A quick list, because there seems to be a great deal of confusion:

1. Adult children may remain as dependents on their parents’ policy until age 26
2. Children under age 19 may not be excluded for pre-existing conditions
3. No more lifetime or annual caps on coverage
4. Free preventative care for all
5. Adults with pre-existing conditions may buy into a national high-risk pool until the exchanges come online. While these will not be cheap, they’re still better than total exclusion and get some benefit from a wider pool of insureds.
6. Small businesses will be entitled to a tax credit for 2009 and 2010, which could be as much as 50% of what they pay for employees’ health insurance.
7. The “donut hole” closes for Medicare patients, making prescription medications more affordable for seniors.
8. Requirement that all insurers must post their balance sheets on the Internet and fully disclose administrative costs, executive compensation packages, and benefit payments.
9. Authorizes early funding of community health centers in all 50 states (Bernie Sanders’ amendment)

I’ve been trying to understand why as a nation, we are so divided about health care reform. You would think every American would be generous enough to think the guy next door deserved decent health care. You would also think we would be embarrassed to have our issues aired in front of all the other developed countries, like our neighbor Canada, who extend protection to their own citizens. (Never mind those socialists in Europe). I mean, the single SuperPower, the country I grew up in, is expected to set a standard for the rest of the world to follow. But in the past year, we have set a standard only for uncivil debate, distortions, lies, half-true talking points, and backroom deals.

Health care reform has ceased to be about health care or reform. Instead, it is now about money, like everything else in the country. That monolith I hear about on C-SPAN every day “the American people,” has taken a collective haircut in wealth over the past few years. No longer to we feel like the richest, most powerful nation in the world. In fact, we feel like China is eating our lunch, the planet is warming or cooling, the Islamic fascists are out to get us, and our children may not even be getting a good education. We feel poor.

No wonder we have retreated into our shells, a nation of turtles. Recent events have scared the pants off us.  Especially events involving money.

We’ve spent the past eighteen months desperately de-leveraging, denying ourselves things we used to take for granted, and trying to climb out of debt. We are in no frame of mind to authorize spending on a single extra family-sized pizza, much less on an “entitlement program” that might raise the deficit, a concept we never discussed in the passed.

How many of us even know the difference between the national debt and the deficit? There is one, you know.

The deficit is the difference between the money Government takes in, called receipts, and what the Government spends, called outlays, each year. Receipts include the money the Government takes in from income, excise and social insurance taxes as well as fees and other income. Outlays include all Federal spending including social security and Medicare benefits along with all other spending ranging from medical research to interest payments on the debt. When there is a deficit, Treasury must borrow the money needed for the government to pay its bills.

The national debt goes up and down, depending on what’s happening in the country. For the last couple of years, because of the downturn, tax receipts have gone down, so the deficits have gone up.  Those accumulated deficits make up the national debt.

When well-run businesses run into a downturn, what do they do?  They don’t just stop taking risk. Often they use the time to invest in the future. The next time the economy turns around, they are well-positioned to grab a leadership position. Not that there’s anything wrong with paying down debt, but  you can’t downsize your way to success. You have to raise revenues.  You have to sell. You have to grow.

If we keep our population healthy and educated, then when the turnaround comes, we can quickly pay off our debt, because the deficits from income tax receipts will go away. We can grow. That will raise revenues.

Not passing health care reform is the flip side of fighting wars on two or three different middle Easts fronts at a time. It’s what we do out of fear. It’s not what we do out of strategy, or leadership, or even our Christian underpinnings.

Here’s my take on the health care summit:

• Underneath the talking points, there was a theme from the Republicans: We do not want people with pre-existing conditions to be covered. They had to admit that in public. If you weren’t listening, I’ll try and find you the exact point where it came through loud and clear.
• The President made it clear that his priorities begin and end with those who are left behind. His pointed questioning about whether GOP Senators would be willing to give up their health plans through the Senate for a high-deductible plan with a health savings account. While they said yes, he pointed out that they can afford it with $176,000 in salary, as opposed to those of us who are scraping it together on $40,000 a year.
• Mitch McConnell affirmed that the Republicans have no intention of coming together on health care reform in his press conference afterward.
• The value of this summit was lost in talking points and repetitive distraction. A better use of time would have been to take real-life cases and apply the law to them as exemplars of how reform would impact real people.

I’m sure I have more, but honestly, I’m just so disgusted with the idea that people think it’s okay to discriminate against people who are unfortunate enough to get sick that I really can’t think clearly.

I spent most of the day watching the health care summit President Obama held at Blair House today. I’ve drawn only a few new conclusions.

1)The process needs an independent, trained facilitator.  The President isn’t one. He’s in favor of his own proposals; his party has a dog in the hunt. That reduces his credibility. It also made him talk too much; I bet he took up almost a third of the time after dividing it pretty evenly between the Democratic and Republican members of Congress. The Republicans will use that to flog him in some way.

2)On the other hand, President Obama is very smart. He’s up on the issues, and he wasn’t reading from notes or a TeleprompTer. He’s immersed in this stuff, and he has been studying all the angles. You don’t have to agree with him, but you should admire him for the seriousness with which he approaches the job. In his dreams, he wishes we were post-partisan, although in reality we are not.

3)The Republicans have some good ideas. Most of them have already been worked into the existing bill, but it is difficult for anyone to admit that.  They would rather keep on talking about “nuclear options” and “government takeover of health care.” There are many things we can all agree on.

4)Everyone forgets that the President was elected on a platform of change. When the Republicans say “the American people don’t want this bill,” do they know whether the American people want less reform? More reform? No reform?  Are they objecting to the process or the product? There’s a possibility that most Americans want greater reforms; and at the same time there’s a possibility that they don’t want change at all (people have a tough time adjusting to change). Fact is, things will change no matter what we do in Congress. Longer life spans, an aging population, an increasing national debt, and more advanced technology will see to that.

5)It was remarkably difficult to watch the Summit on TV. MSNBC was covering the Olympics, and CNN kept breaking in and cutting away. Even C-SPAN only covered the summit live on C-SPAN 3, which not everyone gets with her cable service. At several points I had to stream it, and the streams weren’t dependable either.

6)The Republicans keep saying “let’s go back to the beginning” and “the American people don’t want this bill.” What if we DID go back to the beginning, and produce a much stronger bill with a nanny-state?  I’d bet we would be surprised how many people would want that; there is still widespread support for a single payer system that would take these decisions off our hands. People are not as prepared to embrace freedom of either markets or lifestyles as we would like to think. Eric Fromm wrote Escape from Freedom in the 1940’s about how man attempts to escape freedom: through authoritarianism, destructiveness, and conformity.

7) Nobody mentioned health IT, remote patient monitoring, patient-centered medical homes, or reimbursement changes as ways to cut costs. Why not?  Because the discussion centered so much on who has insurance rather than outcomes or patient care. Yet these innovations will probably both reduce costs AND raise quality of care. Ah, but they don’t have support from doctors, pharma, or insurance companies, because they are less about the free market than about improving quality of life.

8)From what I could tell from my social media streams, only extremists followed the debate. You would think there was no one but #tcot and #p2 who cared.

Actually, everyone cares–but if your opinion is any combination of R and D, you can’t get heard. At least Congress was on its good behavior today; Twitter was not. Normal citizens seem to have covered their ears.

That’s really about all I learned.  It’s not a lot from seven hours of listening and watching.

With the introduction of President Obama’s blend of the House and Senate health care reform bills, there’s been a flurry of activity in the Netroots over the missing public option. Several groups are mobilizing for it at the same time that key Senators who supported it in the past are quietly leaving it on the table. Because it is still a cause of controversy and division, I think it’s worth listing the arguments for and against it in as objective a fashion as possible.

Arguments in favor

1. A public option creates competition in the marketplace.
2. A public option saves money.
3. A public option puts downward pressure on premium costs.
4. A public option establishes a framework for a national single payer system in the future.
5. A public option gives individuals a choice not to fund commercial health insurance companies.

Arguments against

1. A public option establishes a new government agency.
2. A public option puts government in charge of making health decisions.
3. A public option duplicates the Medicare framework already in place.
4. A public option will be costly to initiate and manage.
5. A public option may result in providers refusing to participate because of low payment rates.
6. A public option may result in adverse selection; that is, where the oldest and sickest gravitate to the public plan, driving government costs up.

Within this framework, there are individual arguments to be made about whether each point is valid or not. My goal here was simply to list the primary arguments for and against and let the discussion flow from there.

Are there any I missed? Leave a comment and I’ll add to the list.

Medicare Part D is, indeed, a scam. I wasn’t sure until I cross-posted my piece from here on the Huffington Post and read the seventeen comments it got. One of the most interesting was from a pharmacist, who compared what he knew the costs of the prescriptions his dad paid were to what his Part D plan charged him, and found that the Pharmacy Benefits Manager for his plan charged a higher co-pay than necessary just to get him to the donut hole faster. Another was from a woman who priced drugs with and without insurance and found the cost of her drugs to be $200 a year cheaper without insurance.

This is yet another thing health care consumers don’t totally understand: when you add a layer of management, you add a layer of profit. Managers don’t manage for nothing. Now that we have our drugs “covered” by insurance (public or private), someone has to be paid to manage the benefits.  That entity is a Pharmacy Benefits Manager. The cost of that Pharmacy Benefits Manager (PBM) is added on to the cost of your prescriptions, as are other costs associated with marketing and selling drugs to the Pharmacy Benefits Manager (which is called “getting the drugs added to the formulary”). The “formulary” is the list of drugs your plan will pay for. Like everything else, Medicare Part D has a formulary, and the different Part D plans have PBMs.

To the consumer, sick or well, this is all so much mumbo-jumbo. What you have to know, whether you are on Medicare or on a private plan, is that all this “management” costs money, and that for the past few years, the drug companies have been claiming their expenses are research and development.  Some are, but others are marketing, and still others are management.

And this is why health care needs to be single payer: in any other industry, if the prices of a product got to be higher than you could afford, you would tell the company to take a hike, substitute a cheaper product, do without the product, or make it yourself to save money. You cannot do this with health care (although more consumers are trying). But you can’t do that with health care, can you. And that’s why after all the noise against Obamacare, socialized medicine, and everything else nasty, the debate is coming back around. We have to do something to reign in costs. Period.

An Intelligent friend of mine, who is now on Medicare, just found out inadvertently about yet another deal between Congress and the drug companies.  In this deal,  Medicare Part D (prescription drug benefit)  was passed with a right of the pharmaceutical companies to raise drug prices during the open enrollment period.  For the person choosing a plan during the Open Enrollment that occurs every year from November to the end of the year, this means it’s  a bait and switch.

He wrote a letter to his Congressman about it, the text of which can be found here.

Like me, he was under the impression for the last five years that during Part D Open Enrollment, the plans were not allowed to change prices.  He was shocked during this last open enrollment to discover that two of the plans he was reviewing changed the full price of some of their drugs AFTER November 15. When he reported this to Medicare he was told that because my complaint was against CMS he had to complain to his Congressman.

Congressman Ed Pastor (D-AZ) confirmed that Congress did write into the MMA law of 2003 that CMS could not interfere with the pricing of drugs and <em>companies could update their prices as often as every 14 days, including during open enrollment</em> and thus <strong>Congress either deliberately or unwittingly stacked the deck in favor of the plans and drug companies</strong>. My friend, who was saving search results on his computer, discovered this by accident.

He says this is a bait and switch tactic that was resolved by an act of Congress as far back as 1946.  How can a consumer properly evaluate and compare plans if the prices unbeknownst to him or her are changing during the process and they have no awareness that prices are changing?  He’s done research to support this.

This is either an outrageous hoax that Congress played on the American people who are on Medicare, or a frank admission that no members of Congress read the legislation they pass.

It makes no difference if you have a standalone Part D plan or you are a member of a Medicare Advantage plan. For the last five (5) years the insurance companies and the drug companies have been getting away with robbing the pocketbooks of senior.

IOnly Congress can correct this.  You might want to write a letter to your Congressperson, reminding them that it’s an election year and that seniors vote. And that this isn’t much different than what the banks and credit card companies do with the small print in their mailers.

No matter which side of the political fence you are on, this is a startling situation, reported this morning in the Wall Street Journal– not a liberal rag:

For the first time, government programs next year will account for more than half of all U.S. health-care spending, federal actuaries predict, as the weak economy sends more people into Medicaid and slows growth of private insurance.

The figures show how federal and state spending is taking a bigger role while Congress hesitates over a health-care overhaul.

Government health programs are a growing burden on the federal budget, which is running annual deficits of more than $1 trillion, and rising health costs continue to batter private industry.

By 2020, according to the new projections, about one in five dollars spent in the U.S. will go to health care, a proportion far beyond any other industrialized nation.

“It’s going to be a desperate issue five to 10 years out,” said Gail Wilensky, the former top Medicare official in the George H.W. Bush administration. She said the U.S. will have to decide soon between raising revenue to pay for Medicare or reducing benefits.

Public funds accounted for 47% of the $2.34 trillion of national health spending in 2008, the last year for which figures are available. The federal Centers for Medicare and Medicaid Services estimates in a paper to be published Thursday in the journal Health Affairs that the proportion will rise to 50.4% by 2011. Last year, the federal actuaries had predicted the 50% mark wouldn’t be reached until around 2016.

Obama isn’t making this up. Health care is an issue for the entire economy. Let’s imagine for a moment that we want to reduce Medicare benefits. That might be a way to solve the problem, so we ought to look at it first, because no one likes her taxes raised.

But the Baby Boomers started turning 60 last year. They have paid into Medicare for their entire careers. How do you think they, the largest cohort in our history, would feel if their benefits were lowered just as they were coming in to Medicare? That would be pretty fun to watch. And the Seniors come out and vote if someone even threatens Medicare Advantage, the bloated private program that provides gym memberships and other bullshit that regular Medicare does not, and overpays the private insurers for managing the extra benefits. So anyone who advocates for Medicare cuts gets his head handed to him.

As for Medicaid, its growth is a function of the layoffs in the work force. If you let the working population get sick and die, who will support the economy? Not to mention their children, who are already being rejected by government programs in Arizona.

It’s really hard to avoid the cold hard truth: we need comprehensive reform, whether that takes the government further in or further out. Where things are now won’t stand. And that reform has to address COST FIRST. Cost of delivery, cost of private insurance to individuals and small businesses, cost of new technology, cost of pharmaceuticals, and the inevitable cost of doing nothing. The health care industry — and it has become an industry — has to lower its prices and thus its cost of doing business, or it will go out of business, replaced by a disruptive technology, like Ayurveda or naturopathy.

Every year, Medicare tries to cut payments to providers, and can’t. Why? Because if providers are paid little enough, they won’t continue to provide services (that’s already happening). They hold the government hostage, while taking home their profits. Silly government, outsmarted by the private sector again.
That’s why the simplest thing to do would have been to create a single payer system, in which the cost of everything was pre-determined by the single payer (could be either public or private) and everybody in the supply chain had to accept the price. That’s what Wal-Mart does to keep prices down — it squeezes the suppliers. That’s what Wal-Mart does. Why do you think clinics in Wal-Mart have been so successful?

We like Wal-Mart. We like the every day low prices. So much so that we allow the company to control wages. So why not establish a Wal-Mart system of health care. Cheap, and not necessarily of high quality (good enough).

The last alternative is to raise taxes. That will send people into a tailspin. But I bet it happens, because Americans are not willing to settle for reduced benefits, or reduced quality, or reduced cost of care.
In Denmark, if you buy a car, there’s a 200% tax. Sounds shocking to me, but people continue to live in Denmark. And they have health care. It’s a trade-off.

Well, health care has gone to the back burner. Now everyone, not just Republicans, is unwilling to talk about it. In theory, Democrats are scrambling behind the scenes to figure out a way to pass something, but we are definitely finished having a debate about it.

President Obama revealed his budget today, to the usual “OMG the debt will leave our children with a lower standard of living” from the people across the aisle.  Pressed on how he thought the budget deficit ought to be addressed, one of Chris Mathhews’ Republican guests admitted that the only way to lower the deficit would be to “transition people 55 and under out of Social Security and Medicare benefits and into a different plan that isn’t so expensive.”  I bet that will be a sure election-winner: work all your life and get kicked to the curb in favor of someone else’s grandchild.

Nobody talks about changing the objectives of the system, the delivery, or the costs.  All they talk about is the budget deficit and cutting. In the mean time, what’s the quality of life for people who need health care now?

In Arizona, where I live for most of the year, Medicaid enrollment has gone up 18% since last year, and the state has one honkin’ deficit itself. As a response,

…Governor Jan Brewer, struggling with a $1.4 billion deficit this fiscal year (and a projected shortfall of $3.2 billion in fiscal 2011), ordered the state to stop enrolling children in KidsCare, that state’s CHIP program that provides coverage for 47,000 children. Brewer has also introduced a ballot measure that would roll back a 10-year-old expansion of Arizona’s Medicaid program, resulting in 310,500—more than 4 percent of all Arizonans—losing their coverage.

It will be interesting to see how long it takes everyone to figure out that if we reformed not the money piece, but the delivery piece, of the health care system, we might be able to provide care for children and the elderly and still decrease the deficit.

I actually do think automating the systems will help a little, and auditing Medicare and Medicaid more carefully and completely will also help. Both programs, according to people I know who have done pilot recovery auditing projects for them, are full of waste — excess utilization, incorrect billing, duplicate payments. And as for fraud, “60 Minutes” exposed how easy it is to defraud Medicare in Florida several months ago.

There are all sorts of other pilot programs in the bill-that-will-never-be-passed, from the Primary Care Medical Home to prevention to outcomes research. Now most of that will be scrapped, and a paralyzed Congress will just keep trying to figure out how to reduce the deficit on the backs of the vulnerable.

The military budget? Two wars at a time? That might be a little expensive, but why cut back on that? Instead, the budget has been framed as a Hobson’s choice: leave our children with debt later, or leave them without health care now. Let’s just throw some poor kids out of a Medicaid program and use the savings to buy drones that kill civilians in other countries.

Looks like the Massachusetts election sent everybody scurrying for cover. Congressional Democrats and Republicans are retiring in droves, lest they lose an election and forego those pension benefits. Try to imagine how I feel about that cowardly behavior. First, Congress sabotages true reform, and then it heads for the hills.

The only one speaking out even a little is President Obama, who told Diane Sawyer that he’d rather be a one-term president who did the right thing than a two-term president who did nothing (exact words are mine, not his). However, today he said something about a “discretionary spending freeze” to attack the budget deficit, and that also means he has turned from wanting to be transformational to resigning himself to the usual battle about what’s discretionary, what’s necessary, and what’s pork.  All of these, of course, are in the eye of the beholder.

And what of health care reform now? As evidenced by the performance of health care stocks, no one knows. As near as I can tell, Nancy Pelosi, who might have been the root cause of all our problems because she represents a very progressive district that doesn’t reflect the country, is wildly looking around for eighteen votes so she can pass the Senate bill and we will have something rather than nothing.

Go back to sleep. Nothing will happen today. Pre-existing conditions may end up being outlawed only for people under the age of nineteen. That will be hard to swallow.  Formerly big issues like the right of a poor woman to an abortion (rather than being forced to have a child she can’t afford and will probably not be able to support in any sense of the word) have completely vanished. And the public option? Out the window, or under the bus, or both.

Ugh. We are not going to have real reform even though it is an economic necessity.

And the quality of our care isn’t even being addressed, even though my son-in-law’s dad had a stent put in last week and he got a hematoma from a supposedly routine procedure that was supposed to be performed by a surgeon and was instead performed by a resident. There are countless anecdotal data points about what happens in American hospitals, even though people in Haiti can be operated on in the open air with pen knives and still recover. The operative word isn’t money. It’s care. The doctors in Haiti are there because they care. In America, does anyone in health care still know why they are there?