A humane and intelligent approach to end-of-life medical care

This interview with physician Sherwin Nuland was very thoughtful and IMO is a prudent approach to the uncomfortable subject of managing end-of-life care decisions. I know medicine and death are very personal and emotional subjects, but I think if we dispassionately put the patient's best interests first and keep expectations reasonable, everyone will end up happier (especially the deceased) and society can save a lot of health care resources.

One issue that the doc didn't cover in the interview was assisted suicide, which has few rational arguments against it, and is becoming more accepted nationwide - similar to legal pot and gay marriage.

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Also heard something about end-of-life care on NPR the other day.  There was a particular city that had a big promotion of advanced medical directives.  What they found was that, as a result, medical costs went down quite a bit in their city.  Apparently when people make a positive choice about the type of life they consider worth living it is significantly less expensive than the care legally mandated in the absence of a positive choice.

The major roadblock to those advanced directives is human effort and human emotion.  Understandable and probably not an incredibly high hurdle to overcome.

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Agreed. More and more people are preferring to die relatively peacefully at home or hospice rather than "keep fighting" to the end with all the tubes and drugs in them at County General. And the irony is that the former group tends to last longer, and with less grief on themselves and the family, than the latter (obviously at much lower cost too as you said).

There are plenty of war stories where the stubborn commander refused to face reality and sentenced himself and his men to preventable death. Even worse, a stupid, egomaniac dictator doesn't understand opportunity cost, ignores his generals' pleas, and keeps throwing finite resources at an unwinnable battle, which ironically contributes to losing the overall war - see Stalingrad or Guadalcanal. We tend to mock those men and use their folly as teachable moments. So why can't we apply the same logic to medicine? Unfortunately there is such a thing as a no-win scenario, so the sooner we come to terms with that, the better it is for everyone. Would you gamble your life savings on 1 play at 1/1000 odds at the casino? Of course not - so why do we do it at the hospital? Is it because of moral hazard, or the finality/unknown nature of death?

On a personal note, what I really hate to see are relatives pressuring the dying person to "keep fighting" and "not let the disease win". It gives the false impression that the outcome is mostly in the patient's control, and it's a matter of effort/will. The patient has enough to worry about without that guilt. No one wants to be reminded that they are the source of the everyone's sadness, like it's their fault. Families may bring up outliers like Lance Armstrong, but forget that 99.99% of folks like Lance didn't make it. I'm not saying to abandon all hope, but at least don't impose ludicrous expectations. Unfortunately, the next of kin can get pretty selfish and they may not be ready to let go. But during these tough times, the best thing they can do is show as much comfort and compassion as possible for the dying.

But if it's the patient insisting on exhausting every medical possibility no matter the odds or costs, I am not sure how a physician or relative can/should dissuade them respectfully. 

Immigration reform bill, amnesty, and path to citizenship

I am really intrigued by the whole illegal immigrant bill and associated debate going on right now.  There seems to be a lot of effort and general support from dems to provide amnesty or a path to citizenship for illegal immigrants.  I also see opposition to reporting those here illegally as part of booking them for other crimes.  What i never hear is the justification for amnesty or the justification for not considering someones immigration status when booked for other crimes.

To me I get that there is a human rights aspect to this.  A family moves here with a 1 year old child illegally, child grows up here for 10+ years, does it really make sense to deport him back to wherever?  Is breaking up that family ok?  On the other hand I think of the analogy of someone struggling to feed their family breaking into a home and robbing them.  He uses that money to feed his children, raise them right, and send them off to college.  But if he is caught after all that time, he still owes the money back.  He still stole it.  What legal or moral right does he have to any of it?  Sure it isn't his families fault he got the money illegally but tough cookies he broke the law.  

So what exactly is the argument for giving those currently here illegally citizenship?  Is it similar to the drug war where making something illegal doesn't solve any problems and creates new ones to boot?  What do we say to those who are still in the waiting line for the legal option?

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Thx for your thoughts. I am not aware of the fine print, but I also agree that the Dems' push for a path to citizenship is a bit excessive. I mean, Reagan gave the last amnesty with very few strings attached, so the GOP don't really have much credibility to be hard on the Dems - though to be fair Reagan would not really be identified as a Repub. today on many issues/practices. Citizenship is a pretty big deal (and as you said the legit line is very long), and for sure not many of the illegal immigrants currently here would qualify or see it through if it were law tomorrow. But still, it may send the wrong message. I would be OK with giving them work permit/legal resident status instead as the ultimate goal. Why should there be a path to citizenship specifically vs. residency status? I didn't see really compelling arguments for that online. Maybe the rationale for granting citizenship is kind of ideological: as you said these folks have demonstrated "American-ness" in every other way possible, so why not out of respect grant it to them after paying some fines? Or as the GOP says, maybe it's a hand-out to win Latino votes.

I would disagree regarding your burglary analogy. In that case, the thief is hurting an innocent private citizen and taking something from them. For illegal immigration, in most cases it is a "victimless crime" where no one is harmed and in fact many Americans may benefit without even realizing it. Of course that immigrant (if amnestied) may be "taking a spot away" from someone in line who played by the rules. And if that immigrant got some gov't assistance, that is fewer resources for others in need. But in general I think immigrants contribute more to the US than they take.

Did you know that you can also buy your way to a green card? Doesn't that also disadvantage the immigrants who are waiting patiently but can't afford a $0.5M-1M fast-pass?

http://www.cleveland.com/business/index.ssf/2009/08/us_attracts_rich_foreign_inves.html

For individuals booked with a crime, depending on the severity I guess it's valid to ask for immigration status and deport/imprison bad offenders. But I think the big problem was in states like AZ, they passed profiling laws where authorities could ask anyone they wanted for proof of citizenship on the spot. And of course they tend to ask people who look a certain way.

Tangentially, Maher commented that the GOP's insistence to "militarize" the southern border (Border Surge) as a prerequisite for imm. reform is a direct consequences of our draw-down in the War on Terror. Many contractors are going to be assed-out, so they need to replenish their revenue with more ludicrous spending on high-tech hardware and troops (in this case B. Patrol agents) we don't really need. Supposedly in the Senate bill there are specific provisions for the purchase of certain tactical systems from certain companies. In total the Surge would be $38B in additional spending - advocated by the austerity-or-bust party. For scale, all food stamps spending in the US in 2010 was $64B.

http://www.washingtonpost.com/politics/immigration-deal-would-boost-defense-manufacturers/2013/07/01/d1c115e4-df63-11e2-b2d4-ea6d8f477a01_story.html?hpid=z1
http://www.huffingtonpost.com/2011/05/13/10-states-with-the-greatest-food-stamps_n_860233.html

Also an interesting side-note about drones: I thought they would be a lot cheaper than manned craft. But according to "The Newsroom", an F-16 is about $500M while a Predator is about $300M - not much savings! Well if you include the pilot training and future care costs, maybe that's another $5M to the manned craft bill? How the hell can an oversized RC propeller plane (that is lower tech, can be hacked, and is slower than an F-16), cost 3/5 as much!?!

Less publicizd but critical reasons why Congress isn't working

M sent this insightful article: http://www.washingtonpost.com/opinions/the-three-reasons-congress-is-broken/2013/05/23/8b282d2c-b667-11e2-aa9e-a02b765ff0ea_story_2.html

I think the author brought up a good point - why should we have fairly ignorant people write our laws? I often hear interviewed Congressmen compliment each other for being very sharp and smart. But I think that org is no different than any other American professional group - you have a bell-curve where about 15% are actually smart (Frank, before he retired), 15% morons (Bachmann), and the rest mediocre (McCain). That might work most of the time at Walmart or the United Way, but the risks are greater in Congress.

Lobbyists and interest groups would say that there is where they come in - to give Washington the info and persuasive arguments it needs to make the best decisions. But then we need to trust legislators to scrutinize info properly and be impervious to COI (especially when these biased sources come bearing gifts vital to them and their parties). And if staffs write most of the bills, then they are even more susceptible to influence because they are less established in their careers, and their dealings are mostly unmonitored by the public. A Congressman has staff to support them, not to do their job. But I guess this situation arose because Congressmen now need to spend so much more time fundraising, traveling, and campaigning, to avoid getting primaried or falling out of favor with their party bosses. Where is the time left over to be a Congressman?

A term exists called "technocracy" where subject matter experts rule. I think that would be a disaster as well (Einstein turned down being the first leader of Israel for a reason), but I would hope there could be some balance between political knowledge and actual knowledge. Maybe the best solution (and one that played out during America's best decades - politically speaking) is for leaders to be humble and conscientious enough to seek out the counsel of the right sources, and then have the good judgment to use that counsel to help the nation. Barney Frank was on the SF Commonwealth Club last night talking about Dodd-Frank and gay issues. He said that in committees, Congressmen love to work on the one or two issues they care deeply about and know about, but of course they have to deliberate and vote on all issues that are raised. And some of them sit on like 3 cmtes. So if they show up to vote, like 90% of their votes are ignorant and apathetic (or they just fear sweeping, divisive issues that could affect their careers). There has to be a better way?

So we know that too much apathy/risk-aversion is bad, too much ignorance is bad, and too much obstructionism is bad. An arbitrary, artificial solution I could come up with is a "points system". I know there are many unofficial Congressional scorekeepers out there, but in this case let's give it teeth:

-Congressmen need to pass a basic knowledge test before being able to vote. If they miss too many votes, they lose points, and that will hinder their seniority and demote the bills they care about down the queue.


-Congressmen have to achieve a minimum level of creative productivity too (# bills co-authored, # bills passed - like performance goals in the private sector). Conversely, very productive/helpful/engaged members will get more perks (raises, fast-track to chairmanship, etc.). Heck there could even be a leader-board and a cut like golf.


-Senators get X filibusters per session, and each time used, the Senate scores the quality of the argument. If the score is too low, then that Senator gets reduced filibuster privileges for the rest of his/her term. Same thing for floor speeches.

Various scores and evaluations like that could be aggregated, and if the Congressman's total score is outside of "acceptable" limits, then they can't run for re-election or some other punishment. This will never come to be, but they need some sort of punishment for not "doing their jobs" and some rewards for doing it right. Right now the GOP's biggest fear is getting primaried or their party losing seats, and that should not be the case.

In order to encourage real debate, maybe there could be some private, closed-door deliberations. I know I am contradicting myself because I just said that staffers writing bills is risky because they have less oversight. But the situation is different in the actual Congress. With the cameras on during floor debates, as the author said, legislators feel pressured to just posture and rehash talking points that poll well in focus groups. But in confidential proceedings, they can actually talk like respectful adults with each other and negotiate without getting crucified by their own parties/media. Secrecy is usually not good for a free society, but in some cases it's a part of the process. State said the worst thing about Wikileaks was now diplomats are paranoid of being exposed, and can't be as frank in their communications. Maybe it will make them more conscientious in what they say, or maybe it will make them too reserved. I guess there has to be a balance in order to come to the best political solutions.

BTW have you seen "The Campaign"? Horribly hilarious and scarily realistic stuff.

Why is China such a bad global citizen?

This is coming from an Asian-American, so there is a certain level of obliviousness and hypocrisy here, but I am tired of Chinese BS like this: http://www.businessweek.com/ap/2013-02-20/a-look-at-mandiant-allegations-on-china-hacking

I know in their society, stuff like hacking and currency manipulation isn't seen as dishonest cheating, but instead a clever and necessary part of competition. Morals have nothing to do with it; it's about winning. I guess China does use soft power, but their antics are just so annoyingly passive-aggressive: spying but denying everything, cracking down on peaceful dissidents but calling them terrorists, stealthily building up their military, laying claim to new waters, and buying up raw materials all over the globe. And of course they manufacture unsafe, defective, and poisonous products just to shave a yuan here and there. Surely the US is guilty of all of that too (and worse), but at least we cowboys are more brazen with our bad deeds (part of that is due to our freer political system and press). And at least the US does help some people around the globe (Americans are some of the most generous in terms of foreign aid), our inventions/actions have reduced illness and poverty, and we did fight global threats like Hitler and the USSR.

In almost every arena, the Chinese government is playing a negative role (note that I am criticizing the Chinese GOV'T here, not Chinese people). Apart from the unique economic relationship with the US, I don't think any other nation can say that they are so grateful for what China is doing for them - maybe with the exception of Iran, Myanmar, etc. No other state is coming to China's defense and singing its praises. I know I am misinformed and exaggerating here, but there is just case after case of bad news. Uncompetitive behavior with their solar industry and fears of stealing IP have probably set back global green tech innovation a decade. They are the #2 consumer and #1 polluter in the world now (not per capita of course). They don't respect property rights and trade laws. They are usually one of the last states to condemn crimes against humanity (except for America's shielding of Israel), and they commit plenty of atrocities themselves. Their system is rife with corruption and injustice. Their wealth gap is even larger than ours.

Like Israel, China almost "gets a pass" for its poor global citizenship because of its meteoric rise and tragic history. Only the USSR had more dead from WWII. Maoism was taking them in the wrong direction, but then Nixon and Deng shocked everyone and started a new partnership that changed the world. China went from Third World to #2 economy in a GENERATION. Many people got rich and many new products/jobs were created in Asia and the West. Many want China to be a feel-good, zero-to-hero story. And some may like a powerful China to counter-balance Russian and US imperialism. Previously ignored, poor African nations enthusiastically welcomed Chinese development and merchants. But they "overstayed their welcome" and caused major resentment by displacing local businesses and "scamming" naive African governments (trading the rights to precious resources for shoddy infrastructure projects made with crappy materials and imported Chinese labor). China has been an impediment to Western interests on Darfur, Iran, North Korea, Syria, etc. They really don't have much of a stake in those conflicts, and have little to lose by cooperating. But they don't (maybe they still fear Western domination, or have a chip on their shoulder and want to be respected?). They have made little to no serious effort at conflict resolution over Tibet, Taiwan, and democratization. They don't volunteer troops or resources for peacekeeping missions or natural disasters. A poor, developing nation may deserves a pass for that, but China always wanted to be a global power and now they are. So they are held to a higher standard, which they are not living up to. I know the #1 priority of any gov't is self-preservation, as well as maintaining harmony and growth. But a global power should think bigger. They have to make friends and work with others if they want major, mutually-beneficial accomplishments - which will better ensure the continuation of their gov't than repression.

I guess China has its 5, 10, and probably 50 year master plans for development. What are their plans for getting along with the rest of the world, and maybe making the world a better place? Some Chinese people are working selflessly and tirelessly on those issues, but what is the gov't doing? Because even those rooting for China will eventually tire of their egocentrism and more-or-less sociopathic behaviors (= inability to empathize with and care about others). China was so successful since the 1980's partly due to its soft power and peaceful cooperation. Yet they seem to be straying from that now, flexing more hard power and possibly losing friends (empire syndrome?). Some businesses are tired of Chinese corruption, inflation, and IP theft, so they prefer to set up shop elsewhere in more democratic, cooperative places like India and Malaysia. The global economy will be "dependent" on China for decades to come, but clearly the winds are changing and we are coming up with substitutes and strategies to wean ourselves off of China. The West has known about Chinese hacking for years, but maybe it has finally reached the tipping point. Nations are collaborating and deciding what to do about it. But the problem is, how will it escalate? We can get together and tell China, "Hey, stop doing this crap or we will ____ you." But what will the stick be? What will get them to desist without making matters worse for everyone? Because no one wants a cyber, trade, or conventional war with China - especially because China would probably prevail in cyber and trade (and can hurt our allies militarily). I don't know, what else can we do to peacefully encourage them to change their ways? Because it only seems to be getting worse. I think China is loathe to succumb to outside pressure, especially when we have so little leverage with them. Change has to come from within, but how much support can we covertly funnel to dissidents and reformers? China clearly won't tolerate what we did to Iran and Qaddafi.

The tragic part is, China can have awesome socioeconomic growth and global admiration without engaging in these annoying, ultimately mutually harmful antics. The gains they can reap from transparency, trust, reforms, and lawfulness vastly outweigh the fleeting benefits of cheating. They can win fair. But this is the side-effect of a one-party system. There is no check or balance to say no and act as a sanity check. Their state-run enterprise system is now an impediment to innovation and growth in my opinion. China may be the #2 economy, but they are like the #10 creative economy (or worse). Maybe they make up for that with stealing and cheating, but it can't last forever. Some are concerned that China's economic model has run its course and plateaued. I am not sure yet, but clearly they will have to move towards a more democratic market and society in order to have the free flow of ideas necessary for entrepreneurship and economic success in the 21st Century.

Health care Court decision

http://www.npr.org/blogs/health/2012/06/18/155269171/supreme-court-upholds-care-health-law-rules-mandate-is-a-tax
http://www.kqed.org/a/forum/R201206280900

I think the health care economics effects of this legislation are still too opaque to comment on (plus I am fairly ignorant), but in terms of effects on the campaign, it should get interesting. Obviously it's a win for the Dems, but it may become a rallying cry for the GOP. Though if you look at things logically, I don't think this legislation should be the prominent conservative issue that it is (and why is it so unpopular and getting more so? misinformation?). I guess the right doesn't really have much else to work with besides the economy, though. The candidate the GOP chose is obviously not in a great strategic position to advocate Obamacare repeal. But really, I don't think true conservatives should so dislike this health care reform. It's far from perfect (and we all had plenty of debates together 2 years ago), but look at the underlying principles:

- Conservatives don't like "free riders" right? Insurance only works by spreading out risk, especially if they are now not legally able to price discriminate (or reject) based on customer traits (which most of us feel is ethical - shouldn't pregnant women be the first to be covered and not blacklisted?). It won't work if the healthy and young skip out on health insurance premiums, leaving only the older and sicker (and gov't) to pay - another manifestation of the generational conflict? And then when the uninsured need care, they often burden the system by using emergency services and may not pay full cost. The sick don't get off Scot free either, since they will still pay more into the system in the form of copays.

- Conservatives feel that the Constitution is their 2nd Bible, right? The conservative-leaning High Court ruled that most of the Affordable Care Act is constitutional, with the Chief Justice siding with liberals and writing the majority opinion (so it's not like the liberal justices hijacked the ruling - they can't anyway). They keep accusing the Dems of trampling on the Constitution, but what about now? And no one questions Roberts' conservative chops. He said that the Court's job is to decide whether Congress acted within its powers, not judge the merits of what the bill would do. So if the GOP don't like it, write a better reform. But now if they want to repeal Obamacare 100%, they're going to piss off people who think it's not right that the current insurance market excludes pregnant women and unemployed adult students.

- This Act doesn't force anyone or "take away" any freedoms (the "mandate" was kind of a misnomer). Americans still have a choice whether to buy coverage or not. They just have to fork over a small (~$300/year) fine/tax to pay for the social cost of their decision. Those funds will be used to make health care more affordable to the needy, which benefits everyone. The young and healthy may take that choice anyway, since the cheapest individual health plans they could get would run $1-2K/year, until the health exchanges maybe become efficient some day. Employer health care will be preserved, and customers may even get rebates. This is no different than other laws: I can have a non-neutered dog if I want, but I just have to pay a higher registration fee due to the risk I am imposing on my community.

But the problem is the anti-Obama crowd doesn't care about these facts. Everything he does is automatically evil and un-American, so he has to be stopped. They want to go back to 2008 (minus the recession I hope). So how to convince them that this really won't be as bad as they fear (and were taught to fear by the right wing media)? But by all means, if they have better ideas on how to reduce our health care expenditures (which is the highest % of GDP in the world, and in terms of raw dollars, and growing much faster than inflation) and make it more available, we're all ears.

PS - I think it's funny that Romney and Obama probably both had 2 versions of speeches (or more) prepared for today

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http://www.cbsnews.com/8301-3460_162-57464549/roberts-switched-views-to-uphold-health-care-law/?tag=contentMain;contentBody
http://news.yahoo.com/roberts-switch-health-care-signals-leaky-supreme-court-195755275.html

There's quite a bit of chatter on the possibly clerk-leaked revelation that Roberts changed his mind mid-course on the health care reform decision. If true, this would be an unprecedented breach of confidentiality and a major betrayal in Court history (especially considering that the leak came just 4 days after the Court revealed its decision). I guess some conservative circles (and maybe even Roberts' right-leaning peers) viewed his act as betrayal as well, but does that justify this significant breach of decorum? Like the Wikileaks fiasco with the State Dept, I think this leak will only serve to erode trust and collaboration on the Court, and ultimately hurt our ability to govern. I think people are allowed to change their mind sometime, especially when confronted with new evidence and arguments. People don't have to vote along party lines all the time, otherwise why not just have the parties rule the nation? And even within each party, there is quite a diversity of opinions (maybe begging the question: why not have more parties like the rest of the developed world?).

The right chastised Obama for supposedly deliberately leaking details of his anti-terrorism decisions to shore up his defense chops, but where is the outrage over this SCOTUS leak? But getting back to the Roberts court, this leak is another public example of the right's disrespect and intolerance (Barton yelling "You lie!", ludicrous birther/Muslim accusations, etc.). I know the right feels that "gov. is the problem", but I thought they also believed in the sanctity of the Constitution, respect for American traditions, US exceptionalism, etc.? Begging your pardon, but they're acting more like trailer trash Republicans than Lincoln or TR Republicans. Though I wonder where Roberts goes from here. Will his future decisions be more conservative in order to get out of Scalia's doghouse? Or will he be so offended by this act that it will push him more centrist or liberal? I am not sure what cases await them in the next Court session, but it should be interesting. Though I think the SCOTUS is one of those institutions that does a good job if it seems "boring" and stays out of the headlines. It would be a real tragedy if this controversy becomes new precedent, and the already over-politicized Court becomes more so in the future. 

Student loan reform

This is real reform, and was added to the passed health care expansion bill. Well done, Obama and the Dems in Congress. I have no qualms with this (can you believe it!?!), except that it is long overdue. There is absolutely ZERO reason why private banks and Sallie Mae (top lender managing >10M loans) should serve as the middleman between students/colleges and the federal government underwriting the loans, while of course increasing the cost of the loan for their own profits (another "subsidy for the banks"). The industry is huge (total US student debt is $527B) and their cut is not insignificant (~$6B/year), which is why the banks were fighting the reform so much (Sallie Mae alone spent $3M on lobbying/ads). The government will use that money to increase the size and number of Pell grants (need-based college grants) to keep up with inflation, and also support the hurting junior college system that has seen its funding pillaged by cash-strapped states. Since the Clinton administration, a number of direct student loans were available (~23% of all loans, and about 7% CHEAPER than Sallie Mae), and public schools like UC Berkeley have been using them for years. During the Bush presidency, multiple attempts to close that program were made, but fortunately failed. Direct loans have worked at places like UCB, so there's no reason why they can't work nationwide.

Pells used to cover most of a college education, but now that costs have soared almost as much as health care, the $6k/year grant doesn't go very far, but under Obama government spending on Pells has doubled (almost a million more grants will be given out by 2020). As my last email described, college is one of the best ways that poorer immigrants and the lower classes can advance themselves in US society. And if we're excluding talented, motivated people from quality higher education just because of financial hardship, then that impairs our overall economic and social well being.

This education reform demonstrates why we needed the private option in health care, possibly on the road to single-payer. This will keep student loan interest rates down. It's not putting the private lenders out of business (it will of course force them to shrink), but serving as a check against extortion. The direct government loans will offer an APR of 8% for professional schools, versus 12% in the private sector. It's not like banks will go under because they lose that extra 4% on a medical school loan, but now they have to offer competitive rates to earn our business.

Banks counter that customer service will suffer now that a "federal bureaucracy" is servicing loans directly instead of your "friendly community bank". I'm not defending government customer service (try speaking to a human at the IRS), but that's a load of crap. Sallie Mae (SLM) is a for-profit entity, and JP Morgan, Bank of America, and some private equity firms tried and failed to acquire it for $25B in 2007. If SLM is just a friendly lender trying to help our America's students, why would the sharks show so much interest? The same big bank sharks who destroyed the economy with mortgage trading are the ones servicing student loans too. When the credit crisis hit, worthy students couldn't get college loans because the greedy, paranoid banks weren't loaning. Then why are they even involved when they're not fulfilling their function? Republicans (often from states that are home to the HQ's of these banks) criticized the legislation, saying that it will cost thousands of jobs and is actually a clandestine way to help fund the health bill. Well, the first count is true, but so what? Aren't they the ones against subsidizing failing industries like auto (or are they just against union-heavy industries)? The private student loan industry is obsolete and now needs significant retooling. It's a free market and America is the land of opportunity, right? Sink or swim. No one cried when thousands of Lehman and Enron workers found themselves on the street, even though they weren't responsible for the transgressions of their execs.

And as you would expect, like in other credit industries, abuses abound on private student loans. NY sued SLM, Citi, Nelnet, The College Board (the SAT a-holes), and others for deceptive lending practices in 2007, and SLM settled for a $2M donation to a NY student loan information program. There is another class action suit pending against SLM for discrimination against black and Latino customers (charging them higher rates). In 2007 (apparently a very bad year for the industry), scandals abounded across America involving bank reps offering gifts and favors (even stock options!) to college financial aid officers to promote their banks as the "preferred lender" to students, which led to firings for those who were caught. In addition, unlike with other types of loans, the 1965 Higher Education Act allows student loan providers to also handle collection duties. So they have a financial interest to maximize defaults, which in many cases can lead to more money for them than the borrower keeping up with payments. Just your friendly neighborhood lender huh? I don't think the Feds will be that evil. 

http://thecaucus.blogs.nytimes.com/2010/03/30/obama-signs-bill-on-student-loans-health-care/?8au&emc=au
http://en.wikipedia.org/wiki/SLM_Corporation
http://www.thenation.com/doc/20070521/loan_abuse
http://www.kqed.org/epArchive/R201003310900
http://campusprogress.org/tools/788/crib-sheet-direct-loans
http://www.npr.org/templates/story/story.php?storyId=9803210&ft=1&f=1001

The healthcare bill passing

http://news.yahoo.com/s/ap/us_health_care_overhaul




From a conversation I had with a friend; feel free to chime in:



Regarding health care, I see what you mean about the rope-a-dope but I am not sure if that was their deliberate strategy, rather than necessity. With their huge Congressional majority and Obamania still lingering from the election, I think Obama expected to pass the health bill in a few months, and with a public option (what he campaigned on). He expected to get some GOP on board and celebrate a bipartisan reform. But they were shortsighted to not anticipate the tea party grassroots opposition. And they made the tactical blunder of letting the process be Congress-driven and not responding to the sometimes ridiculous attacks from the right. In short, Obama was too much of an "elitist Washingtonian" last summer, and lost the initiative. The public tired of the "sausage making" deals and such, and instead turned their attention to the inflammatory sound bites from the tea baggers (dealth panels, socialism, etc.). There was a failure to communicate. I can pretty much guarantee that Scott Brown wouldn't have won if Obama didn't mess up so badly last summer. I really think that Obama expected his grassroots army to respond to and defeat the tea baggers. But they have been working 24-7 since early 2008; how much can you ask of these exhausted volunteers amidst a recession? They are his adoring fans and patriots, but not robots. And he didn't give them much inspiration and leadership to keep them going. I think that turned a lot of them off, and Dem turnout in November may suffer (we already saw some early signs with 3 significant GOP election victories besides Massachussetts).



So then Obama had to spend all fall and winter to repair the damage, and figure out how to pass the bill with parliamentary tricks and policy compromises. Then I guess he went into rope-a-dope mode, or war of attrition mode. He used his bully pulpit a lot since the State of the Union, and scheduled all those health care discussions that were mostly media spectacles. It was a good move that he finally published his own version of the health bill in January, but that should have come out last June. Give the nation (and Congress) a roadmap and a vision. He is the president! And he should have been more decisive about abortion funding, public option, taxing union Cadillac plans, and other funding. We kept hearing so many versions and explanations with or without all those components, and Obama was so vague and wavering, that we just got turned off and tuned out. In this case, there was too much communication. Don't say anything until you're ready and you have a finalized plan. I know things change constantly in Washington, but don't confuse the public. I am sure they witheld 90% of the health care negotiations from us anyway, but the portion that were were exposed to wasn't persuasive enough it seems. You're not going to please everyone and have to compromise somewhere, but stop listening to the pollsters and consultants. Pick the best plan you can at the time, and stick with it - that's what made George Bush successful (until it did him in).



So Obama snatched defeat from the jaws of victory, and then recovered to snatch victory back. It is a noteworthy, historic accomplishment for his administration, but at what cost? Over the last year, he definitely lost his election mojo, and the GOP is emboldened. Many Dems will get voted out in Nov., and the public is as angry as ever with Washington. He disappointed (or even enraged) parts of his loyal Dem base like the unions, the pro-choice camp http://www.upi.com/Top_News/US/2010/03/21/Abortion-rights-groups-criticize-Obama/UPI-76141269215815/, and the more liberal wing who still believe that single-payer is the only way and for-profit healthcare is unsustainable (maybe more now than ever!). In fact, who in America is going to rejoice over this bill apart from politicians and the poor/sick who directly benefit from the legislation? It's kind of sad that the only celebrations going on for healthcare reform are inside the Beltway (I exaggerate but you know what I mean). The polls are mixed, but I think it's safe to say that 40-50% of America is not only opposed to the bill, but outraged about it (but maybe those people hated Obama and his agenda from the start anyway?). I wonder how many Obama supporters and undecideds became opponents due to the healthcare effort though. Those who support the bill are maybe just relieved that the debacle is over. Like Kucinich, they'll take the bill, but wish there was more meat in it. I know it's a first step that Obama and future leaders can build on, like the civil rights effort. But for me and many liberals, I think after millions spent on PR, all the man-hours wasted, and a year of Washington wrangling, there should be more to show for it.



I heard some commentary on Friday that the "winner" in the health care fight will actually be the loser, politically speaking. Now that the Dems have prevailed, health care costs will still inevitably rise in the coming years until all the bill's measures kick in by 2014 (and even then the average American won't see drastic cost savings). So the GOP will say, "See we told you! The bill is costing us $1T AND your premiums are still going up!" But if the GOP won and killed healthcare reform, the Dems could say in November: "We tried to help middle class families but the GOP just blocked everything, so we're stuck with the broken status quo and you can't afford health care." What is the GOP counter for that? Contrary to some predictions, I doubt the GOP would try to repeal the bill. It's political suicide and the Dems could play the sympathy card: "Little Sally has leukemia and she was able to get life-saving coverage through the Obama reforms. But now the GOP wants to take it away and let her die!" The Dems had to pass something though, but maybe they painted themselves into a corner. They pass reform, and the conservative backlash will haunt them for several elections. They scrap reform, and the whole country loses faith in them as ineffective leaders. It's enough to make you long for the days of monarchy.



This bill is a healthcare coverage expansion and a respectable reform of health insurance practices. Both those steps are admirable and necessary, but unfortunately they failed to address price negotiation and reimportation for drugs, pay-for-outcome instead of pay-for-service, and other factors that strongly contribute to our bloated healthcare costs. But considering the state of Congress and lobbying today, maybe it's the most the public could reasonably hope for, which is sad.

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In the end, do you guys really feel that this "reform" will actually save both the federal government and regular privately insured citizens money? Will illegal immigrants (who do use emergency services) continue to provide a justifiable reason for hospitals to charge inflated rates on services/products which in turn raise overall premiums?

I feel like I have more questions than answers ... fail.

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Yes the bill does create more questions than answers, and only time will tell. Plus it's hard since history is not a controlled experiment; we can only speculate on the bill's true benefits, since we will never know how America could have been without the bill or with a different/better bill. But the social scientists will be able to mine the data and tell us something down the road.

I just wonder how many private citizens without insurance will actually get covered, or just elect to pay the small fines, which can be much less than insurance premiums anyway. And although the cost burdens to the states won't kick in until 2013 or so (the Feds will fit the bill for expanded Medicaid and higher reimbursements in the meantime), I wonder how near-bankrupt states will be able to handle all the new beneficiaries. Plus, will we train enough doctors, nurses, etc. to handle the increased demand (especially when the Baby Boomer health professionals are retiring)?

Here's a healthcare discussion on KQED today: http://www.kqed.org/epArchive/R201003240900

I haven't listened to it all yet, but it looks to be an informative program.

The bill covers more needy Americans, but doesn't address the quality of healthcare gap. Yes the poor and sick will now get subsidies and protections so they can get Medicaid and won't be turned away by private insurance. But the plans that they are on are fairly terrible. Yes it's better than paying out of pocket with no insurance, but the copays are high, and many doctors won't treat Medicaid patients now because the gov't reimbursements are too low (shame on those doctors though). The "working poor" who do get crappy health coverage from their employers (Walmart for example) have high copay, bad coverage plans. I am not sure if the bill addresses insurers refusing to cover certain procedures? And of course on the other hand, the rich continue to enjoy their Cadillac plans, and wastefully consume a lot of healthcare resources because they can. Obama scaled back his taxing of those such plans to get the necessary Democrat votes.

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the one thing that is perfectly clear about this healthcare bill is the fact that both sides of the political spectrum didn't like it.  obama made all kinds of concessions-no public option, reinforcing the hyde amendment, etc. for the right's vote, but made NO concessions to the progressives.  when this healthcare reform process started, rahm emanuel made some comment somewhere that obama won't have to worry about the progressives.  they'll vote on whatever you give them.  what will happen?  they'll cause a dem. loss on the bill and they'll be thrown out on the next election cycle.  that, and they'll be responsible for the ruination of the obama presidency.

obama has shown his true colors in this process.  he's down with the neoliberal policies of the past several presidents.  he plays a liberal so thoughtless liberals will like his brand.  but, in reality, he's a corporatist like the others.

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I have to agree with that. How much slack can liberals give him? We don't have infinite patience and loyalty. What is the point of running for president on a change agenda when you act 70-90% like your predecessors, for better or worse? Of course he's an improvement over Bush (but that would apply to anyone but Palin), though call me naive for disapproving of the disconnect between his campaign and presidential rhetoric.

Bush favored the neocons, business elites, and Christian conservatives, and lost the support of the fiscal conservatives and independents, many of whom then voted for Obama. If Obama and Rahm keep taking the progressives for granted, they may not jump ship and vote GOP, but they will tune out or support an alternative agenda, like how the Tea Party movement spawned from the feeling that GOP politicians weren't conservative enough. If you claim to be a coalition builder and bipartisan leader, and then fail at it (whether your fault or not), it will only serve to hinder cooperation and moderation. The angry groups who felt shut out of the coalition will turn more extreme and polarized, as we have seen on the right at least. That's the sad irony of governing from the middle. Some say that it's better if everyone is a little unhappy instead of one group gaining favor at the expense of the rest. But if everyone is unhappy, of course they're going to blame you and each other, and that doesn't bode well for future political cooperation.

So what are liberals to do? When the GOP was in power, they used 9/11 to silence dissent and twist arms, so the Dems in Congress just had to approve everything (even invading Iraq) or risk being labeled as unpatriotic during the next election cycle. What was the good of that anyway, since the Dems lost Congress and the High Court too? But now that the Dems are in charge, how are they holding the GOP's feet to the coals and using their numerical advantage? It's almost like David is bullying Goliath here; the GOP just doesn't want to let Obama and the Dems get credit for anything positive. And if the GOP isn't blocking progress, then the "centrist Dems" are. I use quotation marks because they aren't centrists really, but wed to specific religious, regional, or corporate agendas that conflict with progressives. So Obama and the Dems can't pass anything until they water it down to the point of triviality. So forget about bringing up anything to do with tax hikes, abortion, climate change, or expansion of government. I just hope that during the next GOP dynasty, the Dems are just as obstructionist. Government will be paralyzed, and the cynical public will tire of both parties and remake the political landscape into something more constructive and rational.

FYI, I just re-registered as an independent voter, after 12 years as a disgruntled Democrat. If only I didn't live in CA, then I would really be a swing vote.

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We all know the legislation is far from perfect. But a move (in this case, a big move) in the right direction is a big deal. Yes, corporations and insurers will continue to profit, but the next steps - maybe in the next twenty years (hopefully sooner) - may be to take the profit motive away from health insurers (making them non-profits) and/or moving to single-payer by expanding Medicare. 

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I would rather have this bill than the status quo (even though it doesn't affect me, but helps some needy people), but I just worry about the future that you mention. If this bill doesn't show clear, measurable healthcare improvement for the public and our national debt gets under control, the GOP will attack health reform as ineffective and wasteful, making it harder to move towards single-payer. In other words, this was their one big chance in a generation to cram in as many improvements as they could, and they didn't deliver much (in terms of cost controls and quality of care). On the other hand, if the bill is successful, then future administrations will have an easier time building on it. Time will tell I suppose. But you can bet that in the meantime, the insurance companies will be strategizing how to defeat any future reforms and do what they can to show America that these new regulations on their industry are bad.

Comparing the House and Senate Health Bills

Kind of funny (or not): in order to get conservative Dem. Senator Nelson from Neb. to vote for the health bill, Reid and Co. cut a deal.

"The Nebraska compromise, which permanently exempts Nebraska from paying Medicaid costs that all other 49 states must pay, may violate the United States Constitution — as well as other provisions of federal law," Texas Attorney General Greg Abbott said.

... [The Senate] bill was amended to shield Nebraska from the expected $45 million annual cost tied to expanding Medicaid programs.

Comparing some aspects of the House and Senate bills:

http://buzz.yahoo.com/buzzlog/93274

http://www.bloomberg.com/apps/news?pid=20601070&sid=aim3g2AJwUHI

Obama's (d)evolution on the public option:

Candidate Obama, 2008: The Obama plan will establish a new public insurance program available to Americans who neither qualify for Medicaid or SCHIP nor have access to insurance through their employers, as well as to small businesses that want to offer insurance to their employees. And again in another statement.... For those without health insurance I will establish a new public insurance program. (though he never once verbalized this in a speech)

President Obama, July 2009: I am pleased by the progress we’re making on health care reform and still believe, as I’ve said before, that one of the best ways to bring down costs, provide more choices, and assure quality is a public option that will force the insurance companies to compete and keep them honest.

President Obama, Aug-Dec 2009: [The public option was only a] sliver of my health care proposal.... I didn't campaign on the public option.

http://salon.com/news/politics/barack_obama/index.html?story=/politics/war_room/2009/12/22/obama_public
http://www.whitehouse.gov/the_press_office/Statement-from-the-President-on-Health-Care-Reform/

Health care bill making progress

By DAVID BROOKS
Published: December 17, 2009 NYT
Times Topics: Health Care Reform
Readers' Comments

Readers shared their thoughts on this article.

* Read All Comments (190) »

The first reason to support the Senate health care bill is that it would provide insurance to 30 million more Americans.

The second reason to support the bill is that its authors took the deficit issue seriously. Compared with, say, the prescription drug benefit from a few years ago, this bill is a model of fiscal rectitude. It spends a lot of money to cover the uninsured, but to help pay for it, it also includes serious Medicare cuts and whopping tax increases — the tax on high-cost insurance plans alone will raise $1.3 trillion in the second decade.

The bill is not really deficit-neutral. It’s politically inconceivable that Congress will really make all the spending cuts that are there on paper. But the bill won’t explode the deficit, and that’s an accomplishment.

The third reason to support the bill is that the authors have thrown in a million little ideas in an effort to reduce health care inflation. The fact is, nobody knows how to reduce cost growth within the current system. The authors of this bill are willing to try anything. You might even call this a Burkean approach. They are not fundamentally disrupting the status quo, but they are experimenting with dozens of gradual programs that might bend the cost curve.

If you’ve ever heard about it, it’s in there — improved insurance exchanges, payment innovations, an independent commission to cap Medicare payment rates, an innovation center, comparative effectiveness research. There’s at least a pilot program for every promising idea.

The fourth reason to support the bill is that if this fails, it will take a long time to get back to health reform. Clinton failed. Obama will have failed. No one will touch this. Meanwhile, health costs will continue their inexorable march upward, strangling the nation.

The first reason to oppose this bill is that it does not fundamentally reform health care. The current system is rotten to the bone with opaque pricing and insane incentives. Consumers are insulated from the costs of their decisions and providers are punished for efficiency. Burkean gradualism is fine if you’ve got a cold. But if you’ve got cancer, you want surgery, not nasal spray.

If this bill passes, you’ll have 500 experts in Washington trying to hold down costs and 300 million Americans with the same old incentives to get more and more care. The Congressional Budget Office and most of the experts I talk to (including many who support the bill) do not believe it will seriously bend the cost curve.

The second reason to oppose this bill is that, according to the chief actuary for Medicare, it will cause national health care spending to increase faster. Health care spending is already zooming past 17 percent of G.D.P. to 22 percent and beyond. If these pressures mount even faster, health care will squeeze out everything else, especially on the state level. We’ll shovel more money into insurance companies and you can kiss goodbye programs like expanded preschool that would have a bigger social impact.

Third, if passed, the bill sets up a politically unsustainable situation. Over its first several years, the demand for health care will rise sharply. The supply will not. Providers will have the same perverse incentives. As a result, prices will skyrocket while efficiencies will not. There will be a bipartisan rush to gut reform.

This country has reduced health inflation in short bursts, but it has not sustained cost control over the long term because the deep flaws in the system produce horrific political pressures that gut restraint.

Fourth, you can’t centrally regulate 17 percent of the U.S. economy without a raft of unintended consequences.

Fifth, it will slow innovation. Government regulators don’t do well with disruptive new technologies.

Sixth, if this passes, we will never get back to cost control. The basic political deal was, we get to have dessert (expanding coverage) but we have to eat our spinach (cost control), too. If we eat dessert now, we’ll never come back to the spinach.

So what’s my verdict? I have to confess, I flip-flop week to week and day to day. It’s a guess. Does this put us on a path toward the real reform, or does it head us down a valley in which real reform will be less likely?

If I were a senator forced to vote today, I’d vote no. If you pass a health care bill without systemic incentives reform, you set up a political vortex in which the few good parts of the bill will get stripped out and the expensive and wasteful parts will be entrenched.

Defenders say we can’t do real reform because the politics won’t allow it. The truth is the reverse. Unless you get the fundamental incentives right, the politics will be terrible forever and ever.

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I've gone back and forth on this bill; but in the end, I come out with Krugman and Victoria Kennedy. It's far, far from ideal, but the system it will create is better than what we have now. The fight for a better and democratic (note the lower case "d") health care system will have to continue. For now, the corporate/insurance interests are still controlling the democracy through 'divide and conquer' techniques based on misleading information and arguments. The fact that Palin's 'death panel' arguments (or Glen Beck's idiocies) can resonate with any appreciable segment of the U.S. population tells us all we need to know about the failure of our basic (K-12) education system to teach critical thinking. In the meantime, the fact that 30 million more Americans will be able to get health insurance is no small matter, nor is the fact that a person, who now can't get any insurance because of pre-existing conditions, will be able to (even if the premium will be higher, so long as it can be paid, it beats a family losing everything it owns in order to pay for health care for a sick or injured family member). - - -


Paul Krugman: Pass the Bill
http://www.nytimes.com/2009/12/18/opinion/18krugman.html?_r=3&scp=3&sq=krugman&st=cse

Victoria Kennedy: Health bill 'imperfect' but necessary: Kennedy widow
http://www.google.com/hostednews/afp/article/ALeqM5j0m7LbkCWtIOGK-kQWO3bZQDnuug

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even without lowering the cost, of course the whole point to the health care reform was to extend health care to millions of "healthy" americans without healthcare so that we can keep them healthy and keep them from having catastrophic events that could have been prevented earlier.... this is the biggest way to save healthcare spending in the decades to come. But if we were to simply lower the medicare age, we lose on this point because now we are enrolling younger retired age population who may already have catastrophic event, only now on medicare. without lowering the cost then truly, where is the benefit besides more "old=potentially sick but yet undetected" people get sick on government plan and increase our health care spending. then we fall back to our last weakest point of passing health care reform, we just pass something so that it is easier for us to modify this one in the future than try to write the whole thing from the beginning and also have the pop get used to the idea so that next modification comes around ppl are less scared.. so we hope...

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I see where Krugman is coming from, and if I was a Senator (heaven forbid!), I would be forced to support the bill too. But it's tragic that our legislative system allows one or two senators to take a major historic reform hostage, and it's unfortunate that there is so much misinformation and so little support for single-payer reform and inevitable health care rationing.

Surely passing this bill is preferred to the status quo, and yes some incremental improvements can be made to the legislation over time, but I think the bill squanders our current rare opportunity (with all the stars in alignment) for fundamental reform of cost-incentive-accountability structures that is truly needed. Obama and others have said that if we don't pass health reform now, we'll have to wait another generation as costs continue to rise. Politically that is possible (hard to get a fillibuster-proof majority in the Senate to coincide with an administration of the same party), but I think the huge economic pressures of pricier care, plus the retiring Boomers, will compel us to revisit the health debate more frequently. Who knows if future presidents will be more Bush than Obama, and when the next Ted Kennedy will emerge to keep the Senate morally grounded? I think many progressives are disappointed that this is the best "change" we can get with Obama at the helm and a solidly Democratic (though still centrist-conservative) Senate.

The House version has the public option, foreign drug imports, tougher abortion restrictions, and more mandates for insurers (85% of premiums must be paid out as benefits, more oversight, less monopoly). All of those are toxic to Senators, so they'll probably be scrapped. But without the abortion amendment, I don't know if the Blue Dog House Dems will be on board with 2010 midterms around the corner (does Pelosi have a majority without them, Joseph Cao notwithstanding?). Liberal Reps have a right to be pissed about this bill, but I think they will end up voting for the Senate version rather than causing trouble and fragmenting their own party that is desperate for a political win. The Senate wants to tax Cadillac health plans and curb the wasteful Medicare Advantage program, but both are very unpopular with the rank-and-file, pro-union House Dems. So I guess it's not a sure thing Obama will sign this sucker by Christmas, and of course the GOP will do everything they can to stall and let the holidays sap momentum away.

What sucks is that the "party of no" GOP more or less walks away clean. The right wing spin suggests that they were the "patriots" who fought to protect the "good ol' American values of freedom and small government" in health care from a radical Obama who hates white people, but really they were just boulders in the road of inevitability. They'll declare victory because they killed the public option and "socialized medicine". If we want to go broke continuing to over-medicate patients, over-pay doctors/insurers, and under-perform in this country, then by all means do nothing. But the GOP literally didn't offer any constructive alternatives during this whole 6-month process. Obama should have never tried to take the bipartisan route - he'd have better luck negotiating with North Korea. Did he really expect them to cooperate on making him look good? The minute the right started mouthing off and misbehaving, he should have put them in their place. If he came down on them in the bold, righteous manner that he delivered his Nobel speech, we'd be in much better shape now. But instead the Dems were timid all summer while the tea parties and talk show hosts sowed the seeds of confusion and misplaced anger.

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.

Health bill narrowly passes House

http://news.yahoo.com/s/ap/20091108/ap_on_bi_ge/us_health_care_overhaul
http://www.npr.org/templates/story/story.php?storyId=120220977

"The House bill drew the votes of 219 Democrats and Rep. Joseph Cao, a first-term Republican who holds an overwhelmingly Democratic seat in New Orleans. Opposed were 176 Republicans and 39 Democrats."

I called in a favor to my cousin there! You can thank me later, Obama. Well I guess Cao was in a tough spot, getting fluke elected in a mostly Dem district just because the FBI found blocks of cash in his opponent's freezer. He voted yes to hopefully get re-elected (doubtful) by his liberal constituents, but pissed off the GOP in the process. So even if he does get another term, no one will want to work with him (as if anyone wants to work with a guy named Cao to begin with).

The bill narrowly passed the House, which has a much bigger Dem majority than the Senate. So if 39/258 Dems opposed the bill (15%), and the same percentage holds in the Senate, then they can't get the 60 votes needed (even with Snowe). Lieberman said that he feels "morally obligated" to filibuster any bill with a public option in it. So I guess anything that passes the Senate probably won't have a public option.

And Blue Dog Dems even had to inject a sneaky abortion proposal into the House bill for it to pass. These conservative Dems (they should just register Republicans and stop trying to have it both ways) are so worried about their re-election if they endorse the health bill, that they supported an amendment essentially making the ban on federal assistance for abortions permanent. And Pelosi caved. Apparently the ban is currently yearly and needs to be renewed (but it always is), stemming back from Clinton times when he needed a big bill passed and the GOP stuck that provision in there, so he had no choice but accept it to move his bigger policy priorities forward.

Of course it's not like DC is handing out free abortions all the time to piss off Jesus, but that's what conservatives fear I guess. They think that federal subsidies to help the poor afford health insurance will allow them to get abortions covered by their health plans (and currently many health plans do cover abortions), so I guess in a convoluted way that could be seen as gov't assisted abortion. But abortion rights groups worry that with this ban in place, that will encourage private insurers to drop coverage of abortion, because why should they when their gov't-subsidized competitors aren't? So I guess abortions will still be legal, but you will pay out of pocket (assuming the bill passes in current form).

And it's not like Obama would veto this huge bill (and the main mission of his presidency) over a polarizing issue like abortion.

Baucus health bill passing: historic progress but unimpressive impact

http://www.kqed.org/epArchive/R910140900

An interesting panel discussion of the recent Baucus health bill passage and challenges ahead. Some points to consider:

- This bill will increase the number of Americans covered by health insurance from ~85% now to 94% by 2014. Is that much to celebrate? And there is very little in the bill that would control costs, increase competition, or help under-insured individuals (some studies have shown that "health care cooperatives" would do little and may not even get off the ground). At least new rules would prohibit companies from rejecting customers based on pre-existing health conditions, but that would probably increase costs.

- Did Senator Snowe incur GOP ire by endorsing the Baucus bill (the only version without a public option currently in circulation) in order to actually help the GOP and pre-empt more liberal provisions such as the possibility of a public option?

- The Republicans have no health reform alternative, absolutely ZERO. They just want to impede action, but by doing so are missing a key opportunity to advance conservative changes. The GOP have spoken for years about reforming and trimming down Medicare/Medicaid, and now they could achieve it by playing ball and gaining concessions from the Dems for yes votes. But instead they are just the "Party of No".

- In order to get the 60 Senate votes to send the bill to the president's desk, all Dems, 2 Independents, and 1 Republican need to vote yes. It could be very close, because Senator Lieberman was not thrilled with the bill (many health insurance companies are based in CT).

- It will be very difficult to reconcile the arch-liberal and arch-conservative wings of the Dem Party, who are both against this middle-of-the-road bill for different reasons. House Dems are irate with the lack of a public option (which they see as integral to "real reform", and they are probably right).

- In order to keep this bill deficit-neutral (or positive), the "Cadillac" health plan tax (taxing the most generous health plans) and/or a tax on millionaire Americans seems inevitable. But unions are against the former (some union members enjoy Cadillac coverage), and the House is against the latter (no one wants to be labeled as a tax raiser prior to the 2010 midterms).

- By mandating that more Americans get coverage, it would help if coverage was more affordable, but that looks doubtful. And if families who can't afford coverage (even with more gov't subsidies) remain uncovered, they will be fined. On the flipside, the penalty is meager, so this may encourage more affluent people to game the system. While healthy, they will remain uninsured (since that will save them money overall, even after paying the fee), and then only purchase coverage when seriously ill (since they know they won't be rejected). This will of course increase costs to insurers, who will pass that along to us.

- The plan taxes comprehensive, low-cost, long-term delivery health systems such as Mayo Clinic, InterMountain Health Care, and Kaiser Permanente, even though Obama and others have touted those companies as models for reform. Why penalize the companies who are doing it well, and give their more wasteful competitors a pass?

- The financing for this bill is hardly transparent, and relies on many short-term gimmicks to balance costs. So even if it passes to law, it is likely that we will be doing this all over again in the near future. Also, the bill expands Medicaid eligibility (covering 11M more Americans, which in theory is good), which will be supposedly 90% covered by the feds. But states would still be on the hook for 5-22% of their own costs (which would range in the billions, depending on numerous factors). As we know, most states are in terrible financial shape, and the bipartisan National Governor's Association came out against the Baucus bill. The bills in the House would cover Medicaid expansions 100% by Washington.

- There is nothing in the bill to address Medicare/Medicaid physicians' reimbursement modernization. So as Congress is trying to cover more people under Medicaid, more and more doctors are turning away those patients because they make less money from them.

http://www.ama-assn.org/amednews/2009/09/28/gvsb0928.htm

Health Care

http://www.npr.org/templates/story/story.php?storyId=112687935

I'm overseas and missed Obama's speech, but I was surprised to see the "You lie!" outburst on CNN this morning. The look on Pelosi's face was priceless - she would make a good boarding school headmistress if she ever tires of being 3rd in line to the presidency. Do you think much of America watched the speech and could be swayed, or are their minds mostly made up? Well, maybe it was mostly meant as a jolt for Congress and rebutting right-wing media's attacks.

Plus that Rep. got worked up over something so ridiculous. Although it would be humane to give some medical assistance to illegals, even if they don't want to, the costs of minimally covering that population are miniscule in the grand scale of the reform plan ($880B over 10 years at least).

I wish Obama would just come out and say, "Why are you imagining all these evil motives for our health reform? Do you think I ran for president so I could institute death panels and put insurance companies out of business? Believe it or not, we actually want to make your lives better and our country stronger, and health reform is an integral part of that. I understand that people can be distrustful of expanding government and new regulations, but at least be equally skeptical to my opponents like right-wing media and the insurance and medical lobbies. What about their ulterior motives and conspiracy theories? Maybe then you'll see I'm not so bad."

But again, Obama seems to be light on details in his big speeches. He spent a lot of time reassuring America about the things his health plan won't do. I know the bill is enormous and many details have yet to be ironed out, but at least give us a 30-second overview of how the plan will make us better. The Dems say 80% of the legislation is worked out; ok so tell us then. Unfortunately I think a lot of America still doesn't understand what he is trying to do (most Americans don't even understand what health coverage they have, nor how the industry works at present), so of course the fear-mongers fill that vacuum with a lot of rubbish.

And unfortunately I think Obama still wants to hide some of the costs of his plan from us, so as to avoid more lost support. But sooner or later he has to level with us that any meaningful health reform will cost something. We won't get by just by trimming waste and taxing the rich more. To cover more people, we will have to spend more, and to reduce per-capita costs, then we'll have to reduce some services. The CBO concluded that Obama's numbers are wishful thinking, and a zero-debt health reform is either impossible or insignificant. But those sacrifices could reap huge rewards, since so much social and economic productivity is lost due to complications from uninsured sick people and unequal employer-based insurance. Plus we could theoretically recoup some funds by capping malpractice settlements which would lower premiums (not so popular with the Dems) and taxing health-poor products, such as fatty junk foods and alcohol, to promote healthier living as we've already done for cigarettes (wishful thinking though).

I don't think it's realistic for Americans to expect that their health coverage (or any service in fact) to be immune to change with the times. Maybe some of us have "great coverage" now or in the past, but in the future we won't, or we'll have to pay ridiculous sums for it. The nature of group coverage and health policy is communal, so unless we're super-rich, we can't hope to remain on our individual islands, detached from the less fortunate among us, enjoying access to all the best treatments. Maybe our taxes will have to go up slightly, and maybe Medicare benefits will decrease a bit. Call it "socialist" and "rationing" if you want, but what do you think your HMO is doing to you now? The healthy pay for the sick. Try getting an MRI for a bruised knee, or an exotic, expensive drug when generic alternatives are available, and see how accommodating they are. And they have the luxury of denying service to cost-negative individuals, which Medicare of course can't do. Obama wants to cover the uninsured and hold insurers/medical providers accountable to provide more bang for the buck. How can that be bad for America? The Dems have to do a better job clarifying the issue. Of couse if Obama's plan calls for too many sacrifices in order to cover the uninsured, then it doesn't make sense (except morally). If that price is too high to pay, then we can stick with the feudal health care system we currently have.