What happens if the health care system is NOT overhauled?

The current American health care system simply is not sustainable. It is set for collapse in the near future unless is it overhauled.

Reed Abelson of the New York Times goes over what every health care expert already knows will happen if the current Democratic effort to overhaul system fails:

The unrelenting rise in medical costs is likely to wreak havoc within the system and beyond it, and pretty much everyone will be affected, directly or indirectly.

“People think if we do nothing, we will have what we have now,” said Karen Davis, the president of the Commonwealth Fund, a nonprofit health care research group in New York. “In fact, what we will have is a substantial deterioration in what we have.”

Nearly every mainstream analysis calls for medical costs to continue to climb over the next decade, outpacing the growth in the overall economy and certainly increasing faster than the average paycheck. Those higher costs will translate into higher premiums, which will mean fewer individuals and businesses will be able to afford insurance coverage. More of everyone’s dollar will go to health care, and government programs like Medicare and Medicaid will struggle to find the money to operate.

Here is Steven Benen's take on the current status of health care reform in Congress:

If reform comes up short, costs will soar, budgets will be pushed towards bankruptcy, the ranks of the uninsured will grow, those lacking coverage will die, premiums will get even more unaffordable, and our economic growth and workers' wages will be stunted.

This isn't some wild-eyed speculation; this is simply a reality that no serious person contests.

When I read pieces like this, I sometimes just shake my head at public opposition to reform. We know the system is broken; we know we pay too much and get too little. We know the Republican attacks against reform proposals are wrong. Given the mess we're in, the demand for comprehensive reform should be overwhelming.

And yet, the resistance to sound ideas is fairly intense.

The Senate has already passed health care reform with a 60 vote majority. It only remains for the House to pass the Senate bill and for President Obama to sign it.

No, the Senate bill will not solve all the problems of the deteriorating health care financing system, but it is a solid start at doing that. It puts a framework into place. What remains is for Nancy Pelosi to round up 217 votes to pass the Senate bill in the House and the deed is done.

If it is delayed it will still have to be done, but it will cost a lot more and be an inferior system to the one the Senate bill envisions. The message we should be sending Congress is clear.

Pass.The.Damned.Bill!

Harvard's Dr. Michael Porter explains how to cut medical costs and simultaneously get better health outcomes.

The problem with Medical costs is that we pay for and measure medical processes rather that outcomes. When we ask if someone got good medical care we take a protocol and a checklist and see if everything on the list for given symptoms was tested for and the care provided.

The current system does not consider and pay for the results, only for the number of separate procedures applied to any case. So if someone got every possible procedure,their insurance is considered good, even if the patient had a relapse or died. That fragments the treatment by various specialties and encourages more procedures, without measuring or maximizing the effectiveness of the treatment for the patient.

The result of this fragmented care is to increase the cost of specialist treatments without ever measuring or determining how well the full set of treatments works for the patient. The current system also locks the specialists into older checklists and hinders the adoption of newer procedures, protocols and technologies. At the current time patient outcomes are not even subject to effective measurement schemes. There is no incentive for medical care suppliers or insurance companies to measure patient outcomes, just the quantity of procedures applied to each patient.

The solution is to measure and pay for outcomes. Then let the providers determine what sets of tests and procedures achieve the best outcomes. The providers are then measured by the effectiveness of medical care for the patients instead of how many different procedures they apply to each patients. Once patient outcomes are effectively measured and payments are made on that basis, then the medical care suppliers will quickly apply the most effective and lowest cost set of protocols and procedures to achieve those results. It's been known since the late 19th and the early 20th centuries that organizations will improve processes that are measured but will not improve those which are not measured. America's current health system simply does not take advantage of that age-old management knowledge.

Here is Dr. Michael Porter explaining how this works.

This process is built into Barack Obama's and the Democrat's proposed revised health care system. Money is to be spent in revising the medical records system to measure patient health and satisfaction outcomes.

Then a second critical element of the revised system is the public option. The public option is designed to place a competing system based on those outcomes next to the results offered by private insurers. Without the public option the the private insurers will tacitly collude to keep health delivery costs unnecessarily high. That keeps their revenues high without forcing them to spend money adopting new imaginative cost saving techniques. The public option is absolutely necessary to force the shift to measuring and paying for outcomes instead of continuing the current system of paying for individual procedures applied. With out the pubic option competition private insurers have no incentive to lower the revenue they can charge for individual procedures as the currently do. No profit-oriented businessmen will want to have to lower their revenue to meet effective competition.

If you believe in the free market then this system is assured of reducing the overall cost of health care and at the same time providing improved health care outcomes. it's just like the way Detroit found that the costs of including safety devices in automobiles was both much lower than they had predicted and at the same time increased the profitability of the autos sold. We can count on it happening again. But only with an overall health care system installed. Currently there is no system, and America is the only industrial nation in the world that permits the extremely negative results of the lack of any overall well-designed health care system.

While the insurers don't want to have to compete for their revenue, their flexibility and imagination will be a real advantage in that competition. The result will be a major advantage for patients as they get better and more innovative health care delivered to them, while also lowering the overall cost of the system to the nation. The thing is, like when Detroit was forced to install seat belts and safety improvement, they could not plan in advance for how effective their efforts would be. They achieved the installation of those improvements at roughly a tenth of the costs they had anticipated in advance. That's how the free market works.

Interestingly the improved results and lower costs will be a direct result of the proper use of the free market system of fair and well-measured competition.

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The following video describes measuring medical outcomes.

I seriously doubt that America has a competent government

It is my opinion that the first function of every government in existence is to provide social and economic stability and general security to its population. It's job is not to provide protection to the wealthy oligarch or to large corporations nor is it the job of a competent government to fight wars of choice because some stupid leader thinks that they can change another society to something that leader prefers. That's the Iraq war, and earlier the one in Vietnam if you don't already get the reference.

Because of the increasing cost and complexity of health care, and because of the many health dangers that exist in our increasingly complex and globalized economy and society, any government that fails to assure health care to every citizen and legal resident is failing in a major test of what it takes to justify its existence and it should be replaced immediately with a government that will provide universal health care. It is inexcusable that any citizen should for any reason have their health insurance canceled with they file any claim or be forced into bankruptcy because of the costs of care for an illness or accident.

Harry Truman ran for President on a platform that included a demand for and the promise of national health care. That was over 60 years ago, and the wealthy American oligarchs together with a greedy and insensitive medical establishment has delayed and blocked every effort to provide that program in all those decades. The American government has failed its people for more than two generations now. Will it fail again this summer?

Apparently I am not the only person who feels this way. David Kurtz of Talking Points Memo published this email earlier this evening:

TPM Reader AB:

Just to mention something that is obvious, but hopefully not overlooked, i.e., if this country cannot pass a bill which insures that every citizen has access to medical care, which every developed country has managed to do (and got done many many years ago), there is something very fundamentally and structurally wrong with this country.

Such an event, in my mind, would confirm that we live with a completely corrupt and dysfunctional form of government. Forty nine states, each with bicameral legislative bodies, some of which have distinguished themselves recently with unabashed levels of incompetency and cluelessness. Then, graft a federal government over that, which is also bicameral, the non-representative portion of it being filled with officials who are certifiable morons and/or who are bought and sold like whores by wealthy contributors.

Talk about a Waterloo.

This is a defining moment in our history. Do we fulfill our supposed status as a "shining city on a hill" or continue our long slow decline into a second rate oligarchy?

I am not one prone to hyperbole.

I believe this to the depths of my soul.

I have no idea who TPM Reader AB is, but he has it right.

If the government fails to pass the health care bill this Summer, then it is time to change to government to a party that will pass it. That's clearly not the Republicans or Libertarians, and if the Democrats fail this summer, it is no longer the Democrats.

Krugman discusses the cost of universal health care

From today's New York Times:

Let me start by pointing out something serious health economists have known all along: on general principles, universal health insurance should be eminently affordable.

After all, every other advanced country offers universal coverage, while spending much less on health care than we do. For example, the French health care system covers everyone, offers excellent care and costs barely more than half as much per person as our system.

And even if we didn’t have this international evidence to reassure us, a look at the U.S. numbers makes it clear that insuring the uninsured shouldn’t cost all that much, for two reasons.

First, the uninsured are disproportionately young adults, whose medical costs tend to be relatively low. The big spending is mainly on the elderly, who are already covered by Medicare.

Second, even now the uninsured receive a considerable (though inadequate) amount of “uncompensated” care, whose costs are passed on to the rest of the population. So the net cost of giving the uninsured explicit coverage is substantially less than it might seem.

Putting these observations together, what sounds at first like a daunting prospect — extending coverage to most or all of the 45 million people in America without health insurance — should, in the end, add only a few percent to our overall national health bill. And that’s exactly what the budget office found when scoring the HELP proposal.

[...] [Krugman explains specific provisions of the plan together with costs, and compares it to the costs that America is currently on looking towards having to spend under the current system.]

So fundamental health reform — reform that would eliminate the insecurity about health coverage that looms so large for many Americans — is now within reach. The “centrist” senators, most of them Democrats, who have been holding up reform can no longer claim either that universal coverage is unaffordable or that it won’t work.

The only question now is whether a combination of persuasion from President Obama, pressure from health reform activists and, one hopes, senators’ own consciences will get the centrists on board — or at least get them to vote for cloture, so that diehard opponents of reform can’t block it with a filibuster.

The problem now is the "centrist" Democratic Senators. That and the fact that Senators as a group are not the brightest bulbs in the box. They react to the people who actually get in touch and talk to them, preferably to donate money. Can they actually learn that their older attitudes will no longer protect them in office the next time they run for election? Can Harry Reid get aggressive with them?

Those are the remaining roadblocks to America having a semi-modern health care system.

Here's why the Washington D.C. press corps never talks realistically about the American health care system

If you have ever wondered why the Washington Post, New York Times and major TV networks never discuss singly payer (the only health system that provides universal health care at a reasonable cost) Bob Somerby, editor of the Daily Howler explains with the example of newsperson Margaret Carlson. Keep in mind that Lily Weymouth is the current CEO of the Washington Post, Washington D.C.'s hometown newspaper who recently was prepared to organize dinner salons that lobbyists were to pay $25,000 to $50,000 each to attend and meet with top Washington Post editorial staff and other Washington insiders.

In 2003, the grasping climber Margaret Carlson explained the process with remarkable candor in the 26-page autobiographical chapter which drove her semi-book, Anyone Can Grow Up (see THE DAILY HOWLER, 6/18/03). In that chapter, Carlson described the gruesome process by which she attained social standing inside DC’s elite. In her inspiring up-from-steerage tale, she—the child of working-class, Irish Catholic parents—ends up sitting at the right hand of Post publisher Katharine Graham!

What a story! It all began when Michael Kinsley took her to a soiree—at the home of Weymouth’s grand-mother:

CARLSON (page 22): My friends didn’t change from year to year, but their jobs did. It was Michael Kinsley...who first took me to dinner at the big, intimidating mansion of Katharine Graham, the reigning queen of Washington and publisher of The Washington Post. Every few weeks, when Henry Kissinger or Barbara Walters was stuck on the tarmac at LaGuardia, I would get a late call asking if I’d like to fill in. Following the Meg Greenfield rule—call anytime before the main course—I always said yes. Eventually, I would go as me. Like the rings on a tree, my evenings with Graham charted my evolution from rookie journalist to old timer.

“I always said yes,” this classic climber wrote. But when social climbers like the young Carlson agree to say yes, they are typically saying yes to more than a set of dinner invitations. They are also saying yes to the constellation of political views which guarantee them a continuing seat at such Very High Tables.

They’re saying yes to what The Group believes. They’re saying no to everything else.

Today, Carlson is one of the biggest fools in Washington. (She’s also a regular, simpering guest on our biggest “progressive” TV show! Surely, the gods rock with laughter.) But in her very valuable book, she gave us a very valuable look at the desire of these social/career climbers—the desire to gain acceptance at The Highest Washington Tables. But darlings! To gain acceptable at those tables, there are certain things you mustn’t say— mustn’t believe, contemplate or even discuss. Over the past fifteen years, one of the things you couldn’t discuss was this remarkable set of data—perhaps the most remarkable data-set we know of in the world:

Total health expenditures per capita, 2003

United States $5711
Australia $2886
Austria $2958
Belgium $3044
Canada $2998
Denmark $2743
Finland $2104
France $3048
Germany $2983
Ireland $2466
Italy $2314
Japan $2249
Netherlands $2909
Norway $3769
Sweden $2745
United Kingdom $2317

Those are astonishing data. Over the past fifteen years, they’ve almost never been discussed. Everyone but Krugman understands—you simply mustn’t discuss them. Long ago, Kinsley took Carlson to Graham’s house. Last week, he wrote a column in which those data, though highly relevant, simply never appeared.

That dinner at Lally Weymouth’s house wouldn’t have been about giving Kaiser Permanente access to Connolly. If anything, that dinner would have been about giving Weymouth access to her own reporters and editors—giving her the chance to show them where the lines have been drawn. On the national level, Rep. Jim Cooper is not well-known or highly visible. But he played a leading role in defeating Clinton’s health plan—and there he is in Kurtz’s report as Weymouth’s lone confirmed guest!

At dinners like this, Washington’s sprawling collection of climbers learn what they’re allowed to think/discuss. And the pay-offs for consent are huge, as Carlson explained in her book. The heart-warming end to her Climber’s Tale involved her daughter’s wedding. By now, a reigning queen was simply “Kay” in this uplifting tale:

CARLSON (continuing directly from above): One day Mrs. Graham complained that she’d never been asked to my house. A few months later, I was giving a going-away party for Kinsley, who’d been wooed to be editor of Slate.com by Microsoft’s Bill Gates. It seemed the perfect occasion to hide behind. She came, she tossed salad, she scooped ice cream. She became a fixture at my house.

[...]

When Courtney decided to get married in 2000, Kay asked if she would get married in her garden, and that began a wedding my mother would have been proud of. I didn’t make Courtney’s wedding dress, as my mother (and I) had made mine. She preferred one by Vera Wang, proving there can be progress from one generation to another.

A generation of climbers got the message. Their daughters could get that Vera Wang too—if they were careful never to mention the actual shape of world health care.

At such salons, consent gets manufactured within a grasping pseudo-elite. A Kaiser was going to pick up the tab. Was the grand-daughter of a “reigning queen” going to sketch her land’s boundaries?

If you suspect that the major media such as the Washington Post and the TV networks have a very restricted set of views they will permit to be published or discussed, It's true. Margaret Carlson's story explains why. Top pundits and editors get high social status in Washington D.C. if they go along with the prevailing D.C. wisdom and avoid discussing subjects or points of view that the major corporations (advertisers and big time lobbyists) don't want discussed. That's why single payer health insurance, the only system that is both efficient and capable of lowering the overall costs of health care in America, is off limits for discussion and serous consideration. So are most liberal positions these days. The full range of subjects that can be discusses range from very middle of the road to far right wing excluding clear extremism and racism.George Stephanopolus did not parachute in from the Clinton White House and enter the TV hierarchy at the top without understanding these rules. That he took over the Sunday ABC TV news show only shows how well he has met the demands of his masters.

Here are a few things I want to see in health care reform - given the absence of single payer

Here are a few provisions I'd like to see in whatever bill passes short of single payer.

One thing that would help is a single universal health risk pool. A private insurer who operated in the Health insurance market would be required to accept any applicant, regardless of prior history, and would be forbidden to selectively rate up any applicant.

Add to that "risk adjustment" and the health insurance system would be operating pretty much on a level playing field. Everyone would be forced to make their money by paying lower health care costs. There's a lot of room for innovation in that.

Also we need a single standardized definition of the terms used in medical billing, so that physicians and hospitals would have to hire only enough clerical staff to deal with one basic system billing system. The idea that every insurance company has its own system is simply a ploy to lock in health care providers to that insurance company. Any efficiencies found in medical billing could go to physicians and hospitals or to the insurance company. That's another incentive to lower costs and streamline the billing system. It would also lower what it costs to run administration for medical billing in the physicians and hospitals.

I am assuming that insurance companies will be allowed to sell supplemental insurance policies that cover costs above what the standard benefits the new health care system will provide, but such policies should clearly be add-ons to the normal insurance, not included in as part of the normal insurance like the private insurance companies offering Medicare benefits do today. That way the purchasers would know what they were paying and could see whatever additional benefits to supplemental policy provided. Again, the cost of health care needs to be up front and transparent as much as possible.

I'd also like to see a single universal appeals board for all denials of payment, private and government. Without that standardized appeals system the patients have no real recourse usually, which is why the insurance companies have been able to get away with the rescissions.

Sweeten the pot for physicians by paying off parts of the student loans taken by them. My DO graduated from medical school with a 30-year payment schedule. For each year in the system, pay off a year of loan (up to a max each year to prevent gaming the system, perhaps. That would require research, but the date would be easy to get.)

I'm sure all of that could be gamed, but the profit in gaming it would be a lot lower that what we currently pay. Remember, the federal government already pays of half of all health care expenses in the nation.

Good "AMA" health care commercial

Watch this "commercial" by Bill Maher. The AMA will hate it - particularly because it is true, just exaggerated.



Also, Digby makes an excellent point about this "greatest health care system in the world." Free lancers, students, and self-employed individuals have to avoid going to the doctor because if the doctor finds something that is recorded as a "preexisting condition" and you then move out of state or even just out of the network area, you are dropped by your old insurance company and have to find a new one in that great free market that McCain was going to throw us all into.

If you have a preexisting condition on your record then even if you can find new insurance then the premiums will be sharply jacked up. Very frequently that means people are trapped in one location or job just to keep their health insurance.

Universal health insurance with a single rating pool and with everyone paying into the system whether they are healthy or not ends that, even with private insurance companies. It's just that everyone pays and since everyone is in the same universal rating pool, preexisting conditions do not exist. Neither do jacked-up premiums, since the insurance company does not have to ensure that they are only administering insurance and paying for people in their own private rating pool.

The insurance companies, even in a private system, are paid on a per-capita basis. They collect the same premium as every other insurance company per person insured. If someone is especially expensive, then the individual companies themselves pay for loss insurance for themselves. Excessive losses are "reinsured." It's like a gambling casino. For a pool large enough, the losses are quite predictable.

Of course, the high executive salaries are no longer justified. That's why they want to kill universal health care and leave 50 million Americans uninsured. They make much bigger profits that way.

Why the new H1N1 flu is important

This new flu is beginning to look like it is not the new "killer flu" like the 1918 flu was, but it has a real problem anyway. It is genetically novel, and humans have no immunity to it based on previous experience. Here is an explanation of the danger from an expert:

What's important about this virus is its genetic novelty. As far as we know, the human population doesn't have any natural immunity to it. But what people perceive about the virus is its lack of novelty. Clinically it seems a lot like what they are used to with seasonal influenza. It's not (so far) the monster of 1918 and doesn't have the virulence of H5N1. What they are forgetting is what the genetic novelty might mean.

Because there is no natural immunity to this virus, even though clinically it appears to be like garden variety flu to the individual, with respect to the population it has the potential to spread faster and many more people sick than seasonal flu. And remember, seasonal flu is not a walk in the park. It kills an estimated 30,000 people a year.

A bad flu season can fill hospital emergency rooms and in patient beds to the bursting point. We currently have fewer staffed hospital beds per capita than we did in the last pandemic, 1968 (the "Hong Kong flu"). There is no reserve capacity. We can't just add physical beds. Beds don't take care of patients. Nurses and doctors do.

Now take a bad flu season and double it. To each individual it's the same disease but now everybody is getting it at once, in every community and all over the world. In terms of virulence, it's a mild pandemic. It's not a lethal virus like 1918. But in terms of social disruption it could be very bad. If twice as many people get sick, the number of deaths could be 80,000 in the US instead of 40,000. Gurneys would line the hallways of hospitals and clinics. And absenteeism amongst health care workers would compound the problem. Infrastructure would probably survive intact. No need to have your own water supply or electricity generator. But it would be a very rough ride.

All of this could plausibly happen from this virus without it causing anything more than the usual case of influenza. We are pouring tens of billions into infrastructure. I'm a big fan of high speed rail. But the public health and social services infrastructure -- good, job producing infrastructure -- needs attention and needs it right away because of this virus.

We are not in any position to back off of preparations for this flu. We don't want our current health care system to be overwhelmed. How many other medical problems would go untreated if we back off of protective actions and this becomes a mild pandemic?

A great many private health insurance plans don't protect your finances

A major reason for getting health insurance is so that you can have access to health care regardless of your employment status. That's important because is the case of severe illness, you may not be able to work so insurance is essential. The second reason is to protect your personal wealth from the unexpected and, in the case of many severe illnesses, extremely high costs of health care. So when you get laid off, one of the first things you need to do is get individual health care in the individual insurance market.

Consumer reports has recently investigate the health insurance offered in the private health insurance market for people who do not have employer-connected insurance. What they have found is that the private health insurance market offers policies which are either unaffordably expensive or which are so riddled with co-pays and limitations that they leave the insured on the hook for a great deal of the cost of health care which would have been covered by good employer or government insurance policies.

Here is the beginning of the report from Consumer Reports:

Hazardous health plans
Coverage gaps can leave you in big trouble

Many people who believe they have adequate health insurance actually have coverage so riddled with loopholes, limits, exclusions, and gotchas that it won’t come close to covering their expenses if they fall seriously ill, a Consumer Reports investigation has found.

At issue are so-called individual plans that consumers get on their own when, say, they’ve been laid off from a job but are too young for Medicare or too "affluent" for Medicaid. An estimated 14,000 Americans a day lose their job-based coverage, and many might be considering individual insurance for the first time in their lives.

But increasingly, individual insurance is a nightmare for consumers: more costly than the equivalent job-based coverage, and for those in less-than-perfect health, unaffordable at best and unavailable at worst. Moreover, the lack of effective consumer protections in most states allows insurers to sell plans with "affordable" premiums whose skimpy coverage can leave people who get very sick with the added burden of ruinous medical debt.

The rest is quite worth reading so click through.

You may remember that the private insurance market was John McCain's and the Republican party's solution to the rising costs of health care. As this CR study shows, that may get you into the door of a hospital in the case of a major emergency, but it won't cover the costs. If it does, you are broke from paying the premiums before you got sick and you'll very likely be bankrupt when you get out in either case.

The rational solution to this is mandated universal health care financed by the federal government. It needs to be federal because both people and illnesses easily move anywhere in the nation. The problem is national so the solution needs to be national. Also, as medicare and medicaid have proven, they can pay out benefits with an administrative cost less than 10%, while the very best private insurers have an administrative cost of 25% or more. Much of that cost is caused by the fact that the private insurer has to make sure that they do not insure unhealthy individuals and also do not pay for care for individuals who are not paying for their insurance to the insurance company who pays for he services.

Mandated universal health care will lower some of the costs for the federal government because a lot of the administrative expense is involved in just making sure that uninsured and ineligible individuals are covered for health care. That would also lower costs for private insurers, as they could always determine how the individual was covered before they accepted them. The federal government, by dint of its size, also can negotiate the lowest costs for medications and health services. In Germany the similar solution is federally financed and state administered.

This program at minimum would cover catastrophic medical costs, the costs of chronic health problems like diabetes, high blood pressure, and perhaps the wide-spread causes of illness like obesity. I'd like to see it pay for universal dental care, also, since untreated dental problems cause a lot of other health problems like heart trouble and such. Services above and beyond those items like chiropractic care as well as vitamin therapy and alternative medicines which are not well researched could then be covered by private health insurance or by fee for service.

If the government offered this alongside private insurance plans through employers and private insurance, then the difference in cost between the private insurance and the government would have the majority of people move to the government plan because they got equal health care at significantly lower costs and with a lot less hassle and surprise bills or denials of service.

Health care providers (operating as private contractors) would all understand the rules of the major health care financer and be able to focus on providing medical care instead of having to hire three or four medical insurance clerks to deal with differing insurance regulations and with fighting with insurance companies to get various services covered for their patients. Appeals for denials of services would be public record and available to the press, unlike similar "appeals" to private insurers, so the public could be made aware of unfair financing practices. Note the several private health insurers in California were sued for waiting until someone got expensively sick, then going back and determining ways to cancel their policies and merely refund their premiums instead of paying benefits. This unfair process (which is probably widespread) only comes out against a private insurer after expensive and lengthy law suits, and then only if the currently declining media covers it. A government appeals process can be made separate from the issue of making a profit, unlike for private insurers.

Most average workers simply want access to needed health care for themselves and their families. Middle class workers want medical care access and protection of their family wealth, such as their home and retirement funding. Only a universal health care mandate properly designed will provide that. It clearly is not here for a great many people right now, and what is happening to the auto workers demonstrates how uncertain even employer-provided health care is.

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Addendum 10:39 CDT

Here is a link to a story of how the employer insurance is abused by employers. Fired Zales worker recovers. My thanks to the commenter "anonymous" who left this link as a comment to my April 10th post on Social Security and Medicare Notes.

The Swine Flu in Mexico and in the U.S.

There are a lot of questions about Swine Flu, but a really big one is "Why is the death rate from the flu so high in Mexico and not anywhere else? The Wall Street Journal offers an interesting analysis. Here's a fast summary of the factors the Journal reports:

• The virus is the same in both Mexico and in the U.S., so the difference is NOT the virus itself.
  
• The virus started in Mexico, so that country is further into the development of the spread of the flu.
  
• Mexico city sits at a high altitude and has smoggy air. The early development and spread of the flu was masked by normal frequent winter colds with fever and throat infections that occur there.
  
• A lot of flu victims thought they had a normal winter cold, so they delayed a day or so going to the doctor. Then the doctors, with no warning that a flu was going around, often misdiagnosed the illness. The delays allowed it to develop into pneumonia.
  
• Since the medical profession in Mexico did not have advance warning that there was a flu going around, it was not diagnosed early. The U.S. has the advantage that our medical professions have had an earlier warning of the flu, so it will likely be diagnosed earlier. The higher mortality rate in Mexico may be largely because neither the medical profession nor the patients were aware of the level of the threat
  
• The problem may also be cultural. Many Mexican, especially the poor, depend on public hospitals, so they wait for a few days after getting ill to see of it really is severe enough to require going to a doctor. In the meantime they medicate themselves. This is easier since antibiotics are available without a prescription. This allowed the flu to develop and spread more widely before being recognized.
  
• Then there is the fact that going to one of Mexico's public hospitals takes hours or even days to get to see a doctor. The public health care simply isn't funded as well as it would be in a more developed country.
  
• Once inside a hospital, the hospital workers complain that they don't have the safety equipment necessary to deal with highly infectious patients.
  

It's an interesting analysis of the problem. Overall the set of problems that have led to the size of the flu problem in Mexico is a combination of the fact that Mexico is the first nation to be struck by it, the public health care system in Mexico is poorly funded so it did not quickly recognized the problem (the public health Intelligence system is clearly not as developed as in a developed nation with decently funded universal health care) nor did it have all the resources needed to contain it, and the general public simply does not have a close attachment to the medical system except in clear cases of more extreme illnesses for both cultural and financial reasons.

I notice that the Wall Street Journal's article does NOT address the fact that the death rate among working age individuals age 16 to 45 is especially high. This is worrisome, since these individuals are expected to be the most healthy, and this is a pattern followed by the extremely deadly 1918 Hong Kong flu.

It's my speculation that here in the U.s. we have the advantage of the a early warning that came out of Mexico about the existence of the flu, the further advantage that our public health Intelligence system is much better funded and quite a bit larger with respect to our population, and the U.S. has stronger medical regulations so that patients are more certain where and how they can get medical help when they feel they need it.

We will probably see the flu strike largely in the uninsured American population first, incubate there because patients don't have the funds or the time to seek medical help, then it will spread to the more affluent population. Texas, with it's border on that of Mexico and with its 25% of the population without health care will be hit worse by the flu than other states with better medical systems. But just as the flu spreads from Mexico into the American border states and finds unprotected populations there, it will then spread within the U.S. to the more medically advanced states. That's the development pattern I will expect.

If that sounds like I am making an argument for universal U.S. healthcare, you read it correctly. But I don't think it is so much me making that argument as it is the Swine Flu.

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Some additional information about the Swine Flu.

• MSNBC reports that there are presently 91 cases of swine flu reported in 10 states. One toddler has died from the flu. The CDC is considering raising the pandemic alert to phase 5. The pandemic alert is a measure of how rapidly an infectious disease is spreading. The highest level is phase 6.


• MSN Health reports that the possibility that Swine flu is incubated in factory farms is being taken seriously by the experts and is being investigated.


• MSN Health also has an article posted that debunks some common rumors floating around about the Swine Flu. It's worth reading.

Obama, Daschle and health care financing

One major thing about the election of Obama as President will be the effort to break the health insurance lobby and allow Americans to get universal health care. The announcement that ex-Senate majority Leader Tom Daschle will become Secretary of Health and Human Services as well as director of the new White House Office of Health Reform indicates that Obama is serious about health care reform.

Ezra Klein has a really interesting article about how Tom Daschle and Barack Obama are connected. The connection is the previously very powerful chief of staff to Daschle as Majority Leader (Pete Rouse) who came to work for the most junior Senator in the Senate after Tom Daschle was defeated for reelection in 2004. Here is Ezra Klein's description of the Daschle - Obama connection and it's implications for the coming battle to get universal health care.

Obama's campaign was built off the plans Rouse wrote for Tom Daschle's Senate run. It even used the same people. His deputy campaign manager, Steve Hildebrand, managed Daschle's 2004 campaign. His director for battleground states, Jennifer O'Malley Dillon, and his director of communications, Dan Pfeiffer, were both deputy campaign managers for Daschle in 2004. Obama's foreign-policy director, Denis McDonough, was Daschle's foreign-policy adviser, and his finance director, Julianna Smoot, was head of Daschle's PAC. And in February of 2007 -- which is rather early for this sort of thing -- Tom Daschle, who had served with Joe Biden and Chris Dodd and John Edwards and Hillary Clinton, stepped forward and endorsed Barack Obama, giving Obama crucial establishment credibility, a powerful emissary to elite Washington, and a key adviser. And since then, other Daschle confidantes have entered Obama's inner circle, namely Phil Schiliro, formerly Daschle's policy director and now Obama's legislative liaison.

Which is all to say that Daschle is rather better integrated into Obama's political structure then your everyday appointee. And he has the relationships and the information to have made an informed judgment on whether the president-elect was serious enough about health care to merit Daschle's full-time involvement. Which is again why I urge people not to underestimate the importance of this pick, either as a signal of intentions or a signal of strategy. Though this point is argued in greater detail below, the distance between Ira Magaziner and Tom Daschle could not be greater. Magaziner knew nothing of the Congress. Daschle knows nearly everything. If the Clinton plan failed because it was too much the product of a policy process and too little the product of a congressional process, Daschle's involvement is the strongest evidence possible that Obama's plan will not suffer from the same mistakes.

The American health care crisis was supposed to be the major reason why Obama needed to be elected President. People are dying for lack of timely access to health care, while the people are are getting health care are paying a great deal more per person than people in other countries do, and in return getting health care that is not even up to average international standards.

Add to that situations like the health care expenses of the Detroit auto makers have made Detroit automobiles too expensive to compete with those from Japan and South Korea. So health care finance reform is critical to America.

This should not be put on hold because the American economy is collapsing into the worst recession since the Great Depression. The problems of the economy cannot be dealt with effectively without also dealing with the problems of health care financing. So it looks like Obama is going into the Presidency to deal with both health care financing and the economy. Tom Daschle as Secretary of HHS is a sign that the health care financing is going to be dealt with.

Universal health care is near passing

On the universal health insurance front, the health insurance companies are feeling the heat from the recent political season. Now that Obama, who campaigned on universal health care, is President-elect the health insurance industry states that it "...would support a health care overhaul requiring insurers to accept all customers, regardless of illness or disability. But in return, the industry said, Congress should require all Americans to have coverage." So, unlike during the effort to pass Hillarycare, we are not going to see "Harry and Louise" ads from the health insurers this time. What the health care industry is now saying

In separate actions, the two trade groups, America’s Health Insurance Plans and the Blue Cross and Blue Shield Association, announced their support for guaranteed coverage for people with pre-existing medical conditions, in conjunction with an enforceable mandate for individual coverage.

All the government has to do in addition is set a minimum standard coverage, a single rate everyone has to pay, set standardized administrative procedures for filing claims so the every health care provider does not have to train clerks separately for each insurance company, and then offer a government insurance to compete directly with the private insurers. Since the government can administer health insurance at a substantially lower cost than private insurance companies can, this will probably either put them out of business or simply incorporate them into the same overall system.

It will eliminate the excessive costs involved in preventing uninsured individuals and already sick individuals from receiving health care.

Of course, the changes I described above are just about paying for health care. Improving the delivery of services will be more complicated, of course.

Kevin Drum, linking to Ezra Klein discusses the downside of the insurance company proposal. But he is looking at the details that are going to have to be worked out politically. I am looking at the political wind behind universal health care generally. Try though they will, the Republicans and conservatives will not be able to kill universal health care this time.

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Addendum 11:23 pm CST
Mark Kleiman of the Reality Based Community discusses the politics behind the health insurance proposal to accept the individual mandate for health insurance coverage.

McCain's plan to destroy America's health insurance system

McCain agrees with the majority of Americans. He thinks our current health insurance system has failed. He just thinks that the problem isn't that people can;t afford health insurance. The problem, according to John McCain, is that Americans get too much health care and need to get less.

The solution, as McCain sees it, is simple. Eliminate employer-paid health insurance and throw everyone into the private individual health insurance market. "Everyone" That is, who the private insurers will accept at whatever price the insurers want to charge.

Preexisting conditions like high blood pressure, a history of cancer, or back trouble? Have you ever had surgery or medical care? Forget buying insurance. You can't afford the prices. You are on your own.

If you do try to keep your employer based health insurance and if your employer is willing to offer it, you will be taxed on the value of the insurance.

From Bob Herbert:

“The McCain plan will force millions of Americans into the weakest segment of the private insurance system — the nongroup market — where cost-sharing is high, covered services are limited and people will lose access to benefits they have now.”

The net effect of the plan, the study said, “almost certainly will be to increase family costs for medical care.”

Under the McCain plan (now the McCain-Palin plan) employees who continue to receive employer-paid health benefits would look at their pay stubs each week or each month and find that additional money had been withheld to cover the taxes on the value of their benefits.

While there might be less money in the paycheck, that would not be anything to worry about, according to Senator McCain. That’s because the government would be offering all taxpayers a refundable tax credit — $2,500 for a single worker and $5,000 per family — to be used “to help pay for your health care.”

You may think this is a good move or a bad one — but it’s a monumental change in the way health coverage would be provided to scores of millions of Americans. Why not more attention?

The whole idea of the McCain plan is to get families out of employer-paid health coverage and into the health insurance marketplace, where naked competition is supposed to take care of all ills. (We’re seeing in the Bear Stearns, Fannie Mae, Freddie Mac, Lehman Brothers and Merrill Lynch fiascos just how well the unfettered marketplace has been working.)

Taxing employer-paid health benefits is the first step in this transition, the equivalent of injecting poison into the system. It’s the beginning of the end.

When younger, healthier workers start seeing additional taxes taken out of their paychecks, some (perhaps many) will opt out of the employer-based plans — either to buy cheaper insurance on their own or to go without coverage.

That will leave employers with a pool of older, less healthy workers to cover. That coverage will necessarily be more expensive, which will encourage more and more employers to give up on the idea of providing coverage at all.

The upshot is that many more Americans — millions more — will find themselves on their own in the bewildering and often treacherous health insurance marketplace. As Senator McCain has said: “I believe the key to real reform is to restore control over our health care system to the patients themselves.”

Is there any "theory" regarding how this will somehow "improve" the system for providing health care? Yeah, there is. Deregulation. Let the "customer" decide what he'll buy.

This entire McCain health insurance transformation is right out of the right-wing Republicans’ ideological playbook: fewer regulations; let the market decide; and send unsophisticated consumers into the crucible alone.

Only I don't buy health care. I go to a physician and the physician tells me what I need, then we try to get it paid for somehow.

My insurance company is then given the right to refuse to pay for whatever reason they can dream up. This is long after they have been paid for the insurance they are supposed to be offering. They sold a promise to pay when services were needed, but they can only make money either by either over-charging for the insurance in the first place, or by refusing to pay for health care when it is demanded by the physicians.

The idea that I have any control over what medical care I will need is ludicrous. But that's the theory the multimillionaire husband of a very wealthy beer distributorship heiress is working on. But he has Congressional health care benefits. McCain doesn't have a clue.

So what is the social and economic value added by private health insurance firms?

Any fact-based and rational discussion of America's health insurance "system" will get stuck on the question "What do private health insurance companies do to add value to the health delivery system? Here is a brief discussion from Harold Pollack :

Why do we have this industry again? I understand that history and politics make this industry hard to replace, but what social value does it really create? I don't ask this question about the oil industry, the pharmaceutical industry, or computer software giants. Whatever the misdeeds of particular firms and the pressing needs for public regulation in these latter industries, we understand why it's good to have firms competing to find new energy sources, new drugs, new operating systems. I don't believe private insurers are less ethical, as a whole, than soft drink manufacturers or manufacturers of plush carpet. I just can't explain what we are getting here.

In the case of private health insurance, firms have some expertise administering claims and perhaps designing wellness programs. Yet to the extent that their business relies upon avoiding high-cost patients their activities are social wasteful. In so many ways, their incentives are poorly aligned with the public good.

Even if we could correct these misplaced incentives, it seems as though anything beneficial insurers can do could be accomplished better and cheaper by government. Private insurers are too fragmented to promote needed efficiencies such as electronic medical records. A Chicago provider dealing with 20 payers is hardly swayed by the pay-for-performance standard of any one of them. In general, private payers are too fragmented to exert powerful market discipline on providers. The embarrassing history of Medicare managed care provides one of many embarrassments for those who assert the inherent superiority of the private sector.

Private insurers do have two advantages: They are more nimble than government is. More important, they can take the political heat for saying "no" when patients want some desirable but unjustified service, drug, or therapy. This is hard for government to do, and "no" should sometimes be said even when this is painful.

But maybe we have this backwards. It seems to me that even when insurers are justified in saying no--as Cigna might have been in the liver transplant case promoted by John Edwards, and as insurers sometimes are regarding potentially useless or harmful experimental therapies--profit-making firms lack the legitimacy to deny anyone a desperately wanted treatment that provides some plausible benefit. Denying important treatments is an inherently political question. A transparent process, by financially disinterested parties, is required to secure public legitimacy.

If this is so, private insurers themselves have a strong stake in government assuming a larger role in scrutinizing costly therapies. And they have a strong stake in some larger regulatory structure to constrain the more predatory aspects of current market practice.

I write this as (by HuffPo standards) a politically moderate free-trade policy wonk who instinctively favors market solutions for most economic concerns. If people like me feel this way--and many of us do--the industry should be worried.

We know that any reform of the health care system will immediately face insurance company financed "Harry and Louise" ads to try to scare voters out of rationally considering the problems insurance companies cause and their inability to add anything positive to the health care delivery system. But really, are physicians and nurses so brain washed that they are willing to continue to waste thousands of man-hours trying to get insurance companies to do things that are rational and provide decent patient care?

It is fear of government bureaucracy? Why is rational government bureaucracy any less efficient than the existing multiple bureaucracies of thousands of different health insurers? (Answer - a single government-run bureaucracy is clearly capable of being much more efficient than what we have now.) Given that the inherent difference in the source of a bureaucracy is negligible, then the clear cost savings of a single, rational bureaucratic system with a decent appeals system and media oversight is obviously preferable to the current inefficient and corruption-ridden private enterprise system. And health care providers will have greater ability to influence a government-run single payer health care financing system than they do to influence powerful insurance executives who answer to no one except their investors.

I think America is ready for realistic health insurance reform. I do wonder if Barack Obama understands why previous efforts have failed and what he has to do to avoid those same traps if and when he is elected President. Hillary is clearly the preferred candidate if the intent is to reform health care. She understands the need and understands many of the pitfalls that Bill Clinton was unable to navigate around in 1993.

This is a subject that needs to be continually readdressed. America can't afford the gold-plated system that fails one in six Americans when they need it.

Countering the myths about Canadian health care

I am a strong proponent of single payer universal health care provided as a human right. We already try to provide health care to everyone who needs it, at least on an emergency basis, but this is both inefficient, misses a lot of people, fails to provide care to a lot of people with chronic conditions, is ridiculously expensive, wastes tons of money on unnecessary administration that is required so that the company who receives the premiums can't shift the payment off to some other entity, and causes physicians to spend too much time as administrators, thus wasting their extensive medical training.

People who oppose single payer health care offer two major arguments. One is that it is "socialized" medicine. This argument is ridiculous on the face of it, and is not to be considered as a serious objection. The second and somewhat more serious argument is that the Canadian system is single payer and has failed to provide the care the American ("lack-of") system does. The second argument is not much more serious than the first one, but requires more facts to counter. Those who use that argument never provide facts, just anecdotes. A system cannot be built on anecdotes. Facts are required before it can be determined which stories matter and which do not.

So Sara Robinson has provided an excellent article that lays out the details of the Canadian health care system, with both its advantages and its disadvantages.

Here are the facts. Go read the article.

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Bet you thought I was going to write about yesterday's Super-Tuesday primaries this morning, didn't you? Nope, not yet.

I can't provide any breaking news, and it is too soon to know what really happened. We'll just need to collect more information and see what the outcomes from the day are before any analysis that matters can be expected. It's enough for right now to recognize that yesterday was a really important day for America. It will be interesting to see how.

Another reason private companies cannot insure health care fairly

What's really wrong with America's health care lack-of-system? Here is the answer.

Insurance companies make money by not paying for claims.

Here is another example of the way private insurers avoid paying legitimate claims. The story was reported in the Los Angeles Times on Christmas day.

A California State Appeals Court looked into the way California insurance companies cancel health insurance policies. Steve Hailey, an Orange County small-business owner, had an insurance policy with Blue Shield of California when he had a car accident that disabled him. Blue Shield first approved more than $450,000 worth of hospital and other medical care, but when the costs of care exceeded the amount or premiums he had paid, they canceled his policy and demanded reimbursement for more than $104,000 they had spent on his account.

The reason for the cancellation? They claimed that Hailey lied about preexisting conditions when he purchased the policy. However, the appeal court found that his wife had filled out the application, and it was written poorly so that it was not sure how she should have answered the questions. The key point, though, was that Blue Shield had become aware of the apparent misrepresentation about two months after the policy was issued, but waited until their was an accident and the payouts exceeded the premiums paid before canceling the policy and demanding reimbursement. Had they canceled the policy when the errors were first noted, the Haileys could have gotten coverage for Mr. Hailey on Mrs. Hailey's policy through her employer. By the time they did cancel, after an unnecessary delay simply to collect premiums, it was too late for the Haileys to make other insurance arrangements.

The California appeals court rejected the cancellation of the Hailey's policy, sent it back to the lower court for trial, and required Blue Shield to pay for the Hailey's costs of appeal.

The insurance company policy, then, was to delay canceling the questionable policy as long as the insured was paying premiums but not making big claims. Only when claims exceeded premiums did they cancel the policy, which prevented the newly uninsured from making other arrangements for insurance.

The decision by the California state court of appeals has no power in any other state. This technique is available to any health insurer who want to use it outside California. So remember

Insurance companies make money by not paying for claims.

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This is another post that describes how private health insurance fails to deal fairly with the insured. My earlier post was Here's why private insurance companies can't finance decent universal health care.

Here's why private insurance companies can't finance decent universal health care

Every wonder what is really wrong with America's health care lack-of-system? Here is the answer.

Insurance companies make money by not paying for claims.

So private companies will maximize profit by collection premiums and then avoiding paying claims as much as possible. The only appeals to this are to the company itself, to the state insurance regulators (which are staffed either by people from the insurance industry or people who are planning to later work for the insurance industry), or to the prohibitively expensive courts. The Republican Tort Reform efforts are all designed to cut off access to the courts by limiting the ability of tort lawyers to get paid for their efforts.

Christy Hardin Smith has a good article on this subject over at FireDogLake.

While it's not perfect, the solution is single payer national health care with the premiums paid by taxes on both employers and individuals and the crazy-quilt of varied coverages and their administration standardized.

Because there are so many insurance companies, each one can claim that refusal to pay valid claims by a different company is not something they do. The actions of each individual company is concealed in the many different companies all trying to offer different products. No government agency can get away with that. There would be a single system of appeals carefully covered by the media.

Stripping out the unnecessary administrative expenses out of the system would save 10% of the waste, fraud and abuse that characterizes the present lack-of-system. Eliminating the overpaid CEO's and dividends to owners would recover another 10%. Then eliminating the costs of salespeople would save another 10% or more.

We need single payer health care in this nation immediately.

See MichaleMoore.com.

This is what Bush calls the finest health care system in the world

Bush and the Republicans are lying about America's health care system again. Bush Claims ‘We Have Fabulous Health Care’ Compared To ‘Other Systems Around The World’

In 2002, the U.S. spent more on health care per person than other industrial countries like Britain, Canada, France, and Germany. But unlike those countries, which have universal health care systems, there are roughly 47 million Americans who lack health coverage.

In 2000, the World Health Organization (WHO) did a comparative assessment of the health systems of 191 countries. The WHO found that in terms of the five measured performance indicators, the U.S. ranked 37th:

The U. S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance, the report finds. The United Kingdom, which spends just six percent of gross domestic product (GDP) on health services, ranks 18th . Several small countries — San Marino, Andorra, Malta and Singapore are rated close behind second- placed Italy.

Go look at Michale Moore's Latest Sicko News.

I wonder if anyone has even dared tell Bush that the UN has rated the American health care system as 37th in the world, right behind number 36 (Costa Rica) and just ahead of number 38 (Slovenia) and number 39 (Cuba.) Somehow I doubt it.

Like everything else the Republicans think America does so well, it is only really good for the very wealthy who are not kept from accessing it by lack of funds.

Poorly written Republican drug bill hurts drug companies, helps patients

The drug companies who thought they were going to get a whole new set of customers who would have to pay full undiscounted price for their products has found a major flaw in their plans. 'The donut hole' of non coverage is driving patients to buy generic drugs instead of those still under patent and much higher in price.

The Republicans, attempting to pass themselves off as 'Compassionate Conservatives' and retain control of Congress in 2004 passed the Medicare Drug Bill in 2003 so as to avoid the anger of seniors who tend to vote their views and who had no access to insurance covering prescription drugs. Besides being passed one vote, 216-215, in violation of normal Congressional time limits and after some of the most egregious arm-twisting, was recognized as a major victory for the drug companies and their lobbyists. Both the House and Senate passed versions of the Bill that prevented the federal government from using the purchasing power of 40,000,000 patients and negotiating lower prices for the drugs as both Medicaid and the Veteran's Administration already do. It was a great political victory for the drug companies and their lobbyists.

Or maybe not.

The bill as passed was considered extremely expensive, even before it was learned that the Bush administration had prevented Bill Foster, the actuary who knew the real cost estimates, from reporting the $139 billion higher cost to Congress. Because of the anticipated expense of the program it had a strange feature known popularly as "the donut hole." After an initial annual deductible, Part D. pays approximately 75% of the cost of medications until the total costs of medications reaches $2,510 in 2008. After that, even though the beneficiary must still continue paying the monthly premium, Part D. does not cover any further medications until the total out-of-pocket expense reaches $5,726. The $2,510 is based on total drug costs, but the $5,726 is based on the out-of-pocket expenses incurred and does not include drug costs previously paid by the insurance.

In other words, the coverages stops at the total drug costs of $2,510, a limit that includes the amount of reimbursement for drugs, but does not again start until $5,726 in out-of-pocket expenses (which does not count the amount paid by the insurance) is reached. Let's look at some numbers.

Description	Out-of-pocket	Reimburse	Total drug Cost
Annual Deduct	180
CoPay+Reimbur	628	1702
End init coverage			2,510
Subtotals coverage	808	1,702	2,510
Donut hole	4,908	0	7,429

[This is an illustrative example and uses amounts that may not apply to all Part D recipients.]

The $7,429 is the total drug cost less the reimbursement of $1,702. In other words, the donut hole is all drug expenses between $808 of initial out-of-pocket expenses up to the total out-of-pocket drug expenses of $5,726. That is $4908 in drug expenses not covered by Part D of Medicare.

In addition, while paying those drug expenses it is also necessary to pay the monthly premium of $24.80 or more. That is another $298 per year. Only after drug expenses have passed $7,429 does Part D begin paying approximately 95% of the costs of medication.

The trick to using Part D is obvious. Do not spend more than $2,510 in drug costs. Some people just quit taking medications when the coverage runs out at the beginning of the donut hole. But what a lot of people have begun doing is switching to generic medications. Wal-Mart is selling a lot of them now for $4 a month.

Don't wait until you hit the donut hole. Talk to your doctor, get generics instead of medications still under patent protection, and you may never reach the donut hole. And generics usually are as effective as the newer prescriptions.

Who gets hurt? No one, really. A prescription drug benefit has been needed as part of Medicare for decades. It's just that the Brand name drug companies are finding that their profits are lower.

The interesting thing as that this trend among the seniors is retraining health care providers to discuss price and choose generics whenever possible, so the trend is likely to spread to all patients. The result?

Health care costs will go down a little. More interestingly, brand name drug manufacturer's profits will drop. That's because the value of their patents is going to drop and they are going to have to actually compete for profits with the makers of generic drugs.

This really isn't what the Brand Name drug manufacturers paid their K-Street lobbyists to achieve.

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[Note: the premiums and copays used above are the lowest possible. High income people on Medicare Part D may find their own expenses are a little higher.]

If we just ignore medical bankruptcy, no insurance companies need be hurt

Elizabeth Warren describes the manner in which the highly paid defender of the current health care status quo defends the present lack of system against all attacks. He ignores any study he disagrees with, refuses to acknowledge a powerful individual story of personal disaster caused by the current system as "single-anecdote photo opportunity" and offers no research of his own to refute the research he rejects.

Americans can hope that he is beginning to find it harder to earn the large sums of money the Insurance industry is paying him to be an 'expert witness' and defend their profits.