Thursday, August 27, 2009

Tim Bishop follies

I went to the Tim Bishop Health Care Forum tonight. To be fair, the Congressman was patient, and interrupted by frequent outbursts from the crowd. I got to the event nearly an hour before it was scheduled to start (6:30). I was one of the last of the 800 or so folks let in -- there were easily that many others left out. I sat next to an elderly couple Frank and Louise, both clearly against HR 3200, and a lady who jumped to her feet whenever the elderly couple sat on their hands. Unfortunately, we were all in the same row as a very rude, loud and belligerent man.

The League of Women Voters hosted the event. The format was such thay anyone who wanted to speak had to submit their question to panel. It was given the appearance that questions were screened and that the best would be read and answered by the Congressman. I assumed the League would do the screening, and considering the first few speakers were clearly against HR 3200, it seemed that they had not loaded the deck in favor of one side or the other. Later I noticed Bishop speaking off-mike to a staffer, and soon after the same staffer was shuffling through the various question cards. Obviously Bishop wanted a particular question asked and wasn't getting it from the "random" sampling.

Ok, here's the rundown: first speaker asked the obvious question, "How can we possibly afford this, and specifically how can we pull $625B from Medicare and still meet obligations?" Bishop had obviously prepared, as he rattled off a litany of numbers--$220B here, $165B there-- and TA-DA! We can't afford not to do it!! And he won't vote for a measure that isn't funded.

Next speaker was a WWII vet. He wanted to know if HR 3200 would be renamed after Teddy Kennedy. After the union (oh, they were there in great number, early to guarantee seating, and with slick posters) applause subsided, he got to his point and it was clear the union regretted all that applause because he laced into Bishop pretty good.

It only took the fourth speaker to Godwin the whole discussion, "This is like Nazi Germany! This is like Nazi Germany!" Oh boy.

Union leader from out of district was roundly booed to the point that he left without speaking. To be fair, there were 1st CD residents who did not get in, so he shouldn't have been inside, let alone given a mike.

Boy of about 12 asked if the death panels would kill off his grandmother, 71, who just had bypass surgery. OK, here is the party line: "There is no wording in this bill that would even remotely do anything like that. We have review boards right now in NY." Best moment of the night came then: "Well, Congressman, on pages 424-432, that very thing is described." I haven't read the whole bill (I have a job...), but I really admired the kid's spunk.

Not much more to report. Bishop danced around most issues. "There is no wording in the bill..." seems to be the preface for all our "misconceptions." What gets me the most frustrated is the inability to get meaningful dialogue on how they see the health care landscape 5, 10, and 15 years from now. Sure there won't be rationing (any more than we already have) immediately. But what happens if you add even more demand to the system? At some point it is inevitable that if we place government in control of health care, they will also start making decisions based on the behavior of the citizens. (Hey, if we have to pay for this, you have a responsibility to do everything in your power to live a healthy lifestyle. Put down that double cheeseburger with bacon, or risk losing your health care. And don't think you mountain climbers are safe either -- that shit is dangerous! What if you fell and survived, or got caught in unexpectedly harsh weather? Why should we pick up the tab for your reckless behavior?)

Here's an overall observation: Pimping for Obama Organizing for America definitely got the message out. There was a huge union presence, and their signs were all professionally done and matching. Planned Parenthood all had pink signs. You get the idea. The overwhelming majority of folks who were there against HR 3200 had hand made signs, with various messages that obviously were the work, and thoughts, of the people holding the signs. Astroturf my ass! More on this in an upcoming blog.

If I had been able to speak I would have asked this question: I keep hearing President Obama use the term “keep the insurance companies honest” as a selling point for the public option. Can you elaborate on that? Does he mean that they are not currently being honest? Or is the implication that a government program is needed to “keep them honest” an admission that they are not currently operating in a free market arena where the customers “keep them honest?” Wouldn’t it be better to loosen the restrictions on health insurers, for instance letting them insure out of state customers? Wouldn’t that foster more competition, and result in more honest pricing? Could we try that instead first, rather than instituting another government program that will never go away?

Wednesday, August 26, 2009

Health Care and Insurance Reform

My simple plan for health care reform. It’s not by any means a complete health care system, but then neither is what we have nor what is being proposed.

First, repeal the HMO Act of 1973. From their beginnings, HMOs were designed--by Democrats and Republicans--to eliminate individual health insurance. The result is a vast network of health care collectives (HMOs, PPOs, Point-of-Service plans) created by government that are destined to do harm to individuals.

Second, you are just not serious about reform unless you start with completely decoupling health insurance from employment. If your employer wants to use health insurance as a means for employee retention, he can offer to pay for your individual plan. The individual was first discouraged from buying insurance in 1942 when employee health premiums were made tax deductible to employers (as part of the war effort there was a wage freeze, so in order for companies to offer an incentive to retain employees, Congress passed legislation that made corporate money spent on employee health insurance tax deductible) --not to individuals. Think about that – corporations are not charged any tax against any health insurance expenditures, but if you want to buy an individual policy for yourself or your family, you have to do it with what is left in your net, after taxes, income. (I realize some folks can use pre-tax dollars if they are lucky enough to have an employer who participates in the Section 125 plan, but even there, the company is choosing the plan so the choice and motivation for savings is not there.) Anyway, Congress created Medicare in 1965, in effect making individual insurance for those over 65 obsolete. Subsidized, unrestricted healthcare for seniors led to an unprecedented frenzy of spending by patients and doctors. Combined with Medicare, the HMO Act eventually eliminated the market for affordable individual health insurance. If we return the buying power to the individual, we can take steps in the right direction. Every other type of insurance that I can think of is based on an individual choosing the plan/coverage that best fits the individual’s situation. Not 30 minutes goes by on any television channel I watch where I don’t see a commercial for Progressive or GEICO car insurance. A little competition for my dollars would be a step in the right direction.

Third, let the market shake out a lot of the unneeded administration of health care. I remember going to my family doctor as child in the 70s and being greeted by the receptionist, who also served as the billing clerk and the girl who would bring me to the exam room and put a fresh piece of paper over the exam bed. Now my PCP has 3 different people for each of those jobs, plus a staff of ten more who do I don’t know what. There is a huge layer of unnecessary administration. If the individual can deal directly with the provider, fair market price will eventually be achieved. I use as an example the Lasik eye surgery. When this first came out, each procedure would cost as much as $10k. Why? Because it was new and there were only a few providers. HMO’s rightly called that a cosmetic treatment and refused to pay. Wear glasses or pay for it yourself. Well now that the industry has matured, you can get Lasik done just about anywhere and what is the price? Usually less than $1000 for both eyes. Need another example? I have chronic back pain due to some car accidents and the construction industry when I was a young man. I found that once or twice a week trips to the chiropractor for a quick manipulation allowed for better range of motion and less pain. HMOs however do not get the concept of maintenance. They want the chiropractor to “fix” me, in the way a surgeon would. Instead of covering the yearly costs for my weekly trip, they pay for a maximum of 8 trips per year. All of course with the $30 co-pay for each visit. Want to know what the HMO rates as fair and competitive price for the 2 minute back manipulation? $31.35. Subtract the $30 co-pay and the good doctor gets a whopping check from the HMO for $1.35. So what did my chiropractor and I do? We arranged for unlimited chiropractic care for $45 per month. There is no reason this could be the standard rather than the exception. In fact, some PC doctors have tried this approach, only to be smacked with cease and desist orders because they are “acting like insurance companies” ( Health care costs should be coming down, not rising, as competition for individual care leads to greater efficiencies. Instead, we have a perverted market where doctors compete to obtain the biggest block of members in one felled swoop. Then the HMOs and Medicare tell the doctors what they are going to pay for a particular procedure, rather than the other way around. To make up the difference, doctors have to charge the uninsured 10x what they get from the HMOs and Medicare for the same procedure. Doctors want to make a certain salary level. It’s like squeezing a balloon – if you artificial deflate the balloon in one area, then the other areas have to compensate.

Real reform would put decision-making back in the hands of the patients. Doctors would advertise. The best doctors will command higher prices, but the poor would still have access to what they can afford. Charity will have to cover the truly indigent. My boss has a saying regarding payroll, “Leave it to the employees to notice every penny.” In other words, if your payroll check is wrong, you are going to bring it to the owner’s attention because “hey! That’s my money!” Patients empowered the same way will make the best decisions because now it will be their money. Some will want more complete coverage and will supplement with their own dollars, some will prefer to use their money elsewhere. The system will be reformed in such a way that artificial pricing structures that penalize the individual will be greatly reduced, giving greater access to those seeking doctor care.

A lynchpin of the current plan is that savings will be derived from preventive health care. There is ample evidence in the current system that preventive health care is expensive, too. By artificially lowering the cost of doctor access (co-pays), not surprisingly people see their physician for the most basic maladies. There are simple laws of supply and demand in play here. If we increase demand, supply becomes either more expensive or rationed. We have a finite number of general practitioners (many of whom are closer to retirement than they are to their med school days, with fewer med students choosing the family practice when they can specialize and make much more, or work less for the same dollars) and this is a flaw in the system that is only going to get worse. No new medical schools have been allowed to open since the 1980s. Frequently overlooked in the debate is the way the AMA cartel has kept doctor’s fees artificially high. This forces much greater cost into the system, without any improvement in care. It’s another place where free market competition could do wonders to lower costs. Expand the role of medical assistants and nurse practitioners. Nurse practitioners can do many of the procedures that presently require doctors at a fraction of the cost. Allow foreign born doctors to emigrate here and just show core competency, instead of forcing them into repeating residencies. Again, supply and demand. Doctors command exorbitant salaries because the AMA imposes an artificially high barrier to market entry. By limiting the number of doctors, the AMA has reduced the supply.

So we have fewer doctors and a declining population of general practitioners. We are already in the midst of declining service (long waits at the office, coupled with long lead times for appointments). And now we want to inject another 50 million souls into the system who are presently underserved.

Lastly, if Obama fails to read this blog and we head down the road of more entitlements, I don’t know why the idea of vouchers gets so little play. If we are going to pay the way for certain individual’s health care, what’s wrong with handing them a check and saying, “Spend this wisely”? I don’t understand the idea that we should be on the hook for medical treatment on demand, regardless of cost or efficacy. They could use the voucher for routine doctors visits if they feel they are healthy enough, or they could pay for the routine treatments and use the voucher to buy insurance to cover catastrophic events. Their choice, and choosing wrong will lead to some folks not receiving the life saving treatment they could otherwise get, but it puts the decision back in the hands of the consumer rather than the government or insurance company, neither of which has the patient’s best interest as the only priority.

So if we are really serious about reform, I mean the part where we stop scratching the union’s back, appeasing the AMA with laws they help write, and stop treating the individual as too stupid to be responsible for his own well-being, if that reform is what we really want, then maybe the few suggestions I have here will get some sunlight.

Thursday, August 13, 2009

Falling through the Cracks

This blogpost was initially breathed into life as a comment related to what my friend TWC said in a Facebook post about people who fall through the cracks. The story is too long, so I share it here instead.

Last year we hired a guy for the shipping department who, after working here for a few months, ended up finding himself suddenly homeless (and without a car, either, though we later learned that was because of a DWI). When he inquired about getting some help for temporary shelter, he was told he’d have to go to an agency to fill out a form and then have to wait to see a counselor. Well the walk to the agency is about an hour and a half in each direction and with an open-ended wait for the counselor, he’d have to take a day off from work. Except he was a probationary employee, so he couldn’t take off from work because a) he desperately needed the full time paycheck and b) he was on probation and even excused absences had an effect on his future employment. The next day we come to work to find out that Bob slept in the woods out behind our workplace. Apparently he didn’t know how to recognize poison ivy – his arms were covered with pustules from the reaction. I cut my lunch short that day so I could run to the pharmacy and get him some Benedryl for relief. The production manager ran home and got his tent and some blankets for Bob. One guy came all the way back to work after dinner that evening with some hot food, a lantern, and a Bible (Bob was very religious, probably from his AA meetings). I brought my sleeping bag and my son’s bedroll to work with me the next day and offered them to Bob. Anyway, he lived out back for about 3 weeks until his luck changed. Unfortunately, not for the better. He had saved (and borrowed) enough to put the security deposit and one month’s rent down on a small efficiency apartment not too far from work. About a week before he moved in, and feeling pretty good about getting his life back on track, he decided to hit OTB (apparently alcohol wasn’t his only vice). He lost it all, or at least enough of it that he decided to go on a serious bender, and he got so drunk that he tried to get into the workplace that morning at 3AM. He set off the security alarm and both the president of the company and the police were called. Bob was too drunk to speak coherently, but Walther, whom I had never seen display an ounce of compassion (his management style was to berate, belittle and attack), hands the cop a few hundred dollars and asks the cop to get Bob a safe place to sleep it off. We never saw Bob again. Well, that’s not totally true – he returned to the tent out back at some point, but he never returned to work. He had never called in after the incident, and I think if he had, and apologized, he’d have been given another chance. But he never called. We had a fairly mild winter on Long Island, without any major cold snaps, but I’m sure there were some long nights. I have to be honest, I only thought about him a few times that whole winter. Out of sight, out of mind. Maybe there was more we could have done. Maybe he didn’t deserve our kindness. Maybe you do for your fellow man and leave the judgment to a higher power. In the end, spring rolled around, the tent was still in the woods and Bob was gone. I retrieved my sleeping bag and the bedroll I had figured I’d never see again.