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View Diary: Flu And You - Part V (146 comments)

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  •  here's the deal (and I really believe this) (0+ / 0-)

    half the country cares about access and half about cost. The single payer advocates are convicned nothing else will do. In thinking that, as Atul Gawande said the other day,

    Yet wherever the prospect of universal health insurance has been considered, it has been widely attacked as a Bolshevik fantasy—a coercive system to be imposed upon people by benighted socialist master planners. People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse—especially for those who already have dependable coverage and access to good doctors and hospitals.

    Many would-be reformers hold that "true" reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.

    Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have. The country has this one chance, the idealist maintains, to sweep away our inhumane, wasteful patchwork system and replace it with something new and more rational. So we should prepare for a bold overhaul, just as every other Western democracy has. True reform requires transformation at a stroke. But is this really the way it has occurred in other countries? The answer is no. And the reality of how health reform has come about elsewhere is both surprising and instructive.

    Must read, my bold.

    "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

    by Greg Dworkin on Sun Feb 08, 2009 at 10:17:58 AM PST

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    •  Sounds like Third way thinking to me. (0+ / 0-)

      Have the Wingnuts (free marketeers) aggreed to this "third way" already? Have they been dismissed as extremists by their own moderate pragmatic repuglicans? Is there a debate on their side about how they must move to the "Pragmatic" center? The answer is NO. Isn't it true in today's political enviornment Pragmatists rarely demand as much from the Right as they do the left. Why? Experience thats why. The "Third way" in reality always ends up turning to the left for sacrifices because they know the right will never move towards the center now matter how right of center the center is. My argument was not one of contempt for the free marketeers but of a grudging respect that is well earned when dealing with the right. All one need to do is point to the present stimulus plan. The Dems started out conceding to the middle ground, offering a "Bipartisan" plan. The rest is history! I believe we must negotiate from the FAR FAR LEFT then after fighting like hell move as little as possible towards the center. This is my Pragmatic approach to negotiating with the Wingnut right. P.S. I really enjoy this discussion your a powerful debater.

      Disabled Viet Vet ret. My snark is worse than my bite

      by eddieb061345 on Sun Feb 08, 2009 at 11:54:23 AM PST

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      •  thanks (1+ / 0-)
        Recommended by:

        here's another way of looking at it.

        the reason that the free marketers can be safely ignored (debate is between pragmatists and single payer): they lost.

        "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

        by Greg Dworkin on Sun Feb 08, 2009 at 12:02:59 PM PST

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        •  Oh really? They can be ignored? (0+ / 0-)

          If they are being ignored they sure don't seem to act that way. McIsane is acting like he won the election! He and his fellow repigs are enjoying every minute obstructing Obama's plan. Worst of all they're achieving their goal! Reid being pragmatic has caved to the so called "Centerist" who just butchered the bill  pushing far off center to the right, taking out almost every center and center left proposal. So after all is said and done did Obama and his teams attempt at pragmatic Bipartisanship work? This is something we must learn from. No matter how much logic and intelligent thinking we may apply to creating a working universal health care system we must factor in how we must overcome the Irrational, illogical, mean spirited unethical powerful response of the wingnuts ability to muck it up.

          Disabled Viet Vet ret. My snark is worse than my bite

          by eddieb061345 on Sun Feb 08, 2009 at 12:28:43 PM PST

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          •  they are marginalizing themselves, actually (0+ / 0-)

            once the bill passes, the Dr. No contingent will be exposed as out of ideas and out of influence. As a practical matter, Collins, Snowe and Specter are negotiating with the Dems, not McCain.

            "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

            by Greg Dworkin on Sun Feb 08, 2009 at 12:41:22 PM PST

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            •  Those who don't learn from history (0+ / 0-)

              you know the rest. I thought the Dr. No clan was already exposed after the election! Aren't you ignoring reality here. If they were whupped in the election and still managed kick the crap out of the Dems in battle over a bill desperately needed to save our economy. After all that, even though they  and their ideas were rejected by the voters in Nov. They still had the balls to stand against the bill  almost to a man/woman in both houses. And worst of all they managed to get dems to cave on many important issues to dems a gut a great deal of the bill. In my opinion I think they will be emboldened not deminished by this. As for Collins, Snow and Spector they Are negotiating with the Dems but they're working for the wingnuts.

              Disabled Viet Vet ret. My snark is worse than my bite

              by eddieb061345 on Sun Feb 08, 2009 at 01:03:18 PM PST

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              •  they didn't kick the crap out the the Dems (0+ / 0-)

                they were completely ignored in the House and they used the senate as the senate was built to be used.

                "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

                by Greg Dworkin on Sun Feb 08, 2009 at 01:23:32 PM PST

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                •  They weren't ignored in the House. (0+ / 0-)

                  The Dems with out any committment on the Repiglcans part pulled programs like Birth controll services, repairing the D.C. Mall the bill also included Many tax cuts to sweeten itin advance. So what was the response? From the beginning the wingnuts went on a fullcourt press undermining the bill in every and any way they could. They NEVER, never negotiated in good faith. In the Senate once again the Rethugs went into overdrive to mislead and confuse the public in an all out attempt to undermine the President, The Dems and the Stimulus package. There was Never any honest attempt at negotiating in good faith. They forced the Dems back to isolating and soliciting a few Republicans who took full advantage of the stranglehold to gut the bill. Considering as you so clearly observed these badly beaten and weakened thugs who should have had little or no input got up and managed to kick some Democratic ass. All this happened imho because like charlie brown Obama thought this time would be different and the rethugs(lucy) would let him kick the ball right over the goal post and save the nations economy.  

                  Disabled Viet Vet ret. My snark is worse than my bite

                  by eddieb061345 on Sun Feb 08, 2009 at 01:44:00 PM PST

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                  •  now you're talking about something else (0+ / 0-)

                    should Dems be bipartisan at all? Big debate there. I say yes, because it gives you the high ground to say no later if the other side refuses to play (and that's what happened.)

                    In the end, very few concessions were made in the house, though many were made in the Senate. The House had 95% of what we want.

                    But as for the end result and outcome? House D's will negotiate with Sen Ds and a few Sen Rs. House Rs are irrelevant.

                    "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

                    by Greg Dworkin on Sun Feb 08, 2009 at 01:49:13 PM PST

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                    •  How do you see the outcome? (0+ / 0-)

                      Will many of the democratic house programs be reinstated? Will a lot of those useless tax cuts be removed? will the sum total of the bill be closer to what Obama originally wanted? If thats the case? I will be happilly converted to your thinking. To me,  if in the end the bill accomplishes 95% of Obama's goals. Frankly I just don't see it happening unless Obama and the Dems go in full attack mode from now on. what do you say

                      Disabled Viet Vet ret. My snark is worse than my bite

                      by eddieb061345 on Sun Feb 08, 2009 at 02:05:16 PM PST

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                      •  honestly, I think that because the conferees (0+ / 0-)

                        still need 60 votes to pass (a sad fact) we get 80-85%, and some has to be put back or added at a later date. Once Franken is seated, it gets better. But there's no progressive majorit in the Senate, AND that's a lesson for health care.

                        "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

                        by Greg Dworkin on Sun Feb 08, 2009 at 02:11:51 PM PST

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    •  Single Payer reply to Gawande #1 (1+ / 0-)
      Recommended by:


      Atul Gawande is a highly respected physician who has a well deserved reputation as a gifted writer. This commentary should not be construed as an attack on him; rather, it is an attack on his message. On his writing skills I give him an A, but on his content, a D-.

      This article represents what I believe to be a misuse of framing. Gawande uses overly simplistic framing, but then bends, breaks or even replaces his frames as he develops his theme.

      Gawande uses the linear polarity that I condemned in a recent qotd comment. In the four dimensional model that I described, he places single payer at one end of a linear polarity, free marketeers at the other end, and pragmatists in the middle.

      His stated goal is a health care system that works, a goal that most of us share. Single payer is not only a financing system, but it is an administrative system that is specifically designed to make our health care system work for all of us. It is a system designed to address our problems not only in breadth, not only in depth, but throughout the three dimensions of all parameters, and over the fourth dimension of time. It is a system that is not "on the left" as he states, but, by design, it constitutes the health care universe in its four dimensions.

      The free marketeers do not provide us with a universal system, but rather would disassemble much of what we have. They would have us each attend to our own needs, paying for whatever health care we need, or purchasing private health plans, even if the premiums alone are 16 percent of our income. No serious student of health policy would ever consider that to be a system that would work for all of us. At least Gawande is correct when he places the free marketeers out "on the right."

      What about the pragmatists? Of course, pragmatism is the theme of Gawande’s article. He cites path dependency as the natural model to achieve reform. Use what we have, and build on it to bring us closer to our goals.

      But what is it that we do have? We have an expensive, dysfunctional health care delivery system that needs extensive repair along with adoption of efficiencies so that we can pay for it. Within the health care delivery system, we need to build on what is working, and replace that which isn’t.

      But what else is it that we have? We have a health care financing system that is wasting tremendous resources, while impairing access to much needed health care, and exposing individuals to financial hardship or even financial ruin. Gawande’s major error in framing is that he conflates our health care delivery system with our health care financing, as if they were one and the same. Since we need to build on our existing delivery system, he includes as a given that building on our current fragmented financing system is an integral part of the process.

      Look at the example that he gave us: the Medicare drug benefit. By the model of path dependency that he supports, drug coverage should have been added to Medicare as yet another benefit in the program, and it would have served us very well. Instead, it followed another path dependent road - our dependency on private health plans to cover prescription drugs. As Gawande states, this decision has likely killed people. Yet he insists that building on a financing system dependent on private insurers is essential because it’s path dependent.

      He leaves us with an example of a successful application of path dependent reform - the Massachusetts "system of universal health coverage." He glosses over the point that their system is not universal, although he does concede that the plan has done nothing to control costs, even though humane cost containment is an absolute imperative of any reform program.

      But then it is hard to dispute Gawande’s perception that the Massachusetts plan is a success. After all, his surgical fees are being paid.

      The pragmatic approach to financing reform is to follow a path dependent program that works, and discard those that don’t. With improvements, Medicare would work well for all of us; private health plans would work for those of us who are relatively healthy and have good incomes, like Dr. Gawande.

    •  single payer reply to Gawande #2 (0+ / 0-)

      Single payer: mainstream and 'shovel ready'
      To the Editor of The New Yorker:

      In "Getting there from here" (Jan. 26), Atul Gawande suggests that the Massachusetts 2006 mandate plan is a model for national health care reform. He sees his stance as pragmatic, politically feasible, rooted in the particular history of American health care and gifted with the commonsense wisdom that we must start from where we are. Advocates of national health insurance (single payer) are characterized as ideologically driven extremists with "contempt" for pragmatists. I respectfully disagree.

      Most Americans, including most physicians, supported national health insurance even before the recent economic collapse, polls show. Endorsers of the single payer bill H.R. 676 (Expanded and Improved Medicare for All) include 93 co-sponsors in the House of Representatives, 450 union organizations in 45 states, and countless others representing a wide range of constituencies. This is not a fringe movement.

      High costs are the root cause of Americans' health insecurity. Gawande's analysis is flawed by use of a framework centered on insurance coverage rather than the more fundamental issue of health care value. Gawande sees employer-based coverage as the "path-defining" element of our current system because most people are covered by it. Well, it's all in how you look at it. We need to keep our eyes on the prize, the health care dollar, and follow the money. Government already dominates: tax dollars fund most health care expenditures in the U.S. This is because government covers the sickest and poorest people, tax-favors employer-based private insurance, and covers its own employees. To use Gawande's metaphor, the lifeboat is already bigger than the "main boat" of American health care. This is where we start.

      Gawande asserts that Massachusetts "recently became the first state to adopt a system of universal health coverage for its residents." As Yogi Berra said, this is like déjà vu all over again. A nearly identical assertion was made twenty years ago by then Gov. Dukakis about Massachusetts' 1988 reforms. More breathless proclamations heralded reforms in Oregon (1988), Minnesota (1992), Tennessee (1992), Vermont (1992), Washington (1993) and Maine (2003). These plans all had common themes: public spending initiatives, new regulations and mandates, and continued dominance of private insurance in covering low risk populations. None achieved universal coverage. The common denominator of the ultimate failure of all these plans was the absence of effective cost control. Two weeks ago Gov. Deval Patrick of Massachusetts warned that rising costs "threaten to crush families and businesses and doom Massachusetts groundbreaking experiment with universal insurance."

      In the face of economic collapse and soaring unemployment, with a third of Americans forgoing medical care due to cost, "Job No. 1" is getting value for our health care dollar, not preserving employer-based health insurance. The repetition of failed experiments is not pragmatic, it is part tragedy and part farce. Electronic medical records, chronic disease management and more emphasis on prevention are all important for many reasons but we must admit that short- and long-term cost implications are unknown. Some of these measures may actually increase costs. Medicare is not perfect, but it is demonstrably more cost-effective than private insurance and beloved by most Americans. It is "shovel ready." Single-payer supporters say: everybody in, nobody out. Burned in the fires of the failed Clinton reforms, I believe Gawande misreads the plate tectonics of political possibility at this moment in history, asserting, "No, we can't" when the opposite is true.

      Laura S. Boylan, MD
      Clinical Associate Professor of Neurology, New York University School of Medicine
      Attending Neurologist, Department of Veteran's Affairs
      Board Member, Physicians for a National Health Program Metro NY

    •  only plan that controls costs & does access (0+ / 0-)

      Look at Commonwealth analysis, and all the prior analyses by Lewin, and earlier by GAO & CBO. Only Single Payer (or Stark near equivalent/stand-in) controls costs.

      That why Mandates/Obama/Baucus are so terrible... costs explode.

      Single Payer may not "feasible." Politically correct as it were

      But even its objective opponentd (Lewin, KFF, Lewin, etc.) agree that we are right so far as policy & economics.

      The problem with Gawande, and Ezra Klein, and Jon Cohn and Maggie Mahar and Baucus, and Wyden, and SEIU and Families USA, and Obama and Clinton, etc. (and Enzi of course) is that they are wrong about policy and economics.

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