Health Care Reform: Will it Work?
November 3, 2009, 7:51 am
Posted by Cathleen Kaveny
One of the things I appreciate most about this blog is the range of expertise. Peter Nixon has an essay on health care reform in the latest issue, and he, like Unagidon works in the insurance industry.
So as it comes down to the wire, what’s your take on the proposed reform, gentlepersons? How will it work? Will it do the job? Will it actually fix what’s broken?
(I realize that abortion is a controversial issue in HCR, but let’s devote this thread to these other questions).
I guess we are, above all, the society of the easy fix. This is the wrong question to ask because it assumes that there is only one question instead of many.
Will it decrease cost-related obstacles to access? Yes, almost certainly.
Will it decrease non-cost related obstacles? Here, the answer is equivocal. There is some momentum to enhanced primary care training, and payment reform, but this needs more work.
Will it decrease costs in an enduring way? Probably not. The seeds are there, but the follow through is still necessary.
This year’s bill, whichever one emerges, is no more than a downpayment on reform. It is simply impossible to pass anything that would comprehensively address all the things that need to be fixed, even at the margins. It would unite too many interest groups in opposition, even those whose interests normally diverge. This is really the lesson from 1994. It is divide and conquer, or nothing. The perceived winners of that strategy (drug companies, for instance) should be looking over their shoulders, and I am sure they are.
It will not work. It will take more money from the middle class to give to the Insurance Companies. Pierre-Joseph Proudhon summed it up well:
“To provide affordable, quality health care for all Americans
and reduce the growth in health care spending, and
for other purposes.
“Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled that the American people shall henceforth be:
Watched, inspected, spied upon, directed, law-driven, numbered, regulated, enrolled, indoctrinated, preached at, controlled, checked, estimated, valued, censured, commanded, by creatures who have neither the right nor the wisdom nor the virtue to do so. … [A]t every operation, at every transaction noted, registered, counted, taxed, stamped, measured, numbered, assessed, licensed, authorized, admonished, prevented, forbidden, reformed, corrected, punished. … [U]nder pretext of public utility, and in the name of the general interest, … place[d] under contribution, drilled, fleeced, exploited, monopolized, extorted from, squeezed, hoaxed, robbed; then, at the slightest resistance, the first word of complaint, to be repressed, fined, vilified, harassed, hunted down, abused, clubbed, disarmed, bound, choked, imprisoned, judged, condemned, shot, deported, sacrificed, sold, betrayed; and to crown all, mocked, ridiculed, derided, outraged, dishonored…”
The Government should get out of every aspect of so-called “health care” except as a “single payer” as are the various provinces in Canada
Paul Likoudis is an example of how the perfect makes an enemy of the better, so that the truly awful can emerge victorious for a long time if not forever.
Clubbed, choked and shot? Come now, Pierre-Joseph, methinks you protest too much.
It’s coercive, punitive, grossly expensive, unequal, adversarial, draconian, dishonest, bureaucratic, and authoritarian, depriving people of authentic freedom of choice and liberty of action, all while empowering that fraudulent “freedom of choice” that denies all human dignity, but which we are not supposed to talk about here.
Other than that it will work great.
How could anything that creates, according to reports, 111 new bureaucracies, “help” anyone except the bureaucrats?
It’s absurd and the whole process has been a waste of taxpayers’ and lawmakers’ time, in the face of other pressing issues (aka the economy) and smaller efforts that might help the uninsured -but which, unfortunately, do not create more government programs or enrich insurance companies.
I think President Obama was mistaken to leave this in the hands of Congress. Instead, the President should have developed his own plan and guided it through Congress, like Johnson did with Medicare. I think he realizes this now.
Any legislation that is 1900 pages long is either nonsense or bad or both. To even be understandable, the bill will need to be trimmed at least to half its length.
The upshot is that Senators and Representatives find it very difficult to think nationally, and they are naturally more interested in the own re-election and covering their collective derrieres than they are in anything else. As a group, Congress folks tend toward being short-sighted premadonnas and in any case, they are certainly not that worried about putting their heads together and working hard, or taking risks, to satisfy a president – any president.
This 1900 pages of nonsense is not entirely President’s fault, but I think he should step up and take the lead; scrap this mess, work up his own plan, and guide it through Congress.
Peter Nixon’s essay is very good. It’s been a source of frustration for some time now that many on the right interpret “subsidiarity” with “small government and free markets”. But Pius XI was just as concerned with free market liberalism as he was with socialism – he called them the “twin rocks of shipwreck”.
In health insurance, why is it that a single payer system violates subsidiarity while a system dominated by large monopolistic private insurers does not? Surely, subsidiarity is more violated in a private system where one person stands at the mercy of a faceless profit-making insurer will who drop coverage and deny claims at a whim than in a single-payer system where access is guaranteed? And can we not make the point that subsidiarity actually calls for such an organization to be at the broadest possible level, given the need to widen the risk pool? In other words, you can’t have subsidiarity without solidarity, as the pope noted in Caritas in Veritate. One more point – would not subsidiarity call for a pesonal relationship between patient and physician, a heavy reliance on primary care, and isn’t this the major weak link in the current system?
I should add that this is a very important matter, and the time is right for reform. The president has the wind at his sails. If he takes the lead and develops a good plan and moves it through Congress, it will help him greatly and more importantly, will help the country as a whole.
Any legislation that is 1900 pages long is either nonsense or bad or both. To even be understandable, the bill will need to be trimmed at least to half its length.
I’m all for criticizing the proposed reform on the merits, but the page count? That’s opposition for its own sake. If it were 6 pages long the talking point would be “How could a bill that brief possibly accomplish anything worthwhile?” or “Look how little the Democrats care about health-care reform — they could only be bothered to come up with 6 pages’ worth of legislation!” What matters is what the words say, not how many pages they’re dispersed over.
No one is in a position to know just how well the proposed reform will work, not even those who devised it. Much depends on how it is applied by the several federal and state agencies involved. And much depends on how the public responds. If the final bill contains a public option, then one of the big questions — as yet unanswerable — is how many people will choose it, since this is part of what will determine how much pressure the public option puts on hospitals and private insurers (and maybe, one day, on drug companies). If we require certainty about the outcome before we act, we’ll never act. This principle is as true in politics as it is in the rest of life; and it is especially true in cases, like this one, where the outcome is determined by so many things beyond the reach of policy-makers. Enough to think the legislation will improve the current system considerably.
Let Bender tell us how the proposed system is “coercive, punitive, grossly expensive, unequal, adversarial, etc.” It’s an impressive list of adjectives but it’s not quite an argument. Is Bender suggesting that the country (and not just the government) will spend more on health care if the proposed reform passes than if it doesn’t? I’d like to see some numbers. Is Bender suggesting that the proposed reform would lead to more inequality than we already have? Really? In that case, Bender will need to replace his paradoxical suggestion with an actual argument.
And while we’re on the subject of arguments, here’s a bad one: “How could anything that creates, according to reports, 111 new bureaucracies, ‘help’ anyone except the bureaucrats?” I won’t quibble with the exact count (though I doubt it), but this rhetorical question implies the strange proposition that large and complicated programs cannot help anyone because they are large and complicated — not just that big bureaucracies are often inefficient (who would disagree?), but that they are always totally ineffective, just insofar as they are big. Does Mark not shop at Walmart just because it has more than 111 stores? Trust me, Mark, there are better reasons.
“Besides wages, various social benefits intended to ensure the life and health of workers and their families play a part here. The expenses involved in health care, especially in the case of accidents at work, demand that medical assistance should be easily available for workers, and that as far as possible it should be cheap or even free of charge. — Pope John Paul II, Laborem exercens, No. 19.
Why doesn’t anyone ever bring this up?
Dennis Kucinich is right. The current legislation is a windfall for the big insurance companies, and the “public uption” will be totally unaffordable to the poor, the unemployed and anyone making under $100,000 a year.
Paul,
I agree that the best argument against the current legislation is that a single-single payer system would be better: less complicated, less expensive, and more just. The question is whether, given current political realities (F12 on Commonweal’s computer keyboards), it is possible. Radical as the single-payer proposal is, it would require a much more radical transformation of our politics before it could get through Congress. Unlike Barbara, I don’t think it’s enough to say, “The best is the enemy of the good.” This is the line powerful interests have always used to fob off superficial adjustments as a substitute for substantial reform. When the best is possible, we shouldn’t settle for the good. But when the best isn’t possible — or even when it’s just very improbable — why not at least pursue the better. If, as you and Dennis Kucinich say, individual insurance policies will continue to be unaffordable to anyone making less that $100,000 a year, then the reform legislation will have been a failure. If the legislation doesn’t help bring down health-care costs overall, it will have been a failure. But I think those dire predictions fail to do justice to the proposals that are now being considered. Yes, the insurance companies will have a larger market if everyone is required to have insurance, but they will also be prevented from canceling the policies of those who need expensive treatments, and they will be required to offer policies to people with “preexisting conditions.” These and other regulations will eat into their profits. In any case, the profitability of the insurance industry should not be the main consideration. The point is to make sure that everybody has access to good health care, and to do this as cheaply as possible (F12). If this hurts the health-insurance industry, so be it. If it helps them, so much the better.
How it will work depends on what the ultimate goal is. If the goal is to lower costs, it obviously won’t work. If the goal is to shift costs, it will probably be moderately successful.
What I am more interested in is seeing what treatments become required over time. Things like IVF, acupuncture, questionable therapies, seem to find their way into bills after lobbying efforts. All of these, of course, would raise costs.
The basic question is…what is *in* the bill?
Shouldn’t the discussion on “if it can work” start with what’s in it? Point by point?
Will it work work? Some will say yes, some will say no.
Some will say “It has created bureaucracies, so it did not work.” Some, paradoxically the same people in many cases, will say “It did not work because no single authority was in control.”
If health care costs go up, this bill will be blamed. It does not matter if they would have gone up anyway. If they would have been higher than without it. Sometimes people will get sick, and blame that on this bill. “I never spent this much before.”
I do not think those are the measures for this issue. “I was blind, but now I can see” is the measure of success. If those voices are not heard, and all we hear is “I was blind, but no one helped me”, it will be judged a failure.
Mollie – My point about the number of pages is clear enough. The documents upon which the nation was founded, along with most great speeches, whether they were by Lincoln or Churchill, were relatively short.
So many senators and representatives with pet issues piling onto this, and add in lobbyists and routine corruption and pay offs, and you get a bill that is 1900 pages long and which few if any of the congressmen and women have actually read.
As for your puzzling Matthew, the proposition you find so “strange” is not strange at all, and your comparison to Walmart is unbelievable. Walmart and other large firms need to make a profit, government bureaucracies do not. Businesses make a profit by offering customers something they want at an acceptable price, and by being efficient enough so that at end of the day, there is profit left. Heavy government bureaucracies on the other hand, need not make a profit – at all. They can grow as fat as they please, and – walk into your local DMV – they need not be al that pleasing to “customers”, because they do not have customers.
Because the DMV is the only place you can go to obtain your driver’s license or car tags, you are not a customer. The DMV need not earn a profit, and so they are far less worried about pleasing customer or about being pleasing than for example, Walmart does. This is obvious enough, and hardly needs an explanation.
I had run a small non-profit of about ten people where the health insurance costs increased 250% from 1999 to 2009. We have what is considered budget insurance. It was about $250 a month for a single employee ten years ago and now the monthly premium is well over $600 for that employee. Family coverage is about $1600 a month last I checked. Although the current coverage is still pretty decent, we did see a steady erosion of quality during that same 10 year period. (So we were paying a lot more and getting less). We also moved a larger share of the premiums over to the employees, they pick up about 20% of the cost now. Apart from salaries, health insurance was my single biggest operating expense. The kicker is that my husband has almost the same insurance as I do, but costs are almost 50% less because he works for a large employer (NYC Transit). It’s really hard to see how a government sponsored plan could possibly be any worse than what’s out there now. I really, really hope this health insurance reform passes.
Mark has a very good point. In order to have some idea of if this “will work” (whatever that means), we ought to start by examining what the bill actually says.
And so Mollie, would you be good enough to take the time to read the first 1000 pages and give a summary of the contents, along with your thoughts regarding same?
Thanks -
Yeah, forcing people to buy private insurance and enrich the greedy insurance companies, that NEVER works:
http://en.wikipedia.org/wiki/Healthcare_in_the_Netherlands
Thanks, I’ll pass. What I also won’t do is, not having read the bill, assume that it’s all nonsense based on its length. I trust those are not my only two options?
Ken,
You miss Mollie’s point. Then you miss mine. If you think the twenty-first-century United States, or any other modern developed country, could be governed with only the U.S. Constitution and the Gettysburg Address, you’ve got a terminal case of nostalgia. The health-care system we already have, the one you seem so eager to preserve, is very complicated. Reforming it will also be complicated. Replacing it with a single-payer system would be much simpler and more rational, but something tells me you wouldn’t be interested in that kind of simplicity. My point about Walmart was only that the scale of an organization doesn’t tell us all we need to know about its adequacy. But I can see this touched a nerve. How dare I compare a government bureaucracy with a successful private company! This is America, where businesses survive and flourish by doing the good Lord’s will, as revealed to them by their customers. But the point of health care isn’t to make a profit; it’s to make sure sick people get the treatment they need, no matter how little money they have or whether they have a job. There is no reason to suppose, as you evidently do, that Walmart’s formula for success is also a formula for good health care. In pursuit of market share and higher profit margins, Walmart and other big companies create or aggravate problems that can’t be solved as long as you are treating Americans only as customers and not also as citizens.
You and Mark have it backwards. You attack a bill you say you haven’t read. If you don’t need to have read it in order to attack it, why do we need to have read it in order to defend it? Or is it that you think newspaper accounts of the proposed legislation are not to be trusted? In that case, maybe you really do need to read the whole bill before you can allow yourself to say anything about it. We’ll be here when you’re done.
It’s easy to dismiss the perfect being the enemy of the better as rationalization, but in this case I don’t think it works. Health care is complex, and to remake it according to a utopian vision is simply, in my estimation, impossible.
I assume that Kucinich views Medicare as a model single payer program, and Medicare has significant advantages, but it overlooks some real and substantial problems with Medicare, primarily involving reimbursement, but also Medicare’s lack of management structure that results in misallocation of resources. Insurers, believe it or not, have better capabilities in this regard than Medicare, but (1) they lack Medicare’s power to force changes on providers and (2) we don’t trust them to make the appropriate trade offs in making care and systems more efficient.
Allowing buy-in to Medicare to co-exist alongside private insurance would elicit opposition from insurers (of course) but also many providers, who understand Medicare’s structural problems even if Kucinich or Paul does not.
To just go to Medicare would ignore the fact that Medicare is, itself, being subsidized by the private side of the equation. (Now, I am a big skeptic that it’s as bad as providers say it is, but I have no doubt, as I said above, that Medicare does a very mediocre job of directing resources to facilitate efficient and high quality care — but fixing those problems at the same time would create opposition on an entirely different front.)
Indeed, some of Medicare’s policies (physician payment) have aggravated the structural problems that will remain in place even if universal coverage is achieved.
Also of note: E. J. Dionne’s column on what to expect from the rollout.
I’d like to see employees and owners of small businesses, part time employees, contractors and others who work for a living have affordable and effective health insurance options for themselves and their families. If the current legislation pulls that off without an inordinate additional expense, then in my book it will have been successful.
If it pulls that off but is extremely expensive, then in my book it will be a mixed succcess.
If it doesn’t pull that off and is also extremely expensive, then it is a failure.
Like many other folks here, I also have concerns about excessive government involvement in the marketplace, overregulation, price ceilings, and the like. But the two criteria I outlined above are, to my way of thinking, the critical factors.
Whoa Matt – I do not necessarily have objection to Canadian-style national health insurance. Indeed it seems that would be more simple and straightforward.
First, I would insist on what the USCCB has called for; 1) No funding of elective abortions and 2) Universal coverage i.e., including indocumentados.
I am originally from the Northern Plains, and in the Dakotas, one occasionally comes across Canadians. While some complain about it, by and large most Canadians seem to get along well enough with their national medical system. They have had it for years and are not inclined to do away with it.
In my opinion, the trick for an American national system will be to level the various policies from New York to California, from North Dakota to Texas; to make sure all Americans have the same basic policy, and then they can buy whatever supplemental insurance they want in the private sector. Now, given the regional differences in patients and patients’ expectations, initially this might need to be handled via some sort of regional system, but the overall goal should be to have the same basic medical insurance policy across the land; that all Americans have the same, basic coverage plan.
My initial point is that, rather than President Obama leaving such an important matter to Congress, which frankly (as I described earlier) is not inclined to develop such a plan, he should have put together a team, developed his own reform plan, and guided it through Congress.
If he had done that, President Obama may well have found that simply enlarging Medicare to a single-payer system – like other modern nations use – would fill the bill. He might have found another approach. However he would not be in akward position he is now i.e., waiting and hoping for the various “thinkers” in Congress to come up with a reasonable plan for national healthcare.
My point referencing your comment about Walmart is twofold; first, that any national plan would be far less efficient and responsive than any profitable business and secondly, that any comparison between 111 government bureaucracies and 111 parts of a profitable business is meaningless.
As for Mollie’s point, I think my objection to the insane length of this bill goes directly to my main point; that instead of allowing the Congress to write some monstrosity, President Obama should have made it more simple for them by developing his own plan, presenting it to them, and guiding it through.
An addition to my earlier remark.
To succeed, the bill has to NOT be “coercive, punitive, grossly expensive, unequal, adversarial, draconian, dishonest, bureaucratic, and authoritarian, depriving people of authentic freedom of choice and liberty of action.”
It also has to have 1) No funding of elective abortions and 2) Universal coverage i.e., including indocumentados.
Can anything accomplish both of these? I suspect any attempt at universal coverage will be seen as coercive, punitive, etc. And any attempt to dictate ‘treatments’, eg disallow abortion, will be seen as bureaucratic, authoritarian, depriving people of freedom of choice, etc.
Until there is a consensus on what the bill should accomplish, there will be divergent assessments of its success.
Jim – What you mention takes us back to what should have been done in the beginning of all this. We need to review the situation and settle on wants and needs; what do we want and what do we actually need.
We need to realistically assess the problem, and thoughtfully consider how to improve matters.
A simple, basic example of one tool is to make a listing of needs and wants.
We “need” to have, or we must have, a system that:
1 – Provides a basic, rudimentary health care plan for all residence of this land
2 – Is free to those who cannot pay, and is affordable to everyone else
3 – Is decent; a plan that covers medical necessities and offers catastrophic care, not just emergency room (one-time) care
4 – Is fair and ethical; universal coverage, no elective abortions or euthanasia, and follows established ethical norms
We “want” to have a system that:
1 – Provides a bit more than the basics, that coves routine matters and maybe dental and vision problems
2 – Is free to all, and is paid for directly from the federal income tax base
3 – Eventually would subsume private insurance and simplify and thereby improve our lives
Now with this sort of listing, we can more easily determine what we need to do and what we can afford. For example, while we might want to have free dental care for all, if – given our budgetary realities – we come to realize that giving free dental care to all would mean that we could not buy enough wheelchairs for the handicapped, then of course we would need to drop the notion of free dental care and set that money aside to buy wheelchairs. After all, when spending this amount of public money, we ought to try to get the greatest good for the greatest number, we ought to try and get a bang for our buck.
In a sense I agree with you Jim. This is the sort of thing I think was missing in this entire exercise. President Obama should have developed a plan using these sorts of basic tools, presented it to the public, and guided it through Congress.
I find nothing whatsoever to disagree with Peter Nixon about. But I have a couple of observations to make.
First, we once again seem to be juxtaposing what the Church wants to what Capitalism wants. I will maintain that we can only do this if Catholicism and Capitalism (at least in this country) are competing moral systems.
As a businessman, I can see two good business reasons for supporting Catholic social doctrine in this case. The first I go into in more detail in a blog I just posted above but compared to the rest of the world we are spending too much on medical care in the US. Why? Because we are so inefficient. And between health expenditures and our perceived mandate to defend the universe via our military-industrial state, it is not wonder that countries that don’t have this double burden have higher standards of living, stronger industrial bases, and surpluses rather than massive debt. All of this is not the inexorable result of our capitalist free enterprise system. Admit it or not, we have chosen to live this way. And this leads to a second business case.
Modern civilization is not something that simply springs up from material abundance, as though if we take good care of the production part the civilization will take care of itself. Economic systems build something; even free market ones. With the current health care system we should ask “what kind of American civilization are we?” Because these things to not happen in a vacuum.
The very first question in any business case is “what are we trying to do here”? The problem is never that we don’t get what we want. The problem is that we don’t like to admit that we got what we got because we really wanted it.
Unagidon’s comment here as well as in the thread he has just started strike me as quite important. In a not wholly unrelated vein, let me offer the following observation.
What I hear about the health care issue from the media, both print and TV, especially, is the cacaphony of self-interested bleating about how one or another proposal will hurt the bleater’s pocket, whether in the form of profits, taxes, etc. I hear next to nothing about the health care crisis from which the poor are presently suffering. The sense seems to be that yes, we’d like to help the poor, but only if it doesn’t cost us much of anything.The same sort of self-interested (actually selfish) talk is beginning to show up in connection with climate change initiatives and other issues.
These issues, and other large issues that we face, are surely complex and there is good reason for lively debate about the solutions proposed to deal with them. Nonetheless, from the standpoint of human decency, I find it dispiriting that so much of the public talk is devoid of any significant reference to the poor, whose needs, in our crazy system, are so often disregarded. Why can’t we insist that the advocates of any proposal be pressed to say how their proposal would impact the chronically poor? Is this not a project that Catholic lay people, expressly supported by their bishops, could undertake?
Arguably, the bishops themselves have spoken out about abortion and health care for illegal immigrants. In my vioew, though, they do not have either the resources nor the proper political status to engage in the sorts of confrontations that are needed if we, as a nation, are to face up to how we are dealing on a daily basis with the poor.
” — they do not have either the resources nor the proper political status to engage in the sorts of confrontations that are needed if we, as a nation, are to face up to how we are dealing on a daily basis with the poor.”
You are too kind. Way too many of these bishops don’t have the proper political PRINCIPLES to deal with this issue. Their obsession with public funding of abortion overshadows what should be their proper vision of how the gospels should be played out in a practical sense. A “Pie in the sky” approach to Christianity on the ground has been discredited in the minds and hearts of the populace for a long, long time.
In this time and place, people vote with their feet. The pitiful record of Catholics and abortion reflects that the bishops simply are unable (or unwilling) to make a compelling case on abortion in general and, with a large part of the electorate, on the public funding thereof.
My response to Cathy’s question got too long, so I posted it separately above (sorry Cathy!).
And–for the record–I have generally seen myself as working in the care delivery side of the industry rather than the insurance side, but my organization brings both together under a single roof, so I suppose you can put me in that bucket if you want.
“How will it work? Will it do the job? Will it actually fix what’s broken?”
I think this question is impossible to answer at present until they clean-up the document a bit, in particular Sec. 100 (a) (1), as it is not clear what the purported goals of the legislation are. Although I hear there was an Amendment which was time-stamped at 20:53 last night or something which may address this, but I have not read that yet. Anyway, there are whole sections of this document which do not conform to Sec. 100, in particular almost the entirety of Division C. My reading there is that there is quite a bit of expansion of certain appropriations found in Title VIII, Div. A of ARRA and new ones such as found in Sec. 2551 or 2563 but no mention of this is made in Sec. 100.