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Profile Information

Gender: Female
Hometown: Washington state
Home country: USA
Current location: Directly above the center of the earth
Member since: Sat Aug 16, 2003, 02:52 AM
Number of posts: 51,907

About Me

Major policy wonk interests: health care, Social Security/Medicare/Medicaid, election integrity

Journal Archives

What We Give Up for Health Care

[What We Give Up for Health Care
By Ezekiel J. Emanuel

When it comes to health care, most liberals are committed above all to ensuring that every American has insurance. In their view, the greatest achievement of the health care reform act passed under President Obama is to finally erase the moral stain of the United States? being the only major developed country without universal coverage. But we also hold the questionable distinction of having the world?s most expensive health care system ? what about cost control? For many liberals, that just sounds like a cover for heartless conservatives who care only about cutting benefits and not about helping people in need.

But liberals are wrong to ignore costs. The more we spend on health care, the less we can spend on other things we value. If liberals care about middle-class salaries, public education and other state-funded services, then they need to care about controlling health care costs every bit as much as conservatives do.

During the campaign season and into 2013--a vital year for health care legislation--liberals must make the issue of cost control their own.

(Ezekiel J. Emanuel is an oncologist, former White House adviser and a vice provost and professor at the University of Pennsylvania.)

Comment by Don McCanne of PNHP:

Truly universal coverage and effective cost containment were the goals from the beginning, but Congress and the administration selected a model of reform that cannot possibly bring us either.

It is likely that tens of millions will remain uninsured because of affordability issues, and the measures supposedly designed to control costs will have very little impact. A new CBO report confirms that some of the mechanisms proposed have already been shown to be ineffective in pilot studies.

All other wealthy nations provide comprehensive services to everyone, and at prices that on average are half that of the United States. The other nations use similar technology, experience aging of their populations, and have similar rates of health care utilization, yet they are still able to contain their costs. The difference is that they have strong public oversight of their systems of social insurance or government health services.

Although single payer systems are well recognized for their savings through administrative efficiencies, they use many other tools to slow the increases in health care costs. These tools are not experimental, like those in the Affordable Care Act. They have already proven to be effective beyond any doubt in nations with such systems.

We can cover absolutely everyone, which should make the liberals happy, and we can do it while truly bringing our health care costs under control, and isn't that what the conservatives want as well?

My comment: Health care is the one problem we can solve without spending more money than we already spend. As Kucinich once said "We are already paying for universal heatlh care--we just aren't getting it." Note that the CBO could care less about how much consumers would save with single payer health care; their mission is only to analyze costs to the government. IMO anyone who prefers a $900/month premium to a $125/month tax shouldn't be allowed outdoors without adult supervision.

Wendell Potter on the Sarah Burke death


Instead, her family will be laying her to rest in her native Canada — and pleading for money to help cover the estimated $550,000 they owe for the medical care she received at University of Utah Hospital over nine days.

The irony is that had the accident occurred in Canada, her family would not be facing having to come up with more than half a million dollars to pay for her care. Her care would have been covered because, unlike the U.S., Canada has a system of universal coverage.

An estimated 700,000 American families file for bankruptcy every year because of medical debt. No one in Canada finds themselves in that predicament, nor do they face losing their homes as many Americans do when they become critically ill or suffer an injury.

One of the things my colleagues in the insurance industry tried to get Americans to believe was that Canadians flock to the U.S. to get medical care they cannot get in their own country. That is a myth. Yes, some Canadians come to the U.S. for treatment, but not in large numbers. In fact, polls in Canada consistently show high levels of satisfaction among citizens with their country’s single-payer system.

I probably would not have known about a fundraising effort that has been started by Burke’s friends had my wife not come across a tweet about it Friday morning. I haven’t been able to find anything about it so far in any media here in Utah. There was a report about her accident on the morning news, but no mention of the fundraiser.

Wendell is a Senior Analyst at the Center for Public Integrity where this first appeared on 11/23/12

Commentary from Canada--note that Alberta is Canada's most conservative province


Morgan says Burke's case should be a sobering reminder to Canadians of what could happen in a privately-insured market, rather than a public system where everyone is insured against a catastrophic event.

In 2000, the U.S. health policy journal Health Affairs wrote about the issue under the heading "Gouging the Medically Uninsured: A Tale of Two Bills."

"Overcharging the uninsured is one of the many unintended and largely overlooked results of our decade-long obsession with curbing health-care costs," it said. "Powerful interest groups — government, employers, insurers, hospitals, medical equipment vendors, and health care professionals — have fought vigorously to protect their interests. The uninsured, with no organized voice, emerge as losers."

Since 2001, family health insurance premiums in the U.S. have increased 113 per cent, according to the Kaiser Family Foundation, with annual premiums for employer-sponsored family health coverage growing to $15,073 in 2011. Due to the economic downturn, the number of Americans going without insurance has grown by one million to 49.9 million people.

We complain of health-care costs and outcomes in Canada, but the U.S. ranks behind Australia, Canada, Germany, the Netherlands, New Zealand and the U.K. in five areas of health system performance: quality, efficiency, access to care, equity and mortality, according to a report by the Commonwealth Fund.

It is, indeed, a sobering reminder to Canadians how lucky we are. As one commentator wrote of the Burke family’s experience with the U.S. system: "We are sorry for your loss. Here’s your bill."

Lessons from Medicare's Demonstration Projects on Disease Management, Care Coordination, --

-- and Value-Based Payment


In the past two decades, CMS has conducted two broad categories of demonstrations aimed at enhancing the quality of health care and improving the efficiency of health care delivery in Medicare's fee-for-service program.

* Disease management and care coordination demonstrations have sought to improve the quality of care of beneficiaries with chronic illnesses and those whose health care is expected to be particularly costly.

* Value-based payment demonstrations have given health care providers financial incentives to improve the quality and efficiency of care rather than payments based strictly on the volume and intensity of services delivered.

The evaluations show that most programs have not reduced Medicare spending: In nearly every program involving disease management and care coordination, spending was either unchanged or increased relative to the spending that would have occurred in the absence of the program, when the fees paid to the participating organizations were considered. Programs in which care managers had substantial direct interaction with physicians and significant in-person interaction with patients were more likely to reduce Medicare spending than other programs, but on average even those programs did not achieve enough savings to offset their fees.

Comment by Don McCanne of PNHP: Recognizing the need to slow the increase in health care
spending, much hope has been placed on disease management, care coordination, and value-based payments such as pay-for-performance. Medicare has authorized numerous demonstration projects to prove that these programs are effective. They aren't.

The results of these demonstrations have shown that they have not reduced spending because the costs of the interventions were not offset by the savings, and frequently the costs were greater, resulting in a net loss.

The one exception in the report - bundled payments - doesn't really belong in this list anyway. The demonstration study negotiated a single fee for coronary bypass surgeries, covering both the hospitals and the in-hospital treating physicians. The negotiated fee was about 10 percent less than the itemized fees had been previously. Thus the savings for Medicare was about 10 percent for these bypass surgeries. There was no attempt to determine if this reduction resulted in efforts to recover the difference from other patients or payers, which makes it difficult to know whether or not bundling actually reduced total health care costs.

On the other hand, imagine a system in which all payments are negotiated, as with a single payer system. Hospitals negotiate an annual global budget. That budget includes their costs of services, such as coronary bypass surgeries, without the need to itemize each single item for the services, nor the need to bundle payments in some sort of pretense that global costs are reduced. The hospital already has incentives to improve efficiencies to stay within budget.

Likewise, physicians collectively negotiate their payments, whether fee-for-service, capitation, or salary, as appropriate to their clinical circumstances. Payments are adequate to ensure a very comfortable net income.

Other nations have proven that negotiated, administered payment is effective in obtaining greater value for health care spending. We've now proven that intrusion of market-model games players such as outside disease managers, or pay-for-performance administrators, have failed to improve value. So we should go with a system that really does work - a single payer national health program.

My comment: "There was no attempt to determine if this reduction resulted in efforts to recover the difference from other patients or payers, which makes it difficult to know whether or not bundling actually reduced total health care costs." Of course not. The job of CBO is to analyze the cost to GOVERNMENT. They don't care about costs to patients by definition.

Fighting for Our Health; new book by Richard Kirsch on the genesis of health care reform


In an encyclopedic new book that sheds fresh light on the defining fight of President Obama’s first term, one of the administration’s key health care reform allies recalls a thin-skinned, “weak-kneed” White House, strategically unwilling and temperamentally unable to face criticism from progressive reformers, whose toughest tactics were reserved for its natural allies.

Many of the revelations will be unsurprising to those who followed the year-long fight over health care reform closely. But they serve as a thorough reminder of the administration’s uneven strategy during the debate, including its horsetrading with private industry, and private dealing with supporters on the left — particularly those, like the author, who fought a bruising fight for a public health insurance option and lost.

The book is Fighting For Our Health, by Richard Kirsch, who directed the advocacy group Health Care for America Now during the push for reform. HCAN is a well financed umbrella group backed by scores of liberal groups, unions, and other reformers — making Kirsch a close witness to the entire saga. He confirms that the White House treated the public option like a bargaining chip with powerful industry players, and believes that when his group became most critical of the bill mid-way through the fight, that top White House aides sought to have him canned.

Janis Ian on downloading--from 10 years ago.

The Internet Debacle: An Alternative View


The premise of all this ballyhoo is that the industry (and its artists) are being harmed by free downloading.

Nonsense. Let's take it from my personal experience. My site gets an average of 75,000 hits a year. Not bad for someone whose last hit record was in 1975. When the original Napster was running full-tilt, we received about 100 hits a month from people who'd downloaded "Society's Child" or "At Seventeen" for free, then decided they wanted more information. Of those 100 people (and these are only the ones who let us know how they'd found the site), 15 bought CDs. Not huge sales, right? No record company is interested in 180 extra sales a year. But... that translates into $2,700, which is a lot of money in my book. And that doesn't include the ones who bought the CDs in stores, or who came to my shows.

Or take author Mercedes Lackey, who occupies entire shelves in my local bookstore and library. As she says herself: "For the past ten years, my three 'Arrows' books, which were published by DAW about 15 years ago, have been generating a nice, steady royalty check per pay-period each. A reasonable amount, for fifteen-year-old books. However... I just got the first half of my DAW royalties... and suddenly, out of nowhere, each Arrows book has paid me three times the normal amount!.... And because those books have never been out of print, and have always been promoted along with the rest of the backlist, the only significant change during that pay-period was something that happened over at Baen, one of my other publishers. That was when I had my co-author Eric Flint put the first of my Baen books on the Baen Free Library site. Because I have significantly more books with DAW than with Baen, the increases showed up at DAW first. There's an increase in all of the books on that statement, actually, and what it looks like is what I'd expect to happen if a steady line of people who'd never read my stuff encountered it on the Free Library - a certain percentage of them liked it, and started to work through my backlist, beginning with the earliest books published. The really interesting thing is, of course, that these aren't Baen books, they're DAW---another publisher---so it's 'name loyalty' rather than 'brand loyalty.' I'll tell you what, I'm sold. Free works."

One other major point: in the hysteria of the moment, everyone is forgetting the main way an artist becomes successful - exposure. Without exposure, no one comes to shows, no one buys CDs, no one enables you to earn a living doing what you love. Again, from my personal experience: in 37 years as a recording artist, I've created 20+ albums for major labels, and I've never once received a royalty check that didn't show I owed them money. So I make the bulk of my living from live touring, playing for 80-1500 people a night, 200-300 nights a year, doing my own show. I spend hours each week doing press, writing articles, making sure my website tour information is up to date.

Why? Because all of that gives me exposure to an audience that might not come otherwise. So when someone writes and tells me they came to my show because they'd downloaded a song and gotten curious, I am thrilled!

Who gets hurt by free downloads? Save a handful of super-successes like Celine Dion, none of us. We only get helped.

Emails received on this subject: 1,268 as of July 30, 2003 (does not include message board posts)

Number of times the article has been translated into other languages: 9. (French, German, Chinese, Japanese, Italian, Spanish, Portuguese, Russian, Yugoslavian.)

Times AOL shut my account down for spamming, because I was trying to answer 40-50 emails at a time quickly and efficiently: 2

Winner of the Put Your Money Where Your Mouth Is award: Me. We began putting up free downloads around a week after the article came out.

Change in merchandise sales after article posting (previous sales averaged over one year): Up 25%

Change in merchandise sales after beginning offering free downloads: Up 300%

Offers of server space to store downloads: 31

Offers to help me convert to Linux: 16

Offers to help convert our download files from MP3 to Ogg Vorbis: 9

Offers to publish a book expose of the music industry I should write: 5

Offers to publish a book expose of my life I should write: 3

Offers to ghost-write a book expose of my life I shouldn't write: 2

Offers of marriage: 1

Number of emails disagreeing with my position: 9

Number of people who reconsidered their disagreement after further discussion: 5

What American health care could learn from Finnish education

A lot of people have probably seen this in the Education forum. Parts relevant to health care are excerpted.

What Americans Keep Ignoring About Finland's School Success


As for accountability of teachers and administrators, Sahlberg shrugs. "There's no word for accountability in Finnish," he later told an audience at the Teachers College of Columbia University. "Accountability is something that is left when responsibility has been subtracted."

And while Americans love to talk about competition, Sahlberg points out that nothing makes Finns more uncomfortable. In his book Sahlberg quotes a line from Finnish writer named Samuli Puronen: "Real winners do not compete." It's hard to think of a more un-American idea, but when it comes to education, Finland's success shows that the Finnish attitude might have merits. There are no lists of best schools or teachers in Finland. The main driver of education policy is not competition between teachers and between schools, but cooperation.

Decades ago, when the Finnish school system was badly in need of reform, the goal of the program that Finland instituted, resulting in so much success today, was never excellence. It was equity.

In fact, since academic excellence wasn't a particular priority on the Finnish to-do list, when Finland's students scored so high on the first PISA survey in 2001, many Finns thought the results must be a mistake. But subsequent PISA tests confirmed that Finland -- unlike, say, very similar countries such as Norway -- was producing academic excellence through its particular policy focus on equity.

Comment by Don McCanne of PNHP: When you read these excerpts from this article on the education system in Finland, what is striking is how much the philosophy behind their vastly superior system contrasts sharply with ours. What is really mind-boggling is that if you re-read the same excerpts, except substitute "health care system" for "education system," you then will have an inkling of what we are doing wrong in both education and health care.

One fundamental concept that has appeared repeatedly on the pages of Physicians for a National Health Program (PNHP) is that excellence is a product of cooperation, not competition. It is not choice between private for-profit and public systems, but rather it is equity within public systems that facilitates excellence.

In both education and health care, Americans emphasize testing, accountability, merit rewards, competition, and choice. Yet Finland does not use standardized testing (analogous to HEDIS testing in health care), nor do they demand accountability - they don't even have a word for it - but rather they expect responsibility. In Finland, all teachers are given prestige, decent pay, and a lot of responsibility. Finns are very uncomfortable with the concept of competition, especially since that interferes with the productivity induced in an environment of cooperation. Nor do they even consider choice - choice between publicly-financed and privately-financed schools - since the latter do not even exist.

So their secret is to establish equity and cooperation within the public sector. Now that it's no longer a secret, we also can have high quality education and health care systems right here in the United States. We just have to shove the MBAs aside and place control in the hands of our own publicly chosen advocates of social justice.

My comment: I've especially emphasized that equity and cooperation are specifically associated with PUBLIC goods. Not everything is a public good, and when this is the case competition and choice have important roles. "Accountability is something that is left when responsibility has been subtracted" is a way cool soundbite too.

Many wealthy Germans to switch to public health insurance

Shocked by premium increases of as much as 50 percent, many Germans with private health insurance are seeking to switch to a national health plan, the news magazine Der Spiegel reported Sunday.

Many private health insurance plans pushed through hefty premium increases at the beginning of the year and that's behind the move to switch, the magazine said.

But it's not so easy to switch once you've opted for private insurance. German law only allows people to change from public to private in exceptional situations. These include when someone has lost their job. You can also switch if you are an employee whose salary falls below the ? 45,900 level. Workers who used to be self-employed but now have a full-time position with a similar salary may also change.

But a public health organization manager said, "There are tricks that we can use to help private patients, providing the employer cooperates."

The Barmer GEK public health organization reported that 27,600 people switched from private competitors in 2011-- nine percent more than in 2010.

Social Insurance and Individual Freedom

By law, every German must have coverage for a prescribed benefit package. German employees and pensioners earning less than 49,500 euros ($66,350) per year (in 2011) are compulsorily insured under the statutory system.

Employees and pensioners above that threshold are free to opt out of the statutory system and purchase private, commercial coverage, but if they do, they cannot ever return to the statutory system unless they are paupers. The intent is to minimize gaming of the insurance system by individuals.

Comment by Don McCanne of PNHP: It's only January, yet Germany already is providing us one of the most important policy lessons of 2012. It may be great politics to allow more affluent citizens to opt out of public health insurance and to express their personal faith in private markets by selecting private plans, but they may decide that it's terrible policy when the private plans come back to bite them.

But no games. If wealthier Germans chose the private plans, then, as long as they maintained their higher incomes, they could not game the system by moving back into the public plan should they lose their bet that they would be better off in the private sector. Many Germans who made that choice are now facing skyrocketing premiums in the private sector. They want back into the public program, but many will have to continue to live with their ill-advised decision to go private.

What is Germany to do now? It doesn't seem fair to allow those who made this unwise decision to escape the consequences when it would expose the public program to adverse selection. There would be no problem had the government prohibited the wealthy from making an imprudent decision to go private in the first place, which they could have done simply by requiring everyone to participate in the public program.

For those who say that it is unfair to not allow choice, as mentioned the Germans were smart enough to prohibit that choice for low- and middle-income individuals, saving them from potential exposure to financial hardship. Ensuring security is fair; permitting the choice of insecurity is not fair for those who end up losing.

There may be less sympathy for the wealthy caught in a financial bind of their own making, but there are two important reasons why the wealthy also should be required to participate in the public program: 1) the insurance risk pools (sickness funds) benefit from including the contributions of this wealthier and generally healthier population, and 2) the influence of the wealthy provides greater political support for the public program in which they would be required to participate. Consider the great support for Medicare as opposed to the meager political and financial support for Medicaid.

The obvious lesson for the United States is that we should eliminate the over-priced private insurers and establish a single national health program that covers everyone. We still may have some compassion even for those who want to play their ideological games but then run into trouble when they really need health care, but we should not allow them to escape their obligation to contribute equitably, in advance, to a financing system that many of them someday would have to rely upon.

My comment: Suck it up, Herr Ein Prozent. Hope you've learned that public goods ar actually GOOD.

It’s no secret that Republicans want to destroy Medicare and Social Security

Why would Democratic Senator Ron Wyden (D-OR) want to help them? Fight back!!

Republican candidate for governor of Washington State Rob McKenna told the UW Young Republicans that it was “unfortunate” that Americans overwhelmingly oppose Medicare changes proposed by Representative Paul Ryan passed nearly unanimously by the House Republicans earlier this year.

The Ryan Plan would eliminate traditional Medicare. Instead of having all necessary care covered, you will be given a voucher to purchase the same kind of lousy private insurance that seniors could not afford before Medicare was enacted.

Republican Congressman Eric Cantor on NPR said “We've got to protect today's seniors. But for the rest of us? We're going to have to come to grips with the fact that these programs cannot exist if we want America to be what we want America to be.”

Senator Wyden and Paul Ryan have walked back the original plan to eliminate Medicare all at once. Now they propose (and are backed by every single Republican presidential candidate) to make vouchers voluntary, destroying Medicare slowly instead of all at once. Medicare patients with poor health or chronic conditions would find that most private plans are closed to them, since it's unprofitable to actually pay to treat them. They would remain in traditional Medicare, where costs would rise as more chronic patients joined and healthier patients fled to cheaper plans that allowed only healthy people. This would raise the costs of traditional Medicare, which would then push up premium prices, co-payments, and deductibles. Since private companies would be allowed to cherry pick the healthy, the once proud public program would be effectively ended.

Tell Senator Wyden and your representatives to save our lifelines. Do not support any candidate for an open Congressional seat who will not pledge to defend Social Security, Medicare and Medicaid.

(constituents only--tell everyone you know in Oregon to contact him)
Toll free: 1-866-220-0044

221 Dirksen Senate Office Bldg
Washington, DC 20510
Phone: 202-224-5244
Fax: 202-228-2717

911 NE 11th Ave
Suite 630
Portland, OR 97232

405 E 8th Ave
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Eugene, OR 97401

SAC Annex Building
105 Fir St, Suite 201
La Grande, OR 97850

Federal Courthouse
310 W 6th St, Room 118
Medford, OR 97501

The Jamison Building
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Bend, OR 97701

707 13th St SE
Suite 285
Salem, OR 97301

Free faxes!


Email, for obvious reasons, is restricted to constituents. Phones and faxes are not. For critical issues, consider adding faxes to your activist arsenal. Sometimes staff will ask your address when you call. If you don’t live in Oregon, explain that you are calling or faxing because of Medicare privatization.

A note on free faxes: they must be from a valid email address. When you send a fax, they send it first to your email address and give you a link to click on. Only clicking the link you got by email will send the fax. Limit 2 per day, no more than 3 pages. For $10/month you can send more faxes and more pages. If you want to ramp up your activities as an online activist, and can afford it, this would be a good investment.

I totally LOVE my communist fire department!

Operating principles straight out of Karl Marx. "From each according to his abilities"--the more your property is worth, the more property taxes you pay to support the fire department. "To each according to his needs"--they don't send a truck out unless you have a fire or some other emergency.

And I cringe everytime a Democrat or other liberal responds to winger whackjob calls of Socialism!! Communism!! by saying "Oh, no--this isn't socialist at all!" Thanks guys, for helping our enemies out. Anyone listening in hears the whackjob say "socialism," and you say "socialism" again, reinforcing his attack.

When will progressives realize what these whiners are actually attacking? They are attacking the notion of PUBLIC GOODS. So call them on it. Call them whiny childish brats who want public goods without paying for them, or sociopathic thugs who hate all public goods. Just because the fire department is communist (all public goods in a very narrow sense are socialist) doesn't mean that department stores or restaurants should be--not everything in the economy is a public good. But they're just ignorant jackasses who don't understand such things, so just mock them.

Insurers Profit From Health Law They Fought


Insurance companies spent millions of dollars trying to defeat the U.S.health-care overhaul, saying it would raise costs and disrupt coverage. Instead, profit margins at the companies widened to levels not seen since before the recession, a Bloomberg Government study shows.

Insurers led by WellPoint Inc. (WLP), the biggest by membership, recorded their highest combined quarterly net income of the past decade after the law was signed in 2010, said Peter Gosselin, the study author and senior health-care analyst for Bloomberg Government. The Standard & Poor's 500 Managed Health-Care Index rose 36 percent in the period, four times more than the S&P 500.

"The industry that was the loudest, most persistent critic of this law, the industry whose analysts and executives predicted it would suffer immensely because of the law, has thrived," Gosselin said. "There is a shift to government work under way that is going to represent a fundamental change in their business model."

The Bloomberg Government report is available only to subscribers, but Peter Gosselin provides the essence of his conclusions in the brief video available at the link above. Peter Gosselin discusses his report, "Despite Predictions, Health Insurers Prosper Under Overhaul" (5 minute video):

Comment by Don McCanne of PNHP: Peter Gosselin's Bloomberg Government report, "Despite Predictions, Health Insurers Prosper Under Overhaul," is further confirmation that, as long as we leave the private insurers in charge, they will always find a way to stick it to us, as we now witness a dramatic increase in insurers cornering taxpayer-financed health insurance programs- Medicare and Medicaid - not to mention the private plans that taxpayers purchase for government employees on all levels.

These trends are very healthy for the private insurance industry, but they're enough to make us sick.

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