A response to “A Damascus Experience”

Opinion from the right!

I usually get short, mostly positive, comments from my Critical Actions messages. Although, occasionally I get a comprehensive response, with in-depth thought, such as the one below from my friend who has agreed to share with you. Here's my response to him on Sept. 21st; his response to "A Damascus Experience" on health-care reform follows.
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Sept. 21, 2009: Virgil, thanks for your comments. Actually, we may not be all that far apart. A Damascus Experience was to be "thought provoking" and not to be specific in reform rectification. It was to raise many questions. Of course one could easily deduce that I might call for a more liberal solution. Actually, a 'Damascus conversion," in part at least, might be as simple as a reformed-commercial-private-health-insurance program. That may be the best system for America, contrary to most other developed nations of the world, where many countries have "public-insurance" coverage. Of course, with each of us, exceptions in thoughts would apply. But hopefully, the end goal would be the same.

Saturday afternoon I downloaded the electronic version of T. R. Read's latest book, The Healing of America, just out this July. For the past year he traveled the world to get the nitty-gritty of health-care operations in many countries. Only read 1/3 of it but it's a very interesting comparison to America's health care. I do believe there are some things we can learn from other countries.

Could I print your comments on my blog and share with other's that may chance to read it's announcement? You may want to reference some of the statistics or other quotes. Let me know and I'll share with all. Other than me trying to learn to write, the sharing thoughts in a civil manner is what my blog is about. It is to even question myself, which I often do, introspection, a medication that I believe might be a healer for our country.

Cornell
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Sept. 19th, 2009: Attached are some quick thoughts on health care. I enjoy exchanging ideas and appreciate your including me in the loop. Virgil

Here are some thoughts on how I see the health care reform needs….

First, I ask myself: what do we need to fix? What is broke, as we say?

Everyone should be covered. No one should fall between the cracks. It may not be a legal right but we agree that it is a moral necessity. Religious people – Christians and Jews primarily – historically have built the hospitals and provided care to the poor.
Costs must be contained. The current system is unsustainable.
Insurance should be tailored to the needs of each person and it should be portable and non-cancelable.

My second question is: why are we falling short of those goals? There are many problems among which are….

Private insurance is encumbered with too much regulation. There is no national market for health insurance which would create more competition and thereby lower costs. Each state regulates its own insurance offerings which cannot be purchased across state lines.

There are over 1900 mandates to insurance companies which increase the costs. Such things as covering massage therapy, cosmetic surgery, etc. When mandated, you get it whether you want it or not.

Tax laws. Much of the problem is from tax incentives. Businesses use health insurance as an employee benefit. It is tax deductible to it. When an employee leaves, the employer has no further interest in covering that person. On the other hand, an individual purchases insurance with after-tax dollars. And, contrary to the President, individual insurance is actually cheaper than corporate when all costs are accounted for. The confusion is because the company picks up much of the costs so the cost to the employee is less than private insurance.

Corporate plans are actually designed and paid for by the companies and the insurance companies are just administrators following the rules.

Medicaid is intended to insure those on the bottom of the economic ladder estimated to be 47 million people in the US. Currently Medicaid covers 58 million people plus there are an estimated 12 million eligible who simply have not signed up.
Add those two groups together and there are over 20 million on Medicaid who are not eligible. That is a significant cost. It is fraud and abuse.

Medicare is a favorite of folks my age and for many it is a good deal. But it is not a good program. Its costs are unsustainable by everyone’s assessment. Doctors and hospitals are reimbursed below costs and therefore “cost shift” the balance to private insurance and charity. Its unfunded liabilities are growing exponentially. It is not a success story and its problems lead to the talk of “death panels.”

The Wall Street Journal called Sarah Palin’s term “death panels” inelegant but not without a point. In the UK’s single payer arrangement there is an overall budget for health care. Modern health care technology is very expensive and no country can afford to give everyone everything they want. So there is a budget and allocation decisions (rationing) favor the young over the old and the decisions are made by panels. It is not what anyone wants but it is inevitable.

Litigation costs. America leads the world in litigation causing in the health care business defensive medicine, prohibitive mal- practice premiums, and passed-along costs.

I also think that our health care system is unfairly criticized. While it is true that the life expectancy in the US is less than in many other countries, it is also true that our homicide rate is 5.9 per 100,000 while Canada’s is only 1.95 and .98 in Germany. Also, the US has 14.24 deaths per 100,000 from auto accidents but only 9.25 in Canada and 7.4 Germany. If you don’t die from homicide or auto accident, we out live citizens of every other western nation.

We spend more on health care than other countries but also less than the Sudan. Spending is not meaningful without consideration of value. The US is THE engine for health care technological innovations. We are the destination for those in other countries who have serious or immediate medical problems and who can afford to come here.

The US is THE location for life enhancing and extending drugs. It costs a drug company about $1.4 billion on average to bring a drug to market. US citizens pay more for drugs than others for political reasons rather than market reasons. If we impose price limitations on drugs, the innovation will slow down proportionally as investment moves to more attractive areas.

I could go on but I don’t want to wear you out. Here is my bottom line. I look at the US government, both Democrat and Republican, pushed and shoved by special interests groups and the need to look good for reelection; I look at the current national health services (Medicare, Medicaid, VA, SCHIP) and I see waste and incompetence; I look at congress (GOP or Democratic) and I see self serving partisan bickering, and I conclude that if our government ran health care it would look just like Canada or the UK: routine care for everyone would be accessible and free, but if you really get into trouble, you’ve got a problem.

I think the answer to our problems –which are very real – is not to turn the problems over to politicians, but to fix the deficiencies one at a time: take care of the 12 million or so who really fall between the cracks; free up the private insurance industry from all the rules which make it inefficient; institute tort reform. It could be done if congress would stop the bickering and work on what is best for the people of this country.

A Damascus Experience

On the road to health-care reform

That was Wendell Potter’s experience! If you’ve not heard his story, you’ve missed a persuasive discourse for health-care reform. Potter worked for Cigna Health Insurance Company until he resigned last year because of a personal, moral crisis. As an insurance executive of twenty years he worked to craft a message that a “government takeover” of health care will be a milestone on the road to “socialized medicine.” But now when he hears those terms, Wendell Potter cringes. He’s embarrassed that opponents are using a playbook that he helped devise.
More on Potter’s credentials later, but for now let’s consider the questionable merits of providing health care through commercial private-health insurance. This query is not to suggest pro-anything specific that should come from reform; rather, it is stimulative to consider fundamental questions with regard to serious health-care overhaul.
Begin with this premise: Americans would not make legal the trading and selling of body organs: It is a moral issue and also a life and death matter. Commercialization, Selling and trading, of our health care manipulated by insurance companies, are also life and death matters, thus becoming a moral issue. Then why do it? Some may say this is a bad or unfair analogy, but think about it for a moment. Can you think of anything that from birth to death everyone will need 100%, no odds, for which private-commercial insurance is sold? (I pay for long-term care but odds are, I hope, never to need it.) Significant odds on health-care needs only come into play, for most part, in the event of a catastrophic need. Not everyone will have a catastrophic need --- but everyone will need some health care at some point from cradle to grave. So the important question is how to found a health-care system on moral ground. Does a person who does not have the financial means have an inalienable civil right, e.g. voting and nondiscrimination, to modern-technological heath care? Some might argue that it’s not even a moral right. Every wealthy country other than the United States guarantees essential care to all its citizens.
We can’t altogether blame the insurance companies where virtuous behavior doesn’t seem to be a precept of their corporate instruction. (Corporate managers are responsible to stockholders to make a profit.) And, certainly we can’t blame those who sell the policies. We have a free market system; it’s a capitalist system I believe in. The question becomes, is it possible for a free-market private-health-care-insurance system to be underpinned by moral rectitude so as to ensure ethics in life and death matters? Of course, that’s the question for any system!
“The biggest weakness of private industry is not inefficiency but unfairness. The business model of private insurance has become, in part, to collect premiums from healthy people and reject those likely to get sick — or, if they start out healthy and then get sick, to find a way to cancel their coverage.” That’s how the status quo ensures 12 to 14,000 people daily will continue to lose their private health coverage! “As The Los Angeles Times has reported, insurers encourage this approach through performance evaluations. One Blue Cross employee earned a perfect evaluation score after dropping thousands of policyholders who faced nearly $10 million in medical expenses.” “A study reported in The American Journal of Medicine this month found that 62 percent of American bankruptcies are linked to medical bills. These medical bankruptcies had increased nearly 50 percent in just six years. Astonishingly, 78 percent of these people actually had health insurance, but the gaps and inadequacies left them unprotected when they were hit by devastating bills.”
“The health insurance industry, in particular, saw its premiums go from 1.5 percent of G.D.P. in 1970 to 5.5 percent in 2007, so that a once minor player has become a political behemoth, one that is currently spending $1.4 million a day lobbying Congress.” Health-care’s slice of our national GDP is 17% and rising (at status quo, projected in 25 years or so to be 31%) compared European countries of 10%. Juxtapose Core Health Indicators by CodeBlueNow which compares the inefficient and expensive USA health statistics to six other countries: Australia, Canada, France, Germany, Japan, and United Kingdom, all of which have a life expectancy of 2 to 5 five years more than the USA and all of which have a health-care cost of about ½ or less per person.
“According to A. T. Kearney, last year General Motors spent $1,500 per vehicle on health care. By contrast, Toyota spent only $201 per vehicle in North America, and $97 in Japan. In 2007, employer-based health insurance cost, on average, more than $12,000 per family, up 78 percent since 2001.” In Our One Party Democracy, Thomas Friedman writes, “Well, to compete and win in a globalized world, no one needs the burden of health insurance shifted from business to government more than American business.” Toyota, after looking throughout North America for two years, put a new Lexus plant in Cambridge, Ontario. One of the primary reasons was the lower health-care costs that manufacturers enjoy in Canada versus in the U.S., says John Kay, a proponent of single-payer.
Insurance policy-contract mishmash: “Kevin a cancer patient couldn’t figure out why his insurance company had denied his claim for chemotherapy charges. His policy seemed to cover the treatment, but its incomprehensible mishmash of cross-referenced definitions, schedules, exclusions and riders made it hard to tell. When my office pressed company officials to explain the denial, we were told that they were still sorting through the policy; they believed Kevin’s claim was not covered, but they needed more time to figure it out. Even the insurance company had trouble understanding its own contract.”
From above clippings, selected from approximately fifty health-care articles, you quickly begin to recognize the broad economic implications and immense challenges facing our legislative government. Unsettled health-care issues over the last sixty years (Or over 100-years counting President Teddy Roosevelt’s initial proposed health care.) allowed for embedment of private profiteers, an impervious, financial monopolist-lobbyist-stronghold on the health system and legislative process.
The most reflective voice speaking to the insurance malaise is Wendell Potter. From The Washington Post, by Richard Cohen: (Listen and watch video for the full story:) “Bill Moyers interviewed Wendell Potter about health care and such matters. Potter is the former head of corporate communications for Cigna, the nation's fourth-largest health insurer. By his own characterization, he is one of those insurance executives who flew from meeting to meeting in private planes and hardly ever touched ground to meet real people. One day he did. He went to an outdoor health clinic over the Virginia border from his home town in Tennessee. This is what he told Moyers: "What I saw were doctors who were set up to provide care in animal stalls. Or they'd erected tents to care for people. . . . And I saw people lined up, standing in line or sitting in these long, long lines, waiting to get care. People drove from South Carolina and Georgia and Kentucky, Tennessee -- all over the region." “‘It was a life-changing event to witness that’ he remembered. Increasingly, he found himself despising himself for helping block health reforms. I knew that once I did that (quit Cigna) my life would be different,” he said. “I wouldn’t be getting any more calls from recruiters for the health industry. It was the scariest thing I have done in my life. But it was the right thing to do.” A Damascus experience!
“Mr. Potter argues that much tougher regulation is essential. He also believes that a robust public option is an essential part of any health reform, to compete with for-profit insurers and keep them honest.” But political hopelessness it seems has stagnated rational deliberation, such as when Senator Chuck Grassley of Iowa, who was supposed to be the linchpin of any deal, helped feed the “death panel” lies. Tell it enough times, it becomes a “truth” for many people. As Mark Twain said, "A lie can travel halfway around the world while the truth is still putting on its shoes." Obviously, to acumen-followers of the warped debate of misinformation and fear-schisms, to a great extent, it has been an offensive for profiteers of big industry, insurance and big-pharma. It is those who give political status to elected officials. “Big money” trumps the need of the American people.
My friend Warren recalls a Rotary Club meeting he attended in Chicago during the 70s where former Secretary of Health, Joseph Califano, Jr. spoke. His prophecy was that in coming years there would be a two-tier health system in America: one for basic health services for the common man/non-wealthy and a second-tier for the rich that could afford expensive advanced cutting-edge technological care. We’ve exceeded his prediction of 2-tier, certainly with a sort of multiple-tier complexity. Some single-payer systems have staunchly been defended: Canadian Nationalized Health and Britain's National Health Service created in 1948. Even without a single-payer system, there may be something we can learn from these systems. Paul Krugman, an economist, relates health-care models from different countries, including a Swiss model as the clearest example most likely the U. S. will end with: “everyone is required to buy insurance, insurers can’t discriminate based on medical history or pre-existing conditions, and lower-income citizens get government help in paying for their policies.”
David Goldhill, a business executive, has written the most comprehensive and thought-provoking, twenty-seven page essay, entitled How American Health Care Killed My Father. (Recommended reading by Fareed Zakaria, Global Public Square.) Interestingly, Goldhill covers the broad scope of health-care business-functions, including hospital billing practices, economy-of-scale savings, and importantly the heavy toll exorbitant medical cost is draining from our country’s economic opportunity and social progression. His reform proposal relies heavily on individual responsibility but yet allows for financing some of our health care through insurance because serious illness or an accident might require urgent, extensive care, an extreme financial burden. (Catastrophic need!) I don’t necessarily agree with him, probably neither will you on much he proposes; however, he make some crucial points. We need more people like Goldhill honestly bringing more of this type serious “critical thinking” to the table. Neither Goldhill nor Potter likely has all the answers but certainly their experiences and Potter’s insider-employment role gives credibility to serious reform considerations.
Measures beyond the obvious criteria for reform must include prevention of moral hazard and stagnation of research and development. The criteria of “Revenue neutrality” is a justifiably concern for many people. What does that mean for each of us? Everyone will have to give something, take less, in some cases. That’s for the insurer, provider, and patient. (Now spread the fear.) We are a long way from a single-payer system, if ever, but John Kay makes a comparison with Canadian’s system whereby they have an average life expectancy of about 3-years more than U. S. and a cost per person of $3,895 to America’s $7,290; comparative savings translated to whole-American coverage is $1.0 trillion dollars annually. If true, we have a double-edge sword cutting our life and pocketbooks. Point is: enormous savings are possible in any system, either insurance based or single-payer. Currently, under a single-payer system, our government pays total-health care for the most sickly and costly group of patients: Medicare, Medicaid, and DVA. In all Medicare cost, 30% comes in last six months of life. In fact the American system may already be more socialist than some others: “The French health system uses a mixture of public and private funding, guaranteeing basic coverage through national insurance funds to which employees and employers make contributions. Most French people supplement these benefits by buying private insurance. The distinctions from the single-payer British system are significant, the results better.” Efficiency in health-care delivery will necessarily become a guiding principle, as illustrated here: 10 Steps to Better Health Care.
My friend David in the care business says his wife refers to the current system as convoluted. Convolution to be sure, in the system and the current reform process, is the unfortunate mudded environment. It is institutionalized inanity, political psychosis/paranoia and red-meat-delirium dealt this administration and all serious attempts at reform. (David Gergen, a bipartisan advisor for Nixon, Ford, Reagan, and Clinton, recently said, you have to wonder if the American people have become so polarized that they’re ungovernable.) Convoluted, for sure when a “U. S. criminal prisoner” can get health care --- but the system is the devastator to “Nikki a slim and athletic college graduate who had health insurance, had worked in health care and knew the system. But she had systemic lupus erythematosus, a chronic inflammatory disease that was diagnosed when she was 21 and gradually left her too sick to work. And once she lost her job, she lost her health insurance.” And lost her life!
The Peterson Foundation, the entitlement deficit watchdog, reports: The Lewin Group, analyzes America's Affordable Health Choices Act of 2009 (H.R. 3200). Should this Act become law, it would nearly pay for itself over the next ten years. However, further budget projections - taking a look at the following ten years, from 2020-2029 - indicate that the Act could not remain self-funding beyond its initial ten-year run. It’s a criticism and legitimate concern that will have to be addressed ongoing. Evans Thomas in this week’s Newsweek: (an exceptionally good article) “Most of the uncontrolled growth in federal spending and the deficit comes from Medicare; nothing else comes close. Almost a third of the money spent by Medicare—about $66.8 billion a year—goes to chronically ill patients in the last two years of life. This might seem obvious—of course the costs come at the end, when patients are the sickest. But that can't explain what researchers at Dartmouth have discovered: Medicare spends twice as much on similar patients in some parts of the country as in others. The average cost of a Medicare patient in Miami is $16,351; the average in Honolulu is $5,311. In the Bronx, N.Y., it's $12,543. In Fargo, N.D., $5,738. The average Medicare patient undergoing end-of-life treatment spends 21.9 days in a Manhattan hospital. In Mason City, Iowa, he or she spends only 6.1 days.”
An extensive criticism of this administration’s has been nonproposal of a specific health plan. Honestly, the nonspecific approach is the only way it could have progressed this far. Irrespective of a particular specific plan upfront, it would have quickly been shoot full of holes. However, the “hammering away” allowing different-interest groups and ideological viewpoints will not result in everything any group really likes. Although something meaningful, hopefully, will be passed. It won’t be a fix for all time; necessarily, it will require tune-ups ahead.
Incrementally, regardless of the end game, the health reform will eventually move forward. The first “small step” will be key to “One small step for man, (hopefully to become:) one giant leap for mankind.” Major-life-changing legislation only happens on the continuum in the U. S. legislature as when “human rights” legislations took many years to evolve. Coalescence of the best health reform policies is probably some years away, even if meaningful major legislation is enacted now because of complexities of its implementation. That’s the sad reality!
Only when we American people have the “Damascus experience,” as a Wendell Potter, will we cede to a new reality of ethical courage and responsibility; letting go the Saul/Paul blinding scales from our eyes for a new moral vision. A “giant leap” in moral conversion to accomplish decent health-care reform! If that can happen, let’s hope it’s not too late for our country and the needless suffering of its many citizens.