once we make it private only. That right there shows how the Repubs have their heads in the clouds.

[Rob Crawford]

Why is this so hard?

Because it's not Hope and Change and Unicorns and Rainbows.

It's freedom -- and some people just don't want it.

[Rob Crawford]

So you're saying Pofarmer that having public elementary school hurts the poor and that we should only have private schooling.

No, that's not what he's saying.

Either you know that, and are purposefully taking his analogy the wrong way -- in which case there's no point in discussing anything with you due to your dishonesty -- or you're too ignorant to understand the analogy -- in which case there's no point in discussing anything with you due to your ignorance.

[Jane]

(Why am I replying?)

Get your answer yet?

[hit and run]

(Why am I replying?)

Get your answer yet?

[hit and run]

oh, shoot.

[Pofarmer]

I think Rob Crawford has the answer.

[Rob C]

This again goes back to the conflation of the idea of insurance with what we actually get for health insurance.

Maybe if we thought of it this way it would make more sense. I buy auto insurance from company A. They vet me at the time and everything is fine. During the two years that I'm with company A I manage to rack up five speeding tickets and two accidents. Worse yet, there are still repairs that need to be made to my car from accident number 2. Now I want to go and switch auto insurance companies and I don't think it's fair that they look at the fact that I've had these speeding tickets and have outstanding repair bills and factor that into whether I can get insurance from them or how much it will cost. Shame on them.

(Of course, if they were forced to take me on then they're guaranteed a loss for my business, but hey they're greedy.)

The only way I see this portability without premium increase thing working would be some kind of industry-wide shared risk pool that would cover these known money sinks. (Remember company A insured you back when you were healthy and was counting on your premiums to build up some cushion for future expenses.)

[Pofarmer]

Rob C

How big of a class are we talking about here, really?

[clarice]

Yes, we will need an industry-wide shared risk pool for catastrophic medical coverage..and it may well have to be subsidized, but yo can bet that will be cheaper than the Pelosi-goldbergish contraption in the wings.

[Pagar]

"school hurts the poor"

What hurts the poor is having public school teachers unions controlling every aspect of the schools.

"The Boston Teachers Union staunchly opposes a performance bonus plan for top teachers"

LUN

[Pofarmer]

Yes, we will need an industry-wide shared risk pool for catastrophic medical coverage..

Then let the industry and consumers get together and work it out.

In the meantime.

How big of a class are we talking about?

[daddy]

Pofarmer,

Charles Darwin had one of his kids play the bassoon to a vegetable in order to see if it would effect the plants behavior.

I think you're sort of engaging in a similar activity. Stick to talking to your cows and chickens---you'll have better luck:)

[Dave (in MA)]

Kantor should be happy she doesn't have the same agent as James Lileks. His post today revealed that his agent stole 100% of the proceeds from his last book.

[sylvia]

Well I am not an Obama fan, but I agree with him in this department. A little communism may not be a such bad thing if it gets this done. All things in moderation!

[Dave (in MA)]

Yep, I managed to post that on the wrong thread.

[Pofarmer]

A little communism is like being a little bit pregnant. Either you is or you isn't.

[EdGi]

Good post, the Harvard dude is correct, as are you and mant commentors that this socialist ruling party approach does not at all deal with our problems under our current regulatory system, and in fact only multiplies those problems. It covers 100% public funded abortion, but only 90% of people. It establishes a US federal version of British NICE board, yes, death panels, mandating protocol based treatment. There is no reform problem solving in ObiWon land, only ruling party domination.

[AL]

How about this:

Institute 5% federal sales tax (with customary exclusion of staple food, goods for kids, export, financial services, medical expenses, rent).

Use portion paid by seniors (on Medicare) to fortify Medicare.

Use portion paid by illegals to fortify emergency rooms.

Use portion paid by poor to fortify Medicaid.

All other proceeds distribute evenly among other US legal residents as yearly vouchers to buy medical insurance of their choice, and tax any other medical insurance premiums as personal income.

[bgates]

How about this:

Institute 5% federal sales tax

No.

[bgates]

How about this:

Progressives give their own goddamn money to Medicaid or Medicare or emergency rooms or whatever the hell else they think needs more money, and stop trying to show their generosity through their willingness to take money from other people by force.

[A Berman]

For many people, the article will be discounted since it was published in the Wall Street Journal and not the New York Times.

[kdackson]

The thing about pre-existing conditions in the post: "In other words, people only have to pass through the door once; after that first insurance company covers them, they can buy coverage for life from any provider without exclusions for pre-existing conditions." is misleading at best.

From someone who has been through this and has had the joy of paying for COBRA, once you have coverage, as long as you maintain coverage, you got coverage of pre-existing conditions.

You get a certificate from the plan when you leave that states the dates of coverage. You show this to the next provider - and you don't have the pre-existing condition restriction. You are allowed to have something like a 60 day lapse in coverage before you get nailed for the pre-existing coverage thing.

The whole idea is to get the initial coverage, and keep some sort of coverage in force.

[mndasher]

AB: For many people, the article will be discounted since it was published in the Wall Street Journal and not the New York Times.
For me it is the other way around.

[Robert]

A good idea, once covered always eligible, but until we address the over-riding cause of cost increases, NO TORT REFORM, you accomplish nothing. Look to Mississippi as a guide in that regard.

[MikeS]

Next to my keyboard, I have an electronic gadget that measures my blood sugar. The gadget was actually free when I bought some of the testing strips it uses. Retail cost for the strips is about $.70 per test. I test about 3 times per week.

When I was first diagnosed with diabetes, I went to about 6 hours of classes about how to watch my diet and generally to take personal responsibility for my own health. My doctor told me that the personal responsibility program had an extremely high success rate.

In the past health care was always a personal or family responsibility. Each family had home remedies that were passed from generation to generation. As it turns out, this is a good idea even in the modern era.

If not for government interference, health care would likely evolve toward the diabetes model. I can imagine small home devices that could perform most lab tests we now use. A computer program or website could pass the data to our doctor and provide us with important advice about the meaning of test results and risks associated with family medical history and possibly let us know when we should see a doctor even though we may be feeling well.

The new Obama Soviet style central planning for health care rationing seems to be taking us in the opposite direction.

[Andrew]

I did not realize that the dean of Harvard Medical School was a racist, Bible-clinging, gun-carrier?

[MikeL]

I like your "Once Covered, Always Eligible" idea.

One of the bleeding heart complaints about health insurance is that it "discriminates" against sick people. So they plan to force the companies to insure everyone who applies. But then this would leave open the possibility of only appying for coverage when one is sick, so they try to close the loophole with a "mandate".

The mandate is blatently unconstitutional. Obama even said is was a bad idea back when it was Hillary's idea. But without the mandate they can't "reasonably" force companies to cover everyone.

Tough Love is a great idea. If someone wants to ensure that they'll get good insurance, then they have to sign up now while they're healthy. If they can't afford to sign up now, then some sort of reasonable subsidy could be used. If they CHOOSE not to sign up now, then they roll the dice and may end up paying higher rates, but only get the same subsidy.

This let's people do what Democrats claim they want. It lets individuals make a CHOICE in regards to their HEALTH.

Did I say "subsidy"? I meant to say "voucher". Republicans like vouchers, right?

[Patrick Henry]

We already HAVE the "once covered..." option you describe. So long as you maintain coverage, no company can reject you and none can avoid paying for your pre-existing condition.

How do I know? I'm one of the unlucky bunch with a chronic problem.

Forcing companies to cover NON-covered individuals' pre-existing conditions will run them out of business - which I believe is the goal of the legislation.

G*d knows I'd LOVE to be able to skip health-insurance premiums and then sign up right before my next-needed $30k surgery - but it doesn't (and SHOULDN'T) work that way...

DD

[TheRadicalModerate]

I'm actually OK with the guaranteed enrollment and mandate portions of any of these bills. There's a pretty broad social consensus that we aren't willing to let anybody die when they show up at the emergency room, so it seems reasonable that everybody ought to pay for that little piece of consensual social largesse.

I'm even OK with some of the community rating stuff, to the extent that it spreads risk over a larger pool. I'd think that tiering that rating by age would make some sense, but cherry-picking only the healthy folks seems to go against the whole "we won't let you die if you show up" philosophy.

However, I think Appalled hit the nail on the head in comment #2 above. Routine care is actuarially uninsurable. The statistical distribution on what everybody pays for routine care is so narrow that all an insurance company can do is charge you the average of that routine care and pass it on to the provider. Individuals can do a much better job of that and will wind up forcing prices down faster than any collective bargaining agreement that an insurance company can negotiate with its preferred providers.

You still need insurance for catastrophic events, but that problem becomes much more tractable when you remove all the routine crap from the equation. That in turn makes the mandates and guaranteed enrollment and community rating problems less onerous.

So my favorite answer is to get employers to pay into HSAs in lieu of providing insurance coverage directly, provide lots of large risk pools for the catastrophic insurance of the individual's choice, and let them pay all the routine stuff (i.e., the CPTs not covered by their catastrophic policy) out of the portion of their HSA that they didn't use for catastrophic insurance.

I normally hate doing little social engineering experiments like this, but you have to admit that the whole thing is FUBAR from a half-century of government meddling in the first place. Engineering a system where the meddling at least has a chance of declining over time seems like about the best we could get.

(Of course, I'm writing as if rational argument could prevent us from getting some Frankenstein's Monster of a bill crammed down our throats, which seems like it's got a >90% chance of happening...)

[cubanbob]

What is missing in all of this is the basic assumption that health care payments are a core function of government. No where is it found in the constitution. So aside from the fact that this monstrosity is probably unconstitutional on a number of levels it begs the question of why is someone else's problem an obligation to the tax payer? This is simply a form of indentured servitude.

Another point seemingly ignored by those shilling for this disaster is if it is not good enough for congress and the other exempted groups why is it good enough for you?

Sylvia just remember the wise old adage " the only good communist is a dead communist".

[Pagar]

"What is missing in all of this is the basic assumption that health care payments are a core function of government."

"The exchange with Speaker Pelosi on Thursday occurred as follows:

CNSNews.com: “Madam Speaker, where specifically does the Constitution grant Congress the authority to enact an individual health insurance mandate?”

Pelosi: “Are you serious? Are you serious?”

CNSNews.com: “Yes, yes I am.”

Pelosi then shook her head before taking a question from another reporter. Her press spokesman, Nadeam Elshami, then told CNSNews.com that asking the speaker of the House where the Constitution authorized Congress to mandated that individual Americans buy health insurance as not a "serious question."

“You can put this on the record,” said Elshami. “That is not a serious question. That is not a serious question.”

The current majority in Congress and the White House is intent on doing the same thing to America that Fidel Castro did to Cuba.