Dennis Prager Has 10 questions. I have 10 answers.

by Karoli on July 28, 2009 · 18 comments

in News, Patients

Dennis Prager posed 10 questions to supporters of “Obamacare”1 This post answers them in the order asked. I have endeavored to support my contentions with facts from sources which are non-partisan, but I will state up front that I am a supporter of comprehensive health care reform that includes a robust public option.

  1. Question 1: “If Medicare and Medicaid are fiscally insolvent and gradually bankrupting our society, why is a government takeover of medical care for the rest of society a good idea? What large-scale government program has not eventually spiraled out of control, let alone stayed within its projected budget? Why should anyone believe that nationalizing health care would create the first major government program to “pay for itself,” let alone get smaller rather than larger over time? Why not simply see how the Democrats can reform Medicare and Medicaid before nationalizing much of the rest of health care?

    Answer: It goes without saying that Mr. Prager has posed 4 questions here, but since they’re related, I’ll tackle them as one. The fundamental question he appears to be asking is “Why should I believe government can do this right when they’ve done everything else wrong?”

    Mr. Prager’s premise is flawed. It assumes that the problems with Medicare and Medicaid relate to the government operation of those funds when in fact, the real problems stem from the so-called “Medicare Reform” and Medicare Advantage plans. Medicare Advantage Plans are a ‘Medicare Alternative” provided by private insurers; in essence, an effort to privatize Medicare. According to the Commonwealth Fund, payments to private insurers increased costs over what would have been paid had the Medicare system remained under public oversight.

    The Medicare Modernization Act of 2003 sharply increased payments to private Medicare Advantage plans. As a result, every plan in every county in the nation was paid more in 2005 than its enrollees would have been expected to cost if they had been enrolled in traditional fee-for-service Medicare. The authors calculate that payments to Medicare Advantage plans averaged 12.4 percent more than costs in traditional Medicare during 2005: a total of more than $5.2 billion, or $922 for each of the 5.6 million Medicare enrollees in managed care.

    A glance at insurers’ profit reports confirms this. From BusinessWeek’s report about United Healthcare’s record profits for the second quarter of 2009 on decreased enrollments:

    “We expect this year’s revenue growth in public and senior business to continue to more than offset the potential for further pressure from the employer market,” UnitedHealth CEO Stephen J. Hemsley said in a conference call with analysts.

    Further, VA hospitals (a government-run single payer system) consistently outperform private hospitals. (Washington Post)

    In other words, Mr. Prager, it isn’t the GOVERNMENT that’s running Medicare and Medicaid into the ground. It’s the for-profit insurance companies whose profits are earned on the backs of American taxpayers.

  2. Question 2: [Re: Pre-existing conditions exclusions] But if any individual can buy health insurance at any time, why would anyone buy health insurance while healthy? … The whole point of insurance is that the healthy buy it and thereby provide the funds to pay for the sick.

    Answer: This is why there is a distinction made between “access to health care” and “health insurance”. To be clear: Health benefits are a risk pool. They are not “insurance” like car insurance or life insurance. The premise behind life insurance is that an insured will live long enough that the premiums paid will cover the pure cost of providing insurance. The premise behind auto insurance is that drivers won’t have car accidents, but if they do, the insurance company will cover the damages attributable to their insured. If drivers don’t have accidents, the company wins. If drivers do have accidents, the company has the option to drop them or assign them to a more expensive risk pool. Now that auto insurance is mandatory in many states, however, all drivers must have access to insurance, and so state-mandated high-risk policies are available and required to be carried by high-risk drivers at, yes, a higher cost to them.

    Health insurance is entirely different. It is implicit that everyone will need health care at some point. The best outcome there is: a risk pool diverse enough so that premiums paid will cover benefits due in any given year. To raise their profit margins, insurers ‘purify the risk pool’ by denying coverage to anyone who might possibly develop a condition requiring treatment. By purifying the risk pool, claims are lowered and profits rise, which makes a healthy balance sheet and an unhealthy population.

    It is a fact that without health benefits, people avoid seeking treatment for conditions which, when untreated, can become life-threatening conditions. Preventive medicine is a cost-saving measure which is included as part of the House health care reform act and which benefits our society as a whole. Excluding people from access to health benefits because they have a pre-existing condition forecloses preventive care,  guarantees that at some point they will turn to the government for assistance because there is nowhere else to turn, and they will do so at the point where treatment costs are most expensive.

  3. Question 3: “Why do supporters of nationalized medicine so often substitute the word “care” for the word “insurance?” it is patently untrue that millions of Americans do not receive health care. Millions of Americans do not have health insurance but virtually every American (and non-American on American soil) receives health care. ”

    Answer: See my answer to Question 2. It is somewhat disingenous to suggest that the government can’t manage health care benefits and then turn around and claim that everyone ultimately has access to health care. Anyone who has faced a serious illness, injury or condition which requires hospitalization, surgery, or chronic illness care knows that they only receive health care at the risk of losing everything they have worked for, including their home, their job, their savings and their livelihood.

  4. Question 4: “No one denies that in order to come close to staying within its budget health care will be rationed. But what is the moral justification of having the state decide what medical care to ration? ”

    Answer Health care is rationed now. Some people get it and others don’t. The ones who don’t are the ones with pre-existing conditions, the middle class, the self-employed, and the unemployed who cannot afford COBRA continuation benefits. Those who decide the rationing process are the for-profit insurers, who make their decisions based upon their balance sheets, rather than any moral, medical or social good. What Mr. Prager is asking us to accept is that corporations who have a duty to make a profit and distribute those profits to their shareholders will somehow make medical care decisions which are morally superior to public servants whose only duty is to the people they serve.

  5. Question 5: “Given how many lives — in America and throughout the world – American pharmaceutical companies save, and given how expensive it is to develop any new drug, will the price controls on drugs envisaged in the Democrats’ bill improve or impair Americans’ health?”

    Answer: Given that the price controls relate to established medications which have gone long past the patent expiration and are available as generics, it would appear that this argument is moot. Further, the price controls on drugs are controls agreed to by the pharmaceutical industry.

    Finally, Medicare is currently prohibited from negotiating drug prices under Medicare Part D, that ‘reform’ passed by the Republican Congress under George W. Bush’s watch, which has caused the costs of the Part D benefit to balloon in the past 5 years to double the original CBO score.

  6. Question 6: “Do you really believe that private insurance could survive a “public option”? Or is this really a cover for the ideal of single-payer medical care?”

    Answer: This is the heart of the argument at last. Even insurance companies agree that everyone should be covered and pre-existing conditions exclusions should go away. However, they want that captive group — the 47 million uninsured who will now be required to buy insurance. Introduction of a public option means they cannot operate in a monopolistic fashion. They will have to compete.

    As demonstrated with Medicare Advantage plans, insurers have figured out how to be profitable and compete, provided they receive government subsidies. Administrative costs in private insurers’ plans are twice the cost of public Medicare costs. Insurance companies “save” by excluding those who might be a risk.

    One possibility for profit margins: Split the company. Make the company providing the basic benefits a not-for-profit company, and offer insurance through a for-profit company for ‘luxury benefits’. Insureds could hold policies with both. That’s just one idea. Trust me on this. Insurance companies always find ways to make profits. I have yet to see one who hasn’t. It just means they’re not quite as in control of things as they were before. Now they have a true competitor in the same market, something that has been sorely lacking.

  7. Question 7: Why will hospitals, doctors, and pharmaceutical companies do nearly as superb a job as they now do if their reimbursement from the government will be severely cut? Haven’t the laws of human behavior and common sense been repealed here in arguing that while doctors, hospitals and drug companies will make significantly less money they will continue to provide the same level of uniquely excellent care?

    Answer: Hospitals and pharmaceutical companies have agreed to these cuts, and have participated in the process and the dialogue. Presumably they have done so because they expect to benefit in other ways. As for doctors, it’s my understanding that there are still some open issues on how they will be compensated and what “outcomes-based” medicine means in terms of the final health care reform bill. I do think this question is valid and deserves a more specific answer, which may be forthcoming as the bills are reconciled in committee.

  8. Question 8: Given how many needless procedures are ordered to avoid medical lawsuits and how much money doctors spend on medical malpractice insurance, shouldn’t any meaningful “reform” of health care provide some remedy for frivolous malpractice lawsuits?

    Answer: Tort reform applies to many areas. Health care is only one. Shouldn’t tort reform be tackled as its own reform dealing with the different areas it touches upon, particularly given the coordination with state law?

  9. Question 9: “Given how weak the U.S. economy is, given how weak the U.S. dollar is, and given how much in debt the U.S. is in, why would anyone seek to have the U.S. spend another trillion dollars? Even if all the other questions here had legitimate answers, wouldn’t the state of the U.S. economy alone argue against national health care at this time? ”

    Answer: No. There is no question that the health of the economy is inextricably tied to the health of the population. Further, no one is proposing the expenditure of one trillion dollars. The President has said over and over again that he will not sign anything into law that is not deficit-neutral.

  10. Question 10: Contrary to the assertion of President Obama — “we spend much more on health care than any other nation but aren’t any healthier for it” — we are healthier. We wait far less time for procedures and surgeries. Our life expectancy with virtually any major disease is longer. And if you do not count deaths from violent crime and automobile accidents, we also have the longest life expectancy. Do you think a government takeover of American medicine will enable this medical excellence to continue?

    Answer: Mr. Prager is basing his assertion on what facts? These are the facts I see:

    1. In 2008, the US ranked last in rankings focused on preventable deaths due to treatable conditions.
    2. The US ranks last or next-to-last on a five-point ranking system of performance: quality, access, efficiency, equity, and healthy lives. It also shows a lag in adoption of IT and use of nurses for care coordination of chronic diseases. (Commonwealth Fund)
    3. The US performs best on preventive care, if patients have access to it. (Commonwealth Fund) See also the Kaiser Foundation report on Health Care and the Middle Class: More Costs and Less Coverage

    The facts point to the truth of President Obama’s assertion. Waiting less time for procedures and surgeries is only good if one has access to the procedures and surgeries. 47 million people don’t. Our life expectancy with any major disease is not necessarily longer, nor is the quality of life better. The problem is not with the practitioners of medicine in the US. The problem is getting access to practitioners.

A pattern and a message emerge from Mr. Prager’s questions. What they are intended to suggest to the reader is that we live in some kind of utopia where we have the best health care available, delivered by the best system in the world. In fact, we have great practitioners, but a growing group of the population has no access to those practitioners. If I had a dime for every person I’ve heard tell me they’re afraid they have some disease or condition but can’t go to the doctor because they don’t have health insurance, I’d have enough money to pay my COBRA continuation premiums for the rest of my life.

Mr. Prager is playing ‘head in the sand’ argumentation. I truly believe that he believes that if we close our eyes and say over and over “there’s no place better than the US”, our health care system will magically improve. The truth is different. Until we face the issues head-on and deal with them, with the understanding that there are just some things government really CAN do better than private enterprise, our economy and our health will continue to suffer.

1 A term I object to since it politicizes a discussion which should be non-partisan and rationally addressed. Health care is an issue that affects each and every one of us, Republican or Democrat.

Updated post at 3:11pm to include VA reference and Medicare Part D reference

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