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It's Not About the Insurers. At Least Not Totally.

publicoptionprotester.jpg

Over the past few weeks, health-care reform has morphed into "health-insurance reform." That's what the president calls it. That's what his aides call it. That, by and large, is what the actual bills contain. And that is what the public option is about.

There's a reason that health-care reform is often framed as an epic war between insurers and reformers: Insurers poll terribly. Much worse than doctors. Much worse than hospitals. Much worse than pharmaceutical companies. And their business model, particularly in the individual market, is by far the most straightforwardly malign: They compete to see who can avoid covering the people who need coverage. That cranky guy on "House" would be a whole lot less popular if the show were about his efforts to hide in the bathroom when sick patients came in.

It's easy to argue that insurers are villains. It's hard to argue that their villainy is the primary problem in health care.

There are two main problems in the health-care system: Coverage and cost. Insurers are responsible for the coverage problem in the sense that not everyone can afford their product. That's true for companies that sell TVs and fancy dinners and keyboards. But we don't care if those companies refuse to sell their products to poor people. We do care if insurers do. This problem, happily, isn't particularly hard to solve. A mixture of subsidies and regulations -- much like the mixture being considered in the current bills -- could answer the coverage question without too much trouble.

The other question is whether the private insurance industry is behind the relentless rises in cost. And here the argument begins to falter. Insurance profits are not a big slice of the system's costs. The average insurer has a 3 percent profit margin. You sometimes hear that it's administrative costs that are behind the cost problems. That's not true, as far as I can tell, and in any case, administrative costs are more about how large an insurer is than whether it's public or private.

The problem is that the really expensive things aren't controlled by insurers. Surgeries are expensive. So too are drugs. Nights in the hospital. Consultations with specialists. But those are all popular things. The way to make health care cheaper is for insurers to say "no" more often, as they did in the late '90s. It worked. Cost growth slowed sharply. There was never any convincing evidence -- that I know of, at least -- that outcomes worsened. But we hated that. So they stopped.

The public plan is not being devised to get much better at saying "no." That would just make people hate the government. The other idea, however, is not to cut the volume of procedures by refusing the least effective ones, but to cut the cost of procedures by bargaining for greater discounts. This is where single-payer has a huge and significant advantage over the American health-care system. This is where Medicare has a large advantage over private insurers. This requires a large public plan that's not limited to the small subset of people on the exchange and that can partner with Medicare to force better deals.

But you can't get that escalator to single-payer for the same reason you can't get single-payer. It might make a lot of sense. But no one can find the votes. Weirdly, though, a lot of people who have resigned themselves to the idea that single-payer is out of reach have decided that this path to single-payer isn't. I don't really understand that thinking.

The other option, of course, is to cut costs in the health system inside of the health system, rather than using the insurance system. That would mean changing the incentives for doctors so that they're not paid more money for every extra procedure they prescribe (if you want to know how that works, ask writers who get paid by the word whether they spend a lot of time voluntarily shortening their articles). That would mean getting a lot more evidence on what does and does not work, and under what conditions, so medical professionals could cut down on ultimately useless treatments. That would mean using heath IT to eke out the same efficiencies that computers and Google and specialized software have brought to every other industry. That would mean a lot of things that are opposed by constituencies that are much more sympathetic than the insurers.

Some of that is under consideration in this round of health-care reform. Some of it isn't. But conceiving of this as "health insurance reform" doesn't really work unless you're willing and able to go all the way to single-payer, or something near to it. And in a broader sense, this isn't a war between reformers and insurers. It's a war between reformers and the economic forces that have prices millions out of health insurance. In general, insurers, like everyone else, are the slaves to those forces rather than the drivers. And the unhappy truth is that the drivers are some of the most sympathetic actors in the health-care system. They're the people who say "yes" rather than the people who say "no."

Photo credit: AP Photo/Hans Pennink

By Ezra Klein  |  August 17, 2009; 3:58 PM ET
Categories:  Health Reform  
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Next: Co-Ops as an Alternative to the Public Plan

Comments

This is what I have been saying for a long time. The problem is not the insurance companies- its simply that people cannot afford the amount of healthcare that they want to have because the costs are too high. If you want real healtcare reform then you need to be talking about how to control costs- not about how evil insurance companies are.

That to me is the core of the problem with a non-subsidized public plan. I do not think there is any chance at all that it can remain solvent. Its simply not possible to cover what people consider to be fair while also only charging what people consider to be fair. The problem is not corporate greed- the problem is that healthcare has gotten ridiculously expensive and no one is willing to talk about ways to control those costs.

Posted by: spotatl | August 17, 2009 4:08 PM | Report abuse

With all due respect Ezra, without a public option there will be no cost containment. Oh sure, Hospitals will announce how they will hold down costs, Big Pharma will announce how they will hold down costs, Insurance will announce they will hold down costs....They all lie. They've said this for the last several decades & they were lying then, they are lying now.

Honestly, Obama should pull a Clinton. Fight for the public option & when he doesn't get it, hang it around the opponents necks, both Democratic & Republican & move on.

Voting in a plan guaranteed to fail will make the populace remember you just like that, a failure.

Posted by: kindness1 | August 17, 2009 4:10 PM | Report abuse

Isn't that precisely the point of the public option? You set up a reimbursement system that rewards hospitals and doctors for above average care at lower prices and penalizes hospitals and doctors that consistently provide either poor treatment, overly expensive treatment, or both. Without the public option all you have are subsidies and mandates. This simply screws over everyone EXCEPT the insurance industry. If I have a pre-existing condition I'll still have to pay through the teeth to get a private plan, only now I'll be forced to purchase a plan or pay a fine. How the heck is that reform? You mentioned earlier that Mass. has a good system. I beg to differ. Go to the state's website and try to find an affordable plan on the private market. It seems to me like the insurance companies have the state by the balls and are slowly squeezing, so by all means, let's go ahead and set up the same system on a national level.

Posted by: besmit02 | August 17, 2009 4:12 PM | Report abuse

kindness1- why would providers accept the public plan if they are paying significantly below market rates for procedures? I don't understand AT ALL why people think that the public plan in its current form has anything to do with lowering costs of procedures. Why would a provider accept a lower payment from a public plan than they would from another insurance company?

Posted by: spotatl | August 17, 2009 4:18 PM | Report abuse

It seems like we really do need both. Otherwise, taxpayers are just subsidizing those drivers of high cost, largely the drs, imaging centers etc.

To begin to solve the problem we need to change the incentives for drs, change the fee-for-service system. Kaiser Permanente charges a capitation fee, then charges minimal co-pays for visits and drugs, more for hospitalization (though they didn't charge for that until recently). No incentives for lots of (unnecessary) tests and procedures. But they have total in-system info sharing and whatever the dr orders you get, so they save on administration. They encourage less invasive end-of-life care, and are set up to help patients and family to negotiate that.

That model should be much more widely copied. Drs have the benefits of not being second guessed and having access to all info about the patient and in-system research about what works. In return they are all on what is apparently a reasonable salary.

But if we have near-universal coverge without cost reduction, then we are relying on Congress to adopt cost reductions in the future out of necessity. That has worked so well with budgets in the last 30 years.

It seems like we are going to either have modest insurance reform, subsidies and some stab at the beginnings of cost control, or we are going to fail at this yet again. If we do fail, the brunt will be borne by the working poor and middle class who don't get employer-provided care and can't afford individual, not by the insurance cos or drs. Something to keep in mind in deciding how purist we want to be about it.

Posted by: Mimikatz | August 17, 2009 4:22 PM | Report abuse

Ezra, what period of time do your figures on profit cover? Since the Great Recession? And don't tell me United Health Care's recent quarterly profits of 350 million were only 3%.

Posted by: cmpnwtr | August 17, 2009 4:24 PM | Report abuse

The private insurance system is still part of the problem, though. Something's wrong if 20+% of the money disappears somewhere between the premium payer and the provider, and that doesn't count the excessive overhead the system imposes on the providers.

Posted by: tl_houston | August 17, 2009 4:28 PM | Report abuse

Cost containment. I should add that in our part of the country Kaiser Permanente with their self-contained system, salaried doctors, hospitals, labs, pharmacy, etc. have been effective in containing cost and building efficiencies. In our state they dramatically out-compete other plans and out-perform in providing comprehensive care with low co-pays. By low, I mean like $5 for office visits, labwork, etc. I think that Kaiser provides a great framework for building an accountable, comprehensive, cost containing health care system. We have been with them for 24 years and have been very happy. I have 24 hour access online to all my health care information, access by e-mail to my doctor, can order refills by mail online, and receive lab reports within 24 hours with explanation of results. I wish everyone in America had as good a plan. By taking physicians, hospitals,pharmacists, and medical technicians out of the business of running businesses, marketing, advertising, paying liaibility, etc. and acting as a collaborative team to deliver health care to each patient, much greater efficiencies are possible.

Posted by: cmpnwtr | August 17, 2009 4:35 PM | Report abuse

Ezra,

you're right on but realize you'll never convince some that insurers are not the bogeyman the president and Pelosi wants to make them.

I've said till I'm blue in the face that back in the 90's insurers were hated for one reason, denying care. Now they're hated for two, sometimes denying care and cost. I'm sure they'd prefer the 90's model.


Ezra said:

That would mean getting a lot more evidence on what does and does not work, and under what conditions, so medical professionals could cut down on ultimately useless treatments.

----------------------------------------

but Ezra insurers already have this info. The government's comparative effectiveness model is nothing more than step therapy for prescriptions. Take a generic statin first and if that doesn't work take lipitor. This goes on every day with insurers and they have all the data you'd want and more about outcomes.

Posted by: visionbrkr | August 17, 2009 4:40 PM | Report abuse

This is one of those "The average insurer ..." things. There's serious concentration in the insurance industry. The industry as a whole had a 4.5% profit margin, and a gross margin of 8.76%.

http://www.reuters.com/finance/stocks/ratios?symbol=CI.N&rpc=66

Posted by: NicholasBeaudrot | August 17, 2009 4:41 PM | Report abuse

i also believe insurers need to stand up to hosptials and the ridiculous reimbursement increases they're saying they need to make up for medicare and charity care shortfalls. It used to be 5-10 years ago hosptials would ask for a increase in their contract of 10% or so. Now its not uncommon in the Northeast to hear about 40-50-60% increases required. That's why if you have private insurance if you ever read what you may consider junk mail about XYZ hospital leaving your network why it happens.

People don't pay enough attention to this cost factor because its what is increasing the rates more than anything else.

When you get a 50% increase on a $2000 per diem stay in a hosptial its much worse than a 20% increase on a $300 doctor visit.


Not to mention the fact that many of these docs own their own surgery centers and they're performing it there for "SAFETY" reasons (ya right) and they are purposefully not having these centers participate and they're getting far more in a UCR figure than they would in a network, contracted situation. Ezra i smell a piece we need on this. Any examples needed drop me a line. I've got some doozies for you where hosptials are raping the system of money. Once some doctors became businessmen or women instead of doctors it spelled doom.

Posted by: visionbrkr | August 17, 2009 4:46 PM | Report abuse

So then how come President gets away with 'hammering insurances' only meeting after meeting? I know that is politics. But when we have the agent of 'change' himself under taking these deceptions, where do we go? How come then you keep blaming Republicans for obfuscating the debate? And then we have respected journalists like Joe Klein saying President was 'good on stump' in his Western Town Hall meetings.

In the end to what an extent 'culpability' is with Commander-in-Sales-Chief then?

Posted by: umesh409 | August 17, 2009 4:49 PM | Report abuse

Next, we have to make medical education affordable (or even free) as well, to discourage doctors from overcharging to pay back their education loans.

Posted by: harold3 | August 17, 2009 4:50 PM | Report abuse

I'd say that we would be better off beefing up the nurse practitioner program to keep to discourage doctors from overcharging. Doctors overcharge because they can, not because they have loans from med school.

Posted by: spotatl | August 17, 2009 4:55 PM | Report abuse

" I've got some doozies for you where hosptials are raping the system of money. Once some doctors became businessmen or women instead of doctors it spelled doom.."

Agreed, and it's something that Atul Gawande's piece on McAllen, TX made clear: that you have doctors who see themselves as entrepreneurs, property magnates, masters of their medical domain, whose subordinates refer people to the Magic MRI Machine that just happens to be owned by their boss.

Posted by: pseudonymousinnc | August 17, 2009 5:12 PM | Report abuse

Very good post.

A couple of thoughts--

1. The system has three challenges: access, cost and quality. Health IT, evidence-based medicine, pay-for-performance is as much about quality as cost, if not more. The Right would highlight your forgetting quality as proof of their concerns. I'll give you the benefit of the doubt. But its an omission nonetheless-- the triumvirate of those is classic health policy 101.

2. The layering on of quality hopefully shows the difference in choices between single-payer driving cost reductions, versus broader delivery system reform. The former merely makes "health care waste" cheaper via lower prices, whereas the latter both reduces costs AND improves quality. Hopefully, you'll see this as reason to focus on delivery system reform, versus single-payer. They both involve tremendous challenges politically, but one provides more benefit. Which as an aside, if you think there isn't a political distinction between public option and single payer, and you agree that broader delivery system reform is better than merely reducing prices, you'd agree that a public option feature in this round of legislation has been a huge mistake. Just recognize your own role in pushing the public option during the campaign... it has its costs, has distracted us from pushing for more broader delivery system reform, and we'll now be left with a bill that doesn't have much beyond more effective insurance regulation and subsidies. That's good, for sure, but we could potentially have had more if we weren't distracted by hoping for price bargaining (single-payer/public option)rather than focusing on better quality and lower cost (delivery system reform).

3. You still focus too much and "learning more about best practices" versus ensuring adherence to what is know today. No doubt there's more, but the pay-for-performance movement isn't based on guessing on good medicine, but there's simply strong opposition to holding docs accountable at that level. Its politically a lot easier to agree we need to learn more and punt enforcement down the road.

4. "Some of that is under consideration in this round of health-care reform."

That's being very generous. As has been said recently by folks at Mayo and Kaiser, delivery system reform has been pretty poor this time around. "Health insurance reform" is much truer to the legislation's likely impact than "health care reform." Pilot studies and a desires for ACOs to exist with no path forward doesn't really cut it.

Posted by: wisewon | August 17, 2009 5:22 PM | Report abuse

Someone said "Ezra, what period of time do your figures on profit cover? Since the Great Recession? And don't tell me United Health Care's recent quarterly profits of 350 million were only 3%."

Is it really that difficult to look up basic facts? Their most recent quarter was $859M (I don't know where you got 350M) on $21.7B in revenue. 4% profit margin.

http://www.bizjournals.com/dayton/stories/2009/07/20/daily34.html

It's pretty common knowledge among anyone who knows anything about the insurance industry that health insurers only make in the 3-6% range, I don't see why you'd feel the need to question his numbers.

Posted by: ab13 | August 17, 2009 5:31 PM | Report abuse

Wisewon,

What about the Independent Medicare Advisory Council (IMAC)? The Mayo Clinic seems to think it has potential (i.e. moving Medicare to moving to a more value-based payment model).

Posted by: PeterH1 | August 17, 2009 5:40 PM | Report abuse

"Weirdly, though, a lot of people who have resigned themselves to the idea that single-payer is out of reach have decided that this path to single-payer isn't. I don't really understand that thinking."

Here, you're wrong. And the answer's quite simple:
http://realignmentproject.wordpress.com/2009/06/11/after-public-option-what-could-be-next/

Posted by: StevenAttewell | August 17, 2009 6:52 PM | Report abuse

PeterH1

IMAC is a good idea, particularly with a Medicare focus. IMAC with a specific mandate, i.e. reimbursement model recommendations/implemetation by 20xx, and/or cost cuts of xx% by 20xx would be a lot, lot better. The latter, once again, requires political capital to be spent. A nebulous vision coupled with a political "out" (Congress can reject the recommendations) is pretty modest by comparison.

Posted by: wisewon | August 17, 2009 6:56 PM | Report abuse

As I remarked in the previous posting, profits are not the issue. Insurers know that to get a good stock price they need a low Medical Loss Ratio which is quite different from profits. An MLR of 75% (typical for a large co.)means that 25% of premiums are not spent on medical benefits no matter what the profit is.

If you compare us with other countries you will see we waste $1.2 Trillion each year simply because they pay about half as much per person as we do. You have add something more because they get better results than we do, say $300 Billion a year to get our outcomes up to theirs. That makes a total of $1.5 Trillion of waste each and every year.

Now roughly a Trillion of this is due to bad medical practice and end of life issues. Another $200 Billion a year is due to the low MLR's of private insurers and another $200 Billion is due to compliance costs of patients and physicians filling out forms and fighting to get paid. The final $100 Billion is due to drug company marketing--not only the odious ads, but the pushers that haunt doctors offices and payments to physicians.

The Trillion due to medical practice will be very hard to get at since it is a complicated mess and most doctors will fight change. Look at what the doctors of McAllen did after the Gewande New Yorker article appeared. In theory, the $500 Billion should be easy to get at since all we have to do is pass HR676, Medicare for All which can easily pay for itself with the $500 Billion a year savings.

But with the cooperation of the media, special interests have yet again triumphed and democracy has failed.

I am 71. I have Medicare. The rest of you can suffer the consequences.

Posted by: lensch | August 17, 2009 7:09 PM | Report abuse

To say that insurers don't add that much cost to the system, given their meager three percent margins, misses a couple of key points, I think. First, their administrative costs are uniformly high, regardless of scale, because of their marketing expenses. In June, Health Affairs published an online policy brief re the public option in which the authors said that original Medicare's admin costs were 1.4 percent of total program costs in 2008, compared to an average 13 percent for Medicare private plans. Medicare's private plans get paid about $100 billion a year, so even a 10 percent savings in admin costs is significant ($10 billion). The other cost that insurers often impose is hidden -- it is the cost that providers absorb to handle claims. An AHIP study two months ago said that it costs the average physician $65,000 to deal with the paperwork of private insurers. I don't know what the cost is for Medicare paperwork, but I think it would be much less. And $65,000 times several hundred thousand physicians is a large number.

Posted by: wdarmes | August 17, 2009 7:20 PM | Report abuse

Its true that insurance companies are not the single reason as to why costs are so high.... but lets put this in perspective.

Doctors provide valuable services.
Hospitals provide valuable services.
Drug companies provide valuable services.

Insurance companies.....errr...they push paper around all day and lavish money on their CEOs.

Doctors, hospitals, and drugs are ESSENTIAL to american health care.. you cant have healthcare without them.

Insurance companies on the other hand, are "errand boys sent by grocery clerks to collect the bill" as uttered in a famous movie. They provide no real value, no real service, they are 100% superfluous to healthcare, and they dont deserve a place at the table.

Posted by: platon201 | August 17, 2009 7:34 PM | Report abuse

Usually I agree with Ezra on most things, but I think he is a little off the mark here. There is no free lunch.

The question is not “will we say no?” Someone – insurers, the government, doctors, or hospitals -- has to say no. If we don’t start saying no to health care management that is ineffective, no more effective than management that costs a fraction as much, or downright harmful we will rapidly – no more than five to ten years – reach a point where working class and middle class people and their employers will not be able to afford access to the health care system. The only insurance choices will be high co-pay and high deductible policies that effectively block access or no insurance at all.

The correct question is how we want to say no -- or put another way, would you like health care that is like the Mayo Clinic?

The Mayo Clinic, Kaiser Bay Area, Cleveland Clinic, Group Health Puget Sound, InterMountain, and others provide better health care for less money than other places, and have done so for a long time. As someone pointed out above, the government and insurers know how that is done – they say no. They say it either because of culture and custom or because of overt policy related to cost controls.

A public option, if large enough and free to do so, could help the government do more to reduce costs. But the government already controls $1 trillion in health care spending. They have plenty of power to control costs if they are given the chance. Many private insurers would be deliriously happy to follow the lead of the government programs in controlling costs if they had the cover from the big federal programs. There is already plenty of information as to how to attain hundreds of billions in savings without more research, although additional research on other topics is needed.

What we need is a way to get the power to say no and make it stick. That is what IMAC is about. It offers a way to stop the power of rent seekers, lobbyists, and their congressional allies in health care.

Negotiating for discounts won’t do it. Medicare and private insurers have tried that for years, and costs rise at over 7%. We need to do what Kaiser and Mayo want us to do: reward the programs that save money and provide better care, and penalize the programs that spend profligately while doing a worse job. We need to do that in existing government insurance programs as well as any new public option. The private insurers will be glad to follow.

Posted by: PatS2 | August 17, 2009 9:10 PM | Report abuse

The biggest problem in dollar cost may not be the insurance companies, but creating a public option saves costs two ways: (1) By eliminating the insurers' profitmaking over you if you want. And even 3% compounds significantly over the years. (2) By offering a plan which the consumer KNOWS is baseline -- and rationing care that way, by choice. Slowly fold Medicare into that line of thinking. If you want more, pay extra. This is a no-brainer, folks.

Posted by: Lee_A_Arnold | August 17, 2009 11:04 PM | Report abuse

" I've got some doozies for you where hosptials are raping the system of money. Once some doctors became businessmen or women instead of doctors it spelled doom.."

Agreed, and it's something that Atul Gawande's piece on McAllen, TX made clear: that you have doctors who see themselves as entrepreneurs, property magnates, masters of their medical domain, whose subordinates refer people to the Magic MRI Machine that just happens to be owned by their boss.

Posted by: pseudonymousinnc | August 17, 2009 5:12 PM | Report abuse

many go so far as to place an MRI machine in a different ROOM IN THE SAME OFFICE, set up a new tax iD number, not contract that MRI "FACILITY" and then rape the system more.

But when insurers go after this practice as fraudulent its "BAD".

These doctors are providing valuable service in "platon201"'s model world.

I'd love for platon201 to find himself or herself in a spot where a surgery is performed out of network and the surgery center his doctor owns bills him $10,000 for it and then BEG an insurer to cover it.

Why should they, they bring NOTHING to the table???

oh and LeeArnold,

what kind of profit/salary do you make? I think its too much. Who are you or anyone to say how much profit margin an INDUSTRY can make. 3-4% is not egrigious and its also one other important thing.

ITS NOT GUARANTEED.

Insurers can and do lose money but unlike the government it must keep funds in reserves to account for times of large claims. I have a client with Aetna who has 180 employees and in a first year they had claims of 2.2 million dollars paid when their premium was only 1.8 million. 2.2 million was the PAID amount, not submitted but PAID, Submitted was much higher. Aetna paid just about every claim, the employees loved the plan but guess what, the price went up 50%. Aetna, in their case needs to say no more. In fact they are moving to an HSA plan that is so underpriced its not funny. Next year unless their utilization goes down guess what their rates are going up again. Not because Aetna's making a profit off of them but because their claims warrant it.

Sometimes i think there needs to be rules that you actually have to have a working knowledge of what you're talking about here to actually comment.

those that come on here and say blanketly that the government should just pay for everything really need to get a clue. THAT'S NOT POSSIBLE. EVEN IN THIS ADMINISTRATION THERE IS A FINITE AMOUNT OF MONEY.

Posted by: visionbrkr | August 18, 2009 12:44 AM | Report abuse

Single payers are monopolies that force rates they do not create economies of scale (because they are the scale). They make the offer no one can refuse. If doctors dig making two thirds less your cool if not, well your underfunded. And you think about moth balling needed technology to save money. Ezra is there a professional cost analysis as to if a single payer/Medicare for all is even affordable? The reason folks won't let go is that they believe in the back door what more can I say. I mean might it not be prudent to save over 65 Medicare for the boomers first? I think it's Medicaid for all (pays 54 % of market rates) we're really talking about here. People don't want that. Really.

Everyone just be thankful Wyden/Bennett has shown a better way. On that count be sorry that revising the employer tax exemption is considered too radical.

Posted by: DougHuffman | August 18, 2009 12:57 AM | Report abuse

Visionbrkr: “those that come on here and say blanketly that the government should just pay for everything really need to get a clue. THAT'S NOT POSSIBLE. EVEN IN THIS ADMINISTRATION THERE IS A FINITE AMOUNT OF MONEY.”

Definitely right.

But Wisewon’s idea of targeting Medicare for some set percentage reduction is a bad one that is too broad to be helpful. Cuts are needed, but they need to be targeted at specific procedures and other management approaches that are ineffective. A 3% cut in spending for flu shots would be too much, but an 80% cut in spending for coronary stenting might leave patients better off. In some cases, a small amount of additional spending might actually lead to major savings, as demonstrated by the SMDC congestive heart failure project in Minnesota or the “checklist” approach to quality assurance illustrated by Atul Gawande.

We need smart cuts, and that is where effectiveness research and IMAC have their role.

Posted by: PatS2 | August 18, 2009 10:39 AM | Report abuse

You said: "It's a war between reformers and the economic forces that have prices millions out of health insurance."

Lets flesh that picture out. On one side you have reformers, and the people they are trying to help (the uninsured or inadequately insured). On the other side are the economic forces, and those who benefited from them, including: insurers, doctors, medical equipment providers, pharma, and the millions of people happy with their current insurance.

It's the last group that is causing the most problems for the "reformers". The only reason Republican's can demonize the current proposals is because a huge chunk of society doesn't need reform (or doesn't realize they need it). They fear that what they have will either be lost, or be changed to something less good. Republican's play to that fear, and its a good tactic, because its true. A strong public option is probably the death knell to existing private insurance. Most reformers know this, even if they deny it, and they are very happy about it.

Public option --> single payer (give it twenty years) --> real cost containment (but you may not like what you have versus what you used to have).

Posted by: WEW72 | August 18, 2009 11:21 AM | Report abuse

PatS2,

i agree. cuts are necessary but they need to be the right ones. I'm all for taking the 170 billion in incetives for Medicare Advantage away for example. Let them truly compete against Medicare directly but if you take it all realize you'll see rates go up (not to the full amount but some) and you'll see seniors very angry about it. They're funny too because they won't blame the insurer, they'll blame Obama for disturbing their medicare.

Posted by: visionbrkr | August 18, 2009 3:04 PM | Report abuse

Concur with most of your ideas. However I do not want some hyphenated American on a panel telling me what ails me. I am a disabled Veteran of the Korean War so I have VA coverage. Excellent care and good doctors that do not have the overhead of Private Practice Docs have. But Bureaucracy Reigns. And “0” medicine will ruin Veteran Care!!

Posted by: springco1 | August 19, 2009 11:14 AM | Report abuse

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