Saturday, August 1, 2009

Health Care Saturday: White Flour Edition

Krugman: The invisible program

Matthew Yglesias leads us to a commenter at Marginal Revolution who looks at life expectancy and concludes that “semi-socialized medicine” is good for the young but bad for the old. Tyler Cowen made the same argument in the Times a while back:

On average, European systems are relatively good for the young, who are generally healthy and need treatment for obvious accidents and emergencies, with transparent remedies. European systems are less effective for the elderly, the primary demanders of discretionary medical benefits.

As Yglesias points out, such arguments weirdly miss the fact that older Americans are covered by Medicare. If you say that American health care works well for the elderly, then the part of our system you’re praising is the “socialized” part.

This is part of a broader phenomenon. Everyone’s favorite story about the evils of socialized medicine is the fact that Canadians wait longer for hip replacements. But who pays for hip replacements in the United States? Medicare, in most cases.

So we make fun of people who want to keep the government’s hands off Medicare. But Medicare blindness isn’t just a problem for the rubes.

Greg Sargent:

* HuffPo reports that Obama’s political operation is gearing up its ground game for the health care wars — in the districts of Blue Dog Dems.

* TPM reports the stunning response from the office of Dem Senator Ben Nelson to an ad by outside liberal groups attacking him for slowing health care reform:

“If this is an indication of the politics going into August, then health care reform may be dead by the end of August.”

Shorter Nelson: Criticize me and health care reform is doomed…

* Sam Stein reports that the groups targeting Nelson, Progressive Change Campaign Committee and Democracy for America, have absolutely no intention of letting up.

  • Steve Benen adds:

    Now, it's true that DFA and the PCCC are not Nebraska organizations, but it's worth remembering that the groups' ad features a small businessman, who owns a shop in Ralston, Neb., who supports reform and opposes the delays Nelson has demanded. The ad is not "outside special interest groups telling them what to think"; it's one voice -- that of a Nebraska shop owner -- urging his senator to do the right thing.

    Nelson is up for re-election next year, and it's not surprising that he'd like to avoid any and all criticism. But threatening to kill health care reform because a couple of groups are running a television ad he doesn't like seems rather petty.

    People are allowed to express their political opinions, even if they're critical of Ben Nelson. The ad doesn't make any false claims; it doesn't include any personal attacks; and the criticism itself is a little out of date since we already know the pre-recess deadline won't be met. For that matter, it's my understanding that it wasn't an especially large ad buy anyway.

    So, with so much on the line, and the health and hopes of millions in the balance, perhaps Nelson can drop the threats?

  • Atrios adds: I love it when our elected officials reveal themselves to have the emotional maturity of emotionally stunted 11-year olds. His widdle feelings are more important than people having access to health care.
Waldman (DK): Pull the plug on Senate Finance
Two quick observations on a Nate Silver post:

This is not exactly to suggest that Grassley is bargaining in bad faith. But he has almost no reason to compromise on any points of substance. At best, he's probably somewhat indifferent between a weak health care bill passing and the whole enterprise failing apart; that's a very dangerous person to be negotiating with. The same thing certainly goes for Mike Enzi, who is more conservative than Grassley and hails from a much redder state. Olympia Snowe is different: she is a de facto independent in a very blue state, who might even have some hopes of being on a Presidential ticket someday.

Mike Enzi is not really negotiating in this. He is there as the political officer. The "minder" for Grassley and Snowe. This should be obvious to Baucus. It's obvious to all his colleagues in the Senate, and pretty much everyone else in the world, too.

Instead of Grassley and Enzi, Baucus should be sitting in a room with Ben Nelson and Mary Landireu -- and maybe Olympia Snowe. Those are the swing votes -- the pressure points -- the people with whom there's actually something to be neogtiated. If Grassley wants to come in and snack on beef jerky and spitball a few ideas, then sure -- door's always open. But I don't know what good he's doing the Democrats by being given so leverage over the process.

Absolutely true, and a very important point. Right now, it's Enzi, Grassley and Snowe why? Because these negotiations are ostensibly a function of the Senate Finance Committee. Enzi, Grassley and Snowe are members of the committee, and Nelson and Landrieu aren't.

But so what? The reality, as everyone up to and including Baucus has acknowledged, is that they're after a bill that can get 60 votes. And not only that, but the Finance Committee product still has to be merged with the HELP product, anyway. So what difference does it make whether that's negotiated with the people who hold those votes, or with their political proxies on the Finance Committee? In fact, common sense would tell you that there is a difference, and that it's presumably always better to be negotiating directly with the other parties you're after rather than some intermediary. So if you're aiming for 60, why not negotiate directly with those few votes out there that can get you to 60?

Nobody had any problem with negotiating the settlement to the stimulus impasse outside of the formal framework established for that purpose. Collins, Snowe and Specter weren't on the conference committee, and Snowe isn't on the Appropriations Committee, either. But everyone knew where the votes were, and the negotiations happened around them, with the results carried to the formal committee structures for approval thereafter. Why we should continue with the charade of carrying on these negotiations in the Finance Committee when everyone on the Finance Committee has their eyes on votes outside of the committee membership, anyway, I have no idea.

And I just have to throw in a third point here, now that I think about it:

So what was Baucus hoping to achieve by negotiating with people who have an incentive to see the process fail? There are two basic cases here. Either the Democrats can muster all 60 votes on their own, and Grassley's vote would be the icing on top of Obama's victory cake and would only serve to improve the Democrats' electoral prospects in 2010 and 2012. Or they can't, in which case Grassley has it within his power to cause the Democrats a huge, potentially back-breaking headache.

Democrats in all likelihood can't muster all 60 votes on their own. The probability that Senator Kennedy will ever be able to return to the Senate and cast a vote is, unfortunately, minimal -- and that's an optimistic assessment. Senator Byrd is only marginally more likely to be able to appear. There are, for all practical purposes, still only 58 Democrats in the Senate.

That means that the 60th vote, if that's what we're shooting for, is going to have to come from a Republican. But the political complication in this is that no Republican wants to be that 60th vote all by themselves. There are still a few of them who might be willing to be the 61st vote, so that no one can be singled out as "the one who did it." The two votes we need to get to 60 are going to want company and cover. So it may turn out to be the case (assuming the ability to hold all 58 Democratic votes) that getting two Republicans is actually harder than getting three. And that means the search should be on for #3. Is it Grassley? Maybe. But since it doesn't matter as regards final passage whether that vote comes from inside or outside the Finance Committee, you should probably be looking at a wider roster.

I wrote the other day that it was time to consider easing Baucus out of the driver's seat on this. It's not that he's "too conservative" for this job. It's that he's not doing it, conservative or not.

It seems that call tapped into a sentiment that was much more widely held than I knew. Since the likelihood of that happening is probably pretty slim (think Lieberman), we might as well start looking for other, frankly simpler, solutions. There's really not much reason to remove Baucus as Finance Committee chair, necessarily. But there's plenty of reason to remove these negotiations from the Finance Committee.

If it's all about getting to 60, get to 60 where the 60 are.

Publius: Least Surprising News of the Day

I'm not sure Max Baucus and staff read Jonathan Cohn, but they should. This comes from his latest report on where things stand on Capitol Hill:

Baucus, as you may know, has been trying to hammer out a deal with a bipartisan group of six members. But on Thursday the most conservative member of the bunch, Republican Mike Enzi of Wyoming, made it clear he didn't think it possible to get legislation ready for the August recess.

By all accounts, Enzi has been under enormous pressure from Republican leadership, which wants no bill at all and sees time as its ally. Whether Enzi was responding to their pressure or simply following his own conscience is anybody's guess.

I, for one, am shocked that Republicans see delay as a tactical device rather than as a time for careful study and deliberation about policy merits. I'm equally shocked to Enzi dragging things out. And here I thought he only cared about Doritos...

The conventional wisdom among many political observers is that Democrats and Republicans should be able to work together to find compromise solutions to pressing problems. Politicians should "put aside their differences." Legislation should be "bipartisan." Effective leaders should be able to "bring people together."

It's worth noting, from time to time, the practical and ideological problems with this approach to problem solving. The parties disagree -- as they should; it's why they exist -- and are more polarized now than at any point in modern political history. Ezra has posted this chart from Nolan McCarty, Keith Poole, and Howard Rosenthal before, but I'm glad he ran it again yesterday. It shows current political polarization is at its highest point since the 19th century:


This political environment obviously makes compromises and "bipartisan" solutions very difficult, since the parties, more so than at any recent point, simply see matters of state in fundamentally different ways. But the polarization among lawmakers in both chambers also, as Ezra noted yesterday, "makes it virtually impossible to govern in a system that is designed to foil majorities and require a constant three-fifths consensus. It's not good if the country is virtually impossible to govern. Problems don't stop mounting while we try and figure things out."

There's been some talk lately about the effort to convince at least some Republicans to support health care reform, the way plenty of Republicans support Social Security and Medicare in previous generations. In those eras, the parties were closer together, and there were center-left GOP lawmakers from across the country who were amenable to outreach.

This period, it should be noted, did not last long. Looking at the chart, we see the parties came much closer together in the wake of the Great Depression, and the polarization remained low for several decades. It created an environment in which bipartisan policymaking was considerably easier.

And that's long gone. To reiterate a point Harold Meyerson emphasized this week: "Nationally, the [modern Republican Party] is dominated by Southern neo-Dixiecrats. In their book 'Off Center,' political scientists Jacob Hacker and Paul Pierson compared congressional Republicans of different eras and concluded that a Republican House member in 2003 with a voting record that placed him at the median of his party was 73 percent more conservative than the median GOP member of the early '70s. Max Baucus, then, isn't negotiating universal coverage with the party of Everett Dirksen, in which many members supported Medicare. He's negotiating it with the party of Barry Goldwater, who was dead set against Medicare. It's a fool's errand that is creating a plan that's a marvel of ineffectuality and self-negation -- a latter-day Missouri Compromise that reconciles opposites at the cost of good policy."

Regarding the leaked strategy memo advising conservative operatives on how to disrupt Dem "town-hall" meetings, sgwhiteinfla suggests:
My advice is that every Democratic member of Congress should get intimately familiar with this memo. And at if they plan on holding a townhall during the break they should employ what I like to call the "8 Mile" strategy. For those who never saw the movie, Eminem's character wins the rap battle at the end by predicting all of the lines of attack that his opponent will use and then he goes in on his opponent. By the time his turn comes Em's opponent is flustered because for one he didn't have any disses left to use and for two because Eminem had ripped him up. So he just hell the microphone and froze.

The first thing these Democrats should do is present the memo and inform the audience of all of the things that are to come. That there will be people yelling, and interrupting and they will also fan out to inflate their numbers. And then they should point out that these people do not want honest debate. They are there for one thing only and that is to deprive the rest of the attendees of the opportunity to learn about health care reform and have their voices heard. And then they can always point out that these people are paid for by the health insurance companies. (whether that is true or not isn't really important) Once they get that out of the way they will have the audience on their side and against the obstructionists. Instead of allowing these people to hijack the townhall, more than likely what will happen is the audience will turn on them and boo them out of the event.

That, to me, should be a no brainer. Why even give them an opportunity to try to derail the discussion? Or for that matter why try to act like they won't be there when its likely that they will. Just punch them in the mouth first and then you win the battle before it gets started.
Yglesias: The Land of the Free

And I thought that in the United States we didn’t ration health care:

An insurance company that initially refused to pay for a liver transplant for a 17-year-old Northridge girl who died in a hospital should face criminal charges and pay civil damages, an attorney for the girl’s family said Friday.

In the real world, it’s not possible to have an insurance program that will pay for just anything. A private insurance plan will try to find reasons to avoid paying for anything that’s expensive. And it’s natural inclination to do this will be checked by the sloppy method of public outrage and lawsuits. A public program, by contrast, could operate according to an explicit budget constraint, with elected officials and the voters who vote for them in a position to make a choice about how much resources they want to dedicate to health care services rather than to other things. In either case, people with the means and inclination could step outside the insurance circle and purchase additional services.

Knisely: Health Care Reform and “Dr. Avarice J. Greed, M.D., P.C.”

I hadn’t decided whether to bring “the design of government” to health care reform, but at the request of Anna D. (“Thanks, Anna!”) and having seen this WaPo article on Dr. Avarice J. Greed, M.D., P.C., and his confreres, and having received a long email from my sister, a retired nurse (see below), I think I’ll give it a shot.

Over the next few posts, I’ll comment on several issues:

1. Supply. The AMA (American Medical Association) closed half the medical schools in America about the turn of the last century. And, ever heard of “barefoot doctors”?

2. Demand. How much of obesity is due to low incomes? The Danes have a saying, “You have to be rich to be thin.” Would encouraging unions reduce obesity more than education? The GINI Index again.

3. System inefficiencies. Two flavors: Opportunities for information sharing and insurance company profits.

4. Medical mal-avarice. See below for starters.

My sister was first in her class in nursing school, and is now retired and raising show quality dogs. So she’s experienced hospital pricing from the inside and vet pricing from the outside. Her observations:

I never had a job in any “company.” Obviously hospitals try to make money, and particularly in Union [SC] they invited the head RN’s to the top staff meetings. Such things as the base room rate being as low as possible-around $105 a day at that time — 1990 — because they said people call around if a procedure is non-emergency, and what they ask is the base rate. So then you just add higher prices for everything else, and I do mean everything.

At that time, a bag of IV fluid cost the hospital $1.00, we charged the patient $10.00. A foley catheter cost us $5.00, the patient paid $57.00. But then of course, they added for 1-1 RN care, etc.

Same basic thing at my previous job in Psych at MUSC, [Medical University of South Carolina, in Charleston] the base room rate was low, but they had at least 5 therapies for each patient, and I mean the group ones like physical therapy, music therapy, this isn’t counting the medical student seeing the patient, the intern, the resident, the MD, the staffing, etc, etc.

But what got me the most was in Union. I worked there about the time Office Max and that type of store opened. Of course they sent catalogs to everyone. I knew the prices we paid in Central Supply for packs of 3 x 5 cards, pens, all sorts of stuff, and of course there are hundreds if not thousands of those things. Some of the prices that hospital paid for office supplies were 10X what Office Max charged. So I went to the head of that department with the catalog in hand, marked, but he said they liked to order everything from one supplier, so paid whatever that supplier charged.

The darn vets are the same now. If I buy a bag of IV fluids from my vets, it is $35.00. They are exactly, and I mean brand, label, everything, the same as we used in Union, and every other job I have had. IV fluids are considered a prescription drug, whereas the tubing and the needles are not. I can get the identical fluids for $3.99 a bag from KV vet but the Vet has to call or fax the prescription in. They do allow for the vet to tell them what you can have in a year, and you can order it however you want. Of course the shipping is fairly high, so I order maybe 12 at a time, which that lasts me usually a year. And I can buy if from a site that is supposed to be for vets, but I have a password, every breeder I know uses it, for $4.99. The same stuff, Propofol, that Michael Jackson used IV, it is on that site.

The lady that is the financial head of my Vets’ 2 offices, told me the same identical thing, they want to order everything from one place. I have a catalog that the medicine for preventing the dog version of Alzheimer’s, called Old Dog Encephalitis, Selegiline, 5 mg twice a day, costs $5.99 for 500 tablets. The first time I had Huey, Andrew’s father, to the vet for confusion, maybe 2 years ago, the vet told me she had read it helped, but had offered it to 3 clients, but the $200 a month caused them not to get it. I had her write down the name and dose, (just so I could remember it) — the dose is the same for people – and when I went to Wal-Mart it was $46.00; I called Pet Care RX, it was $26.00. Then I saw it in a catalog for vets for $5.99 for a huge size. I can order anything from that catalog except for prescriptions. I got a box the size that a pair of high top sneakers would be shipped in, absolutely stuffed with IV tubings, for $4.99 the other day, 100 of them.

Would it not pay a hospital or a busy vets’ office, really 2 offices with 7 vets, one full time person’s pay to check prices and order things from different suppliers? In IV fluids alone they could pay that person a week’s salary a month. They even order packages of sweetener and sugar and instant coffee from the same place!

How do things like this fit into the direction of having a great company? And of course I only see a few things!

And all I’ll add is that (a) if you can pass on all your costs to the patients (customers) AND add a percentage for profit, who cares what things cost? And that (b) when your customers or patients have no idea of your costs, you can charge them whatever you like!

When I worked for DOD, back in the 1960’s, we had both “cost-plus contracts” and “contractor-furnished lunches.” I loved CFLs – can you guess who paid? It was you, the American taxpayer!

Both are now outlawed in DOD – now how about health care? Duh!

No comments:

Post a Comment