John Edwards!

Where's the choice of opting into a public option?

I notice that many of you are avoiding that question.

Three thoughts:

-- On the affordability/financial measures, I'm unclear what in the plan addresses that point before 2020. Given that three of the eight principles are focused on that-- and its the primary policy benefit to the currently insured-- we should be holding the Obama administration accountable to actually delivering on this, not just talking about it. Which means they need to take CBO assessments to heart-- CER and Health IT are not the answer to helping people with cost-savings for at least 10 year (As I've said previously, 15-20 is more realistic on these measures.)

-- Portability of coverage-- excellent principle, hasn't been focused on as much recently, and sort of requires a Wyden-like solution to be feasible. (Job X you had BCBS and love it, job Y doesn't have BCBS- so how can you keep your coverage? Benefits provided as wages, a la Wyden. Not sure how else this is logistically feasible for employers.)

-- To have eight principles and not have any of them more directly address the Wennberg/Berwick issues, is disappointing. Its very subtly alluded to in the quality of care bullet, and of course a more direct point would be politically treacherous. But in the spirit of doing a wonkish analysis of this, not having a more direct focus on improving the practice of medicine via EBM and reducing practice variation is a huge, huge gap.

Where is the choice of having a public option?

Medicare for All/Single payer is still the most honest and complete way to get actually control total health costs, limit individual liability, and get to coverage that is both universal and comprehensive.

I have no problem with an honest argument that single payer is difficult politically because AHIP is powerful.

But let's stop lying to ourselves that any of the mainstream inside the beltway alternatives such as Obama/Baucus, or Wyden, actually controls total costs (they don't) or is fiscally responsible (they are not).

One way (premiums, out-of-pocket), or another (taxes), we the people are paying for health care. Hence, one needs to clarify whether a proposal is actually controlling total costs (important), versus just federal government costs (not so important).

Don’t take my word for it. That is according to Commonwealth Fund and the Lewin Group, which do not support single payer/Medicare for All (they push their so-called Building Blocks proposal which is essentially the same as Obama/Baucus).

See more at the Commonwealth Fund report:
http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Jan/An-Analysis-of-Leading-Congressional-Health-Care-Bills--2007-2008--Part-I--Insurance-Coverage.aspx

Kos diary:
http://www.dailykos.com/storyonly/2009/2/25/85211/4019

More and better preventive health care and chronic disease management (which is what I do for my work), evidenced based medicine (which is what my wife teaches), and health IT are all good things.

But the literature says they don't actually save money, at least not in a 10-15 year time frame.

And single payer does them better too.

And private insurance does not care about doing them.

So, yeah, they are all good things. But they have nothing to do with the reform of how the funding stream should be done, except to actually add to the single payer argument.

I willing to accept the idea that it's not politically good to have single payer. In fact, I am not a single payer supporter.

What I do have a problem with is the lack of as I said any public option from what I can tell. If there is no public option- this is a give away to the private sector. It's just that simple.

The fact that bloggers like Ezra are not talking about whether there will be a public option or not is disturbing.

I am hoping I am just not reading the proposals right or that the bloggers will talk about it more soon. Otherwise, I will question what this bill is meant to do.

I would point out this isn't "what health reform looks like"; this is what a discussion of healthcare reform needs as a basis for beginning... but in itself, it's a vague set of general principles that, as nearly every comment has noted, starts to fall apart when faced with specifics. The fact that, I too, agree with the eight "principles" says nothing about the plan we wind up with, how it works, or how it actually sets out to achieve things like cost reduction. I get the sense that what we're about to get - as with the stimulus - is a set of broad outlines from the Administration, leaving specifics to others, and being cagy about settling on a specific plan until there's consensus. And frankly, I think it's a frustrating way to do healthcare, because we know all too well that a lot of vested interests have all kinds of ways to throw wrenches into this. Without getting beyond general principles into some specific changes (like, just how Medicare can adapt fee for service into payment for outcomes; or how Medicaid can have a more direct federal role in setting health plans for the poor), we're not getting the guidance that's needed, I think, to make this happen. Moreover, I continue to point out, as Ezra's kind of getting around to, that we're not explaining much of any of this to the general public, especially to the already insured, healthy people who don't have a lot of personal problems with the healthcare system (yet). Acceptance requires buy-in, and buy-in requires... more than we've done up to now. Nice principles there... shame if anything should happen to them. Specifics, details, really starting to lay out what's possible and what isn't... these, I think, are things we need, and we need them now, not later, in a Congressional process that's bound to complicate matters... not simplify thinking.

I agree-- the program will not be deficit financed.

And that raises a question as to where they will get the money . . . .

As Bob Laszewski points out: "With $318 billion in tax increases and another $175 billion in Medicare HMO cuts, the $634 billion "down payment" only contemplates a total of another $141 billion in federal health care cuts over ten years (which amounts to about 1% of annual federal spending each year). "

Also, see the Commonwealth Fund report released last week. (wrote about it on HealthBeat yesterday.)

It makes it clear that even if you require upper-income Americans to papy up to 10% of income for premiums (while lower-income Amercans pay 5% plus deductibles and co-pays), and even assuming that the public sector alternative pays doctors significantly less (as Medicare does now), and even if you assume that the public-sector plan requires a referral before a patient can go for any of the most popular and lucrative procedures, and even if you assume you pay doctors less in regions that the Darmtouth research shows are high-spending (Manhattan, LA, Boston, etc.) ---
even assuming all that, health care inflation continues to be unsustainale--at least two times, perhaps 3 times likely GDP growth in the future.

We are really going to have to reorganize how we deliver care, and persuade the American public that "more is not better" if we want sustainable universal care.

Finally, the many middle-income upper-middle income families who think universal coverage will help them do not realize that most will wind up paying more--not less--in order to pay for IT
subsidize the uninsured, pay for reserach, etc.

Somewhere between 8% to 10% of income is realistic--unless your employer continues to subsidize.

And more employers will be backing out, particularly
with likely changes in tax law regarding employer- based insurance.

agree with webboy about process. this is what obama did with the stimulus. it ended up making the process more, not less difficult for him to leave it to congress to decide

weboy- I really enjoy your posts.

that we're not explaining much of any of this to the general public, especially to the already insured, healthy people who don't have a lot of personal problems with the healthcare system (yet). Acceptance requires buy-in, and buy-in requires... more than we've done up to now. Nice principles there... shame if anything should happen to them. Specifics, details, really starting to lay out what's possible and what isn't... these, I think, are things we need, and we need them now, not later, in a Congressional process that's bound to complicate matters... not simplify thinking.

I agree with this.
As anyone familiar with my comments here can tell, I fell out of love with Barack Obama. There was a time, however, when I thought he was amazing. I was a fan because I thought he- more than any of the other candidates at the time- would have just the kind of conversation you describe above. It is what is needed, and he has the talent and public support to do it.
Will he?

Richard Nixon could have supported the principles that Ezra and the Prospect uncovered. In fact, he proposed something quite similar.

I used to think that Democrats forgot nothing and learned nothing from Clinton's health care debacle. But now it's clear they remembered everything --and learned the wrong lessons, the chief lesson being voters wanted to keep the insurance they had. But that wrongly frames the issue. Clinton's proposal was a hideously complicated scheme to condemn people to HMOs and to buy off the insurance industry (which can be defeated, but cannot be bought). People said, "I'd be a fool to give up my current benefits for something I don't understand and might not be as good as what I have."

They would, of course, have been happy to switch to a program that provided better benefits, at lower cost, backed by the full faith and credit of the United States. In other words, they would have supported a single payer system that was simple, offered better benefits, and was backed by the full faith and credit of the United States. That was the lesson that Hillary Clinton, Obama, Baucus, et al, failed to learn.

Jacob Hacker and others think the public insurance option will be more attractive and less expensive, and therefore will be adopted by more and more Americans until we have a defacto single payer system. The insurance companies concur -- which is why they never will agree to it.

But they will agree to a mandate to purchase health insurance, and to a government subsidy for those who cannot afford even the least attractive plan. And they think they can get it. After all, the Medicare prescription drug "benefit" is largely a subsidy for private insurance companies.

A health care system based on the principles reported by Ezra will not be fair, it probably won't cover everyone in practice, and it won't save money. In fact, it will make health care more expensive.

Private insurance is the problem. It cannot be the solution. But if Obama, Baucus, et al, get their way, Richard Nixon's health care plan will be jammed down our throats -- by Democrats.

As an idealistic single payer advocate and health wonk who's been casting real pearls to real swine for years it's hard to " be comin' in from the cold." I want to fight over details, marshall my (obscure) facts, put up my (often disingenuous) slides at Grand Rounds and rail about all that must be changed. In fact, everything has changed.

I was depressed for 3 years after a mere $18 million from HIAA on TV (Harry and Louise) put away Hillary Care at the opening bell. If there is a lesson there it's a structural one: the House initiates a spending bill and the Senate has to pass it too. Obama is popular, but like it or not those 2 lovely Republican ladies from Maine, and that smarmy wretch Lieberman have to go along with us. ( I am perfectly happy to give Rohm (sic) some census money to spread around judiciously to buy a few votes.)

The posts so far seem to have forgotten that the way government ran in America used to be pretty darn good, and still is in many states and some federal departments. The savings that can be accrued by not continuing to do the wrong things will be staggering. Case in point? $175 billion savings by dropping Bushes stupid Medicare Advantage Plans right out of the box.

In short, I love having Obama's "mechanics" in the White House, and I am astounded by the horse sense and clear logic in every piece that has come out so far including this approach to health care reform. Becoming a pragmatist will lose me a lot of my friends on the left, but it's the only way to get this legislation passed. Let's do it!

The approach reminds me of Caro's book on Robert Moses, who built all those parkways and bridges in and out of New York. The first step was always to put a stake in the ground and then marshall your forces. Everything else would fall in place with a lot of luck and hard work. AS I said, let's do it!

As an idealistic single payer advocate and health wonk who's been casting real pearls to real swine for years it's hard to " be comin' in from the cold." I want to fight over details, marshall my (obscure) facts, put up my (often disingenuous) slides at Grand Rounds and rail about all that must be changed. In fact, everything has changed.

I was depressed for 3 years after a mere $18 million from HIAA on TV (Harry and Louise) put away Hillary Care at the opening bell. If there is a lesson there it's a structural one: the House initiates a spending bill and the Senate has to pass it too. Obama is popular, but like it or not those 2 lovely Republican ladies from Maine, and that smarmy wretch Lieberman have to go along with us. ( I am perfectly happy to give Rohm (sic) some census money to spread around judiciously to buy a few votes.)

The posts so far seem to have forgotten that the way government ran in America used to be pretty darn good, and still is in many states and some federal departments. The savings that can be accrued by not continuing to do the wrong things will be staggering. Case in point? $175 billion savings by dropping Bushes stupid Medicare Advantage Plans right out of the box.

In short, I love having Obama's "mechanics" in the White House, and I am astounded by the horse sense and clear logic in every piece that has come out so far including this approach to health care reform. Becoming a pragmatist will lose me a lot of my friends on the left, but it's the only way to get this legislation passed. Let's do it!

The approach reminds me of Caro's book on Robert Moses, who built all those parkways and bridges in and out of New York. The first step was always to put a stake in the ground and then marshall your forces. Everything else would fall in place with a lot of luck and hard work. AS I said, let's do it!

All I see here relates to financial "health."

I don't see ANYTHING about the public health or the health of patients, or the quality of care they receive. I thought that was the primary point of "reform" in the first place. Perhaps I am sadly mistaken on that count.

If all Obama cares about is "financial health" and there's no public option, then that seems to add up to even more rationing from the private sector than there is now. I hope I'm wrong about this.

This isn't change. This is applying a 50-cent band-aid to a sucking chest wound and calling that "cost effective health care."

We're still going to be stuck with the fact that the rich will be saved, while the rest of us will be left to suffer, albeit more affordably.

Where are transparency and its live-in partner simplicity?

Medicare for all is the only way we can afford universal access to health care. It will save money and provide economic stimulus for business. Take the middle man out of it. I don't want or need an insurance company between me and my doctor. HR 676 is the best way to go. Employer based is not right for me or my employer.

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