Tuesday, March 9, 2010

What does the American public really want?

As part of their closing argument against health reform, Republicans argue that Democrats who vote for the bill will be ignoring the will of the American people, at their own political peril. Senate Minority Leader Mitch McConnell accuses Democrats of wanting "to plow ahead on a partisan bill Americans don't want..."

McConnell is correct that just about every recent poll shows that majorities of Americans dislike the current legislation.

Supporters of the legislation counter that it really has more public support than a simple "for or against it?" poll would yield. The Kaiser Family Foundation tracking poll finds that the country is evenly divided on the legislation, but large majorities support many of the major provisions in the bill. And, when asked about the next steps for health reform, a plurality of 32% said that Congress should, "Move soon to pass the comprehensive legislation that has already been approved by the House and Senate" compared to 22% who want to "Put health care on hold, so Congress can work on other priorities and try to deal with it later in the year," 20% want to "Pull out a few key provisions where there is broad agreement and pass those, even though this won't be comprehensive reform," and 19% want them to "stop working on health care" this year.

Economist Uwe Reinhardt has another interpretation of what the public wants, not from polls, but his own keen observations. He blogs in Health Affairs that "as the policy-making elite stews in its stalemate, the American plebs dreams of a political Messiah willing to build for them a health system that:
1. Lets only patients and their own physicians determine how to respond clinically to a given medical condition, never an insurance clerk or, even worse, government bureaucrats.
2. Limits their families' out-of-pocket payments for health care to make it "affordable."
3. Keeps insurance premiums and taxes for health care low.
4. Does not ever ration health care, because that is un-American and practiced only by un-American alien nations with inferior health systems.
5. Does not allow public or private insurers to let "costs" or "cost-effectiveness" ever enter coverage decisions, because that would implicitly put a price on human life which, in America, unlike elsewhere in the world, is priceless.
6. Does not mandate individuals to purchase health insurance, if they do not wish to do so, if for no other reason than that this would be unconstitutional and, therefore, un-American.
7. On the other hand, grants every American the moral right - backed up by a government mandate called EMTALA - to receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, even if they are uninsured and could not possibly pay for that expensive care with their own resources.
8. Controls Medicare spending, which is widely thought to be completely out of control, as long as it does not reduce payments to hospitals or to doctors or to producers of medical technology, or to any other provider of health care.
9. Provides universal health insurance coverage to all Americans, provided it does not mean raising taxes or cutting Medicare spending or raising premiums on healthy Americans.
10. Keeps government out of health care but somehow makes sure that insurance companies do not exploit patients through incomprehensible fine print, no one engages in price gouging - e.g., charge $10 for an aspirin - and no one in health care earns excessive profits (or any at all).

That's all.

One must wonder why America's policy-making elite has found it so hard to satisfy these simple wishes of the American plebs. And as the American people anxiously wait for that Messiah, I wish them luck. In the meantime, we shall muddle through as usual."

I think Reinhardt is onto something. We tend to blame the politicians for the muddle in Washington, but I wonder if they are just reflecting the muddled views of people they represent. This could be why polls can simultaneously show that the public is against the health reform legislation - except when they say they are for its key elements.

Today's question: Do you think Uwe Reinhardt is correct in how he characterizes the muddled views of the American people?


Arvind said...

For the first time ever, I have to completely agree with Reinhardt. One could add:
- Nobody should tell us how we choose to eat, drink, smoke or watch TV

Steve Lucas said...

I would have to agree with the list. We are all full of contradictions.

On a serous note, I think we all agree the system is broken. The problem comes in choosing a solution. One of the many issues I have is the complexity of the bill. We fear what we do not know and the size of this bill leaves many of us with a great deal of fear.

The problem with polls is the way the questions are asked. Do we want to take care of people? Yes. Are we willing to pay for this service? No. The list goes on.

I am part of the group that would like to take this bill and break it up into smaller bites were we can see and debate the good and bad points of that issue. My starting point would be tort reform. Everyone has their pet peeve with the medical system.

I have a growing concern with the role of hospitals in cost containment. If insurance is a cost plus business who is driving cost? A local hospital just purchased its 16th pediatric practice. Do we need to guess where and the number of referrals that will be going back to corporate headquarters, oops, the owner hospital?

We need to deal with this issue and starting from scratch is not the solution, nor is passing a bill that we will all have to figure out later.

Steve Lucas

Don Mitchell said...

I very much agree with Uwe Reinhardt. And the best way to achieve these goals is through a single payer system of healthcare, not through the current health bills in Congress. Those bills would continue to rely on the for-profit private health insurance industry--actually "mandate" that an additional 30 million people buy their products. This will exacerbate the problems that Reinhardt wants to correct.

Donald W. Mitchell, MD

Jay Larson MD said...

Uwe Reinhardt has a utopian view on what people want. The unfortunate reality is that it is not economically feasible.

Patients and their own physicians already determine how to “respond clinically to a given medical condition”. I have never had a test ordered or medication ordered be prevented by an insurance clerk or government bureaucrat. The only thing that is “denied” is the amount of money that the insurance is willing to spend. Even medications that are “non-formulary” can be prescribed, it is just that the patient has to pay for all of the cost out of pocket.

Keeping insurance premiums and taxes for health care low and limiting out-of-pocket payments for health care to make it "affordable” would only work if the actual cost of health care goes down. We have a $2.5 Trillion dollar annual budget for health care in this country. If one person does not pay for what they consume, someone else has to.

It is ironic that Uwe Reinhardt thinks that un-American alien nations have an inferior health system. Uwe obviously has not seen the outcomes of the different health care systems.

Of course public and private insurers have to let "costs" and "cost-effectiveness" enter into coverage decisions. Insurers have a fiduciary responsibility, so they have to make financial decisions. A coverage decision is different than a clinical decision.

Americans already receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, even if they are uninsured and could not possibly pay for that expensive care with their own resources. Hence the high rate of bankruptcy due to health care costs and cost shifting.

Harrison said...

Uwe Reinhardt is facetiously suggesting that American public opinion is hopelessly contradictory. Of course it is not. American public opinion is as informed and intelligent and consistent as any public opinion in the world. Probably better than most.
Can we fall prey to bad leadership?
I think that is what has happened. Our leaders are aiming messages at different constituencies and leaving the impression that their reform ideas are vastly different.
They are not vastly different.
I've heard Dr. Reinhardt speak on public radio recently. He favors the idea of the campaign version of Senator McCain, in which the employer based health care system is replaced by an individual mandate to buy health insurance. He thinks that the Democrats are too wedded to the employer based system which is burdensome for business and not very efficient.
If we mandate individuals to buy insurance, that begins to look a little bit like a tax. The difference is that the amount of money spent on the tax is determined by individuals and the beneficiary of the money is left in the private sector.
Of course the government role would be in regulating levels of insurance coverage, and perhaps in subsidizing those who cannot pay.

I don't think that American public opinion is to blame for the current problems with government.
I think that the health care debate is completely a function of a dysfunctional government.
It is dysfunctional because congressional leaders answer to very homogeneous districts that have been designed for them, and because campaigns have become too expensive and this has caused our legislators to spend too much time concentrating on fundraising. And the funds come from those who have their ears.

Our political system is broken. Our political leaders need to fix it.
And when we have our representative democracy back we will see Republicans and Democrats serving the interests of their constituents over the interests of their party (whose only interest is to gain political power so as to garner all of the lobbying money that can be gained by being in postions of power). And we will see that Americans are not as divided and contradictory as Dr. Reinhardt facetiously suggests.


Unknown said...

Considering Reinhardt's list, it's obvious that he's being sarcastic. But, in seriousness, I know not what course others may take, but I don't want "healthcare reform." I simply want to continue to have the freedom to:

1. Consult with my own physician(s) to determine how to respond clinically to a given medical condition; and never be compelled to consult, take the advice of, or solicit and/or extract payment from anyone completely disconnected from the situation.

2. Limit my families' out-of-pocket payments for healthcare by choosing to spend my earned income on preventative activities and food consumption that will keep us healthier and less in need of paid healthcare, rather than throwing it at an insurance company that may or may not pay out when I "need" it.

3. Realize that insurance has nothing to do with healthcare; it is simply a financial vehicle for (maybe) paying for healthcare. I choose to have no premiums and pay for healthcare out-of-pocket, or through my own careful savings and investments. I don't want anyone else being forced to pay for my healthcare, either through “somewhat” voluntary insurance premiums, or through involuntary taxes.

4. Oppose healthcare rationing because it implies that some are more worthy than others to (a) receive care; and/or (b) receive payment for their labor. Who sets the criteria for who gets a ration and who doesn't? Could it be age, skin color, gender, religion, creed, political affiliation, nepotism, preferential treatment, how much care they've already received, ability to stand in line all day to request treatment?

5. Expect "costs" or "cost-effectiveness" to enter coverage decisions, because the healthcare provider is worthy of his pay.

I am amazed by the difference I experience from healthcare providers when I tell them that I don't have insurance. They don't ask about my ability to pay; but they do immediately take cost into consideration when prescribing medicine and/or treatment. When someone else is "paying" or the cost is distributed among (a) everyone in my group insurance plan, (b) the profits of the insurance company, (c) the ROI of the insurance underwriters, (d) the pharma's in-network discount, (e) the pharmacist's $25 coupon for transferring a prescription, (f) the doctor's agreed-upon "in-network" rate, ad nauseum, the doctor is often less thoughtful about the cost involved in the treatment he prescribes.

6. Not have a mandate to purchase health insurance because, yes, it is unconstitutional because the Framers intended to keep the newly-formed federal government from usurping the rights and sovereign will of We the People. Thomas Jefferson stated, "To compel a man to subsidize with his taxes the propagation of ideas which he disbelieves and abhors is sinful and tyrannical." Is forced payment of insurance premiums ultimately any different from taxation?

7. Expect no moral right - backed up by any government mandate - to receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, especially if I cannot possibly pay for that expensive care with my own resources, and have not made arrangements to pay.

8. With regards to Medicare spending (or more appropriately, forced contribution to Medicare), see Pres. Jefferson's quote above.

9. Ibid.

10. Keep government out of health care, but like any civil or criminal allegation, allow for cases to be filed, heard, and adjudicated should insurance companies exploit patients through incomprehensible fine print, price gouging - e.g., charge $10 for an aspirin, etc.; or if an individual commits fraud to make an insurance company pay a falsified claim. Health care workers should earn profits according to what the market can bear.