More on health reform

The Democrats have to be very careful if a health insurance 'reform' bill is passed and Americans (majority, at least) don't like it. Social Security and Medicare have passed the test of time; that's why to tamper with the benefits is considered to be a political "third-rail." What finally emerges and Obama signs has to have the same positive and enduring reception by the people as social security and medicare. We'll see. I am for a robust public option not any public option (actually, I'm for single payer, but that's off the table due, in my opinion,to the vast sums of money that have been poured into the fight against it and the public option by the health insurance companies). But I'm with Obama on the point that the object of the exercise isn't a public option, per se, but an effective mechanism to control price (premium) gouging by the insurance companies, and to make sure people are insured for all (including pre-existing) conditions with no lifetime maximums imposed. As the saying goes "the devil is in the details," so let's see.

Offhand, it is the older Americans who will have more pre-existing conditions, so taking them into Medicare and out of the pool that the private insurance companies have to insure, will lessen the costs to the private insurance companies since younger people, thankfully, will have fewer pre-existing conditions. This may turn out to be a win-win compromise. The Republicans get to say they like and are supporting the expansion of Medicare (even though it is in fact a public option) while at the same time saying they've defeated the public option. The Democrats get to say they've expanded Medicare to a large segment of our population (and, by the way, while it may not be said - have opened the door to future expansion of Medicare to the entire population, perhaps incrementally, but nevertheless opened, and if Medicare one day becomes open to all, that's the end of the private, for-profit, insurance companies -- that in itself is a hammer that can be dropped if the private companies don't do right by the American people).

But let's see what finally emerges; we're getting closer, but all of this can go down if one of the so-called 'fiscally moderate' (read 'in the pocket of the insurance industry') Democrats doesn't stay on board.

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Yes I agree that single-payer can be the most efficient system if administered properly. Some commentators I heard thought that the leftist Dems should be happy with the Medicare extension to 55-and-overs, because Medicare is America's single-payer plan, and now at least it's available to more Americans. And if the bill passes, insurance will be more or less mandatory, so insurance companies will gain millions of new customers. So everyone is happy? I guess the real trick is how to pay for it, since unions fought the Dems to remove the "Cadillac plan tax". Maybe there will still be a tax on the rich? But I think the administration and CBO think that the savings from not having to treat the uninsured will pay for expanded coverage for all?

I just don't think there is much in this legislation to control the costs of premiums and fee-for-service doctors. I thought in big bills like this, everyone has to give back a little, and then get a little. Insurers won't be able to turn away sick people any longer, but in return they get more customers. I don't know if they will still maintain their regional monopolies or not. But what have doctors had to give up? Maybe with a cap on lawsuits, they can pledge to charge less for services, and not turn away Medicaid/Medicare people because reimbursements are lower than private customers. As a legal professional, how do you feel about the medical malpractice situation?

Yes as you said, the voting is so close that just one senator can derail it all - might be Lieberman. But I also think the Dems and the administration should not just throw all sorts of proposals and amendments out there and hope they get their 60 votes. As you said, a good bill needs to stand the test of time and be well researched to have a meaningful positive impact, and can't just be an exercise in throwing darts until you get a passage. The Medicare plan seemed to come out of thin air, and I don't think it was publicly discussed in the fall. I worry about these last-minute desperation ideas. If the negotiations aren't public, that leaves even more room for industry lobbyists and the like to tamper. And when you're in a hurry, you make mistakes of course, like the rushed TARP plan and Wall Street bailout. They were necessary (I suppose), but obviously flawed.

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All I can say is the details are not all public and we don't know what the final version will look like. As for me, I'm disgusted with the thought that we have a for-profit health insurance industry. I'd like to simplify this with single-payer and extend medicare to everyone. I agree with you completely as to last-minute, ill-conceived deals and the influence of lobbyists. But I voted for Obama because I had confidence in his judgment and so for now I have to assume he will not sign off on any legislation unless he believes it will indeed benefit the vast majority of Americans and not turn out to be a debacle which will hurt the country (and the Democratic Party).

As to the medical malpractice situation, in my opinion at least, the tort system is what keeps the powerful in check, and having financial incentives for lawyers to take cases for plaintiffs is important to justice in our country. "Tort reform" is code for the insurance industry (again!) wanting to maximize its profits. The fact is that insurance companies and major U.S. corporations have armies of lawyers working for them at very high hourly rates. And these armies of lawyers at the top corporate firms are typically the top legal minds coming out of law school (law students usually go for the gold upon graduation, and those who get it are usually the top 10% of the graduates from the top law schools in the country. (Obama, by the way, was one such graduate, but he resisted the temptation and became a community organizer -- talk about taking the long view, 'out of the box' thinking' and deferred gratification.) The average person cannot afford to pay a lawyer in anything resembling a major case. He/she must find a lawyer willing and able to take cases on a contingent fee basis and have pockets deep enough to advance costs and expenses. A big case is usually hard fought by the companies being sued. It's not uncommon for a lawyer to take a case and put in a thousand hours and have many thousands of dollars in expenses paying for depositions and expert witnesses. Since the plaintiff can't pay for this, the incentive has to be there for the lawyer to take the case and take the risk of coming up with nothing in the end. Thus you have the typical contingent fee of 33 or 40% of the recovery. If you cap damages, say in a medical malpractice case, it means lawyers don't take them unless they're potentially huge cases, and they pass on cases that may in fact be meritorious but where the potential damage recovery will not justify the expenditure of the attorney's time and expenses to be incurred. Take a look at this link for an example of the injustice of capping pain and suffering damages in medical malpractice cases in California: http://www.lectlaw.com/files/lit13.htm. I had a professor once who was adjunct faculty and took a plaintiff's antitrust case on a contingent fee basis. He was up against many corporate lawyers. He came in one morning after being up all night working on a brief in the case, and said he'd like a rule that limits the number of hours any side can put into a legal brief, but without it he had to just work harder to be able to meet the arguments of 3 or 4 lawyers on the other side working against him. The insurance companies may want tort reform by limiting damages, but I can guarantee you they would oppose a rule limiting the number of lawyers, their pay, or the hours they invest or in working on a case for them.

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Thanks for writing. I think even if McCain won, there would be some sort of health reform now because the status quo is just so unsustainable (16% GDP on health spending and rising). He might have some crazy GOP ideas about health spending accounts (can be more efficient than Medicare if regulated properly and used wisely, though I doubt Americans are up to the challenge), but they would pass something. So I don't think it's a great accomplishment if Obama just passes some watered-down token bill, as any American president now should be able to do at the minimum (a lot of urgency and political momentum). I think if health reform was a heavyweight boxing match, it's Round 7 and the Dems are down 64-68. Though as you said, a lot of details remain unresolved so it is possible to turn things around. But sad to say that the GOP hate and misinformation campaign seems to be working, as usual. Public option would have changed the playing field in the people's favor, but I guess for now that looks doubtful. Lieberman said he wouldn't support the P.O. or the Medicare-to-55 plans, and without him the Dems don't have the 60 votes. Though maybe he can still be bribed?

But after so much media coverage, fighting, and PR blitzes, each party needs to leave the health care issue claiming that they won. The Dems will pass some version of health reform by February or so, and they can claim a victory for the people. It will cover more of the uninsured poor and make private plans more accessible to people, so I don't want to make light of those gains. But the bill won't likely contain any sweeping reforms, so the GOP can claim victory that they didn't let America go socialist, and all the while the insurance, physician, and drug industries are fat and happy as always.

As you said, for-profit health is borderline immoral, if not completely obscene. I know medical workers should be paid fair compensation for their services, but insurance companies reap huge profits while not really providing us with any service at all (just headaches mostly). But like the prison system, now these behemoth bureaucracies are "too big to get rid of" (or even regulate it seems), and they have billion-dollar legal and PR teams to lobby Washington and fight any challenges to their earnings. Actually working for a large biotech/pharma (even one rated highly in the field), I am tired of seeing the mismanagement, propaganda, and decisions based on profits rather than patients. I plan to switch careers this year and am applying for a "green MBA" program to work on business development for biofuels or green engineering in the future. I hope it works out better, but I am sure there will be plenty of hypocrisy and BS there too.

I agree with what you said about tort reform. It's pure lies how the doctors & HMOs claim they need to keep raising fees because of the "rising" threat of malpractice. As the attachment shows, malpractice payouts per capita have remained flat in the last decade, while medical costs have gone up sharply, so they're uncorrelated. But aren't most malpractice cases settled without ever going to court? Like the MD's malprac. insurance basically tells him to settle, and he has little choice since fighting a court battle will take him away from his practice for months, thereby costing even more money (even if he is innocent). I guess in the single-payer health care nations, malpractice suits are much less common and for less money? Maybe that is due to better quality of care, but probably also fewer ambulance chasers? Lawyers should have financial incentive to take on these cases, but if the incentives are too great, they will over-pursue cases, like fee-for-service doctors over-prescribing procedures. Obviously doctors need to be held accountable for mistakes, but they can't be "practicing scared" and prescribing care based on lawsuit paranoia. It's not good for the doctor or the patient. Medicine is not exact and some people will die even if the doctor goes by the book perfectly. Angry patients and grieving families have a right to be upset, but of course we can differentiate between honest mistakes and negligence. Though if the industry favors settling out of court, then the truth will never be able to come out.

Wow, I didn't realize CA had a cap that was so low and enacted so long ago. It's just a tough situation because obviously HMOs, MDs, and hospitals pass on the costs of malpractice protection onto the government and customers. Yes as you said, maybe it would be more fair to not have lawsuit caps, but instead a cap on legal hours per side. Not just in malpractice, but I think it's terrible if one side can afford an "OJ-sized" legal defense All-Star squad, while the other has an overworked rookie public defender. It would be hard to regulate and enforce of course. Or maybe doctors shouldn't just fear the financial repercussions of malpractice, but fear losing their license instead. Too many repeat-offender doctors still practice and make lots of money. If an independent agency can evaluate malpractice cases, like the Trustee's Office for debt cases, and bar guilty doctors from practicing medicine (either a fixed time period or permanently), then doctors will be more careful for their own career's sake. And then they won't have the excuse of needing to charge more to cover their malpractice insurance, because they won't be financially liable for any damages. Maybe the agency can make payments to victims, funded by a tax or modest penalties to offending doctors. I don't know, just brainstorming. It's a frustrating situation for everyone I think.