Ezra,
My only issue with the proposed planned is one I have with regulatory boards in general: Quis Custodiet Ipsos Custodes? (Who watches the watchers?) On many regulatory boards, you have X number of Democrats and X number of Republicans but both sides end up being, to a large degree, former lobbyists or insiders for those industries that they regulate.
If I were an insurance company or health-care-insider with a stake, that's where I would strike during conference committee.

"-- you can presume that Obama is serious on health reform." - Ezra Klein on May 14, 2008 3:00 PM

WE CAN?

I don't like the idea of a Health Board. Isn't it just an end run around Congress, the elected representatives of the people? How would we react if the Republicans set up an Iran War Decisions board? The point is not to compare the two, but to point out that any decisions made outside of the congress will not be viewed as legitimate by anyone who opposes the conclusions.

A doctor as the board chair? As long as the doctor isn't wearing a tie with dollar signs. I'm serious. This happened to a friend of mine when he was seeing an orthopedic doc. Even doctors can have serious conflicts of interest and I'm not sure we would want our entire health care system run by doctors either.

Ezra,

Providers can’t stand the government’s meddling, and resent the attempts of know-nothing politicians to set payment rates and dictate treatments.

Build in a provision ensuring that a doctor will always be chair of the board, and then run ads saying, "We've seen what happens when insurance companies run health care. We don't want the government doing it. Isn't it time we had a health system run by doctors?"

This is a fundamental misunderstanding of why doctors are resistant to having an outside authority get involved in health care decision-making.

It isn't about government meddling.

It isn't about big, bad insurance companies.

Physicians don't want anyone, including other doctors, telling them how to practice medicine.

Read about their resistance to "cookbook medicine." Read about their reluctance to buy into "population-based medicine" (the basis of a centralized authority's decisions).

This type of thinking is illustrative of policy people who "get the issues" but really don't have grasp of the nature of the challenge. Physicians don't want anyone looking over their shoulder. Period. (Read about the importance of autonomy to physicians relative to other job characteristics.) No one is looking over their shoulder now and they'll trash any reform proposal that aims to change that.

And I would simply ask the question, if you think our banking system today is reasonably regulated, why not try the same type of model for our health care system?

Surely he jests?

The Bear bailout was justified on the grounds that it's collapse could take down the whole financial system. The system is so shaky that one investment bank getting into trouble could take down the whole thing. And Daschle thinks that's an example of an adequately regulated system?

Unless he meant the converse of what it sounds like: the current banking mess is a great example of what happens when industries are left to regulate themselves, and we really don't want that happening any longer in healthcare.

I don't like the idea of a Health Board. Isn't it just an end run around Congress, the elected representatives of the people?f

And yet you don't say a word about delegating a constitutional responsibility to a quasi-private corporation to regulate the (phony) money.
what's with *that*?

Ohh sure, elect the black guy then have him prop up the old tired white power structure.

Not going to happen. Look for a Carol Moseley Brown or a Dina D. Strachan.

No sense bring the white boy club back.

Doctors are the ones who are denying certain coverages at insurance companies. It's called cover for the insurance companies - your doctor was just being overzealous with that test we are denying, our more clearheaded doctor knows best.

I think his idea is a good place to start a conversation. We know from our research that people would trust health care professionals (vs.simply doctors) and nonprofits that had some elder statesmen associated with them.

I think it is incumbent upon us to start thinking of how something could work rather than simply dismissing an idea. We can't stay with what we've got and its time we started to look for some reasonalble ideas.

We have an online discussion forum we are just starting on his book. http://www.codebluenow.org/vital-signs/the-forum

I invite you to join the discussion and see where it leads.

Kathleen O'Connor
www.codebluenow.org

Obama now has to drag out tired old white boy Edwards to get the taste of West Virginia out of his mouth.

It amazes me when people still think the government is the first place to look for answers when we know every single federal program is a disaster, it is poorly run, badly managed, wastes huge amounts of money and has zero accountability.

I guess when you get a little older you finally start to see what an absolutely poor job government does at delivering anything.

...cue Nate's cri de coeur: "The politicians are going to destroy everything!!! They must be stopped so that Wal-mart can save us!!!! Why am I the only one that see the truth of this?!"

Only, of course, not spelled as well...

Co-opted second round of appointments, if not first. Not even clear what the point is under idealist expectations - I can't see what this accomplishes besides strengthening the bureaucratic corner of the iron triangle.

Great transcription.

Flattering DMonteith,

I’m so in your head you can’t read a single post without worrying about my opinion of it. You could save me a ton of time commenting if you could just figure out my beliefs. Why you haven’t been able to grasp them when I post them all over the place troubles me.

The difference between you and I and why I am successful and you are not boils down to your saving comment. Where as you hope and count on politicians saving you I seek no savior. I’ll work my ass off to provide for myself and those I care about. If that effort falls short I’ll look to my family for assistance or friends. That assistance I provide in return.

No one is expecting savior from Wal Mart. The reason corporate solutions are preferred over governmental is control. I have a moderate level of control over a corporation I choose to do business with or not. If a company provides terrible service and enough people withhold their business eventually change will happen.

Government imposed programs offer no such mechanism for change. The government can and has mandated terrible programs for generations.

Yes our healthcare system has many faults, most bestowed by politicians, but the majority of participants have choice. Almost everyone with insurance could change carriers if they had to or if the rates where completely unjustified they can choose to exit the system altogether. In a government mandated system you could lose your choice of carrier/plan or to even participate. The government can charge you any rate they feel like with no concern for justification, through taxes or premium you’re forced to participate.

I can’t help the fact your to stupid to realize government will take control of your life if you let it. That doesn’t mean I have to throw my life away with yours. I don’t need the government to insure my retirement, provide my healthcare, pay for my education, or any of the other obtrusive endeavors it has engaged in the past 50 years. I do need it to protect me from foreign aggressors and to provide a legal framework under which we can live. Regulation related to keeping businesses honest and safe are also acceptable.

While you waste your entire life waiting for someone to “save” you I’m out working to provide. That is why your progressive wealth redistribution is so annoying. If you spent half as much time working as you did trying to leach off me you would be successful enough you wouldn’t need to.

QED

I think that the "doctor" needs to be a primary care physician who understands intimately how decisions will affect the front line of medicine. A dermatologist or radiologist is unlikely to have the needed perspective to help set rates for reimbursement of primary care.

Regulatory. Capture.

To do this right, you'd need an organization pretty much the reverse of the Federal Reserve in all ways (except perhaps the strong regional component and the enormous independent research staff). The Fed's decisions, and the rationales for them, are mostly shrouded in secrecy. Some kind of health board would have to have open deliberations, and would have to publish extensively the data it relied on to make decisions, or it would have no credibility at all.

(Of course, if you are deciding what gets reimbursed and what doesn't, what do you need credibility for?)

Better yet, why not the Federal Deposit Insurance Corporation -- whoops, I mean the Federal Health Insurance Corporation? Similar idea, though. It does three things: (1) it completely covers catastrophic losses (over X) for everyone in the country -- there's your "mandate": "You're covered, period, forever"; there's your "single payer," too, but don't need to raise everyone's hackles by calling it that; (2) it offers non-profit low deductible insurance policies underneath the catastrophic layers that compete with private policies for any insurance company that wants to offer them; and (3) it sets ground rules for private policies, mainly no pre-existing conditions and simple, standardized deductions, co-pays or exclusions to allow ready apples-to-apples comparisons. The objectives are (a) prevent anyone from ever suffering from a complete financial catastrophe from a healthcare problem, (b) make sure healthcare providers know they will get paid (at least most of a big bill) so they can just go ahead and provide it, and (c) put a ceiling on potential benefits costs so employers can begin to hire emoployees again. Medicaid and the like can be transferred to subsidies for low income people to buy the insurance underneath. Simply by solving the insurance problem, we (1) eliminate the armies of people looking for and fighting pre-existing conditions; (2) we tremendously reduce the cushion healthcare providers build into their fees for delinquencies and collection; (3) we can virtually eliminate 1.5% finance charges that accrue on a high proportion of healthcare bills because payment is so spotty. Reducing coordination of benefits with a clear sequence of responsibility will also help. These are huge aggregate cost reductions in and of themselves.

Do the insurance first. It's the most crying need for one thing, but also we can then isolate and attack the other irrationalities more effectively. It's also simple in concept, which helps build political support. Complexity destroys political support. Explain it in 10 words or else. As with anything, promote the benefits -- the problems to be solved -- more than the features.

urban legend,

There is already a highly functioning market providing catastrophic insurance. It’s referred to as stop-loss, is arguably the most efficient insurance market in this country or the world, highly competitive, and has low margins. It is also one of the only true forms of health insurance sold in this country, it’s an ideal product to be sold by businesses called insurance companies.

The only thing stopping small employers and individuals from cheaply ceding off their high dollar risk is Federal and State Regulation. Specifically the Democrats have determined that entrepreneurs and individuals don’t deserve the same access to affordable care as unions and government agencies get by joining together.

Low deductible generally means your no longer buying insurance. If you know you’re going to hit it why by protection from it? Buy a high deductible and use the premium savings to pay more claims. Low deductibles and co-pays are inefficient use of capital.

There are no armies looking for pre-ex. It’s all automated and done by computers. If your date of higher is within X days of the claim the computer mails a letter asking if it was pre-existing. If the person responds the claim is processed if they don’t it is denied. Since HIPAA passed pre-ex is a rare case, seldom are claims denied for it any more.

There is already a clear sequence of responsibility called the birthday rule. Underlying plans will still have to coordinate. And the number of people with dual coverage has dropped tremendously since co-premiums have increased so much. It’s not like the old days where both spouses had next to free coverage. The proliferation of HMOs and closed networks also made dual coverage worthless in most cases.

Why do you view insurance as the most troubled area? Financially it’s pennies of the big picture, most people are happy with their carrier if they have coverage. Politically it is the most popular because the media paints it as such and it scores easy votes. Anyone that actually knows the system knows all the attention being spent on insurance is detracting from the real issues. The deaths and added cost from bad prescribing are far more significant then insurance. With minor regulation requiring E-Rx you could save 100,000 lives a year by some reports. Other reports say it is only 7,000 lives but even that is more then any changes to insurance would get you. Insurance would cost billions to “reform”; changing Rx practices would save money. Insurance reform could fail and crash our entire economy. Better prescribing has no risk yet is almost completely ignored. Why do you overlook easy solutions that immediately return benefit with no adverse risk?

Any potential savings you invision would be lost by the 10% fraud rate. If I was a provider I would be salivating knowing once I got biled charges past $X everything was paid at 100% by the government. Service rendered and cost would go through the roof. It's these praticialties that are voer looked by all these pie in the sky reform schemes. We gave providers open reign on our wallets in the 80s and early 90s and they abused it so bad we created PPOs.

What would be an extremely effective use of a federal reserve like system is information. The Fed processes ACH transactions for .07 I think, something close to that. The charge to send a claim via EDI is $.25-$.50+. Technologically speaking it’s only a larger file, no reason for it to cost so much more. The Fed should set up a new agency to remit claims between providers and payors. This would also have a HUGE public health benefit as they could capture and study all the care happening in the country within days of it taking place. Once the claim is paid they could clear payments back to the providers, very similar to what the Fed already does. This would also have some huge benefits in detecting fraud and tax evasion.

"most people are happy with their carrier if they have coverage."

Um, that's the whole point here. 47 million don't, another 200 million don't know whether they will end up naked if they lose their job.

Not sure about all your information, which exceeds mine, but it seems like you really aren't getting it. I personally have nothing against insurance company involvement, but the ability to exclude some -- for which I don't blame the companies, because that's their job, they aren't charities -- is the eseence of the national problem. Everyone must have health insurance, and the current system is failing miserably in that regard.

urban legend,

Most of this is urban myth. The 200 million, I think that number is high, with group insurance, majority of people, are protected by HIPAA. You have to try very hard to lose your insurance in America if you’re covered by a group plan. Of course Ezra and the others who make a living of demonizing our current system and the reporters selling sob stores are never going to tell you this. HIPAA waives pre-existing condition limitations in almost all situations where someone isn’t trying to game the system by waiting till they are sick to purchase care. COBRA gives you 18-36 months to find another job or coverage.

Insurance companies are not denying people to avoid paying claims, anyone telling you that is a liar.

If someone loses their job and doesn’t have enough savings to pay their COBRA premium is that a problem with our insurance companies or our personal saving habits? If you don’t have adequate unemployment insurance again that is not the problem of our Health Insurers.

47 million don’t have coverage but the vast majority of those are by choice. Again anyone telling you 47 million Americans can’t get insurance is lying to you. Half of those are already eligible for government coverage and decline to enroll. Another large percent make over 75K a year and choose to not purchase insurance. There are only 3-5 million Americans that truly can’t afford insurance. Is it worth scraping a system 300 million Americans are happy with so we can cover 3 million? Does it really take a trillion dollar government reform bill to insure 3 million people?

INSURANCE COMPANIES CAN NOT EXCLUDE PEOPLE WHO HONESTLY PARTICIAPTE IN OUR INSURANCE SYSTEM. There is no arguing this statement, in every state there are government plans, private plans, HIPAA plans, and other coverages available to every single person no matter how unhealthy.

Why so many people choose to stay out of the insurance system and why it is so expensive would be a whole other post but the majority of the problem came from politicians and their past “reform” efforts. HMO Act, NY State Surcharge, COBRA and HIPAA being 4 perfect examples. Throw in small group reform like that in CA, NY, and MA and it is obvious to anyone that wants to see it Politicians are killing our system and making it unaffordable.

Compare small group reform and rating in CA and NV. CA has a spread of .9 to1.1. If you’re an unhealthy group you have no incentive to improve you loss ration because your rate won’t drop. This also pulls the cost for healthy people up to a point where common since would dictate they don’t take insurance. The healthy subsidize the unhealthy to such a large extent in CA they drop out which means neither they nor the sick can afford insurance.

NV has a rating spread of .85 to 1.55. With this margin little changes in health can have a noticeable impact on premium. The healthy are still getting a fair deal and thus purchase insurance while still subsidizing the unhealthy making it slightly more affordable for them. This is the difference between progressive reform with no basis in logic or economics and sound conservative reform that actually works.

Nate. For someone "so successful" at whatever it is you do to make a living, you sure do have a great deal of time on your hands. As I've told you many times before, you're a joke. You're not going to change the minds of anyone on this site, as your presentation is replete with an ideology( right wing.) that has proven itself time and again to be an abject FAILURE. The reason that the country is in the economic mess that we are in is because of the idiocy of those with whom are your ideological bretheren. The gramm-blilely-leach act. The "Enron" loophole. Unassailably direct causes of our current economic malaise. What you FAIL to understand,is that no one wants government to solve all our problems, but we do believe that it (We.) does play a major role in the speed of social progression. Bottom line: A health care system that involves the government on a more fundamental level for the purpose of insuring that ALL citizens have access to it, without jeopardizing the individual's economic well-being, or that of the country's, IS coming. If you don't like that, then I suggest you move to some place where corporations run every aspect of the individuals life. Oh, I forgot. That place does'nt exist.

>> INSURANCE COMPANIES CAN NOT EXCLUDE PEOPLE WHO HONESTLY PARTICIAPTE IN OUR INSURANCE SYSTEM. There is no arguing this statement, in every state there are government plans, private plans, HIPAA plans, and other coverages available to every single person no matter how unhealthy.

hahahaha. that's funny. i would love to live in your world.

true scenario: lose job. either pay huge amounts for cobra to maintain insurance until you find another job. if you miss out on cobra or can't afford it (because, uh, you have no job), if you go for 3 months without, you can have prior conditions excluded when you finally do get insurance

or are you referring to getting medicaid/medicare during your job loss? cuz have you ever tried to apply for that? really? with previous salary history? obviously not.

it's funny how, on one end, you say that any government program sucks and is run horribly. but then you say, during a bad time, there are plenty of state and federal options that can keep you healthy.

plans cost money. no job, no money, no plan, no insurance. how hard is that to understand?

Fear: fear of not getting the care we need, fear of being denied coverage, fear of impending expenses: we've been twisted around this condition for far too long.

First, as a health care provider and as a patient, insurance companies add NO VALUE and divert precious resources of time and money. We do not need them. Get rid of them. Retrain those workers to add value by becoming health care workers.

Second, regarding the assertion that the government never does anything right: that's wrong too. The VA medical centers are exceptionally well run and deliver much better care than the private institutions I have encountered.
What we need is to identify and replicate GOOD MODELS of health care delivery.
As a provider, we all need to have our outcomes studied: right now we all assume we're great, and even if we are lousy, nobody would know, least of all ourselves. As a consumer, with an ill child, wouldn't you want transparency in the system so you could tell if the treatment being offered was the most effective? WE ALL NEED THIS INFORMATION NOW BEING BLOCKED by a competitive, market-driven, for-profit model. We need a different model. Just look at the auto industry: the good efficient cars are being made elsewhere...The lesson is that sticking with what we already DO without reference to what actually works well is not going to get us where we need to be.