Update4: The Great Health Care Debate

KT--

So does McCain expect us just to take his word for it? What are these other reforms he has proposals for? Holtz-Eakin needs to understand that we bloggers are on top of things. We want proof attached to promises.

Karen, is it your sense that the McCain proposal is actually a good faith proposal or just an attempt to smother the issue with mush?

Is there any sense that McCain himself understands any of the details of the proposal?

Thanks.

I would like to have John McCain go on Medicare and standard supplemental insurance only and I'll go on his insurance.

Bet his ideas about the possibilities would change.

are designed to slow cost growth or even reduce it where possible.

So the McCain plan is to make health care costs down? Is he also planning on walking on water and squaring the circle?

So this Great Health Care Debate will be McCain's camp making a claim or proposal and then having McCain's people make the case for their plan after questions arise.

So this Great Health Care Debate will be McCain's camp making a claim or proposal and then having McCain's people make the case for their plan after questions arise.

That's Phase I. Phase II is to have Tim Russert and the Washington Post editorial board write in favor of the proposals.

The one thing that undermines this whole discussion, because no journalist could ever say this outloud without risking their reputations for objectivity, is that Republicans want any government effort regarding healthcare to fail. Philosophically, they want it to whither on the vine, and if McCain's plan worked, they would respond as Bennet did when asked to support an education program -- he said he wouldn't because if it succeeded it would undermine the case for vouchers.

So, the only way the Republican Party would get behind this would be if it drew support away from a more effective bill, allowed them to claim to be for reform to provide cover to destroy any real plan, or like Social Security privatization, it would bankrupt the system, giving them the excuse they need to kill it.

Major conservative thinkers have said they fear healthcare reform more than anything else because, as with Roosevelt's New Deal, it could create an entire generation of voters who like what government is doing for them and can't give up their benefits. They can't have that.

If McCain's plan worked, no Republican would support it any more than they would support reform that shored up SS.

Here's a thought: ask McCain why he thinks government should intervene, or could be trusted to fix the healthcare system?

Let's find out if McCain even believes in the principal of offering a good faith healthcare plan.

Kt here--

P-NNTO says So this Great Health Care Debate will be McCain's camp making a claim or proposal and then having McCain's people make the case for their plan after questions arise.

Actually, that's the opposite of what I'm trying to do here. I'm thrilled that the CAP people and Justin have weighed in on the McCain argument, and that Holtz-Eakin thinks it is worth his time to engage on specific questions that have been raised here in Swampland. This is one of the most satisfying days I've had in my new demi-career as a blogger.

KT, and we thank you for it. I'm thrilled, too, because we have so many smart people making intellegent rebuttals to McCain's plan.

My only, poorly worded, point was that this seems to be all about McCain's plan.
That this important discussion wasn't broached until his campaign came out with one.
I'd love this kind of scrutiny on all the candidates' plans.

From my earlier post:

Questions regarding John McCain's plan to which I'd love answers:

What's in John McCain's plan with respect to insurers' refusal to cover the costs of "pre-existing conditions", or the industry's abuse of consumers and contract law with respect to recovering payouts for "pre-existing conditions" "discovered" by firms employed by them precisely to scrutinize customer application forms designed to maximize such recoveries?

What in John McCain's plan compels insurers not to price the sick and injured (or terminally ill, for that matter) out of coverage?

What in John McCain's plan compels insurers to pay for necessary treatments not necessarily explicitly covered by plans for which consumers have been paying expensive premiums for years (even decades), and yet discovered to be necessary for their health (or life) precisely at the moment of diagnosis--when it is too late for the consumer to change to coverage of a now "pre-existing condition"?

Here's what John McCain basically has to say in response to my earlier questions (from a speech he gave in Arlington, VA--gotta work in the war-hero angle, apparently--April 29, 2008):

Health care in America should be affordable by all, not just the wealthy. It should be available to all, and not limited by where you work or how much you make. It should be fair to all; providing help where the need is greatest, and protecting Americans from corporate abuses. And for all the strengths of our health-care system, we know that right now it falls short of this ideal...

...These reforms will take time, and critics argue that when my proposed tax credit becomes available it would encourage people to purchase health insurance on the current individual market, while significant weaknesses in the market remain. They worry that Americans with pre-existing conditions could still be denied insurance. Congress took the important step of providing some protection against the exclusion of pre-existing conditions in the Health Insurance Portability and Accountability Act in 1996. I supported that legislation, and nothing in my reforms will change the fact that if you remain employed and insured you will build protection against the cost of treating any pre-existing condition.

Even so, those without prior group coverage and those with pre-existing conditions do have the most difficulty on the individual market, and we need to make sure they get the high-quality coverage they need. I will work tirelessly to address the problem. But I won't create another entitlement program that Washington will let get out of control.Nor will I saddle states with another unfunded mandate. The states have been very active in experimenting with ways to cover the "uninsurables." The State of North Carolina, for example, has an agreement with Blue Cross to act as insurer of "last resort." Over thirty states have some form of "high-risk" pool, and over twenty states have plans that limit premiums charged to people suffering an illness and who have been denied insurance.

So, mindboggling as it may seem, John McCain's answer to the problems I outlined is:
"...those without prior group coverage and those with pre-existing conditions do have the most difficulty on the individual market, and we need to make sure they get the high-quality coverage they need. I will work tirelessly to address the problem."

He personally will work tirelessly to address the problem...In some unspecified way...Over some unspecified length of time.

Believe me, if John McCain were putting out anything approaching John Edwards' plan, I'd be singing the man's praises from the rooftops. I couldn't even bring myself to vote for Hillary, but I will defend her plan as being the best amongst the candidates at the drop of a hat. My dog in this fight is health care.

But..."I will work tirelessly to address the problem" of cancer patients being denied care due to the "discovery" of some debatable "pre-existing condition" in the application documents filled out by unsuspecting consumers by third-party firms hired specifically to save insurers from paying out claims?

"I will work tirelessly to address the problem" of health insurance policies effectively terminating each year they are "renewed", such that arthritis diagnosed on December 31st of this year becomes a "pre-existing condition" not covered by the policy on January 1st of next year?

"I will work tirelessly to address the problem" of claims being denied retroactively, i.e. after the patient has been in the midst of individually unaffordable treatments for months or years?

"I will work tirelessly to address the problem" of claims being denied by insurers due to failure by health care providers to submit properly processed claims by the insurers' deadlines --and the bills for the providers' services therefore sold directly to collection agencies, as per the contracts patients are required to sign in the office just prior to seeing a doctor?

"I will work tirelessly to address the problem" of patients being denied care because the treatments prescribed for them by doctors are deemed by the insurers to be "alternative" or "experimental" or even "not worth the trouble", such that the patients die while their doctors appeal those decisions (and hospital administrators order the doctors to wait for the insurers to commit to pay)?

Can someone please explain to me how John McCain has the credibility on this or any other subject to stand up in front of me and tell me "I will work tirelessly to address the problem" instead of telling me any part of what he actually plans to do to address the problem?

Isn't this the very sort of double-talk coming from "Washington politicians" that leads John McCain to reject the kind of "entitlement program that Washington will let get out of control"?

I'm not out to prove anything here; I just believe that Americans deserve answers.

Karen?

Justin Fox?

Holtz-Eakin?

Anyone?

Sorry, the link in that was such that the patients die while their doctors appeal those decisions...

KT here--

P-NNTO: I've written about both the Clinton and Obama plans, and as I've mentioned before here, I even moderated a health care forum that included nearly all the Democratic candidates last spring. But as I said in the post that started this ball rolling, I really believed that the Obama and Clinton approaches are far more alike than they are different. McCain has now framed health care as a very stark choice.

What I'd also like to do is get a discussion started of the other ideas that are out there. There's single payer, of course, and also I'd like to get Joe to post something on the Wyden plan, which he is a big fan of, because it gets away from employer-funded insurance entirely, and basically replaces it with an individual mandate (though it still puts consumers in big purchasing groups, not out on the market as individuals, the way McCain's does).

I'm also making the argument with the High Sheriffs that it's time for major treatment in dead-tree TIME of the real philosophical choice that is now out there, though I think that could be some weeks away. This is the kind of package that it takes some time to do right, and we could do it any time between now and the fall.

...and thank you so much for these posts, Karen.

This has been a better day for democracy in America because of what you've done here.

KT- Thanks for this. I'm glad this has been satisfying for you as this is what I hope swampland can be.

Smart, interested people from across the spectrum discussing real issues.

With the added benefit of it being 'led' to a degree by people that actually have access to the campaigns, politicians, movers, shakers, candlestick makers.

I'm more of a lurker than a commenter as what I want to say is usually said quicker and faster by others. But this type of in depth look is exactly why I come here.

Now, the only remaining question is if Time will take the comments from this thread, one on Obama's plan, and one on Clinton's plan and consolidate them into a dead-tree article that compares, contrasts, and scrutinizes?

I do want to get back to the premise that as more people drop out of their companies plans because the insurance industry is providing better and cheaper coverage, which is something McCain's plan really depends on.

KT mentioned that Justin brought up the lower cost of elective surgery such as lasik and cosmetic procedures. I don't know what the current statis is for boob and nose jobs and where the work is done but I do know that lasik is a day surgery that is not performed in hosptitals. When I first checked it out about eight years ago the cost was $6000. I had both eyes done last year for $4000. Not a significant difference overall.

I don't have faith that the market will drive down the costs of cancer treatment or heart surgery significantly enough to "allow" insurance companies to provide comprehensive, affordable coverage to individuals.

KT here--

SB: Still, with overall health care costs soaring, that kind of cost reduction is huge. There are clearly some efficiencies out there to be had. Technology, for instance, has turned some procedures that used to be surgical art (hip replacements, for instance) into something that people with far less skill can do. It also seems I had read stories a few years ago about companies flying their employees to India for heart valve replacements, and getting similar outcomes for a lot less money. And a physical is now such a commodity (especially under managed care, where docs are driven to spend less and less real time with patients) that Wal-Mart was talking about doing them in their stores, in an approach that people were calling "Doc in the Box." But other things aren't commodities, and people who are sick and stressed out are likely to be less able to figure out what the best choice for them really is.

What about keeping the same thing we have now but with government mandates on plans and standardizations?

Is that possible?

KT here--

Here's one of those stories about India:

http://www.atimes.com/atimes/South_Asia/HF09Df01.html

It also seems I had read stories a few years ago about companies flying their employees to India for heart valve replacements, and getting similar outcomes for a lot less money.

Is this the kind of thing the McCain health care plan is going to promote? I don't see this going over well with Joe Sixpack.

KT here--

TomT: Good point. And yes, it would seem so, wouldn't it?

I'll repost here:

As a mostly free-market-oriented non-economist who doesn't know all that much about the health-care system, I'm naturally sympathetic to it.

With all due respect to Justin, Karen, this kind of stuff is just so incredibily damaging. I mean, it's like debating the value of various designs of levee systems by a bunch of free-market-oriented non-engineers:

WHAT POSSIBLE VALUE IS THEIR OPINION ABOUT IT?

Jeebus, why, if you are so interested, not get the opinion of someone WHO KNOWS SOMETHING about the health care system. Urban Institute has fine, fine scientists who devote their lives to evaluating various permutations of the health care system.

These stupid, strategist-designed health care proposals are like Frankensteins, none of them are going to work. It's like designing an interstate highway system whose only criteria is that it passes through every political contributor's district. When actually, we want it so we can *get where we want to go.*

Do you realize that you are actually making the issue worse, and not better. Jeeez. At least give Ackroyd the floor on this. He understands the complexities. IT ISN'T ALL ABOUT POLITICS! Get it?

Good Article

Explains the way some people view the 3 different plans and also reiterates KT's view that the dems plans are too close to really get too "heated" as Michelle Andrews says.

Also a neat little issue chart by Michelle

Chart

Sorry I know I am blowing up this board but wow, McCain compares health insurance to a college education.

"I think we owe it to them to have it affordable and available. It's their decision as to whether they want to take it or not."

McCain has compared having health insurance to getting a college education: something people can choose to do.

What! He's off his rocker!

Yes, that's completely insane.

One cannot choose to lie unconscious in a speeding ambulance any more than one can choose to opt out of the 1 in 3 over-65 people who fall each year, any more than one can choose to avoid illness and deteriorating health that inevitably accompanies life past one's thirties--excepting suicide, of course.

...and religious reasons not to get health care (AHA!!!)

On my obsession with way the credit would work, McCain's website resolves that. If the amount of tax savings is less than the credit, the difference goes into a Health Savings Account.

I don't see how he gets his free market argument to square with his interventions to cut costs arguments.

I'm looking forward to see him talk about this. Can I take up a fund to get Ezra a week on the Straight Talk Express? If it's still running, that is.

Can I take up a fund to get Ezra a week on the Straight Talk Express?

I'll contribute.

Maybe Ezra will be able to stay off of Hardball that week (as a bonus).

jayack,
i'm in. let me know.

KT: thanks so much for pushing this discussion forward.

And if the High Sheriffs are reading, I'll buy a dozen copies of TIME offering that healthcare article from the news-stand. (One sample boxout: "How The Rest Of The World Does It, And Pays For It." Another: "How The Future Of Medicine Changes Health Insurance", examining the way that access to genetic testing threatens the actuarial model of non-universal, non-mandated risk-pooling.)

This is a discussion that turns the cliché about TIME being on the corner table at the doctor's office and spins it around: it's the sort of thing people should be reading in their doctors' offices.

pseudonymous:

Well said!

...and Karen, do you mind if I just thank you and laud you with medals' and monuments' worth of praise and honor for this worthy examination of the issues that matter to people's lives (again)?

Some great blogging happened at Swampland today...

KT here--

Thanks, but I think the great blogging here has been done by our commenters. And by the way, I give Holtz-Eakin great credit for engaging here. Alas, I am going on the road today to spend a weekend watching Obama on the trail, so I don't know whether I will be adding to this thread.

Two points, one issue-related and the other personal:

Issue-related: Some of you (James esp.) are criticizing Justin for preferring a more free-market approach. However, one of the reasons that health care is such a mess is that parts of the system are so insulated from free-market pressures. People buy stuff but they don't really pay for it.

Personal: I know I got a lot of flack here for walking away from an earlier engagement on that whole Lurita item. But as much as I have found this experience to be--overall--a good one, what ticks me off is the suggestion that somehow I am lazy because I am not simultaneously reporting every single story that is going on in the world. Criticisms that begin along the lines: "A REAL reporter might think SUBJECT X was worth pursuing..." A reminder to you guys that the stories you love are the ones where a news organization has freed reporters to spend years digging into a single topic. That is basically the opposite of what I'm doing here. But I do think I'm doing a service. And by the way, I'm working my butt off. More than ever.

KT cont'd--

P.S.: I WILL continue to call attention to that kind of in-depth work. I think it's great, too, and the more attention it gets, the better.

Just want to note that atrios' comment on Lurita was not a search on "Tumulty" AND "Doan" but on TIME and Doan. And that his point was entirely correct. It "took so long" because the coverage following up was minimal to non-existent. Just as the coverage following up on the Sockpuppet Generals has been minimal to (on television) non-existent.

While the NYTimes has three followup stories on Wright today.

People buy stuff but they don't really pay for it.

You're right, that's definitely part of the problem--of prices. Prices for services are now almost completely out of the reach of individuals, because insurers pay the actual costs. I'll leave it at that.

what ticks me off...

This may be small comfort, Karen, but at least you are getting an idea of the normal, everyday American common knowledge that the national media--especially the national political press--is a even more of conscience-less, untrustworthy, rapacious billionaire's beast (existing solely to screw people through the exploitation of thoroughly broken system) than are the despised, soulless, ambulance-chasing, misery-profiteers the attorneys. That's right: according to polls, in the minds of a majority of Americans, the press has joined divorce lawyers as the worst people in the world.

At least you're not part of a bubble that isolates you from the real-world consequences of how your profession as a whole has and continues to degenerate. At least you know the extent of the blame and sometimes irrational antipathy that's out here. There's reason why Bob Somerby's audience is growing and growing by the day. There's a reason why we come here, too.

One of the reasons that I come here is that we don't have to pretend for appearances' sake that everything's just peachy, and that we love our Media Stars (like Brian Williams). One of the reasons I come here is to hear the trade side of the story, and you've done a wonderful job explaining to us how ledes work, how editors influence the product and process, how it is for reporters on the road, how the profession has changed--all of these important facts and subtexts that allow our understanding of the media to become deeper and more rationally informed. It's not fan-boi stuff--I don't care about the "inside scoop" or the "backstage pass" aspects--it's that we can get a better idea of the forces and situations behind why things are the way that they are. You have been invaluable; you deserve great credit for acting as professor for those of us not just here to blow off steam. We want to be fair, Karen. Your input, including yelling at us when we're not being rational/fair/well-informed, is key to our fair judgment. That's why I keep thanking you all of the time--because I truly mean it.

I do think I'm doing a service. And by the way, I'm working my butt off. More than ever.

Yes.

It's pretty clear to regular folks around here how hard you work, Karen.

Thank you so much for taking this blog seriously.

Karen,

In your second update to the GHCD, you indicated that the McCain "plan" would "encourage" employers to drop their group plans for their employees. You also stated that, "The current system of getting your health insurance as a fringe benefit from your employer does not make a lot of sense economically..."

In fact, it DOES make economic sense: First, more people are insured, leading to more well-care and catching health problems early, reducing to "emergency-room" system we have for the growing legions of the uninsured. Second, the employer gets a deduction for every dollar paid for health costs, thus paying for those costs with pre-tax dollars. Third, group plans MUST, by law in every state, take ALL of the employees, regardless of health history, pre-existing conditions, or other demographics that individual plan issuers use to weed out all but the youngest and healthiest.

Also, are you aware that the McCain "plan" virtually guarantees that most -- if not all -- employers will terminate their plans due to one too-powerful-to-ignore fact of the McCain "plan": the deduction for employer-paid health insurance will be eliminated, in toto. What shareholders will stand for paying this cost when it reduces the bottom line with no tax-advantages whatsoever?

Lastly, you may have notices my quotation marks when I refer to McCain's "plan." It is clear that McCain has not much more than vague generalities in regard to lowering health care costs, improving health care access, how shifting costs from the employer to the employee will at all reduce the number of uninsured, and how those now ineligible for coverage (pre-existing conditions, poor health, old, etc.) will be covered (McCain simply says he will "work with the states" to cover everyone - How, when Medicaid is being slashed more and more every day). Worst of all, where the heck will he find money in the federal budget (except by borrowing from China) to provide a $5,000 TAX CREDIT to each American?

It is just more bamboozlement, and the press just keeps hammering Obama and Clinton for not having realistic or serious proposals -- they do; but McCain keeps getting a free pass because he is so "likeable." We can see what terrible things can happen to our country and the world when a "likeable" but clearly unqualified and unprepared man is given a free pass by the press (and the Supreme Court); do we really want to have at least 4 more years of the McSame?

KT here--

AL: I think employers would continue to offer coverage under the circumstances I outlined earlier (they are covered by union contracts, or in industries where the competition for workers is so great that they've got to offer it). But I do think that if we were designing a system from the ground up, we wouldn't go for insurance through our employers. And I think insurance itself is a weird concept when it comes to health care. It's usually something you buy to protect against catastrophe; the health care system is something you need to use on a regular basis to keep you well. (One reason I hated the Michael Moore movie is that he completely distorted the origins of HMOs; at the time, they were actually a REFORM that liberals liked.) In so many ways, single-payer makes more sense as a delivery system--as the extraordinarily successful Medicare program proved. But given that insurance is the system we have, decoupling it from the workplace--as Wyden envisions--also has some really good arguments going for it. It is far easier to move it when you change jobs, for one thing.

A. Liberal

The first post or two on this subject wasn't clear, but the Times article was clear. The deductibility of health care provision for employers would not be eliminated. The change in treatment is for individuals. The benefit would be reported as income.