Friday, September 4, 2009


The Spinmeister

In a thread below, Diane makes the extremely important point that the repeated arguments against healthcare reform have been scripted for some time. Frank Luntz, who has made a career as a propagandist, has indeed been central in writing that script.

It is also relevant that some of Luntz's largest clients are the major preemptors--The US Chamber of Commerce, the National Association of Manufacturers (NAM), and the Business Roundtable. NAM has been headed for several years by John Engler, the former Michigan Governor who put our blanket shield law in place.

Re: healthcare propaganda, it is noted:

"Here are some suggested arguments for Republicans that Luntz calls “clear winners”:

—“It could lead to the government setting standards of care, instead of doctors who really know what’s best.”

—“It could lead to the government rationing care, making people stand in line and denying treatment like they do in other countries with national healthcare.”

-“President Obama wants to put the Washington bureaucrats in charge of healthcare. I want to put the medical professionals in charge, and I want patients as an equal partner.”

Read more:


  1. Pfizer is also one of Luntz's clients.

    Surprise, surprise.

  2. Frank Luntz, author of “WORDS THAT WORK - IT'S NOT WHAT YOU SAY, IT'S WHAT PEOPLE HEAR, coached anti-health reformers to “pretend to support it [healthcare].” That statement makes whatever else he has to say about anything irrelevant. He is a self proclaimed liar and someone not worth listening to.

    What I hear is Frank’s nose is growing and his pants are on fire.

  3. I don't know. A direct statement to "pretend" is itself an example of "words that work"--they work to unmask the rest of the BS that Luntz purveys.

    So I would give him some credit here.

  4. Calling Luntz a Liar serves no useful purpose, becuase the fact is whether he is lying or not the Republicans have gained control over the Healthcare Debate.
    The much of what Luntz states is true, up to a point. The problem is he describing a condition that already exists. He tells people that the government is going to decide who receives treatment and who does not. The fact is the Insurance companies already do this, and although he references the insurance companies in his talking points there is no mention of a solution to the problem of denied coverage. His talking points focus on an individual receiving whatever procedure his or her doctor believes is necessary without any consideration of the fact that this is the very system that is unsustainable.
    The problem is very few people understand how the current Healthcare System works and this is understandable because the current system is extremely complicated. Most people do not understand that Healthcare insurance is already regulated at the State Level. They have no understanding of Medical Loss ratios or CPT or DRG Codes and how these items factor into their current premiums or the care they receive. I am not saying they need to know these things but it is a lot easier to sell fear to an uninformed population then it is to sell fear to a well educated population and if there is one area in which the Republicans excel it is selling fear.
    As to waste, fraud and abuse, Medicare and Medicaid do suffer from these problems because the task of monitoring the actions of every doctor is impossible. However, the insurance companies also have the same problem, doctors who over-charge or prescribe more medication then is necessary or who perform unnecessary surgeries will do whether the payer is the government or an insurance company(see attached link, which I believe I previously provided).
    The call for a Single Payer option is not going anywhere and even the call for a Public Option for all Americans is probably dead even though Single Payer already exists in this country (Medicare).
    The Republicans are really not even the problem, the problem lies in the Democratically controlled house. You can say a lot of nasty things about the Republicans but they did tend to vote in lockstep with the White House, with immigration a notable exception.
    Obama faces a monumental task in selling reform and the unfortunate thing is, if gets a compromise bill passed he will lose a large part of his base and probably lose the House in 2010.

  5. Hi James--First of all, good to hear from you.

    I was not sure what you meant by this: "The Republicans are really not even the problem, the problem lies in the Democratically controlled house. You can say a lot of nasty things about the Republicans but they did tend to vote in lockstep with the White House..."

    Did you mean during the Bush administration?

    I agree with a lot of the gist of what you say. I would take it a few steps further. I think the health care debate reflects deeper issues in American life, political and otherwise--how lonely, vulnerable, and helpless people feel in general.

    The Republicans have been able to frame the issue in terms of government, qua government, being the enemy. While I agree that government, in itself, is not "the answer," Luntz-type propaganda appeals to a primitive version of that perception.

    Meaning: the truth is that we live in a society in which sick and elderly people _are_ put out on the ice floe; people _are_ treated as essentially disposable, as the latest Pfizer scam is only one of a zillion examples; we _do_ live in a society in which in essence, being "disposable" is more the norm than the exception.

    So people want to hang on to whatever security and control they think they have, even while imagining that it is "outsiders" (the government, immigrants, etc.) who threaten even that. As opposed to asking the genuinely hard questions about the system we have created.

  6. Hi Justice

    Yes, I was primarily referring to the Republicans during the Bush Administration. However, while I have not looked at the voting record the Republicans probably did not rush to endorse Bush's expansion of the Medicare Prescription program either.
    The Democrats are much more splintered. A sizeable portion of Democrats in the house are opposed to the government adding any program that has the possibility of increasing the National Debt. I believe the total is approximately 20. Even if Ted Kennedy was alive and well I doubt that the Democrats would be able to muster the 60 necessary votes to pass a truly Democratic Healthcare Bill.
    As to the Luntz Propaganda appealing to a primitive version of individal fears that is exactly his goal. Some 240 Million Americans currently have some form of Healthcare and they are afraid that any changes will diminish, not enhance the level of care they currently receive.
    I watched Meet the Press today and Rudy Guiliani was a panel guest. One of his arguments was the same crap that the Republicans keep tossing out and that is malpractice reform. The Article I previously attached demonstrates that this is a bogus argument. The State of Texas caps all malpractice awards at 250K, yet they have a town, McAllen Texas that has the highest per capita medical expenditures in the country. He did raise one good point, and that is inter-state marketing of health insurance should be allowed. I believe this is the centerpiece of the Wyden-Bennet plan, which right now is not even under serious consideration.
    The Republicans tout this option as a cost neutral option. I watched two Republican Congressman on Bill Maher's show and they stated that this plan is similar to the coverage they receive as Congressman under the Federal Employees Health Benefit Program, but in order for the plan to be revenue neutral there would have to be no government subsidy for entrants into the plan. Under the current system, Federal employees pay 25% of the premium and the government pays the difference. The Postal Workers are somewhat different in that the Postal Service picks up 85% of the tab. When Federal Employees retire, including Postal Workers, OPM picks up 65% of the tab. Without the government subsidy these plans would still be unaffordable for most Americans.
    The attached Website has a lot of good information on the Healthcare debate and even though the author of the site, Alan Katz, is a health insurance broker he writes some very informative articles on the Reform issue. The cite also has several links to pending legislation that are somewhat helpful. I will caution you however that most of the responses appear to come from the Town Hall Crowd but Mr. katz usually responds to the fringe element by challenging their bald assertions.

  7. Some interesting points here:

    Justice you said that essentially we live in a society were treating people as "disposables" is more the norm than the exception. Sadly, I think you have hit the nail on the head. The settlement against Pfizer is an admittance at the highest level of that. Yet we will not hear about what happens to the Pfizer employees who thought up and planned that marketing scheme that cost innocent people who had too much faith and trust in their doctors and health care in general, their lives in some instances. Can it be that these people were allowed to commit murder and stand behind the cloak of corporate immunity? Are these people still employed by Pfizer? If not, I sure hope they haven't gone on to another Pharmaceutical company only to perpetrate the same crime again.

    James: It seems you are saying that the republicans have decided that it is probably best to keep the multitudes ignorant and play on their ignorance with fear mongering rather than educate them. What will it take to change this? The mistakes with the Town Halls were that it did not require those attending to prove they had real knowledge of what the Obama Plan is supposed to do. People should have been given some pre-work material, then fill out a questionnaire. once it was clear they had the basics of how the current system works and what the proposed changes would mean then they could attend a meeting for some meaningful discussion.

    I listened to Arne Duncan, Secretary of Education on "Face the Nation", he points out that 1.2 million students who start grade 9 will not complete grade 12, every year. The amount of students in elementary school who are homeless and hungry is staggering....

    But I have a feeling that many of those drop outs were in Town Hall meetings this summer.

    We have to all realize that if we do not take the time to educate our children, we will have a very hard time keeping up with the other countries in the world. The U.S. ranked 31st among countries testing 15 year olds on math and science. If we do not increase these numbers, how can we expect people to understand health care?

  8. On the Pfizer/accountability issue, it is unlikely that one could pick out a few folks who were most directly responsible. Schemes like this are almost always widely known and facilitated throughout a central marketing division, and here we have four drugs involved. When the Neurontin scam first broke--essentially, same stuff--the DOJ made a point of the fact that it was organized systemically throughout the company, then Warner-Lambert.

    There are precedents for holding very high execs responsible, including CEOS, even if they genuinely didn't know about the plan. But, as you'd guess, that very rarely happens. Ironically, perhaps, those folks are _not_ considered "disposable." Like AIG, they must be "saved" for everyone's sake......

    Re: the health care debate, the Gawande article that James cites in his first post above is, indeed, excellent. It has been used by many folks within the debate--unusual for a single piece to have so much impact. So much to be recommended.

    The tort reform response is also "interesting," and unquestionably we will hear more and more of it. Indeed, it is predictable that preemption will also be revived, and the cost of healthcare attributed in significant part to those "greedy trial lawyers" whom we have already heard so much about. If Congress moves significantly toward a new MDA, negating Riegel, it is a certainty.

    Thanks, also, for the Katz link.

  9. Folks, there are certain facts no one seems to contest:

    1. Obamacare will increase access to health care in the US

    2. We already have a physician shortage in the US

    3. US medical training is in terrible shape economically (most academic medical centers are on life support these days)

    4. Therefore, there will be increased demand for health care in the US with no immediate increase in supply, particularly physicians, and no long term increase, either, as there's no unused capacity in the training system

    5. Therefore, costs per person per unit of care will go up not down. Those are facts

    6. The only way to reduce costs therefore would be to ration access to care and/or technology. it may be rational to do so, it may be political suicide to accept it, but those are simple facts

    7. Since Medicare is now 55-60% of US healthcare anyway, we're talking about the 40% of health care not covered by Medicare.

    8. The only way to seriously impact on health care costs in the US, even if you begin rationing care to that 40 percent, something will have to be done to Medicare if costs are to be controlled

    9. The notion of constraining physician payments in Medicare is political suicide, too. Moreover, with medical students graduating medical school with $150K-200K in loans before beginning residency, it is also unrealistic in the extreme.

    10. Unless someone has a means of dealing with Medicare, the debate going on about Obamacare misses the main action: Medicare.

    11. Pharmaceuticals are 10% of healthcare, diagnostics 8%, MDs 14%, hospitals 45%. Guess what one has to work on to really impact health care costs? But guess what's going to be perceived by the elderly as an attack on Medicare? My question is whether the effort to nationalize health care right now is worth the political capital it will require. Essentially, to do so will mean not moving forward on the education initiatives, the economic initiatives, the regulatory initiatives, etc for the next 3 years. Having just gotten the WH and the Congress for the first time in 14 years, I'm not so sure Obamacare should be the first priority, even if the Democrats in the Congress can stuff the bill down the Republicans' throats. I'm also not sure that having the evangelicals back in control for 16 years (and they will be) is a reasonable price for the increased access, especially since the evangelicals and the Republicans can simply defund the increased access anytime they want.

    Some food for thought...

  10. Dear Anonymous,

    Care to site your sources for your points number 3 and 4?

    We also need to look at the impact of prevention and in some cases, getting patients out of the health care system who do not really belong there. The case where people could use lifestyle coaches to help them recover from diseases that are a factor of poor lifestyle choices. What about the roles of PA's in the system?

    Clever way of bringing up the rationing statement, but I think you need open up your view finder a bit more and look at other variables that you have not taken into consideration.

    How much of the 10% of pharmaceuticals is causing the 45% of hospital costs in health care? Judging by the Pfizer scam recently exposed, I can see there is a stronger link then we care to realize. How are the percentages in your point number 11 arrived at by the way?

  11. I think anon. makes an interesting argument, but I would also like to see some documentation as Former requests.

    I've cited here, as I used to on Pharmalot, an article in Chemical and Engineering News which quesitons the 10% number we always hear. Shondelmeyer, who teaches pharma econ at Wisconsin, estimates it to be at least 20%. (I know that's not what PhRMA says.)

    Still, the problem remians. I think the largest gap in Anon's argument is the cost of _not_ acting. Health care costs are obviously not going to go down in the present system, and it is not clear to me that Medicare is not at least as likely to be bankrupted if we do, essentially, nothing.

    I have been personally most struck by the fact that 50% of health-care dollars goes into care during the last six months of lives. So, if one were looking for where to make the most cost-saving, one-dimensional impact that is certainly where I'd look first.

    Yes, I know Sara Palin will claim that means putting her mom on the ice floe. But we know that even the extraordinarily modest proposal of covering discussions with docs about end-of-life carfe could, indeed, make an enormous and voluntary difference.

    That is just one piece of a many-pronged strategy. For reasons that don't need to be reiterated, the system as it exists is not sustainable. It will crash sooner or later--it may already be too late.

    So I think the real discussion is _what_ reform plan one wants and whether one wants to make that decision before the system goes over the cliff or after.

    As far as the relevant industries,we all know that the incentives for short-term thinking--make hay while the sun shines--create a probably incurable addiction. So we cannot wait for them to avoid the deluge. They will have to be by-passed.

  12. Former

    The table below is a breakdown of medical expenditures by category. This information is from the Government’s Health and Human Services Department. The Title of the Report is National Health Expenditures, 2007 Highlights.
    The report breaks down the total expenditures by category and if you add up the individual category expenditures on the report, the dollar figures do not equal the 2.2 Trillion dollar number quoted at the top of the report.
    I added a category and named it Unknown; I am guessing that this figure includes the cost of Insurance Premiums paid by business and individuals.

    The second link provided is from the Kaiser Foundation. The link provides a Pie Chart on total medical expenditures for the year 2007 and also states that Public Health Care spending accounts for 45% of the total of all health care spending during 2007.

    Category Percent
    Total $2,200,000,000,000.00
    Hospital $696,500,000,000.00 31.65909
    Physician & Clinical Services $478,800,000,000.00 21.76364
    Other $62,000,000,000.00 2.818182
    Dental $95,200,000,000.00 4.327273
    Other Personal $66,200,000,000.00 3.009091
    Home Health $59,000,000,000.00 2.681818
    Nursing Homes $131,300,000,000.00 5.968182
    Prescription Drugs $227,500,000,000.00 10.34091
    Medical Equipment $24,500,000,000.00 1.113636
    Other Equipment $37,400,000,000.00 1.7
    Unknown $321,600,000,000.00 14.61818
    $2,200,000,000,000.00 $100.00

  13. My apologies on the format, apparently Excel tables do not copy well to this site.

  14. The table from the above in a more readable format. The dollar amounts are in Billions and the percentages have been rounded.

    Hospital 696.5 32%
    Physician & 478.8 22%
    Other Phys 62.0 3%
    Dental 95.2 4%
    Other Personal 66.2 3%
    Home Health 59.0 3%
    Nursing Homes 131.3 6%
    Prescription Drugs 227.5 10%
    Medical Equipment 24.5 1%
    Other Equipment 37.4 2%
    Unknown 321.6 15%

    Total 2.2 Trillion

  15. Anon here again. As for the problems of the academic medical center, I suggest going to the CEO of your local one. That there is an AMC not on life support will be a point of cheer for the rest of the academic medical centers in the country. I'm surprised that's the point getting questioned, because it's been pretty well known for some time. As for the lack of capacity to increase training, let's start with the medical schools. Right now, the cost of medical education is covered about 50 percent by tuition, the rest is covered by federal and state capitation payments. Sorry, don't have a ref ready for that one, but the 50 percent is about right. Now, if you want to increase capacity, that means increasing lab space to teach the med students. Increasing lab space requires an environmental impact assessment--more exposure to formaldehyde and the like. Don't think that's true? I suggest speaking with the folks at Rush (I think it was Rush) who ran into this problem a few years ago. Eventually, capacity can be increased, just not overnight. Sounds like 4-5 years.

    The 10 percent figure for pharmaceuticals is pretty widely accepted. It's used by CMMS, it's used by the CBO, and it's used by RAND. Probably not the answer you're looking for, but it will have to do.

    Do understand, I voted for Obama. I was hoping for an overhaul of the system. What's being discussed isn't an overhaul, or even an underhaul, and it will do nothing to deal with costs. There probably is a fair bit of the hospitalizations are due to improper use of medications, but I don't think it's simply the marketing end of it, though everyone seems to think that. Unfortunately, though, to deal with the problem, you need to change the way medicine is practiced and the degree to which medical records can only be accessed after the patient has consented. Again, health system overhaul. Not happening. So the likelihood is that the opportunity to really reduce costs is lost and we will have increased demand (anyone who doesn't think there will be increased demand is whistling past the graveyard, as the boomers are coming into their prime utilization ages with lots of comorbidities like diabetes impacting on a whole range of diseases, and we haven't gotten close to the likely use of biologicals (read dollars) by the boomers yet).

    So defend the proposals if you like, but the reality is that having EHR alone doesn't do much, it's what you do with the data that provides value (which isn't much given the need to consent patients before use of the data, even if de-identified). The reality is that per unit costs are going up, or there will be rationing, or both. Especially since the Bush Red did such a grand job of destroying about half the wealth in the US by raising rates during the summer of 2007. Nice going, guys!

    Real overhaul would have been a godsend. What's being put forward now, however, is like a tummy tuck on Phyllis Diller. I suggest you take a read of David Brooks' op-ed piece from this past Sunday's New York Times. He was among the last persons I expected to draft such a piece, but I'll give him kudos for doing so.

  16. Anonymous, anti-reformers don’t bring up the fact that health care is and has been rationed for a long time. People on Medicare and Medicaid are covered. However, out of luck are individuals who lose their job or make too much money to qualify for Medicaid but can’t afford insurance, or whose employer drops their coverage and they have a preexisting condition. If they become ill or have a catastrophic event, they will most likely become bankrupt. A lot of Americans are a paycheck away from not being able to pay for their insurance.

    We could bring down the cost of healthcare by giving back to Medicaid administrators the right to negotiate drug prices. Those negotiating days ended when Billy Tauzin pushed Medicare Part D through Congress. The effect: Billy became the head of PhRMA with a beginning salary of $2.5 million (how much does a U.S. Representative make?) and taxpayers got stuck with paying $3.7 billion more for prescription drugs in the first two years of the Medicare program. See:

    Also, Former Marketing commented on Dr. George Lunberg’s ideas that could save billions of dollars a year. See:

    Per Dr. Lunberg:

    “Fee-for-service incentives are a key reason why at least 30% of the $2.5 trillion expended annually for US healthcare is unnecessary. Eliminating that waste could save $750 billion annually, with no harm to patient outcomes.”

    Obviously, “Yes we Can!” greatly reduce the cost of healthcare. Greed, however, allows too many with power to say, “No Can Do!”

  17. wow, it's nice to have a discussion on this with people using actual data rather than Chamber of Commerce funded talking points. Great contributions.

    The issue of percentage of pharma spending is clearly not the heart of the matter, but here is an excerpt from the June, 2006, issue of Chemical and Engineering News. The data itself is old--2004--but the bases for figuring percentages are probably roughly the same:

    "Meanwhile, according to the federal Centers for Medicare & Medicaid Services, total U.S. expenditures on health care were nearly $1.9 trillion in 2004, or 16% of gross domestic product, and more than two-and-a-half times the $717 billion spent in 1990. In the same period, 1990 to 2004, retail sales of prescription drugs increased from $40.2 billion, or 5.6% of total health care spending, to $190 billion, or 10.0% of the total.

    "The 10% number is based on old data and does not include drugs dispensed in hospitals, clinics, and other nonretail settings," says Stephen W. Schondelmeyer, an economics professor at the University of Minnesota who studies drug pricing. "The data today show that prescription drugs in all settings account for about 19% of total health care dollars."

  18. Observer et al,

    Observer, thanks for bringing up the Dr. Lunberg piece. Here are his seven steps to cut costs in the system. I copy it here for its relevancy for this conversation....

    "An alliance of informed patients and physicians can widely apply recently learned comparative effectiveness science to big-ticket items, saving vast sums while improving quality of care.

    1. Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually.
    2. The same for invasive angioplasty and stenting (currently around 1 million procedures per year), saving tens of billions of dollars annually.
    3. Nonindicated prostate-specific antigen screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most cases of prostate cancer should also cease because it causes more harm than good. Billions saved here.
    4. Screening mammography should be stopped in women younger than 50 who have no clinical indication and sharply curtailed for those over 50, because it now seems to lead to at least as much harm as good. More billions saved.
    5. Computed tomography and magnetic resonance imaging scans are impressive art forms and can be useful clinically. However, their use to guide therapeutic decisions is unnecessary much of the time. Such expensive diagnostic tests should not be paid for on a case-by-case basis but could be bundled together with other diagnostic tests by some capitated or packaged method that is use-neutral. More billions saved.
    6. . We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved.
    7. Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy that only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved.

    Interesting suggestions....

  19. Not to make a personal anecdote count for much, but I recently received a copy of what a hospital billed my own insurance for two (count them, two) pills I was given as part of a procedure.

    The charge was $150 per pill--about 20 times what the same pills would cost if you bought them from a pharmacy (with no insurance help).

    So this is presumably part of what Schondelmeyer is talking about--the used of meds in hospitals settings is probably folded into hospital costs rather than disaggregated as pharma costs.

  20. Disposables

    A large part of the problem is the media and I am not just talking about Fox news, even the so-called liberal cable news network (MSNBC) gives too much air time to the morons who show up at Town Hall meetings with guns.
    As a nation we no longer seem to be able to debate issues intelligently and your post addresses a large part of why this is, as a nation we are becoming less educated. "Dumb and Dumber" is not just a movie title it is fast becoming our new national motto.
    Maybe Obama should have concentrated on Education first and then tackled healthcare.

  21. The attached link is for the proposed Health Care Reform package put together by the Baucus Senate Committee.

    Any comments?

  22. We can surely reduce expenditures of pharmaceuticals, though that 19% number contrasts with the 10% used at U of Penn and at Brookings. I'll defer to those two.
    There's a basic issue not being considered in this discussion though: you say that there's already rationing. Fine. If we reallocate funds from pharmaceutical R&D (and let's face it, that's what's happening already), then the chances of new therapies to address the challenges coming down the pike are reduced. Reducing physician reimbursements likely reduces access to physicians. (Sometime in the past decade, HCFA concluded there weren't enough cataract procedures in the Medicare population. So it reduced cataract procedure reimbursements to physicians, arguing that the docs would increase the number of procedures performed to keep up their incomes. The docs responded by lowering the number of procedures and spending their time on other procedures that generated more income or they reduced their office hours.)
    The problem with the proposed plan (and why the federal program Congress gets can’t be offered to the American public is beyond me, but that's a different discussion) is that they're band-aid solutions. Real reform is lacking. All there have been is attacks on the insurance industry. Everyone talks about the tremendous administrative cost of insurance. Take a look at Medicare. There's a lot of administrative cost there--by design. It's the anti-fraud documentation needed because Medicare is such a big chunk of the system already. So, what's really the effect of removing the insurers? Probably under 5%, maybe less than that when all is said and done (and don't take their profit margin and think you can recoup that directly because first, 1/3 of that margin goes into taxes already and the remaining 2/3s will likely get consumed with inefficiencies; look what's happened with the conversion of the Blues to for-profit agencies, with a lot of inefficiencies suddenly disappearing).

  23. (Cont'd)

    Also, unless there is more consensus (and right now, there really isn't any--other than Nancy Pelosi saying she has the votes to pass whatever she wants to), then whatever passes the Congress now can be repealed in two years. In the absence of consensus, the 2010 elections may be won by the Republicans, and that will affect a lot more than health care. (Lest you think that can not happen, remember that many who do have health care insurance already do not agree with the philosophy of fining someone who doesn't have it. In fact, that alone may get me to stay away from the polls next year. Fining someone for not having health care insurance? That's insane.) The economy is still mighty sick and not generating much wealth (how do we pay for the health care package coming out of Capitol Hill? Sure, you can propose taxes, and hike existing taxes. You can tax the insurance industry into submission, though I'm not sure what societal good that really serves. Why not tax the unions--they're a good portion of why we haven't had rational policy up to now (yes, the national unions didn't want the federal government taking away a principal benefit of union membership)? The Canadians showed pretty nicely during the past half century the problem of losing your tax base because taxes get to be too high. (Note: I don't see Americans running to Canada for health care, except to buy pharmaceuticals. Ditto for going to Europe. Aren't those systems supposed to be better than ours? Those advocating for one payer certainly think so, but there's been minimal discussion of that on this blog, fortunately.)
    Bottom line: for a "reform" that's going to cost a fairly hefty chunk of change and not change the current system beyond adding 50 million additional consumers (never mind the lack of consensus about it, even among Obama supporters like me), this isn't much reform--certainly not what was needed (largely because Obama has shown absolutely no leadership on this issue). When one starts by saying people with health insurance won't be affected, there's not much one can do that will not effectively increase per-capita costs. And that's the crux of the problem. In the end, Medicare is 60 percent of the pie and growing. The only way to control health care costs is to control Medicare expenditures. Yet the elderly won't tolerate that. Does anyone reading this discussion realize that in the 2006 federal budget, taking out interest on the federal debt and defense expenditures (so we're talking just domestic expenditures), 55% of the money went to programs benefiting those over 65 while barely 10% went to programs benefiting those under 18? (That's from OMB data on the budget.) What society has ever prospered investing more in its past than in its future? Oops, I forgot, kids don't vote, and communities prefer the elders who don't use services like schools. My bad.

  24. Anon wrote:

    "The problem with the proposed plan (and why the federal program Congress gets can’t be offered to the American public is beyond me, but that's a different discussion)..."
    How do think the Baucus plan differs from the FEHBP (congressional plan)?

  25. Lots of interesting stuff here.

    As far as Lundberg's list, almost all of the procedures he would eliminate are based on efficacy data that is still contested, and not only by those with an obvious self-interest in the matter. As someone who has been pro-reform, a list like this actually makes me run the other way if this is what the plan would entail.

    My guess is that most people with serious (life-threatening) health conditions who have clearly benefitted from some of the items--even if the population data remains debatable--would feel the same.

    But there are ways to move on this. The core studies that have raised efficacy issues are, in general, underpowered. That is, they were not desgined clearly enough to differentiate what subest of pts are more likely to benefit from which procedures. As they stand, Lundberg's pronouncements would freeze a research process that is ongoing.

    I think the point about Medicare that Anon has highlighted has been a very useful contribution.

  26. There a really interesting article in the current issue of Forbes on the German system (with the undertone that it could work here). Worth a read.

  27. The Forbes article can be found at:

    Haven't read it yet--I look forward.

  28. Probably, we're burned out on discussing it, but any unexpected (to you) responses to O's speech last night? Personally, I would have liked him to use the word "lie" a few more times. On the other hand, the dude from South Carolina made it perhaps unfashionable.

    The analogy to public/private universities is probably a non-starter. Many public universities are still primarily funded by private funds in the form of tuition, etc..
    The percentage that comes from state budgets can be surprisingly small.

    In general, though, I thought it was mostly strong, and perhaps strongest at the end--not the Kennedy part as much as the two-facets of American character. Rhetorical, but on point, I think, about what so much of the policy particulars really hinge on.

    I also look forward to people being "called out."

  29. I would like to be optimistic but nothing in Obama's speech was new. Although he spoke of cost containment, his references to sick children receiving unaffordable "necessary care," and the standard of care remaining strictly between you and your doctor leads me to believe we are right back to the "waste, fraud, and abuse" he plans to eliminate.
    In addition, unless EMTALA is repealed, illegal immigrants and Americans who will fall through the "mandatory" health insurance cracks in the system will still have access to medical care and the rest of us will still be paying the bill.
    Additionally, the more Obama tries to reassure the majority of Americans who currently have medical insurance that their coverage will not change, and if anything it will improve, the less credible he becomes on the issue of cost containment. We cannot continue current level of care, or worse expand the level of care and contain costs. This is the reason for the current crisis.
    Maybe I am missing something but why not focus on eliminating the "waste, fraud, and abuse" as a first step and then proceed from there.
    I will reserve comment on Obama's Malpractice initiative until I see more details. While I see some merit in caps, I am afraid that capping awards will just allow particularly egregious actions on the part of physicians to go unpunished.
    As to the American character, I think Dylan summed it up best when he wrote that "goodness hides behind the gates" and the only key I see for these gates is an immediate identifiable catastrophe or a mass movement.

  30. I wasn't impressed by the speech either. It was basically more of the same. No leadership, no indication of any understanding of the problems in the system, and no basis to assume that costs will be contained. If anything, he confirmed my worst fears that costs will only go up, not down. Everyone tells me how great single payer is. Well, he didn't talk about how great Medicare is that we should all be entitled to it--because costs aren't contained in Medicare. He didn't talk about how great Canada or the British NHS are--no American is running to Canada or Great Britain for care. And the notion that there won't be any increase in the deficit from the reform initiative? Pleeeeeeeeeeese! There are limits to credibility, and he really pushed out to his limit with the speech. Lots of promises, not nearly the specifics. I feel like I'm back to buying a Buick SUV--looks great on the commercial, it's horribly expensive to run and it doesn't handle that well, either. I guess it's better than a Porsche SUV--now there's a contradiction in terms!

    Bottom line: this issue needs a lot more than a speech, and this speech wasn't even a good beginning to that "lot more".

  31. In Obama's defense, Healthcare Reform is a very complex issue and it is impossible to provide specifics in a 47 minute speech.
    Even if a Bill is ultimately passed the specifics will not be known until the "Intent of Congress" is determined by an Administrative Agency and the legislation is actually put into place.
    I would rather see Health Cost Reform as as opposed to Healthcare Reform and to reform costs you have to first identify the problems and implement solutions addressing those problems. This should be the foundation of the plan.
    When you construct a building you start with the foundation, the current proposals seem to me to be the equivalent of building the house first and adding the foundation after the fact.

  32. this guy kills me:

    "House Minority Leader John Boehner (R., Ohio) was dismissive, calling the hourlong speech before a joint session of Congress "just another lecture."

  33. So let me see if I understand. Medicare is off the table, so there goes about 55% of health care. Then, people with insurance aren't to be touched, that that's another 30% off the table. So, all this effort to deal with 15% of health care? Are you kidding me? That's silly. The economy's looking rather gray, we've got a potential trade war cooking, Iran is seeking to become the next nuclear power (with missiles, no less), and swine flu might shut down the country this winter, and we're focused on 15% of the 16% of the economy that's health care? Wow. And I thought Obama promised reform and overhaul of the system. He's doing to the health care folks what's he's done to the gays. And the finance system reformers. And the court system reformers. And the... Looking a lot like another JFK.

  34. Anon.,

    You leave out all the issues about regulating insurance cos. which certainly does touch those who are covered.

    I want more too. I thought the FDAAA was a similar "joke." But I don't think it's turned out to be--it was a beachhead.

  35. DDay

    The only reason to touch the insurance industry to shake them for money. Also because the industry became very indentified with the Republicans in 1993 during the Clinton failed effort.

    The real problem is that everyone is focused on how you pay for the system. The problem, though, is with the system itself. Even if only 20% of health care in the US is in play, that's not enough to do the systemic restructuring needed. Then one might get cost savings. But it would mean restructuring Medicare as well. (Horrors!) It also means having a national debate on whether everyone with cancer should get every possible shot at treatment (damn the cost, full speed ahead), whether everyone with Alzheimer's should be revived at every opportunity. At some point, further treatment doesn't make much sense, but as a society, we haven't had that discussion. And the political rise of the Immoral Majority makes it that much more difficult to have that discussion.

    At the same time, it's worth remembering that every dollar spent on Medicare is a dollar less that's spent on the kids--education, vaccinations, etc. Sure, it would be nice if it could be taken from the military, but with Iran going nuclear in the next year, it's highly unlikely one can get funds from the military these days.

    There is a trade off here. Also, if health care is such an important "right", why isn't food or shelter? Also, why not acknowledge that in order to have universal health care in the US, we will need to have rationing. Just like in Europe. Again, a discussion we haven't had. It's great to say health care is a right, but to what degree? Avastin for any and all tumors (at $100K/yr)? What about the HIV postive person who insists on unprotected sex with everyone? Should we have to pick up the bill for his/her promiscuity? Or the cigarette smoker who won't quit his/her 2 packs per day habit? Or the alcoholic needing a liver transplant for his/her cirrhosis? Where does the line sit?

    That's the debate we should have had, and the fact we didn't is something I chalk up to Obama's failed leadership.

  36. Oh, and it's worth remembering that a lot of the administrative overhead everyone inveighs against isn't just the insurance industry--a lot of it is CMMS's approach to Medicare reimbursement to minimize the occurrence of fraud. Even if you made insurance illegal in this country, those costs (CMMS pegged them at 5-8% of each health care dollar) won't disappear. Ever.

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