The Face

The reason I started this blog was seeing my friends, neighbors and relatives suffer without affordable, comprehensive health insurance -- but there's another reason, I think, that it seems like such a serious responsibility to me that we all cooperate to provide that insurance.

I experienced an incident in China about five years ago that has made the fight for a public option, and for real, affordable health care for all Americans seem critical, immediate, and crucial. China is controlled by its communist government, but their health care system is considerably more influenced by the free market even than ours in the United States, and (partially due to limited resources) they don't have guarantees we have such as the emergency room mandate, guaranteed basic health care for seniors, or care for the poor.

My partner and I were traveling in Dandong in northeast China, and were coming back to our hotel one night when we saw a couple on a motorcycle run over an older man on a bicycle who was making a left turn. It was dark, but not late, and there were about fifteen or so people on the street. She ran over to see if he was okay; I started trying to get passers-by or people working in shops to call an ambulance; the couple on the moped, who had been knocked off it, got up and fled.

I couldn't get anyone to place the call, or even to lend me their phone so that I could make the call in my half-broken Chinese. Who will pay for it, they said? We'll be responsible if we call an ambulance. They'll trace my phone. I can't call from my business, because they'll fire me for putting them at risk.

I was essentially having a health insurance policy debate. They can't make you pay, I said, they'll pay. Who is they, they said. Everybody pays, I said. The city keeps the hospital open. The city will pay. The city won't pay.

Sadly, they were right and I was wrong -- there was no system in place to help this man, and no community support to help those watching him do the right thing.

What I didn't have to do -- what too few of us who are having this debate ever do -- is what my partner did: stay with the man lying there waiting in the street, his bike twisted underneath him, ribbons of his face hanging from his jaw, trying to breathe through the blood.

Waiting for his neighbors to make the call. Waiting for me. Running out of time to wait while we figured out who is responsible and what we should do.

It was one incident in an enormous city in an enormous country -- only fifteen people saw it start to finish -- but if you did see it, if you had stood there, helpless, waiting for nothing, it would be as clear to you as it is to me. The health of our brothers, sisters, mothers, fathers and children is our responsibility. When a man dies who could have lived, it diminishes us all. We can shirk our responsibility -- can get up in Congress and say that we don't have the money or we don't like the government -- but we can't escape it. 44,000 Americans will die this year because they lack health insurance. You and I may not have seen it happen, but it is happening, and until we take responsibility for ourselves, our communities, and our nation, it will continue to happen.

We're the people on the roadside: we look away from the suffering around us, because we feel helpless to do anything about it. But we're not helpless. Public option legislation is our best chance to provide real protections and real care to people at affordable prices. We are so close -- today, with just a few Senate votes between us and the change that we need -- we have come so far from the days when disinformation (death panels! socialism!) and apathy dominated the debate. We can keep up the pressure -- increase it -- and we can have a strong, national public option. But it will not be given to us; we have got to take it.

The injured, the sick, and the suffering wait for you and for me; they've waited for years. What are you going to do? Who is responsible?

Republicans for Reform

A quick rundown of the surprisingly numerous and influential Republican supporters of comprehensive, cost-saving health insurance reform. I'd assumed Republicans were a solid front on this because I was focusing on Senate Republicans: the party at large is not quite so partisan, or quite so monolithic. They're listed by name (with a link to their statement of support), position, and secret superpower.

Arnold Schwarzenegger, governor of California, can dual-wield shotguns;

Michael Bloomberg, mayor of New York City, poops money;

Shepard Smith, Fox News commentator, able to fit his whole fist in his mouth;

Bill Frist, former Senate majority leader and medical doctor, secretly repairs railway trestles;

Bill O' Reilly, Fox News host, world's third hardest blower;

Bob Dole, presidential candidate and former senator, can bench press a VW microbus.


Now, this is more complicated than it looks -- Bill Frist said straight out that he'd vote for the Baucus bill, then sort of walked back from it -- Shep Smith basically just made an impassioned argument for the public option on TV (he said "every vote against the public option is a vote for the insurance companies"), and then contradicted himself later, as is the nature of his show -- but Bloomberg and Schwarzenegger both cited the Obama administration's plan by name in official press releases, and Bill O'Reilly was quite explicit about favoring the public option in particular, and the reasons he cited -- that it will keep insurance costs down for working Americans -- were identical to those you'd find here.

Even admitting, though, that the views of these conservatives are varied and occasionally tentative, this is not what the picture looked like in August. The public option and other forms of wide-ranging health insurance reform are no longer poorly understood, fringe ideas -- they're something the nation has clearly grown more comfortable with, and more able to analyze in practical terms (what saves money? What insures the most people) rather than emotional terms (who is a Commie? Who is killing my grandmawmaw?).

Here's hoping that this collection of elected officials, elder statesmen, and political commentators finds some kind of voice among the Senate Republicans, and opens the way for a practical bill to be passed -- one with provisions to insure everyone and keep costs down.

As It Should Be

There's a lot of disappointment and outright snark that SuperObama hasn't trained his unstoppable firevision on the evil hordes that have delayed public option legislation for so long:
Sold us out. Obviously holding back the ultra-falcon-punch maneuver that could have ended this debate long ago. And maybe that's true -- maybe he's an alien exile, biding his time to see whether or not humanity is worthy of his advanced technology. People who believe this are probably really heartened by the news that he's quietly trying to shore up support for a public option. They might say, here it comes! The part where a million lobbyists surround him and he wrecks them all with nunchucks or maybe a Klingon Bat'leth.

I'm heartened, too, but not because I spend much time paying attention to the president's temperature on the public option. I'm heartened because I see lines like this in the article above:

...at a closed-door meeting of Senate Democrats on Tuesday, Assistant Majority Leader Richard J. Durbin (D-Ill.) marshaled polling data from districts represented by conservative Democrats that showed a majority would back the requirement that Americans get health insurance so long as there was a public option.

"To argue that this is some fringe position is to ignore the obvious," Durbin said.

That's us represented there -- not swept up in the wake of a charismatic politician or a wave election, not knee-jerk motion towards Democrats because George W. Bush was a bad president and the economy went sour, but people reading the newspaper and deciding that this policy is good for them and their children, and supporting it.

We're the only part of the political process that can't be bought outright -- we are the only part of this debate that isn't worried about re-election, or donations, or finding a golden parachute in private industry. This is why FreedomWorks tried to falsely inflate the numbers of people who attended the 9/12 rally -- it's why town hall opponents tried to yell over the voices of others, and why opponents of reform generally want to look like 'regular people' and not an amalgamation of strong party supporters, industry beneficiaries, and ideological extremists. Because we, and by that I mean we the people, have the promise of the Constitution that the policies that we want will become law.

And what we want is cheaper, less exploitative health insurance for more people. Of the many programs that have been proposed, it is the strong public option that puts people over profit and respects the American tradition of private industry. We know -- the mortgage crisis and Bear Stearns/AIG/Fannie/Freddie taught us -- that unregulated industry can literally destroy itself, and we're the ones that end up suffering when that happens. Any crucial industry, and there are few more crucial than health-related industry, has to be carefully balanced into our national community.

This will only be brought about through citizen action: that's as it should be. We wouldn't want something as important as this to be dictated from Washington.

All this is to say -- keep up the pressure. Google your Senators and put in four calls -- two for each, one at the national office, and one at the nearest local office. If they have an office in your town, stop by and tell them what you care about and what you expect from your representatives.

I'll do the same, and somehow try to encourage constituents from Arkansas to visit the blog. I've got a dozen hits from Turkey, and one last night from Japan, but no Arkansas so far -- and people from Japan can't pressure Blanche Lincoln (D-AR) to get her head right.

EDIT: This great article ably underlines the point that it's not just whether we get a public option, but how strong that public option is -- which is a great point to make when you're talking to your representative. The best public option is one that anyone can choose, as well as one that has significant license to negotiate prices with providers.

Every Country You Wouldn't Mind Moving To

Proponents of the public option often point out that nearly every industrialized country has created a government-based policy to address the basic health needs of their population. This is hard to visualize -- which may be a reason that detractors of public option legislation barely ever mention the fact. But look at this:

(from this blog, which is the weirdest place I've ever been in my life, via reddit)

Knowing just a little bit about which countries are rich and which are poor, the map above basically shows that nations who have resources guarantee their citizens health insurance. Even some nations that don't necessarily have the resources -- India and Mexico, for example -- are working on a way to provide basic universal care. Now, not all these health care systems are top notch -- Japan's has had some problems during their long recession, and Russian hospitals are famously corrupt -- but none of these nations are seriously considering or have seriously considered giving up their universal health insurance.

I believe this is because the people in the blue countries above -- over a billion people, by my count -- understand that health insurance and the profit motive do not mix. Insurers who are responsible to their stockholders will always try to take more in premiums and give less in care -- exactly opposite to our interests as a nation and our individual benefit. This is why simple regulation of insurers won't decrease their ability to refuse insurance and care to the sick or needy -- if a company like GradMed has the resources and motivation to monitor the entire web looking for mentions of their brand, then they have plenty of resources and motivation to discover ways to get around government regulation. We end up in an arms race: a well-funded industry trying to outwit a less well-funded government agency. The insurers have been winning that fight for generations.

A public option would, for a small part of the population, change that equation. It would create an insurer whose responsibility was first to the people, and only to the people -- the voters that create and shape it are the same people that it is intended to serve. This is no big secret to the countries on the map above -- they all know this -- those who haven't created a system of universal health insurance haven't because they lack the resources to put such a system in place.

We've got those resources. What's stopping us? Industry lobbyists? Partisan bickering? Lack of political will among those who support real change?

How Much is Too Much?

The long-awaited second part of Professor Reinhardt's article on insurance costs and loss ratios was posted yesterday. In the first part, he explained that it's not just insurance company profits that drive the cost of insurance up: they have considerable overhead and costs, sometimes reaching, sometimes passing 15%.

That article, though, was about the group market. When you insure a large group, risk is distributed more widely and you can do things like look at historical data, rather than give individual physicals, and cut out a great deal of brokering and marketing. For the individual non-group market, which is especially important now that Fox News is reporting that 149 million Americans are unemployed, overhead is much, much higher. How high? I say I say, how high?

-- So high that insurance lobbies fought 2008 state laws that tried to restrict their 'loss ratio' (i.e. the percentage of income that they pay out in care) from going below 70%.

-- So high that they claim that 55 to 60% is average -- which means that for every dollar you give them, you have purchased the right to get two quarters and a dime's worth of health care.

-- So high that small firms, who buy insurance for fewer than 10 people at a time, pay up to 18% more in premiums than large firms.

-- So high that three fourths of all families who shop for individual health insurance policies end up buying nothing.

That's hiiiiigh. Forgetting your debit-card at the grocery store while you're buying a bag of Doritos and a 2-liter bottle of Squirt high.

A public option would allow the government to create one large group out of this terribly underserved part of the population. These people have money; they need and deserve insurance -- although opponents of reform like to blame the victim ("I don't want to pay for somebody else's..."), these people would be happy just to have a deal similar to those who are covered by large companies. Large companies, I would add, that almost all started as tiny businesses, or groups of freelancers -- if we continue to unfairly punish customers on the individual or small-group market, we may not even have the next generation of innovative large businesses -- the financial and health risk won't be worth striking out on one's own.

But a 55% loss ratio (let's call it a 55% care ratio) makes insurance industries big financial players with a lot of money to throw around, and this is why we have Blanche Lincoln channeling Ronald Reagan in the Senate Finance Committee. 45% of our premium dollars are more than enough to buy a little democracy.

EDIT: but not all the democracy: progressive stalwart Shakesville transcribes this exchange between White House spokesman Robert Gibbs and ultrajournalist Helen Thomas, who has been asking him whether Obama will veto a health care bill without a public option over and over again for over a week.

Money and the Power

Just a brief note: I have to go talk about kigo in a train station cocktail lounge.

This article in the Guardian tries to count the obscenely huge amounts ($380 million!) that the insurance industry has spent in its quest to prevent a strong public option, or any other reforms that might affect their income. Sad, perhaps-I-will-have-a-cocktail-in-abovementioned-lounge ironic twist: it's our premium money they're using to buy off our own elected officials.

The other notable thing about the article is that it relies in part on officials from the Clinton administration, who are a particularly interesting kind of witness, having themselves gone up against the opposition to reform and failed. Here is Clinton-era labor secretary Robert Reich, explaining the public option in concrete terms:


EDIT: sorry about the overlap with the sidebar -- Reich is ok-looking, but I'm not so sure that anybody really needs to see him in widescreen. We should at least have the option to see him in a variety of dimensions, but alas.

If It Gets Real Bad, Think About Space

Well, the public option amendments were both voted down yesterday in the Senate Finance Committee. Three questions: first, why? Second, what happens next? Third, what can we do?

1) The reason this amendment was voted down was lobbyist money. One of the votes that almost nobody counted in the press, and which I overlooked as well, was that of Max Baucus himself, the chairman of the Finance Committee -- who kept repeating that the bill didn't have 60 votes in the Senate, so he couldn't vote for the amendment. But Baucus, as 538.com points out, has told his own constituents that he "wants a public option too" and there's a strong argument to be made that his leadership alone could have motivated a fence-sitter like North Dakota's Kent Conrad. The Senate as a whole, when they take up the debate, could easily strip the Finance Committee's public option amendment -- the HELP committee didn't seem to have any trouble putting a public option into their bill, whether it would pass the general vote or not. For the Schumer amendment, Baucus and Conrad alone would have been enough for passage -- just these two senators. But Baucus (as well as Blanche Lincoln, and frankly all the 'no' votes on the public option) is a MASSIVE recipient of health insurance lobbying money. Here is a graphical representation of the clouds of buzzing health insurance industry lobbyists that feed on the Montana senator (explained here). A comparison of 'no' voting Democratic senators with the money they accept from industry lobbies is here -- Baucus is at the head of the list with 7.7 million dollars raised over the course of his career, and Lincoln is second. We could have had this amendment: we should have had it. Voters and activists have done their part and the nation wants it. It is very specifically the political patronage of the health insurance industry that has prevented the passage of a public option.

2) Nobody really knows what happens now. The Baucus Bill will have to be merged with the Health, Education, Labor and Pensions committee (HELP) bill, which contains a public option, and it will have to go up for debate on the floor of the Senate, and it will have to be merged with the House bill, which also contains a public option. It seems true that there are more than 50 votes to pass a public option in the Senate -- but to prevent a Republican filibuster, we need 60 votes, which means all 58 Democrats, plus Sanders of Vermont, plus one other vote. Nobody can work on that one vote, though, and nobody can really put together a strategy to pass parts of the plan through budget reconciliation (a legislative option that only requires 51 votes) until Senate Democrats get it into their heads that a public option is what the nation wants, that it is overwhelmingly what the party wants, and that the coming election will be much harder for everyone if the health care plan they end up passing is a give-away to insurance interests.

3) What we can do now is much more than what we could before we knew what was going to happen in the Finance committee -- in the coming floor debate, we will be well served by Senators of all stripes, from all states coming forward to support the bill. Signing up with HCAN or just using their service to call your senator sends a clear message that supporters of the public option have supporters among the public. If your senator's for the public option, tell them to get up and speak out for it. If they're waffling (this list is a good source to figure out who's a trustworthy supporter, and who's weak), tell them how much you hate waffles, and threaten to make pancakes of them in the 2010 elections (or some such metaphor, which is better constructed and less threatening).

And if you find yourself wanting to hock a lugie at Max Baucus for selling us out, maybe it'd be a good idea to take a second, chill out, and listen to Carl Sagan sing techno about space.

The Loss Ratio and Insurance Industry Profits

John Rockefeller is in the Senate Finance Committee right now hammering away in the speech that everyone needs to hear most -- that health insurance companies are bleeding our benefits dry, and that a strong public option is the best solution to the problem.

Most of what I learned about health insurance industry profits, I learned from a single person's writings -- Uwe Reinhardt, Princeton economist and opinion writer for the New York Times. My favorite article on the topic, so far, is this one -- it breaks down the way to answer the question "how much do insurance companies make" in a comprehensive way.

This is important because an insurance company -- and we saw GradMed claim that they don't even collect this data for themselves or the insurance companies that they broker -- will never share this information with potential customers. They are forced by law, however, to share it with potential investors, and that's where Professor Reinhardt comes in. I've seen pictures, but I picture him with a monocle and a handlebar mustache. Egads, he says.

Insurance industry profits -- that's the amount that the company takes out of the economy, free and clear -- usually hang between 3 and 6%, which is not exceptional for most kinds of industry. What is exceptional, though, is the amount in marketing and administrative expenses that the company spends. Keep in mind that, unlike buying a cell phone, where you give a guy some money and he gives you a cell phone, insurance companies essentially take your money and then give it back -- the product you get is the insurance company holding your money, and the money of many others, for you, and then reorganizing it to pay for the medical care of the people that need it. So these costs become extremely important: the money taken out of your premiums, and the money that's left, determines what kind of coverage you get.

Not much of a product, true. But it's even less of a product when the insurance companies are only paying out 84.4% (in Reinhardt's example, Wellpoint in 2008) of the premium money that they've collected. That's an 84% loss ratio -- to the insurance companies, GradMed included, the company has lost 84% of "its" money (actually your money, but held by the insurance company). 84% loss for them means 84% care for you.

Where does the money go? Profits are substantial, but don't explain the whole picture. The rest is marketing -- GradMed paying alumni associations to run advertisements, insurance executives googling their products and leaving dodgy comments, TV ads, newspaper ads, etc. etc. etc -- as well as 'administrative costs', which covers the salaries of the people who work in the insurance industry. What seems absolutely true to me is that even if these costs aren't considered profit on the company's 10-K, they are profit: the company investing in its own future enrichment through advertising, and directly profiting the people who make up the company through salary and benefits.

You have to hand it to them, though. Taking 15% off the top of your health care dollar: not too shabby as a con game. A strong public option would also have administrative costs, but estimates for Medicare put their administrative cost at between 3% and 8% (and their profits at ZERO, where they should be), which is nowhere near the expense and waste we're experiencing with private insurance.

UPDATE: The Rockefeller public option amendment was just defeated, 8 to 15. Democratic senators voting against it were Conrad of North Dakota, Lincoln of Arkansas, Nelson of Florida, and Carper of Delaware.

DOUBLE UPDATE: The Schumer public option amendment was also defeated, 10 to 13. A slightly weaker option, it picked up Thomas Carper and Bill Nelson, but Kent Conrad and Blanche Lincoln (who was wearing an enormous green lapel pin that said "BLURGH") still voted against it. No Republicans, of course, voted for the amendment or even bothered making serious arguments about the bill -- it all seemed to have been posturing for the general senate debate, and insistence on this new weird "defend Medicare" attitude they've all suddenly come to after decades of trying to slash Medicare.

Treating Swine Flu: Unprofitable!

Very short entry today: I burnt out my laptop backlight because I am on the computer all the damn time. So this is coming to you from a new machine that's still busily deleting all of its push-marketing "support" programs.

(Yeti does not NEED link to e-bay on desktop! Do not contact Yeti with offers for new Compaq products! Yeti wants to blog! And smash!)

One of the things I hear from almost all insurance customers who have been forced to file claims -- I heard it again two nights ago, from someone who'd had GradMed-style temporary insurance -- is that the absolute worst time to try to negotiate with insurance industry bureaucrats is when you've just had a staple put in your head, your blood replaced, your eyeballs rotated, etc. etc. But this is, of course, always the time they pick to deny coverage.

Case in point: Ted Rall stood in the pharmacy for over an hour trying to get his TamiFlu covered -- coughing up bloody phlegm and spreading the swine flu like a syphilitic hooker in a Navy port (no offense, Ted).

Did anyone ever really think this system over? Is anyone honestly motivated to persist in entrusting public health to people who have no interest whatsoever in protecting public health?

Gradmed: Spending Your Insurance Dollars Wisely

Since my previous post on how exploitative, dishonest, and useless GradMed Health Insurance is, I've had an enormous spike in traffic from the fine folks at GradMed -- since last Friday, they've viewed my blog pages seventy-one times -- have viewed the blog more than four times as much as I have over the same period, an astonishing amount considering that there are only fifty-two pages here -- and spent almost six hours on the site. I've been chatting with them in the comments about the way in which they're negligent in selling a product that even they don't consider a real insurance solution to penniless graduates. They say, "If someone knows that they will need more permanent coverage, many alumni associations sponsor a renewable major medical program through us as well...", neglecting to recognize the fact that everyone needs permanent coverage whether they know it or not, and that the non-permanent coverage they sell only creates pre-existing conditions that are life-long uninsurables.

It didn't occur to me until I was sitting at my desk, procrastinating on my own project, to ask the question: what the hell are these people doing wasting their time at this tiny blog? I mean, look at the drapes. This isn't exactly the Hilton.

So I drilled down into their data a little bit. They found the blog by doing a blogsearch (not a Google search, mind you, but Google's specific search for blogs alone) for "GradMed" and finding my post from there. At that point, the employee that found the site passed it on to another employee, and then spent about the next hour surfing the site and crafting a comment. They checked again at the start of work Monday, and then again about halfway through the day. Since the start of business Tuesday, they stayed on the site continuously until lunch, refreshing or clicking a link at least once every fifteen minutes.

So who is this person? They identified themselves as "Customer Service" in their comment, but it seems clear that one of the things they do on the blog is fighting the war for GradMed on the information front: the IP address that left the comment on my blog is the perpetrator of at least three vandalism reverts on Wikipedia, one of which was an article created to publicize the USI Consulting Group -- GradMed, as far as I can tell, is a subsidiary of USI Insurance Services, a division of USICG.

But none of this is as important as why we care about all this as insurance customers. GradMed/USI doesn't provide care, of course; but they also don't provide insurance. They organize marketing for insurance that they then obtain from state insurers -- they're insurance brokers dealing with alumni associations. But this whole group -- the alumni association, USI, and the insurer -- gets paid with the money you and I send in as premiums. Every billable minute (and all the GradMed access to this site has come during working hours) that they spend promoting, marketing, giving greasy answers to straightforward questions, and making up fake and poorly structured Wikipedia pages is a dollar of your premium money that doesn't get paid in benefits. I am sure that the people at USI consider this good business: I consider it legal embezzlement from America's limited health care resources.

People say that government bureaucracy is inefficient and I agree, it can be -- but it's nowhere near as bad as being a 22 year-old recent graduate, broke, unemployed, and forced to pay for an insurance broker to surf our hooptie blog.

We need a public option to help get the profit motive out of health insurance. The waste and the lies have to stop.

Insurance Companies Need Our Support

A meaningful debate about healthcare reform has to include voices on both sides. There just aren't many people willing to take an unpopular stand and defend the interests of health insurance executives. Thankfully, a team of celebrities has stepped up to invigorate the discussion. Check out the Protect Insurance Companies PSA:

Protect Insurance Companies PSA from Will Ferrell

Olympia Snowe and the Audacity of Cost Control

Over five hundred amendments were suggested to the Baucus bill today, which is frankly a little bit disappointing -- I had hoped that one of the other committee bills would be getting more attention for the simple reason that most of them are better bills.

There's one amendment that I'm really interested in, though -- Olympia Snowe's amendment to create a public health plan as a 'safety net' if insurance costs don't decrease in the coming years. This isn't, I don't think, as good as having a public health option -- but it's certainly better than the Baucus bill itself, which does nothing to control costs. One of the things that the bill reflects, though, and I think that this is the reason that this amendment is canny and smart, is that insurance industry costs are under the control of the insurance industry.

It's pretty simple, but it's something that those that insist on the free market don't usually get. When an insurance company has a monopoly, or an 'agreement' with the competition, or when it simply realizes that people can be persuaded, shamed or tricked into paying more money for fewer services, that insurance company will raise rates. This is not the invisible hand: this is someone coming to a meeting with a PowerPoint that ends, "...so if nobody figures out what we're doing, then we can safely raise premiums by 9% in the next year." What limits this -- even in the current system -- is government. We regulate what is fair and unfair to do. The most profitable attitude for an insurance company would be to promise you a bunch of stuff, take your premiums, and then never pay for a dime of your care. And that happens -- except when we make it illegal.

The triggered public option would be another kind of regulation for insurance companies. It would require them to keep costs down, which they have the power to do, and if they failed, it would punish them by opening government competition. In doing so, it would insure that costs were at or below some particular level.

Unfortunately, a triggered public option wouldn't create (absent the trigger) an insurer that people could trust -- it would be fairly easy for insurance companies to keep profits high by surreptitiously cutting benefits every time they cut costs. There's simply no good way to get your health insurance from an entity that has shown itself to be overwhelmingly untrustworthy. Additionally, the 'trigger' part of the public option is just a bone thrown to those untrustworthy industries. If the public option is effective in keeping down costs, and if it can ensure that people pay a rational amount for their health insurance, then why don't we have it now?

All that having been said, there's been a lot of talk about Senator Snowe being an important moderate, and I have to say this amendment really does represent something in between the two sides. This is a very large, very rarely traveled, and very necessary territory in the Senate debate, and the people of Maine should be proud of their representative for having the courage to go there.

Cost Control

Almost every serious proposal for health care reform tries to insure more people -- even many conservatives will agree that in the current system, we would all be better off if more people had health insurance. The public option, though, is a special way to provide that insurance, and the best thing about it (and I'm taking off my liberal 'provide health care for everyone and let God sort it out' hat here) is that it cuts costs.

This is an important point that is often lost in the heat of debate. The public option in and of itself does not insure more people -- it's not an entitlement, it's a mechanism for delivering insurance. We could ensure everybody without ever having a public option -- this is what the Baucus plan tries to do, by expanding Medicaid and Medicare. Why have the public option, then? To cut costs.

A lot's been made of the price tag of HR 3200 -- almost $1 trillion dollars over ten years, about 20-30% more expensive than the Baucus bill -- but this is the government expense, or the cost that comes out of our taxes. The costs that the public option would cut would be our private expenses, the money that comes out of our paycheck to pay for health insurance. Look at the history of an average family's health care expenditures:

(from the Kaiser foundation)

In 2007, we spent 16.2% of everything that we produced in the country -- that's one dollar out of every six -- on health-care related expenses. In 2008, we spent 2.4 trillion dollars on health care. If we could enact a plan that cost one trillion dollars but saved 5% of our yearly costs, it would pay for itself in less than nine years. Since we know, too, that 30% of all the money we pay to insurance companies is spent in the form of overhead, administrative costs, and returned to stockholders as profit, the insurance industry is a natural place to try to carve out some of these savings.

Those savings would come from competition. Blue Cross/Blue Shield currently holds 90% of the market in the state of Alabama, and has been raising its rates between 7 and 12% every year since 2003, when its last major competitor exited the market. All across the country, health insurance corporations are getting bigger and taking larger chunks of market share, as often happens in a situation where an unregulated industry gets its hands on a part of the economy where demand is inelastic (i.e. there are really very few situations in which you choose not to purchase a life-saving medicine; most people will buy health insurance no matter how much it costs) -- Enron's control over the deregulated California energy industry comes to mind.

A government option -- one which would be offered to people at cost, and would negotiate with health providers for cost decreases -- would change the competitive landscape. Companies that have long since stopped trying to attract or serve customers would suddenly have to start. Policies would become clearer, trust would start to matter (right now, what's the incentive for monopoly insurers not to deny care? They don't rely on their reputation to attract business), and most importantly, premiums and copays would start to come down. Just as private universities have to either compete financially with, or offer better educations than, public universities, so would insurers have to either do better than the government -- offer more, give better service -- or charge less. Many of the conservative objections to the public options assume that this would happen -- by saying that it's a socialist policy, they admit that it would be extremely competitive with, and threaten the profit margins of, private insurers.

Like a subway line, a public university, a city park, an irrigation canal, or a highway, a public option is a group investment, not a give-away. It's intended to, and will, create returns for government, and especially for individuals.

I've been pretty critical of the Baucus plan in recent posts -- it serves industry interests and leaves us out in the cold with regards to cost. But the insurance industry wins, as well, if we do nothing or make minor changes -- without competition, specifically the kind of competition that would be provided by the public option, we may be able to insure everyone, but we're going to pay through the nose to do it.

Getting Involved -- New Media Style

Got a comment yesterday from a facebooker who's starting her own group in support of the public option -- so I thought I'd go through some ways that individuals can affect the debate, but this time, with Web 2.0 sparkle! This will be difficult for me, as my level of social media savvy can be described as Yeti-like.
(Picture of me from About.com. If you crane your neck, you can see that I'm reading HR 3200 on a Dell Inspiron B130 laptop, held in my right hand.)

But my research savvy is average! So away we go:

Public option action on Facebook seems spread out, reasonably enough, among groups of friends -- one of the first and easiest things anyone can do is change their wall status to "I support a strong public option to reform our broken system of health insurance." or "I want lower health insurance costs, so I support a strong public option."

The next step would seem to be joining one of the fan clubs/interest groups. There's one with more than 11,000 members here, one directed at President Obama and the Senate here, and "I Support the Public Option" here. Abby's group, which I haven't been able to get through to yet, should be here shortly.

Twitter is actually -- this is the first time I've really rolled up my sleeves and gotten into it -- kind of cool, although I'll never use it due to the ancient Yeti law which requires me never to be fashionable. Congress uses it like nobody's business -- TweetCongress tracks the last tweets of all the standing members of congress and shows community responses as well. A lot of progressive-to-progressive conversation happens at the #publicoption hashtag, which you can search here, and is full of fast (although not always perfectly accurate) information that falls through regular media cracks (i.e. public statements an official might make that aren't important enough to warrant a news article, but which indicate that they're moving in one direction or the other on health care reform).

All in all, though, my gold standard for organizing is still Health Care for America NOW! -- professional, targeted pressure that is completely issue-specific and designed to create the maximum amount of change. Just in my region, they've got one event coming up in Los Angeles and two in San Francisco -- it's likely they've got something in yours, too.

Regardless of how you get involved, though, it comes down to the same few things: talk to your friends. Call and write your senator. Get your voice heard through letters to the editor, and your face seen through public demonstrations.

And why? Because courts from South Carolina to Los Angeles agree that insurance companies break their promises for the purpose of profit. We deserve at least one trustworthy option for insurance coverage so that no more HIV-positive teenagers or breast cancer victims are dropped by their insurers.

The Baucus Bill

First, a little stock music: as was pointed out in this Metafilter comment, Humana, Aetna, Cigna and UnitedHealth all had a stock gain of more than 3.5% after Senator Max Baucus announced his bill.

I waited most of the day to write about this because I was honestly not sure how the bill would sort out, and I wanted to look at the Chairman's Mark (Baucus' first draft of the bill for negotiation) myself before I jumped in all aggravated with the riot elbow. I've been pretty sure for the last two months that whoever Baucus is representing, it's not Americans -- but this bill seems, all in all, to be pretty clear proof. A rundown:

An insurance mandate for individuals. That means that if you don't buy insurance, you'll be fined by the federal government. This is a major money-maker for insurance industries, who want federal laws to force new customers into the market. Democrats should hate it because it punishes people who are already lower-middle class and have it hard enough; Republicans should hate it because it's a government intrusion into something that should probably be an individual decision.

The free-rider policy. This forces businesses who employ individuals receiving government health insurance services (i.e. Medicaid or other subsidized health services) to pay a fee towards defraying that cost. Ezra Klein has been excoriating it all day -- for the simple reason that it makes businesses less likely to hire low-income employees. If you could hire a high school kid for $7.25 an hour or a mother of three for $8 an hour (because her children are Medicaid recipients), which would you do? This policy expressly reinforces the cycle of poverty. Whether you're on the left or the right, it's a loser.

An end to the use of pre-existing conditions as a means by which insurance companies can deny insurance. This is a good thing, but the insurance companies are likely to raise rates to counteract lost profits caused by having to actually insure sick people. Call it a wash: we'll get more, but it'll come out of our pockets, not out of the insurance companies'.

Medicaid and Medicare expansion and subsidies. This is the bill's method of addressing what drives much of our desire for reform -- the tens of millions of uninsured Americans left out of our current system. It's also, I think, President Obama's key demand: insure the uninsured, and increase national health. The question is how much we will pay to get this, and how we'll do it; Senate Republicans have treated almost any expenditure in this direction as completely nonnegotiably unacceptable. I would also point out, to opponents of the public option, that in its absence what we are getting is an expansion of the considerably more government-centric single payer system that is Medicaid and Medicare.

No cost containment. This is President Obama's other big request -- a way by which we can slow or stop the double-digit yearly increases in health costs that are throttling industry and household finances. A public option -- government competition -- is the best way to control these costs; in its absence, many have suggested regulations on executive pay, profit-taking, coverage maximums, or other insurance industry mechanisms that enrich individuals at the expense of the country. The Baucus plan has neither -- and in this respect, fails entirely to get to the root of the problem. This is why the bill is so popular with the insurance industry and its stockholders: it maintains the gravy train, as is pointed out in this NYT "Room for Debate" brief.


All in all, as much as I want some kind of reform, I can't get behind this bill, which is why I'm glad, I guess, that it has no Republican support (and, as 538.com points out with much better prose, not much Democratic support, either). Back to work, Senators.

Doctors and the Public Option

A short post today because I'm going to spend some time trying to get campus newspapers interested in all things GradMed.

As the public option, at least in the opinion of the Times and some other media outlets, fades from view in the Senate negotiations, it's becoming clear just how many people really support it: the New England Journal of Medicine released a study whose results you can read about here. Some highlights:

-- Among doctors, combined support for a public option and a single payer system (which would be a Canadian-style system where the government has an even larger role in health insurance, and whose proponents would likely support a public option if forced to) is at 73%.

-- This proportion holds steady among rural doctors, urban doctors, specialists, general practitioners, etc. -- it's not that one group of doctors intensely supports the public option and others don't, it's that a majority of all doctors support the public option (the ways in which the public option would benefit rural America deserves its own post).

-- Even American Medical Association members -- and this is a large lobbying group that has, after signaling support, come out in opposition to the public option -- even their member base is in support of a public option.

Count this, perhaps, as another kind of sign that the more people know about the public option, the more likely they are to support it. Doctors are particularly well-versed in our current insurance system, have a good idea of the nation's health needs, and have been following the facts of the national debate -- accordingly, they're even more in favor of the public option than the average American.

Giving One

I've been reading about the demonstration yesterday, and trying to think about what I want to say about Dick Armey (it looks like the demonstration was somewhere between 60,000 and 75,000), and was poking around at Metafilter when I realized: man, I don't give one. The interests and arguments of the FreedomWorks demonstrators sound a little bit like this to me, or something like this:
(from Cake Wrecks)

Where opponents of the public option are concerned, these protesters are neither the most numerous (rank-and-file Republicans) nor the most committed (the insurance industry) nor the most authoritative (perhaps the AMA, although they only represent about 15% of practicing doctors). But I don't even really give one about them, either -- at the heart of it, their own interests (power, profit, and profit, respectively) drive their objections.

After the coffee runs out and my rancor subsides, basically all I really give one about is the people who will be affected by public option reform. Consider:

-- We currently guarantee universal health care to all Americans by making it illegal to turn away ill patients from emergency rooms. We know and accept that it is wrong for a person who is sick or dying to be refused treatment. However, we make that guarantee in the most inefficient, expensive, and dehumanizing way possible. We know that we are morally responsible for the health of our fellow Americans -- I'd like to see even a committed tea-partier withhold antibiotics from someone with an infected wound -- but we refuse to care for them.

-- Our society provides guaranteed health care to our congressmen, but not our cab drivers; to our child molesters, but not our children. If you are schizophrenic and stab a stranger on the street, you will be locked up and given medical care which can vastly improve your condition. If you are schizophrenic and do not stab a stranger on the street, if you manage to hold down a job, then you will be left alone with the torments of your treatable illness.

-- The reason we do all this? The profit of the few. The health insurance industry employs about 400,000 people nationwide, a FIFTH as many people as are uninsured in Los Angeles County RIGHT NOW. Insurance companies provide no service; they heal no wounds; they are a financial artifact intended to share risk among large pools of people, and they should not be allowed to keep 30 cents out of every dollar we give them.

So call your senator, find an event, or make your voice heard. There's no mechanism in the Constitution or in Congress that will make sure that we do what's right: people have to make that happen.

The 9/9/9 Speech

First off: people watched it. 2500 comments on Fark, the top two slots at Reddit (this and this -- Reddit is pretty liberal, though, in addition to its Ron Paul contingent), headlines in every respectable newspaper, and twenty-three THOUSAND comments at the Huffington Post, plus another five thousand in the sub-stories about Joe Wilson, etc. Now, Internet fancyparties aren't really an indication of what the rest of America is doing or thinking, but interest online is pretty intense. I didn't hear too many televisions through my thin thin Los Angeles walls -- but the speech played pretty early here, and most people likely weren't home from work yet.

From the perspective of someone who believes very much that a public option for health insurance is the best way to limit costs and provide insurance for those who don't have it, the speech was a punt. Congress will decide -- the President pointed out only that legislation needs to pass, that it's Congress's job, and that too much time has been wasted bickering. He remains, it seems, a personal supporter of the public option (much has been made of the text of his recommendation at the whitehouse website) but seems to have no compunctions about triggers, co-ops, or any other way Congress thinks might work to cost-effectively insure Americans. His "door is open" -- his priority is clearly to get effective legislation in place, and to do it quickly. This is hard to hear for me, a little -- because there's a lot of doubt as to whether a public option has enough votes to pass in the Senate, and other policies might have a better chance -- but I, for one, was never expecting him to release some sort of magic fungus that would digest and then replace senators who've been bought off by the insurance industry, mimicking their shapes long enough to pass a strong public option. I wasn't expecting that at all. It might have occurred to me as a nonzero possibility, but I wasn't expecting it. This is okay. I have always suspected that the best policies are those that the people dictate to the government, rather than the other way around: I'll continue dictating, and I invite you to do the same.

As an American, though, and someone who's sat through interminable debates (I got called a fascist AGAIN today -- wassup, guys? Wass! Up!) that use divisive language, code, and 20th-century cliches in the place of substantive discussion of policy, I was really relieved that the President did his best to insist on change without the assumption that he or his party was the sole determinant of that change. He seemed to understand that there is a significant part of the nation that has their own ideas about how to best bring about reform, and that Congressional Republicans and Blue Dogs represent a lot of those people. At heart, he really is a negotiator, and regardless of the right's fears about him, he seems to be pulling for a majority solution. I'm sorry if we lose the public option -- and I fully intend to keep advocating for it as a fiscally responsible, morally preferable, centrist policy -- but it's a small price to pay for a real reform that we feel like the whole nation weighed in on. I poked around the conservative rageblogs a little bit this evening, and their response was muted: a lot of talk about tax-and-spend, a lot of talk about number-fudging with regards to uninsurance rates and cost overruns. Not a lot of "treason" or "Communism". That seems like an improvement, to me, and well worth some negotiations with regards to reform.

I know that a GOP representative from Louisiana heckled the President during his speech -- he's since apologized, probably realizing that it wasn't that sort of speech and that we're no longer having that kind of argument.

If, I say if, the reform Congress produces ends up representing a real and positive change. The most valuable plan plank for the insurance companies -- an insurance mandate, with fines for Americans who don't get insured -- seems to have gained wide acceptance in Congress, but cost limiting measures and social assurances for the unemployed and underemployed have not. Luckily, someone's been jamming up the phone lines at the Congressional switchboards (1-877-264-HCAN), and maybe they should just stay jammed until Congress gets the idea.

Holding Pattern

I'm still waiting on about a million little pieces of news -- I may not put up another entry until after the President's speech tomorrow night -- but here are some interesting tidbits:

1) I haven't seen anyone, of any party, come out in favor of Max Baucus' 18-page draft plan. Delmoi at Metafilter, however, points out that the author listed in the plan's PDF identification data is Liz Fowler, former VP of public affairs (ahem lobbyist chieftain) for Wellpoint. Also, it looks like the special interest lobbies got a copy of the plan before the President. Baucus' moment on center stage, having extended long past several deadlines for delivering a workable bill, and taking longer than any other committee, looks increasingly like a swan song. Democrats believe their representatives are trying to insure more people and save money; Republicans believe their representatives are trying to save money and decrease government control over citizens -- what's Baucus trying to do? Flap till he flies?

2) The actual plan itself absolutely lacks the sense of plan -- it is a list of inchoate, disorganized patchworks with no executive summary and no feeling of direction. It does include an insurance mandate (i.e. the government would fine you if you choose to remain uninsured) and does not include a public option, although it allows for new non-profit co-ops that receive some government start-up funding, which might just mean loans. It also has this hilarious Dungeons & Dragons-inspired marketing system for products in its insurance exchanges -- you can be insured at the bronze, silver, gold or platinum level. (Secret plans will also be provided for celebrities and billionaires: adamantium and mithril, respectively). Seriously, though, this is yet another indication that there are lots and lots of people in government and the health insurance industry who consider individual health to be just another commodity to be bought and sold on the open market.

Presidential Address to Congress, 9/7/09

My fellow Americans and members of Congress,

We have been engaged, for the last four months, in a heated debate over the future of American health insurance and the shape of American health care. Most agree that our system is broken, that when we buy health insurance, we pay too much and get too little as individuals, communities, and as a society.

The debate about reform has too often been described as a debate between parties and ideologies, and I know there are ideological differences here in the Senate about the right kind of reform to make. But the biggest threat to change right now isn't the Republicans or the Democrats. George Bush senior failed to pass health legislation he wanted in 1992, then Bill and Hillary Clinton failed again in 1994. George W. Bush added a prescription drug benefit for seniors in 2003 by a single vote, and his party was forced to write a gap into the bill, in which many seniors still suffer. The biggest threat to reform is moneyed interests, campaign contributions, political action committees, and lobbyists.

The reason we pay so much for so little in the current system is that it is extremely profitable for health insurance, pharmaceutical, malpractice and other industries. The reason that they have spent tens of millions of dollars in the past few years trying to avoid real reform is that they know that they have neither earned nor do they deserve the profits they've earned -- their profits come not from offering us the finest health care in the world, because they don't, but from the inefficiencies and waste of a broken system. They pay government to ensure that the system remains broken.

Soon you will make a vote on a bill to match HR 3200, which has already been passed by your colleagues in the House of Representatives. There is currently no other bill before you with a level of support that makes it likely to pass both houses. Members of my party and yours have gone through the bill to make it as appealing to both sides of the aisle as possible. It is not single-payer socialized medicine, but a piece of legislation specifically crafted to limit costs, insure the uninsured, and prevent the worst abuses of the insurance industry such as rescission and the refusal to insure pre-existing conditions. It is rigorously opposed by that industry, as you well know.

I bring to you tonight a challenge. I challenge this session of Congress to voluntarily and transparently fight the influence of the moneyed interests that have kept us from having reform for so long. I challenge the fifteen senators who have taken the most money from the health insurance and pharmaceutical industries, whether through PAC donations or corporate contributions, to recuse themselves from this vote. To my Democratic colleagues including Max Baucus, Ben Nelson, and Blanche Lincoln, as well as to my Republican colleagues, I mean no disrespect and I do not mean to argue that your vote is or has ever been for sale.

The American people deserve that this issue, about which they feel so passionately, be given a fair vote that lacks even the appearance of submission to the politics of money. Their government has failed them, in this respect, for many years. You have the constitutional power to make this right. May God bless you and give you strength and may God bless America.