The poet Juvenal wrote, “We Romans have forgotten our civic duties; the People who once approved everything, military command, high civic offices, legions, now hold back and anxiously hope for only two things: bread and circuses.”
This was written in the early 2nd century AD when Trajan was emperor. The Latin word circus means arena or amphitheater. The Circus Maximus in Rome was used primarily for chariot races (ludi circenses); it was also used for gladiator sports. The Circus Maximus, originally a wooden structure, burned many times, including in Nero’s famous 64 AD fire. Trajan enlarged and rebuilt the circus to its maximum capacity, probably over 200,000 spectators (Roman writers give various estimates). The Spanish-born Trajan discouraged Christian persecution and was supposedly baptized posthumously by Pope Gregory the Great 380 years later to save his soul or release it from Hell. Trajan was widely respected and often mentioned by Christian leaders as a “noble pagan”.
Americans beg for cheap gas and cheap medicine today.
The Roman Empire was in good shape economically; ordinary citizens were better off than in many other eras. Trajan's conquest of Mesopotamia (including modern day Iraq) increased the Empire to its maximum size but Rome couldn't hold it for even 20 years. Juvenal’s satire implies that the Roman ‘better classes’ felt “on top of the world” and focused only on their short-term pleasures. Whether Roman public opinion had any consistent effect on Imperial policy is doubtful. The Republic was lost when Julius Caesar crossed the Rubicon in 49 BC. Juvenal exaggerated the thoughtfulness of the Romans, just as our politicians do with us today. Americans beg for cheap gas and medicine today, not panem et circenses. We get gas but here I mean “hot air”.
The three-ring circus: Modern circuses began in 18th century London. Crowds came and paid to see Philip Astley’s riding tricks. Riding in a circle made the tricks easier and made it easier to collect money. Astley covered over his riding ring in 1770; it was called Astley’s amphitheatre. The circus flowered in 19th century America; the three ring circus was a grand spectacle with simultaneous acts in each ring or tent.
Healthcare is a big problem today. I know this arena (circus) from the inside. Many Americans are anxious and unhappy about healthcare, but those with insurance usually tell pollsters that their own healthcare status is OK. Their main worry is costs. The average family health insurance policy cost over $13,000 in 2006. Corporations and other powerful groups worry more about costs than universal coverage.
I’ll review three major schools of thought about healthcare reform. We begin with the Hacker plan and briefly consider its children, the Clinton, Edwards and Obama plans. Before starting, I urge those interested in healthcare to read the May American Prospect special report, http://www.prospect.org/... and Ezra Klein’s nice May 7th article, http://www.prospect.org/...
I. Jacob Hacker wrote The Road to Nowhere about the failed 1993 Clinton health plan. He recently developed what he believes is a better health plan. He is a social scientist, not a healthcare worker. Progressive think tanks sold his plan to Democratic presidential candidates, and the Washington-based Lewin group “validated” it. It has some appealing features. People may keep their existing insurance, as long as the employer offers it. Uninsured persons will be covered through a new group market, Health Care of America (HCA) where private insurers compete with a comprehensive public insurer similar to Medicare. Insurance would be portable and out of pocket expenses would be capped. The public insurer won’t need profits, and can negotiate good drug prices; it should cost less and indirectly push down the costs of private insurance. Businesses may save money by enrolling their employees in the public plan. Businesses who don’t insure employees will be taxed at 6% of their payroll. Insurance for those below 200% of the poverty level would be completely subsidized.
Hacker assumes that the public insurer can compete in price and quality with private insurers and control the rate of future cost increases, to 0.5% above the rate of GDP increase. These rest on Hacker’s notions that Medicare is politically popular and financially secure. The first is valid, the second is not. It’s easier to see why the Lewin group “validation” is propaganda if you download the 2007 Medicare Trustees report Trustees report. Go to page 44 of the report and examine Table III.A5.—Comparative Growth Rates of Medicare, Private Health Insurance, and National Health Expenditures. I show three years here:
http://www.flickr.com/... Medicare costs have been increasing faster than GDP or total health expenditures, notwithstanding Hacker's optimism. Medicare is not dead; it collected more money in 2007 than it paid out. However it added frills in the Bush era like the Medicare advantage program, which benefit private insurers more than patients. Hacker assumes that someone will create new guidelines to control costs. As he says, the average increase in Medicare outlays was less than the rate of increase in private insurance costs averaged over 1970-2002. If Medicare bought drugs like the VA does, the rate of increase would be less – perhaps 7-7.5% in 2007. That is still significantly above the GDP increase. Congress prevented Medicare from applying cost controls to reduce provider reimbursement, as Klein notes. Medicare could be actuarially sound, as noted by Feinman and others, but not if Congress continues to add benefits for insurance companies and not without overt rationing (we already have covert medical rationing).
There are many reasons that public insurance can’t compete with private insurance unless everybody pays into the public plan, as in England and most European countries. Private insurers shed high cost patients in many ways- dragging their feet to provide specialty care and telling the patient, “Well, you can sign up with Medicaid and see University Hospital specialists”, being excused from paying for ER visits and mental health, in many states, and starting with a healthier population that is more likely to keep appointments and take medicine as prescribed. Suburban hospitals often send very sick patients to the inner city public hospitals for care even though these hospitals are in suburban counties that don’t support the public hospitals financially, as noted by Dr. Feld, http://stanleyfeldmdmace.typepad.com... Our politicians are eager to help private insurers and private hospitals- the Medicare advantage program is only one outrageous example. Public insurance competing with private insurance would be like playing blackjack with a friend who can exchange one third of his losing hands with you. You can’t win.
The Hacker plan would charge businesses 6% of payroll for uninsured employees. Massachusetts businesses pay only $295 per employee (much less than 6% of payroll) and not even that if they offer coverage to 25% of employees. Hence, the Mass plan has big financial problems. A May 21st Wall Street Journal editorial (not necessarily unbiased) calls it “The New Big Dig” http://online.wsj.com/.... The Clinton Health choices plan says that “small businesses” (not defined) would be excused from paying into the public plan. Obama says that employers that don’t offer or make a meaningful contribution to the cost of quality health coverage for their employees will be required to contribute an unspecified amount toward the costs of the national plan. “Small employers that meet certain revenue thresholds will be exempt.” Neither Clinton nor Obama say how they would control future cost increases. Congress, always alert for ways to help corporate sponsors, would probably excuse businesses offering high deductible HSAs from paying the public insurer if either the Clinton or Obama plan were presented for serious discussion.
In the second tent we find the McCain healthcare plan and Dr. Stanley Feld, of repairing the healthcare system blog, sometimes very perceptive, assisted by libertarian medical bloggers like the Code Blue Blog. McCain’s plan would eliminate tax breaks for employer provided health insurance—and give $5,000 tax credits to families to buy their own insurance. He and other, more thoughtful proponents of “consumer choice health plans” believe that individual policies would encourage competition and choice, and drive down the costs of health insurance.
McCain proposed that the federal government work with the states to cover those unable to “find insurance on the open market.” States would be encouraged to create high-risk pools to contract with insurers to cover people rejected by the market. If family insurance costs well over $10,000 a year and McCain offers a $5000 tax credit, only the top 10% of earners, if no family members have a chronic disease, could afford his plan. A $5000 tax credit is no help to many Americans. High deductible medical savings accounts appeared in 1994 and morphed into health savings accounts, offered by many corporations to save money- the employee pays all medical bills until a certain level is reached. Doctor Feld complains that the insurance companies use HSAs to benefit them and screw the worker/consumer http://stanleyfeldmdmace.typepad.com... A recent GAO report confirms that HSAs mostly benefit high income families and are used as tax shelters, subsidize the wealthy
Feld correctly identifies insurance profits as the biggest problem. He believes that average people can negotiate through the maze of misinformation and advertising to get good medical care at less cost. The Code blue blog has interesting articles about mammograms and what Dr. Boyle calls mammactivists, special interest groups who put breast cancer above all else and have prompted federal regulations which impede the use of other technologies, and have delayed progress in breast cancer screening. This is a small part of the American medical problem but it illustrates that special interest groups demand isolated laws which hurt the system as a whole, similar to the often destructive California ballot initiatives. http://codeblueblog.blogs.com/...Special interest groups have convinced state legislators to require that health insurance cover their special interest, whether wigs, acupuncture, chiropractors, naturopaths, podiatrists or breast reduction surgery. Some states have over 50 mandates, which add up to real money; their cost is passed on to the consumer.
Insurers have reason to ignore the individual policy market. 1) People with jobs are generally healthier than people without (Companies can legally discriminate by focusing on the "group/employer market”); 2) an easy "out" for denied claims - "the policy your employer provided doesn't cover that" (instead of "the policy we sold you isn't right for you" which may cause problems). A large individual insurance market requires elimination of the employer-based market. Insurers can’t sell many individual policies because of our tremendous economic inequality. If I were an insurer, I would oppose the McCain plan and favor some flavor of the Hacker plan. In fact, insurance companies have been donating to Democrats, not Republicans, and expect to make money from whatever flavor of the Hacker plan is voted in http://covertrationingblog.com/.... Feld and “DrRich” grand unified theory are intelligent advocates of individual HSAs, unlike McCain & his cronies.
- The third tent holds jostling angry and self-righteous reformers who insist that politicians are ignoring the real issues in the US healthcare system. I list Dr. Marcia Angell’s essay in the Prospect and two recent books: Overtreated, by Shannon Brownlee and The Corrosion of Medicine: Can the Profession Re-claim Its Moral Legacy? by John Geyman. They stress the problems created by commercial insurance and the over treatment of patients by US physicians who prescribe more drugs per patient and order more tests and surgery than in other developed countries with better healthcare outcomes. Angell’s short article begins “The U.S. ... is unique in treating health care as a commodity to be bought and sold in a marketplace. Care is distributed according to the ability to pay.”
Angell emphasizes the inevitable conflict between profits and affordable, sustainable, high quality care for all: “..., there's a fundamental illogic to trying to contain costs in a market-based system. Markets are about expanding, not contracting. Like all businesses, hospitals want more, not fewer cus-tomers –but only as long as they can pay.” Whether they are drug-makers, medical device-makers or for-profit hospitals, U.S. corporations need growth. They respond to Wall Street and to shareholders who want higher earnings, year after year. That double-digit growth is bankrupting our system.
Angell analyses the current Mass. Plan, which asks very little of employers. Romney in fact wanted no cost to employers not providing health insurance. They pay $295 per employee in the current plan if they don't provide health benefits, but they're considered to have met their obligation if they offer benefits to just 25 percent of their employees or contribute 33 percent of the premiums -- no matter whether employees accept the offer and no matter how skimpy the coverage. A $295 fine is no incentive to provide insurance that costs more than $5,000. These reformers emphasize the incompatibility between profits and universal or near universal care. Private insurance can exist as an add on for the wealthiest, as it does in Canada and Britain. Truly equal competition between private and public insurance exists nowhere- one or the other must dominate. A viable one payer plan can’t allow private insurance to offer the same services, cf. Conyers HR 676 bill, favorably mentioned by Dr.SteveB in previous diaries, section 104 which prohibits duplicate coverage http://www.govtrack.us/....
Ezekiel Emmanuel and others emphasize the need for simultaneous cost control & expanded coverage. Emanuel says “promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records, and improving quality are merely ‘lipstick’”. He means Hacker; I think he’s right. The Hacker health plan optimistically assumes that somebody will somehow control costs and that the public insurer will get a progressively larger share of the market without any drastic action. That is “single-payer by stealth” to quote Ezra Klein and it’s not realistic. The public insurer will rack up unforeseen debts, as in Massachusetts, a state far more tolerant of taxation for social justice than most of the country. The next Congressional election would see the plan repealed as candidates ran against “socialized medicine and its monster taxes”.
I work for a safety net hospital, helping mostly the poor and uninsured. We may save your life if you are shot through the heart, but we make mistakes, have a ponderous bureaucracy, are controlled by venal politicians and our care is not integrated with that of outside doctors, clinics etc. Our ER is overwhelmed. I worry about patients whose serious illness isn’t recognized and die when they might be saved. Few reformers consider the needs of emergency rooms and safety net hospitals. Bush has proposed Medicaid cuts which would take money away from the safety net hospitals; California has reduced its Medicaid payments. A recent study of big city emergency rooms showed that all were overcrowded, i.e. unable to care for new patients promptly- http://news.yahoo.com/... Closing of any urban ERs will make those surviving ERs even less effective. This may happen even before the November elections. Giving money to the safety net hospitals is not enough- we are essential, but often badly run. State authorities refused to step in to control and regulate the corrupt King-Drew Hospital in Los Angeles, a recurring national pattern.
If an underfunded Hacker plan a. won’t get through Congress during difficult economic times b. will crash and burn if it does, and if most insured Americans think that choice of competing plans is essential, how do we move forward? Can a single state like Vermont introduce its own one payer plan? Yes, but the cost would be enormous. A regional one-payer plan including several neighboring states with similar political culture seems the best bet. I can imagine California, Oregon and Washington State in a regional healthcare consortium, just as I see them all supporting same sex marriage while many other states, nearby states like Nevada, Utah and Idaho, fulminate against both. Our country is too big, our people too divided and our federal system too broken to introduce national healthcare or same sex marriage in all 50 states. Such a consortium would not require constitutional amendment but would need Congressional cooperation to allocate federal tax revenue to the plan, to buy out private hospitals unwilling to change to non-profits, etc. One could also imagine some or all of New England as another one-payer region. There is a relationship between same sex marriage and supporting a one-payer system that controls costs by limiting services, providing primary care to all and integrating ERs and safety net hospitals into a common network. Both emphasize human dignity rather than military glory or efficiency. It’s a big leap, and the mainstream media will ridicule all such ideas. Our present federal system doesn’t work; underfunded mandates, whether educational, healthcare wise or with respect to prisons (severely crowded and miserably managed) will only make things worse. The corporations will force cost control on us, services are already rationed, (visit the covert rationing blog) why not do it right?
There is no cheap gas; there is no cheap medicine. "Universal mandates" are misleading if 5 million of the wealthiest Americans opt out with HSAs, and the Hacker plan is seriously underfunded. We can't escape politics. Which politicians will work for real and sustainable change?