Carl's thoughts on health care reform

This is a collection of my thoughts on health care reform over the past few months. I have really tried, but I can't convince these pesky thoughts to stay inside my head. They are original except as noted. While I attempt to be honest, I make no claims for "fairness," because that is not the purpose of this particular page. I happen to think I'm on target, but I acknowledge that thoughtful people disagree with me. They are welcome to communicate their thoughts in any way they see fit, and many of them already do, judging from various editorials, LTEs, and the popularity of "health care" in the Googles.

What's here:

  1. The latest
  2. Comments on Gershon
  3. Comments on Linder
  4. My considered opinions
  5. My credentials
  6. Full Gerson article
  7. Full Linder Article
  8. Jimmy Carter Article (see Gerson comments for explanation of why this is here)

The latest

The wheels of congressional debate have finally begun to turn around healthcare reform. My wife recently asked if I thought the public option was a "must-have." I told her that what I wanted was a bill that would pass, and that is as close as possible to the systems that work well in other countries. In other words, if the bill has all of the provisions that work elsewhere, but won't pass in Congress, that won't help at all. At the same time, I think Congress should do its best to to incorporate as many positive changes as possible, because I don't think the opportunity for significant reform will come again soon. I say let's get something passed now, and tweak it later.

I recently received a letter from an acquaintance quoting from Robert Reich back in 2007. The quote was a hypothetical 'liberal' describing in a couple of sentences what 'liberal' healthcare really means. It was a gloomy couple of sentences. In my observation, the use of hypothetical situations and "projections" is common among people who are trying to resist change. It is actually fairly easy to make scary predictions, and pretty difficult to refute an argument based on such specious "evidence." I'm reminded of a recent comment I heard from President Lyndon Johnson when his Medicare proposal was being hotly debated in Congress. He forbade his advisors from making financial projections, since a five-year analysis would produce such big cost numbers that the bill would never get passed. As The Black Swan so eloquently states, prediction is difficult, especially of the future. I think it's safe to say that none of the gloomy financial predictions that were made during the Medicare debate came true. That's why I prefer to base my arguments on facts rather than hypotheses and predictions.

For those that have ben following my Letter to the Editor saga, I did receive a nice reply from the editor of the Gwinnett Daily Post encouraging me to "keep trying." However, the small number of letters they have room to print, and their curious selection process make it seem unlikely that any letter will see print. I think my time is better spent crafting words that will at least be seen by someone (specifically, you. Thanks!)

Here are a couple of health-care-related quotes I originally found in the Sept. 22 issue of Christian Century, with links to the source articles:

Wendell Potter

Excerpt from article by Wendell Potter, in part defending his claim that insurance companies are behind the town hall demonstrations:

The higher I rose in the company, the more I learned about the tactics insurers use to dump policyholders when they get sick, in order to increase profits and to reward their Wall Street investors. I could not in good conscience continue serving as an industry mouthpiece. And I did not want to be part of yet another industry effort to kill meaningful reform.

I explained during the press conference with Rep. Slaughter how the industry funnels millions of its policyholders' premiums to big public relations firms that provide talking points to conservative talk show hosts, business groups and politicians. I also described how the PR firms set up front groups, again using your premium dollars and mine, to scare people away from reform.

What I'm trying to do as I write and speak out against the insurance industry I was a part of for nearly two decades is to inform Americans that when they hear isolated stories of long waiting times to see doctors in Canada and allegations that care in other systems is rationed by "government bureaucrats," someone associated with the insurance industry wrote the original script.

The industry has been engaging in these kinds of tactics for many years, going back to its successful behind-the-scenes campaign to kill the Clinton reform plan.

T.R. Reid

This is so good you really need to read the whole article. Seriously. Excerpt from T.R. Reid article on learning about successful health care reform from other countries

In many ways, foreign health-care models are not really "foreign" to America, because our crazy-quilt health-care system uses elements of all of them. For Native Americans or veterans, we're Britain: The government provides health care, funding it through general taxes, and patients get no bills. For people who get insurance through their jobs, we're Germany: Premiums are split between workers and employers, and private insurance plans pay private doctors and hospitals. For people over 65, we're Canada: Everyone pays premiums for an insurance plan run by the government, and the public plan pays private doctors and hospitals according to a set fee schedule. And for the tens of millions without insurance coverage, we're Burundi or Burma: In the world's poor nations, sick people pay out of pocket for medical care; those who can't pay stay sick or die.

Finally, an editorial cartoon from Mike Keefe, published in the Denver Post August 21, 2009. (Original link:

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My considered opinions (as opposed to actual facts)

If, as it appears, no Republican will vote "yes" on whatever bill is finally crafted by Congress, it makes sense that the Democrats should not worry about Republican opinions from here on out, and craft the bill they think is best.

Health care reform is hard stuff, and probably difficult to understand for a populous many of whom, no offense intended, can't seem to even remember to use turn signals, or what a driver should do when approaching a flashing yellow light.

I'm glad the discussion is happening. At least we've made more progress that Bill & Hillary's well-intentioned but unfortunately-executed effort.

I'm disappointed that so-called "opponents of health care reform" seem to resort to trickery to advance their "cause". I'm certain there are evidences of the "pros" doing the same thing. But generally it seems to be on the "conservative" side. There seems to be a sense of this being a game, with the goal being "to win," rather than a process to try to improve the lives of our citizens.

When the statement is made that people don't want to pay for abortions with their taxes, I believe that most people would make exceptions for situations such as when the mother's life is in danger. The problem is that to include such exceptions in a health care law would mean duplicating language that has already been decided (or will be decided) in other abortion-related bills. As an engineer, I believe this is adds a significant complication in the process. Health care decisions should be between the doctor and the patient(s), and, naturally, subject to the current laws of the land. Separating these complex issues into their rightful areas of discussion increases the chances of getting both of them right. (Which seems to be, unfortunately, what some opponents want to prevent.)

I believe similar logic to the above applies to the "illegal immigrant" situation. Treatment decisions should be between the doctor and the patient, subject to the current laws of the land.

Incremental changes aren't enough. If you're heading the wrong direction (see "Facts" in my Gerson comments), a minor change in direction ain't enough.

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I have no formal credentials in the area of health care. Informally, I offer the following:

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Comments on Gerson

The event that triggered my first Letter to the Editor was a "Viewpoints" article by Michael Gerson that was published in the Gwinnett Daily Post. Here are some sections I have extracted (generally whole paragraphs to retain the context), and my comments. The complete article is here.

Excerpted section My comments
And so Barack Obama's address to Congress on health care, at a minimum, must answer the question: What is the crisis? When individuals can't get needed health care, it is certainly a crisis for them. This, Obama might argue, creates moral responsibilities for the rest of us to help. Facts
1) The United States is the only industrialized country on the planet that doesn't provide health care for all of its citizens. This would be fine if we had the best health. But....
2) In world health rankings, we are NOT EVEN IN THE TOP 20! This includes factors such as longevitiy and infant mortality. On average, the poorest residents in England live longer than the wealthiest Americans. If health care were football, we wouldn't even get invited to a bowl game. But there is one factor in which we do lead:
3) We pay more per person for health care than any other country, about 50% more than Sweden, and more than double everyone else.
So we're paying more and getting less
But this would argue for a more incremental approach, adding coverage for the working poor instead of remaking the American health system for everyone. Regarding incremental approaches, I believe we have been trying incremental approaches for the last 16 years, with the results mentioned above.
The overwhelming majority of Americans, by the definition of denied care, do not face a health-care crisis. Most polls show that about 80 percent are "very" or "somewhat" satisfied with their health plans. Those in the greatest need are often the most satisfied -- 90 percent of insured Americans who suffered serious illnesses are satisfied with their health care. According to a study published by the Cato Institute, a very small percentage -- even of the uninsured -- are "dissatisfied or highly dissatisfied" with the health care they get in other ways. On health care, the American public brims with satisfaction -- though most are concerned about rising costs. First, this statement is based on an "opinion poll," the results of which are highly dependent on how the questions are phrased. Secondly, it reflects an "I've got mine, you go worry about yourself" mentality. If 20% of Americans are 'dissatisfied' with their health care plan, I think we have a problem. Furthermore, not caring about the plight of uninsured Americans seems a lot like saying that, since I don't have the H1N1 flu, why should I care if others get inoculated. Lastly, if the American public is "brimming with satisfaction," why is health care reform getting any traction at all? I think we know the real answer.
So perhaps this is the crisis: rising costs that will eventually overwhelm state and federal budgets and consume more and more of individual paychecks. But this is precisely the area where current Democratic approaches are least credible. Obama abandoned his pledge to reduce the government's health costs long ago; now he aims only at budget neutrality. But every pending health-reform bill in Congress would increase both short- and long-term deficits, failing even on Obama's modified terms. Americans get the joke. While Obama has made cost control a centerpiece of his public message, only about 20 percent of Americans, in one poll, believe Obama will keep his promise not to increase the deficit with health reform. Again, this statement is based on an "opinion poll," the results of which are highly dependent on how the questions are phrased. Actual facts are hard enough to process, much less random opinion polls.
The main challenge for Obama is this: Announcing a more credible, specific approach to controlling health-care costs will not solve his political problem. Aggressive cost-control options -- squeezing Medicare fees even further, abandoning fee-for-service in Medicare entirely, restricting "unnecessary" procedures through an all-powerful medical board, putting more cost burdens on individuals -- tend to be frightening or difficult. Major tax increases would lessen the need for drastic cost reductions. But the obvious source of revenue -- eliminating the health insurance deduction for employers -- would open a new front of controversy. Regarding his concerns about an "all-powerful medical board", we would actually have more control over a government health care bureaucracy than we do over corporate insurance bureaucracies. American voters have changed many government directions, but we have never removed a corporate board member by voting. Recall the quote from Wendell Potter, above, on the power of insurance companies. I am still mystified why many Americans feel they can trust big companies such as Aetna and Pfizer, over whom they have absolutely no direct control, more than they can trust a government program in which they are regularly given the opportunity to express their opinions directly.

I can't resist pointing out that many of the current arguments ("it's socialism", "it's too expensive", "I'll lose control") were raised against Medicare forty years ago. You may not think much of it, but it works really well (just ask my family members) and few people would want to do without Medicare now.
It is all very Carter-like. Obama presents a political priority as a national crisis. But the economy, Afghanistan and Iran may be crises enough for anyone. Be careful about maligning my man Jimmy. See the article, Stop Picking On Jimmy Carter for enlightenment.

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Comments on Linder

I didn't write a Letter to the Editor when this "Viewpoints" article by U. S Rep. John Linder was published, but I did start thinking seriously about coming up with a good posting. Well, here we are. As before, below are some sections I have extracted (generally whole paragraphs to retain the context), and my comments. The complete article is here.

Excerpted section My comments
As a Republican who participated in a nearly 17-hour markup in the Ways and Means Committee on one of the three bills that passed House committees, and as a co-sponsor of two Republican proposals, that came as a complete surprise to me.
In committee, we offered 38 amendments to the Democrat bill, and all were defeated, most with party line votes. The same was true for the other two committees, though the Republicans on those committees offered more amendments than we offered.
Members of the Republican Study Committee have introduced 35 bills dealing with health care issues this Congress, and three comprehensive health care reform packages have been introduced by Republicans, but all have been totally ignored. When the president says that Republicans have offered no ideas, he knows he is lying.
Wow, those are strong words! I have reviewed the highlights of the Republican proposals, and they include encouraging healthier lifestyles (a sweet idea, but hardly a real solution), allowing insurance to cross state lines (hello, big business), means testing (to keep the welfare queens and their Cadillacs out of the health care system), and the limiting of lawsuits on poor maligned doctors. (Seriously, I know many excellent doctors, and I know they suffer from the impacts of frivolous lawsuits. Like abortion and immigration, I believe that is an issue that should be discussed and legislated on its own merits.) These ideas are certainly not evil, but they are clearly going a different direction than the direction that the Democrats (right or wrong) feel they received in the last election.
The last time the Republican leadership sat at the table in the White House to talk about substantive ideas was on the stimulus bill. Our leadership suggested that our approach, using the president's chair of the Council of Economic Advisor's own formula, produced twice as many jobs for half the cost. He responded by rudely reminding them that he won the election. As noted, I agree that Obama's election indicated a general sense of needing to reduce support for big business. It seems like the elephants have had plenty of chances to fix the health system over the last 16 years since Bill and Hillary last tried. And the results? See the Facts above.
The Democrat approach to health care is to increase the federal government's role in making health care decisions. Then-First Lady Hillary Clinton summed this attitude up during the 1993 debate over her health care proposal; "We cannot trust the American people to make these decisions." What does a statement made by Hillary Clinton in 1993 have to do with today's reform efforts? Does she somehow speak for the current proposal? Or is this just the only thing Linder could find to inject more fear into the discussion?
The Republican approach, in all three comprehensive bills, is to put the patient and doctor in charge. We want the bureaucrats from both government and the insurance companies out of the way. We believe that the starting point is legal reform. We think that you should be able to shop for health insurance across state lines and that the 1,300 health insurers will compete with each other without the need for government to "keep them honest." It is offensive to me that Democrats routinely suggest that the entire health insurance industry is basically dishonest. Speaking for myself, at least, it is a mischaracterization to say that I think they are all dishonest. (Although the Wendell Potter article certainly provides food for thought in that direction.) What I believe is that they have a single goal -- profit -- that ultimately limits their ability to care about people. On the other hand, caring about the citizenry is really the sole job of any elected, constitutional government.
We believe that large associations of doctors, dentists, realtors or any other group should be able to pool their members to provide an opportunity for those 1,300 health insurers to compete for that business.
We support "risk pools" for all of those with pre-existing conditions to get coverage in the private markets with premiums that are subsidized by state governments, the federal government and assessments on insurers which profit in the state.
Why will the Democrats not entertain these ideas? Because they want the power to decide. We want you to make those decisions.
No, its not because we want the power to decide. It's because many of us have no faith that anything will change with this sort of proposal. See my previous comments about our inability to directly control corporations. And quoting from a friend of mine, "And pray that I win the battle with Aetna Insurance to pay for a much needed new wheelchair cushion. Surgery to repair an ulcer that does not heal costs $250,000 & up & Aetna paid for the $4,500 wheelchair a few years back, but they don't want to pay for a new $280 cushion (the cushion I've been using with great success for 26 years). It's madness gone crazy."
On Wednesday night, the president addressed this issue in a major speech to the nation for the 28th time in the last eight months. He reiterated that no one will be forced to change their insurance. He also said that in order for any insurance policy to qualify to sign new members up after four years, the policy must cover maintenance procedures such as pap smears and colonoscopies.
That wipes out health savings accounts, which are designed to cover large losses and in which you pay for the maintenance procedures. About 12 million people who have chosen these plans will lose their coverage. Additionally, 20 percent of Medicare recipients choose Medicare Advantage for their Medicare coverage. Under Obamacare, Medicare Advantage will end, and these seniors will forced into new coverage.
Wait. This is a misleading comment. Health saving accounts aren't insurance programs. They are a "band aid" attempt to help citizens cope with unexpected medical costs, because the current system works so poorly. But they are an individual solution, not a true shared risk approach, which is the essence of insurance.
The president dramatically attacked those who argue that his proposal will pay for abortions. Unfortunately, in each of the three committees in the House, amendments were offered to specifically outlaw such coverage and were defeated on party line votes. He said that those who suggested illegal immigrants would be covered were liars. The impartial Congressional Research Service has declared that illegal immigrants will be eligible for coverage. The politics of abortion and immigration are complex issues. See my comment above. Linder and his folk are trying to complicate health care discussions by introducing topics that are already complex in their own right, and whose discussions deserve to take place on their own time.
This was not an honest presentation by our president on a very important day. It returns me to my conviction that this is not about health care; it is about control. Saying that the current administration wants control over health care makes as much sense as saying that President Obama wants to nationalize automakers. I believe the current administration is trying to find the best solution they can come up with for the US population, by looking at other countries, by discussing options, by asking for input, by voting in Congress. The only explanation I can make for Linder's comment about control is that he thinks in terms of "control," and he feels it slipping away.

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Post info

Original posting September 19, 2009 (Arrrrgh)

If you wish to respond to this posting and you don't already know my e-mail address, perhaps the best thing to do would be to leave a comment to my original LTE posting.