Gratitude Journal: January 15

With luck, one month from today, I will be on the other side of the hip replacement surgery that has occupied my every thought since the pain first became constant last August.  When I received a surgery date earlier this month, my heart opened up to the idea that I won’t have to live in the small world of crippling pain forever.  The relief I feel at having a surgery date is palpable. Aside from the pain and disability of the last 6 months, the way the situation has untethered my general optimism has been hard to bear.  It will be a good long while before I recover from the mental health disaster of draconian food restriction brought on by the requirement that I lose weight to receive medical treatment.  Being denied much-needed healthcare because of weight, especially in the absence of scientific research to support such cruelty, is appalling.  I don’t expect that I will ever again trust a doctor.  When I have seen to my recovery, I intend to speak out about the injustice of the whole situation. 

 For now, I am focused on getting to my February 14 surgery date.  And I am incredibly grateful to my son, my sister, my family members, and the friends who have helped me to get to this point and who will see me through to the other side of surgery.  Their help and willingness to celebrate the surgery date have been an incredible bright spot in this very hard patch.  My heart is full of gratitude for them, aware that I could not have made it this far alone.

The Unhealthy Side of Capitalism

I have health insurance and I am grateful for it.  Like most Americans who have health insurance, mine is via my employer.  Like many people whose employer is a small non-profit, I pay a significant share of my benefits.  In my case, that's 40% of the premium.  To insure JT and me, I pay an amount that is a shade more than $550 a month; more than $6500 a year.  My employer adds another chunk of change, nearly $10,000 a year.  The total to ensure JT and I exceeds $16, 500 per year.  That's a significant amount of money, though I wouldn't consider going without health insurance.

Most years, the company who provides my insurance is making money.  It's a for-profit corporation and that's what for-profit corporations do: make money.  It's clear that most Americans actually forget that fact when they think about health insurance.  But it is important to remember that most health insurance companies are in the business of making money.  They collect a premium from their customers and place a bet that we won't get sick.  The customers pay that premium, hedging against the prospect of illness.  No one actually wants to be sick, of course, and we quickly lose sight of the basic nature of this arrangement.

I mention this because in the current hand-wringing about Obamacare and changing insurance plans, we've once again lost sight of the fact that in choosing an insurance-based for-profit model of healthcare, we've signed ourselves up for a very costly enterprise.  Obamacare's regulations require insurance companies to pay for a host of treatments, treatments that Americans want to be included in their healthcare: maternity care, birth control, vaccinations, regular check-ups, preventative measure tests like mammography and colonoscopies, and host more.  Those things are expensive.  Of course our rates will go up.  This is a significant burden for the people who pay for insurance: employers and employees.

If you work for the government or a large employer with a stash of cash, you likely pay a very modest share of your insurance premium.  For example, state employees in New Jersey typically pay less than 15% of the cost of their premiums, while their employer pays significantly more.  This is not unusual and it creates a challenging political climate.

I am frustrated by this increasingly unequal arrangement and would cheerfully support a single-payer system of government-managed hospitals and physician clinics.  It would be less costly, a fact born out by the current New York Times series about the cost of healthcare, "Paying Till it Hurts."  I've linked to the most recent article in the series here.  A single-payer system would also be accessible to every one of us and significantly better than the system we have today. 

Until then, I've received word that my insurance will cost at least 20% more next year.  My monthly outlay will therefore increase to $610 a month.  That's 610 dollars that will not go into the economy for other goods and services.  If I am lucky and we remain healthy, it will go into the coffers of a private corporation whose profits will pay stockholders.

It could be me, but that seems like an unhealthy arrangement.

The Road Ahead: Healthcare Cost Containment

At the start of the year, I came as close to a New Year's Resolution as I am willing to get by planning some posts on political issues for the next decade.  I've written about cynicism and food security.  This month, I'm thinking about healthcare cost containment.

In the interests of complete transparency, my preference is for universal healthcare using a single-payer system.  If I were in charge, I'd shut down the current private insurance system, organize government ownership of American hospitals, and open government-financed clinics staffed by well-paid physicians and medical specialists for the provision of healthcare.  I am convinced that this would lower costs and improve care.  But I'm not in charge and I've given up hope that the majority of my nation actually considers healthcare a right and a common good that we must provide for one another.

Sigh.

Short of the Sassafras Takeover, we must engage in some cost control of the current multi-heahed hydra that is the American healthcare system.  I have some thoughts.

1.  Wellness Programs
Let's set aside the tyranny of nutrition and instead concentrate on teaching folks how to enjoy food made from things grown in the ground.  Let's make life-long fitness something we pass on to our children.  Let's concentrate on that old-adage that an ounce of prevention is worth a pound of cure.  And for the love of God, let's teach ourselves that just because big Pharma says our lives would be better if we take Drug X, doesn't mean we should immediately demand a prescription from our doctor.

2.  Evidence-Based Medicine
There is a lot of research that suggests treatment protocols for various diseases and disorders range so significantly in the United States that we are often providing care that is neither necessary nor recommended.  It may even be dangerous.  In short, because of the balkanization of the practice of medicine and our focus on physician-autonomy, we over-treat in so many regions of the country that we are spending billions treating nothing.  A recent editorial in the New England Journal of Medicine spells it out.  We could cut our healthcare costs by one-third if we would just stop over-treating people.

3.  Tort Reform
I am not convinced that tort reform will actually lower costs much.  I am convinced that physicians believe tort reform is necessary.  And we need physicians on our side.  So let's engage in setting some reasonable limits on the damages people can collect from suing their doctor.  At its best, this will help to reduce some of the backside-covering over-treating that doctors who fear lawsuits engage in.  And at it's worst, well, it won't make things any worse.

4.  Consumer Cost Control
People who do not pay for their health insurance benefits treat it as some sort of free service whose costs do not exist.  This is just ridiculous.  The frank reality is that employer-sponsored healthcare costs an employer at least $10,000 per year per employee (more if family members are also covered).   Healthcare economists agree that Americans who bear some costs of their insurance (paying  a share of their premiums and also reasonable co-pays) will become more responsible consumers; attentive to costs and cost-control.  Let's insist upon doing right by ourselves.   The predominant expert on this issue is Henry J. Aaron, a scholar at the Brookings Institution.  He has a lot to say on this and many other issues.  Read him here.

5.  Pass Obama's Healthcare Legislation
I was among the Obama voters who hoped that the President and Congress would come together to provide healthcare for the 45 million uninsured people in America.  I now realize that many of the 250 million of us who have insurance don't give a fig about those who don't.  I am profoundly disappointed in my nation.

The bill before Congress is imperfect.  But the Congressional Budget Office reports that it will lower costs over the next ten years.  It will cover some of the uninsured; it helps parents to provide insurance for their twenty-something offspring (thus keeping healthy people in the insurance pool and helping to lower costs); it creates some incentives for lower-cost insurance pools.  To be sure, it is only a start.  But it is a start.  President Obama made a strong case yesterday and the final push is on.  Failure this time will leave millions of people with nothing.  Contact your member of Congress and let them know you support the legislation.

A Guiding Philosophy

Last week, the New York Times magazine had an article about playwright Anna Deveare Smith.  Smith is about to undertake another of her one-woman shows, this one about healthcare in America.  In preparation, she has interviewed hundreds of people, famous and not, about their experience in the American healthcare system.  You can read the article about Smith here.

Among the people she interviewed was Representative Henry Waxman, a Democrat from California whom I have long admired.  Speaking with Smith about the need for healthcare reform, Waxman grew thoughtful about the beliefs that drive his commitment to that reform.  From her interviews, Smith distilled a philosophy from Waxman that I find resonant.  It's not the poetry of it that I find appealing; it's the power and the passion of the philosophy behind the idea.

In Smith's script of the time with Waxman, he says:

I think it's a fight we need to have.
And I think the American people accept those values ---
But there are some people on the right who don't.
They look at
At society as a...
In Darwinian terms.
If you succeed in life because you had advantages
God wanted you to succeed
And if you fail
It's you own fault ---
And if it's your own fault
Why else should anybody else have to help you?
And I reject that
I reject that.
It's inconsistent with my values.
I disagree very strongly with it.

Waxman's statement reminds me of a biblical injunction that governs my thinking about my nation and its place in the world: "To whom much is given, much is expected."  I believe that a generosity of spirit and emotion must  govern  our treatment of one another.  And healthcare reform, driven by a commitment to providing universal access to healthcare is an excellent start.  Tomorrow, I'll add my voice to the discussion.

Live Blogging the Health Care Address

Regular readers (hi Mom!) will recall that last fall I took to live-blogging the presidential debates.  The election put an end to that brand of fun.  But as I started thinking about President Obama's address to Congress, I thought it might be fun to live-blog the madness.

Our helpful assistant blogger is my 9 year old son.  And before you doubt his credentials, I want you to think about the behavior of the Republicans in Congress.

In comparison, the kid looks incredibly serious and well-qualified.

I'll start by disclosing my bias:  I want universal, single-payer healthcare.  I am completely aware that is not going to happen in this round of reforms, if ever.  I'll settle for a public option plan to compete with private insurers; some sort of serious effort to control costs; and a real commitment to real universal coverage: insurance for every person in this nation.

And yes, I know that's probably unrealistic.   The sins of the national news media not withstanding, the Obama Administration handled August badly.  I want the president to get Congress back on track and provide some leadership on the issue, explaining to the nation why we must reform our health care system and offering some serious proposals to help make it happen.

The first issue:  whose coverage to view?  I'm going with MSNBC because I like Brian Williams, David Gregory and Rachel Maddow.  But if they let Keith Olberman talk........I'm gone.  He's a monstrosity.

7:58 pm
Just saw John Boehner.  I hope to hell that he keeps up with his insurance premiums because that kind of suntan has skin cancer written all over it.

8:00 pm
MSNBC is letting Olberman serve as our narrator.  I'm off to CNN.  Wolf Blizter.  Gah.  JT just explained to the cats: we don't like this guy either but he's better than that other dude.  Michelle Obama wearing sleeves tonight.

8:04 pm
CNN opting to show the Clinton speech from 1992...teleprompter trouble that year.  And no reform that year either....coincidence?

8:12 pm
The man of the hour turns up.  JT's only question: Will he shake his wife's hand?  Wife looks pissed off that he didn't shake her hand.  Uh oh.

Caught sight of Senator Tim Johnson from SD who knows his way around the healthcare system as a result of a recent serious illness.  Interesting to hear what he and his staff have to say about reform.

8:18 pm
The economy blah blah blah getting better blah blah blah still need to help folks looking for jobs blah blah blah.

JT:  I thought this was supposed to be about healthcare.

Exactly.  Let's get to it, Mr. President.

Props to Representative John Dingell and an Obama vow to be the last president to propose healthcare reform.  Starting strong.

8:21 pm
Obama: "we are the only advanced democracy who allows such hardship for its citizens."  Amen.

8:23 pm
JT: "Insurance companies let people die?  That's bad."  From the mouths of babes.

8:27 pm
Congress is getting strokes so far...."you've worked hard."  Okay, but I want some heads to roll.....and Obama just said, "The time for bickering is over....we must show the American people that we will do what we were sent here to do."   That's more like it.

The plan:
1.  Security and stability for those who have insurance.
2.  Insurance for those who need it.
3.  Cost control.

I'm in.  Tell me more.

8:32 pm
Insurance marketplace exchange idea is interesting, I guess.  But it's not really going to solve our problems and he knows it.  We need more than a marketplace.  Plus....4 years?  Dude, that's not soon enough.

8:35 pm
He's gonna require everyone to get care with a hardship waiver for low income folks and small businesses.....okay, but I'm not convinced that will do the trick and it's costly.  Massachusetts has been bleeding cash to make that happen.

8:37 pm
And now he takes on the myths......first up death panels.  He's talking to you Sarah Palin; says "It's a lie.  Plain and simple."  Congress cheers.

Says no coverage for folks who are here illegally.  I don't approve, because I am compassionate that way. 

And a member of Congress just yelled back at the president.  Did he call him a liar? Nancy Pelosi is not amused. My 9 year old is shocked.

Update: Yes, Representative Joe Wilson of South Carolina did call the president a liar. 

8:40 pm
He's pointing out that the big 5 insurance companies need more competition and must be held accountable.  That sort of language makes the GOP happy.  And for now, I'll live with it.  Because he just said that he wants a public option to be in the marketplace.

Yes.  By God, yes.

8:50 pm
Obama promises to protect Medicare.  GOP sits on their hands.

8:53 pm
He notes that defensive medicine contributes to rising costs; mentions malpractice reform but doesn't commit.

Obama says the costs of reform will be less than the tax cuts for the rich passed by the last Administration.  Looking at you, George W.  Ouch.

8:55 pm
Obama says his door is open for those with new ideas.  But he won't stand by and endure those who misrepresent the plan; those who want to get in the way of reform.  Says, "Know this: I will not waste time with those who have made the calculation that it’s better politics to kill this plan than improve it."  Says he will call out the deceivers...strong language.

I hope to hell that he means it.

8:58 pm
Closing with Teddy Kennedy, calling health care "a moral issue" about "social justice" and "the character of our country."  Says Teddy was driven by "something more" "a passion born of his own experience" and Kennedy's concern about those who didn't have health care, a feeling that isn't partisan.  I'm sold.

The final words were emotional: "we did not come here to fear the future.  We can meet history's test."

It was an impressive appeal to take some action for the common good.  Let's hope that we can rise to the challenge.

Calling It As I See It

In the circles of those who discuss healthcare reform, use of the phrase "rationed care" is like dropping a bomb on civil discourse. The idea of rationed care (which implies that we'll have to make decisions about providing care ----- a sort of cost/benefit analysis method of providing medical services) raises all sorts of red flags of the panicked variety.

The implication of rationed care that one's beloved Grandma might not get a hip replacement because some heartless bureaucrat will take a look at the paperwork and say, "Hey, she's 85 and doesn't have much longer to live. No new hip." The canard also suggests that rationing means you wait in line for care, as in: "Well get that heart by-pass on the calendar for next month as we're fresh out of by-pass bucks at this time."

The American political culture of individualism gives no truck to notions that we might have to wait for medical care; that we might have to make difficult decisions in the provision of care. The reality, that our current healthcare system is in the rations business (as in: no insurance, no ration) is typically rejected by critics as an over-simplification of the situation.

That's nonsense, of course, as anyone without access to healthcare can tell you. My biggest concern about healthcare reform is that as we move to a system of national healthcare we must also get in place some cost controls. To cover the 45 million uninsured in our current system will bankrupt the nation because the current system is doing just that without covering all of us. So I'm distinctly in favor of a national, single-payer model with cost controls. The 45 million uninsured would get coverage; the under-insured would get coverage, and employers would be able to buy into a system of insurance that doesn't bankrupt the business. We'd be done with the exclusions of pre-existing conditions and other efforts to keep the sick out of the insured pool. Our commitment would be to provide healthcare for every single person in this nation. End discussion.

And yes, I think that we need some kind of rationing system and I'm willing to use the forbidden phrase. And having come right out and said that, I can already hear the screeching and yelling. I'd been working up an argument in favor of rationing when philosopher Peter Singer did the work for me in a recent NY Times magazine article. Thanks, Professor Singer. Read this article, please, and then imagine me nodding thoughtfully and saying, "yeah, yeah, what he said."

Because Professor Singer is spot-on. Let the rationing begin.

Healthcare Reform: The Business of Insurance

Before we can even talk about healthcare reform, it's vitally important that we understand how most healthcare insurance policies operate. Health insurance is a business and it works according to same principle as all insurance: The individual buys an insurance policy for a set amount of money and the policy is a protection against individual payment for a health calamity. For example, let's say that I pay for insurance in the amount of $500 a month. I could just place my $500 in the bank as a hedge against my need for healthcare. But instead I pay it to a company. For their part, the company promises to pay up if I get sick and require medical care.

The company is betting that I will be well and thus the amount I pay in premiums will not be used to keep me healthy. I am hedging against the fear that I will need more healthcare than I could otherwise afford.

Many of us find this arrangement morally dubious and it may very well be. But if you have insurance, whether it's with a not-for-profit or traditional business, that's the arrangement. You are betting that you might get sick, in which case the company will pay out money to get you well. The company is betting that you won't get sick and therefore they can hold the cash paid in premiums.

For obvious reasons, it's in your best interest to stay well. The company feels the same way, of course, because if you get sick it will cost them money. The company is looking to hold onto premiums. This, of course, is where the problems begin. The company prefers not to spend money on treatment; individuals hope that they won't need costly healthcare. But should the need arise, they expect to have their care covered; that's why they pay premiums in the first place.

Healthcare costs have not kept pace with inflation; not by a long shot. Whereas yearly inflation in the U.S. has typically been 1 – 3% per year, over the past 30 years, healthcare costs have risen as much as 5-15% per year. It doesn't take an accountant to figure out the problem. If we seek to ensure the entire nation within the framework of the current healthcare system, we will go bankrupt.

As this debate moves forward, we need to find ways to reduce the cost of healthcare. It may very well be easier said than done....and it will be the subject of my next post.

Some Thoughts on Healthcare Reform

One of the things I like best about Americans is their ability to pull together and get things done. There are endless historical examples of Americans stepping up and taking care of one another (and sometimes the world). These stories of community sacrifice and individual heroism tell me Americans are good people.

I think that's why I've been so disappointed at my nation's inability to enact meaningful healthcare reform. We agree that 45 million of us lack insurance; another 25 million are under-insured. That number ticks up every year. Many of us agree that this is bad for our country; we certainly agree that sick people should be able to see a doctor. But when it comes time to figure out how to change this situation, our vulnerable solidarity breaks down, to be replaced by concerns about what reform would mean for individuals. Healthcare reform is a complicated matter and in the next few weeks I plan to write about some of those complications with an eye toward sorting out the Gordian Knot that surrounds the mess. I'll do this by explaining some of the issues in the debate.

First: a disclosure of where I stand. I am firmly among those who believe that healthcare should be a right for Americans. These days, my access to healthcare is provided via health insurance provided to me and my son by my employer. That's how most Americans have access to quality healthcare. I am not arrogant enough to believe that it's a right I should enjoy while millions of other people are left out. Especially since I understand that it's a massive tax break that helps to provide my insurance.

Those of us who have employer-provided insurance are enjoying an enormous benefit for which we do not pay a fair market price. If your employer pays for all of your insurance costs, that amount is a supplement to your salary worth anywhere from $5,000 - $12,000 per person covered, per year. If that amount came to you in a paycheck, you'd pay taxes on it. But when it comes to you in the form of health insurance, you pay no taxes on it. My employer pays part of my insurance premium (60%) and I pay the rest of it (40% of the premium). That 40% comes out of my income.....and I pay no taxes on that share of my income.

If I had no insurance and had to pay my own medical bills, it would come out of my after tax income. If I knew the tax laws, I'd know that I could create a Medical Savings Account for myself, and pay for my medical bills out of pre-tax income. But many people who don't have insurance are operating at the margins of the economy. These are families who are looking to just get by; not people who are able to utilize the benefits organized by the system.

Don't get me wrong: I don't want to pay taxes on my insurance benefit. But I know that government rules are subsidizing my healthcare, as they do for nearly all of the Americans who have health insurance. To believe that I deserve this tax and healthcare benefit, one paid for by all taxpayers, even those who don't have insurance, is to implicitly suggest that some people are not as deserving. When it comes to healthcare, that's just a ridiculous argument. As a nation, we'd be healthier (and perhaps happier?) if we all enjoyed access to healthcare. We need to find a way to accomplish this, for the good of one another and the good of our nation.

Next up: an explanation of healthcare inflation. I hope that you'll keep reading.

Some Thoughts on Fiscal Stimulus and Healthcare Reform, part II

In my January 27th post, I explained the definition of a recession and I wrote about the last time the U.S. faced one (back in 2001). Seven years later, the nation is once again worried about a recession, prompting Congress to propose some quick spending in the form of rebate checks to tax payers. The House proposal would send $600 rebates to most taxpayers; more for those with kids in the house. The Senate has yet to debate the proposal, but the safe money says that some sort of rebate will be coming our way on the next few months.

I am not convinced that a rebate is what we need. I would argue that our problem right now is more complicated than a recession. Instead, it looks to me like a combination of slow economic growth and inflationary pressures, a problem that is known is stagflation. I've already explained slow economic growth, and the sources of that problem are varied. Inflation (when prices increase without a change in the amount or quality of the good being purchased) is a normal part of the American economy. As long as income rises to cover it, inflation isn't a problem per se. But the average American in the last year has seen prices for certain non-negotiable goods rise sharply, while their incomes have not risen to cover those costs. Those non-negotiables are fuel (in the form of gasoline and home heating costs) and food (the short explanation is that the increase in gasoline costs added to an increase in the price of corn translates to higher food costs.. At the same time that we are suddenly spending more for food and fuel, a greater portion of our monthly income is also being spent on increased healthcare costs. Healthcare spending, (which you will recall was the second most popular way to spend the 2001 Bush rebate) isn't always considered when economists talk about increases in the CPI (the consumer price index). But it should be.

In 2001, Americans spent approximately 7% of their income on healthcare costs (the employee's share of the premium for insurance provided by employers; prescription co-pays; doctor's visit co-pays, and the like). In 2007, we spent 17% of our take-home pay on healthcare. That's a much greater portion of our income, and gives you some feel for how quickly healthcare costs are spiraling upward. In the process, healthcare spending consumes more of our income, and leads to reduced spending on other consumer goods. In combination with the increases in fuel and food, I think that healthcare spending is a major factor in the economic slow-down that we are calling a recession right now.

A rebate check may temporarily cover some of those healthcare costs, but it won't fix the problem for good. 2008 is a presidential election year and, by the looks of it, a lot of people are interested in the election. Healthcare is frequently identified as an issue that American are worried about. 47 million of us don't have insurance at all and many of us who do have insurance are paying thousands of dollars a year for that insurance. Our employers are paying more.
Our healthcare dollars largely support a system of healthcare insurance that has a profit motive. Universal care, using a single payer model, in which we all participate would save us billions of dollars and provide healthcare to all of us.

Is my idea radical? Absolutely. But the problem has reached epic proportions and for the billions of dollars we are spending, we could provide healthcare to all of us, every single person in this nation, and probably for less money. That we do not do so is morally shameful. And, in my view, it's one of the biggest economic problems we face.