To Jeff Merkley on health care reform politics

Chris Lowe

On June 26 I sent a letter to Senator Jeff Merkley about health care reform, asking him to take two modest steps supportive of a single payer system, endorsing Bernie Sanders S 703 bill and speaking up for including single payer perspectives and advocates in hearings and debates. These steps would not conflict, and according to Dr. Howard Dean, would actually support, his primary commitment to working for inclusion of some sort of public insurance plan in whatever reform bills finally emerge from Congress.

The letter well expresses my views on a number of aspects of the health care reform debate, particularly why continuing to advocate for single payer reform of health care financing remains a constructive activity and position. For that reason I've decided to share it here.

Please also note the p.s., relating to the problem of erroneous conflation of single payer system reform with a public insurance plan option.

Letter follows below the jump
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Dear Senator Merkley:

A friend of mine recently shared with me a letter from you, in which you renewed your promise made during the campaign to vote for a single payer system of payment for health care, should one come to the floor of the Senate. First let me thank you for saying that, I will explain why in a moment. Also, I was glad to learn that your position has not changed. I had been hearing rumors that you were backing off that previous commitment, which had troubled me, because it was one of the main reasons why I actually worked for your campaign and donated what money I could, rather than merely voting for you.

Likewise let me thank you for standing up and bringing to wider public attention the scurrilous memo written by Frank Luntz as to how conservatives and big money insurance-medical-industrial complex interests could scuttle serious efforts at health reform. That was a genuine public service showing unwonted leadership for a freshman Senator, insofar as I understand these things.

As a supporter of a "Medicare for All" type single payer system of payment for health care, I would like to ask you to take two further steps, each of which would show similar leadership. Please co-sponsor Senator Bernie Sanders single payer bill, S 703. And please speak up for the full inclusion of single payer perspectives, arguments and advocates in the health care reform debates to render them more honest and make the issues clearer.

It does not seem to me that either of these steps would in themselves detract from your stated intention to focus your energies on seeking inclusion of a public insurance plan option in any Senate health care reform bill. On the contrary, each of the steps would be consistent with the stances you have already taken in support of full and honest debate.

And, as Dr. Howard Dean recently argued in Portland at a Town Hall hosted by Congressman Blumenauer, a full and honest debate, while good for those of us who advocate moving directly to a single payer system, also strengthens the prospects for a "real" public insurance option, as opposed to none at all, or a what Dr. Dean called "fake" public insurance options, so watered down as to be meaningless.

ON HONEST DEBATE

We live in times when the public debate over health care reform is corrupted by the influence of big money. The big money of insurance, pharmaceutical and hospital lobbies, along with the small minority of doctors belonging to the American Medical Association, insulates Congress from the people and muffles the demand of the people for thorough-going health care reform, including in recent years the support of over 60% of people for a "Medicare for All" single payer system of paying for health care. Because of the money, each individual representative or senator looks around and says, "a single payer system has no realistic chance, even if I support the idea myself." This creates a vicious cycle in which mass media editors and producers decide that an idea with "no realistic political chance" does not deserve full coverage, explication, or fair comparison either to the present system or to other proposed reforms.

Yet if the country is to achieve successful health care reform, we must begin with full and honest debate.

By successful healthcare reform, I mean four main criteria: 1) reform that enables everyone equally to get the health care they need, starting with prevention, primary care and early stage disease management, treating health care as the human right it is; 2) reform that stops and indeed reverses some of the cost increases at rates many times those of general inflation, to both the economy as a whole and individuals, families and businesses; 3) reform that gives everyone not just choice of insurance plans, but actual full choice of doctors, hospitals and other care providers (which in fact insurance plans restrict), and 4) reform that cuts the huge costs (30%) imposed by grossly inefficient administrative overheads, cost shifting and profit-taking in our current Rube Goldberg machine insurance and often health care denial set-up.

In my view, a "Medicare for All" type single payer system of paying for health care will best achieve each of those criteria, achieving the most health effective and cost efficient reform. In short, it is the most health realistic and most economically realistic as well as the most equitable approach.

And even if the counsels of "political realism" say that the immediate prospects for single payer are not good, the reform potential of full single payer reform creates a yardstick with which to measure other proposals, establishing clear criteria against which to test them.

Thus even if a single payer system of health care payment may not pass this year, it needs to be fully included in the debates because of its health and economic realism. It is not pie in the sky -- many other countries use it with better results than we get. It is not perfect, and thus not a false standard of perfection, but rather a standard of excellence like any other standard of excellence to which we try to hold ourselves. It deserves to be treated seriously, fully explored, and fully explicated to the public so that the various trade-offs in different choices can be properly evaluated.

PLEASE GO FURTHER

Your stance saying that you would vote for a single payer bill if it comes to the floor of the Senate advances such honest debate, by acknowledging that it is a serious idea, worthy of support from a U.S. senator. Likewise your exposure of underhand tactics on the part of big money reform obstructionists, as embodied in the Luntz memo, advances honest debate. But a full, honest debate is not yet achieved.

Each of the two steps I ask of you is but an extension of what you have already done, that would move us further to full, honest debate. You have said that a single payer bill, should one reach the Senate floor, is worthy of your vote. Why then is the single payer bill proposed by Senator Sander, S 703, not worthy of the much less momentous action of your endorsement? Endorsing the bill would again send the signal that this is an idea to be taken seriously, encourage others of your colleagues to regard it in that light, and thus to at least include it in the debates.

Likewise, you have spoken out against perfidious, deliberate, calculated strategic efforts to distort and derail honest debate. Why not speak out positively, in favor of full inclusion of single payer perspectives? In each case you stand up for the same principle.

Yet, while I hope and believe that such steps would also in a small way also erode the lack of political will that is the real problem in Congress when it comes to making the best health care reform, neither of them would in any way impede you from working on what you think may be immediately accomplished. If Dr. Dean is to be believed, they would help you in doing so. And, as I have argued, they would help to clarify differences among various other proposals in terms of the fundamental criteria for judging the quality and effectiveness of any reform.

Thank you for considering these requests, and for your work.

yours sincerely,

Christopher C. Lowe
Portland, OR 97202
[Address & phone redacted c.l.]

P.S. I feel constrained to point out a somewhat embarrassing error in the letter you sent to my friend, which appears to be part of a standard response to pro-single payer letters, so that you may correct it. You write:

I believe there are many merits to a single-payer system and will vote for single-payer if it comes to the Senate floor. However, I understand that it will be difficult to enact such legislation. This is why I am strongly pushing for the inclusion of a single payer option, such as an extension of Medicare, in the Senate health care reform bill. Every American should be able to choose whether they would prefer public or private coverage. A public option would provide competition to keep private insurance companies honest and lower costs, and help ensure every American receives affordable health care.

The phrase "inclusion of a single payer option" literally makes no sense. You are describing what you later more correctly call "a pubic option," which is a widespread shorthand for "a pubic health insurance plan." When you say that such a plan would compete with private plans, that inherently means a continuation of the current situation of multiple payers (insurers) with its resultant huge bureaucratic inefficiencies, that a single payer system would eliminate.

The reason this error ought to be embarrassing is that Frank Luntz specifically advocates confusing a unified single payer system of paying for health care with a public insurance plan offered by the government, as one of his main talking points, a means simultaneously to undermine both ideas, while obscuring our choices and why the current set-up is collapsing around our ears. I trust you will have your staff correct this erroneous formulation.

C.C.L.

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Many of these reflections have a bearing on an opportunity Congressman Earl Blumenauer has, as a member of the Health Subcommittee of the House Ways & Means Committee, and as a cosponsor of a public insurance plan option bill proposed by Subcommittee Chair Pete Stark, to advance and raise the quality of the debate, a subject on which I will publish something soon.

Comments

  • Bill Bodden (unverified)
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    The problem with this debate about health care reform is that it is being controlled by politicians with most of the leaders being blatant beneficiaries of campaign donations from the medical-insurance-pharmaceutical (MIP) complex. A bi-partisan bill is worthless. The MIP complex has bought agents in both parties. (Remember how Billy Tauzin rigged the Medicare prescription bill with the doughnut hole and went on to work for Big Pharma at a reputed million dollars a year?)

    If we are to get an honest and fair reform this task has to be delegated to a NON-PARTISAN, NOT A BI-PARTISAN commission. Anything else will just mean trading one deficient system for another.

    I watched part of a Senate committee hearing on health care on C-Span this week. It was chaired by Chris Dodd, senator from Connecticut, home of several insurance companies. Bernie Sanders was reading off a list of fines and penalties in the hundreds of millions of dollars paid by insurance and "health care" corporations. While he was doing this, the camera panned to catch Dodd and Senator Harkin ignoring Sanders to share some little joke that had them grinning. Obviously, Dodd has lots to keep him busy in the senate, rigging hearings for the bank bailout and now making sure the insurance corporations are taken care of in this "reform."

    Senator Mike Enzi (R-WY) followed Bernie Sanders and made a point of noting that these fraud cases involved Medicare, a government-run program, as if Medicare and the government were responsible for the shameless fraud perpetrated by these avaricious corporations.

  • Bill Bodden (unverified)
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    "There is no health-care debate in the United States. There's not even a debate over principles. You'd think a nation intent on overhauling a broken system that presidents going back to Harry Truman have been trying to fix would want to openly discuss what it wants -- universal care? Single-payer? A private-public combination? Nationalized insurance? Nationalized care? All very different things. None is being aired in congressional hearings and town hall meetings, with one exception: tinkering with more of what we have now."

    From "Obama the Collaborator Letting Naysayers Neuter Health-Care Fix" at http://www.commondreams.org/view/2009/06/27-2

  • Kurt Chapman (unverified)
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    Chris, you're an excellent writer and convey the message well. Unfortunately in calling the public option, "Medicare for All", you confuse the issue further. As currently administered, Medicare is one of the primary causes of the 30% overhead in administrative costs, cost shifting and care rationing.

    Without addressing that moose on the dining room table, the debate is over before it gets started. Make no mistake, I support the discussion, the debate and a real move to make healthcare affordable and available to all legally here in the U.S.

  • George Anonymuncule Seldes (unverified)
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    Excellent love note to the DSCC here:

    http://www.samefacts.com/archives/democrats_in_congress_/2009/06/my_love_note_to_the_dscc.php

    Bottom line: no strong public option for health plans, no campaign contributions or support for Democratic senators. This is the moment we were told we had to wait for (Democratic takeover of house and senate and white house) - now it's time for them to deliver.

  • kelebek (unverified)
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    thank you

  • Bill Bodden (unverified)
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    "As currently administered, Medicare is one of the primary causes of the 30% overhead in administrative costs, cost shifting and care rationing."

    Kurt: I Googled for "medicare administrative insurance corporation administrative costs" and received articles on both sides of this issue, such as the Heritage Foundation on the right and The Nation on the left. From the American Association of Family Physicians(www.aafp.org), presumably a non-partisan organization I got this: "Medicaid Administrative Costs (MACs) are among the lowest of any health care payer in the country." http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/state/medicaid-adm-costs.Par.0001.File.tmp/stateadvocacy_MedicaidAdministrativeCosts.pdf

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    I have no idea what Kurt's source is, Bill, but you just linked to a Medicaid report. Medicare and Medicaid are not the same thing.

  • Michael M. (unverified)
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    The biggest (or one of the biggest) problems with Medicare and Medicaid right now is that doctors and clinics are fleeing it, to the point where it is getting harder and harder for anyone who depends upon these programs to find a caregiver. It's hard to imagine how devastating a single-payer system in the U.S. would be to our health care. Currently, the U.S. subsidizes everybody else's systems: U.S. companies produce the innovation and medication, U.S. customers pay market price, the rest of the world pays below-market price because of single-payer. Pharma could opt not to sell elsewhere, but sometimes it is forced to (Brazil's patent-busting, for instance), sometimes it is coerced to, and mostly it just makes more sense to sell into other markets and get something back as long as the profit margin from U.S. sales remains high enough to fund more R&D.

    I haven't seen any cogent analyses of how R&D would be funded to anywhere near the level it is today with a single-payer system or a public-plan option in the U.S. For those reasons, I think both of them are probably non-starters. I know that my life right now depends upon medications that have been developed only in the past 12 years. I suspect I'd be dead already if we had moved to a single-payer system sometime ago.

  • (Show?)

    Honestly, I don't know how we're going to get a public option right now, much less single payer.

    I'm still waiting to see the specifics of anybody's public option plan. It makes me very nervous to see such ardent support for a plan that nobody really understands in terms of cost and implementation. I'm certainly up for robust alternatives to the current private insurance system..by all means. But I want to see some real stuff before I get all activist on anything.

    I don't think a "medicare for all" plan is the right approach, frankly. There are huge problems with the reimbursement structure for medicare. I'm dubious that we'll overcome that in a public option plan.

  • BOHICA (unverified)
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    Just a reminder:

    Article 12 General comment on its implementation

    1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.
    
    2. The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for:
    
        (a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child;
    
        (b) The improvement of all aspects of environmental and industrial hygiene;
    
        (c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases;
    
        (d) The creation of conditions <b>which would assure to all</b> medical service and medical attention in the event of sickness. </blockquote>
    

    International Covenant on Economic, Social and Cultural Rights

    This is a treaty which the United States ratified on October 5, 1977 and thus became the "Supreme Law of the Land".* Can we just get with the program please.

    *US Constitution Article VI

  • (Show?)

    Chris, I understand that Senator Merkley addressed your concern about a full and honest debate for single-payer today at his Multnomah County town hall. I wasn't there so I'm working on getting details...

  • Greg D. (unverified)
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    Interesting to watch otherwise progressive Dems flee the health care reform ship like rats abandoning a burning building. Health care reform, including either single payer or a government option, will require shared sacrifice, increased taxes, and acceptance of reasonable limits on available diagnostic and treatment options. But, incumbent Dem politicians and their apologists on this site get the dry heaves when discussing shared sacrifice, tax increases or limited treatment options. So, I have a feeling our Repub friends will be running in the next Congressional election on the slogan that "We Stopped the Dems From Reforming Health Care, Now Let's Reform the Dems Back To Where They Came From".

    And I think I will puke a couple times in my shoes and vote Republican, because although they are selfish assholes, at least they don't lie through their teeth about health care reform and then run to kiss the ass of every health care industry lobbiest in the country when the going gets a bit rough.

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    Kari,

    Medicare's direct administrative costs are lower than Medicaid's. Kurt is making a different argument, that I find interesting but too shorthand here to understand clearly or evaluate, which appears to be that in some manner Medicare contributes to the excess costs in the private sector. The clearest analogy that is well understood would be the costs of uninsured people using emergency departments for primary care because hospitals are legally obliged to take emergency patients. Hospitals can't recoup the costs directly, so they fold them into "overhead" which then gets distributed to the prices of "services" within the fee-for-service reimbursement structure used by both providers and insurers, obscuring the costs of given procedures, services, tests & so on. So costs from those uses of E.D.s get folded into negotiations over actual prices insurers pay, which vary wildly for the same services according to the size of "groups" on whose behalf insurers are negotiating, the size of the insurer, the size of the provider organization and other factors. So the original costs get distributed unevenly throughout the insurance premium structure.

    Kurt is arguing that Medicare has a similar effect and attributing to it a very large proportion of the roughly 30% administrative, cost-shifting and profits share of "health care" prices (net costs to purchasers, including purchasing of insurance) that actually do not go to pay for medical services or materials at all, or pay for grossly and unnecessarily inflated ways of delivering them. I do not really understand the basis for that argument. I suspect that they may reflect a widespread over-generalization from the right of limited geographically specific and type-of-service specific problems with Medicare reimbursement rates to the entire Medicare pricing structure, but I might be mistaken on that, some of which has also been addressed in recent legislation.

    Kurt, evidently I am not as good a communicator as you say, as I have caused you to misunderstand me. I am not calling "the public option" "Medicare for All," but trying to say the opposite. Jeff Merkley's original letter compares a public health insurance plan ("public option," and insurance plan comparable to private insurance plans and competing in a market of insurance plans, except offered by the government, details to be determined) to Medicare, calling it "Medicare-like." In fact the only inherent resemblance to Medicare is that it will be offered by the government.

    Otherwise any of the "public option" plans mooted would be paid for primarily by premiums, unlike Medicare which primarily is payroll tax funded. "Play or pay" versions would give employers a choice of paying some portion of premiums as insurance-benefit offering employers currently do, or paying a tax or fee that would be the basis for some offsetting of the missing "employer contribution" for those public plan purchasers who aren't employed or whose employers don't contribute. Insofar as a public plan derives its employer-sourced revenues in part or (theoretically) wholly from employer taxes rather than employer premium contributions, it would slightly resemble Medicare.

    Another key question would be whether a government offered insurance plan ("public option") would more resemble private insurers, who in various ways and to various degrees, partly depending on varying terms of group plans, divide people up into different actuarial classes and charge them different premiums; or would resemble Medicare, which is a "social insurance" program that insures all equally on a non-actuarial basis, i.e. doesn't divide them into such classes. The more a "public option" is like private insurance, the less it will represent a change in the system. The more it is like Medicare (treating all subscribers equally), the more it will tend to become an "insurer of last resort" into which private insurers and employers will seek to dump higher risk individuals while cherry-picking lower risk, higher profit individuals.

    But "public option" people like to use the phrase "Medicare-like" because on the whole the public likes Medicare.

    Actual Medicare is a single payer system, but age-restricted to those 65 and older. It is not an actuarially based insurance system, but a form of "social insurance" (a concept rooted in Bismarckian Germany) which is not at all like what we usually mean by insurance. When I used the phrase "Medicare for All" I meant the extension of that principle to the entire population. However, it appears that the Medicare comparison has been co-opted sufficiently by advocates of a government insurance plan competing in a largely private market for insurance plans that when I used it, I confused even a sharp reader & thinker like Kurt into thinking I was talking about "public option." This is too bad for single payer advocates.

  • Bill Bodden (unverified)
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    "I have no idea what Kurt's source is, Bill, but you just linked to a Medicaid report. Medicare and Medicaid are not the same thing."

    My error, but here is an article supporting reform based on Medicare: http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2009/06/15/a_singular_solution_for_healthcare/

  • Bill Bodden (unverified)
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    We have a plan (Clear Choice - www.clearchoice.com) on this side of the Cascades (also in Montana) that is linked to Medicare. It appears the plan gets its revenues for treatment from Medicare plus premiums (less than I pay on my plan) paid by members. A couple I am friendly with have this plan, and it appears to be working exceptionally well. They pay a fraction of what I pay for care, and I have the Federal Employees version of Blue Cross that is supposed to be so good but is, as far as I'm concerned, much over-rated. I would switch, but if Clear Choice folded I don't know that I could return to the FEHBP plan. Also, I'm not sure about Clear Choice covering me on my travels, especially if I go overseas, but I'll give this a more thorough scrutiny when it comes time to enroll at the end of this year. The only plan that the Federal system offers that I would favor is Kaiser, but it isn't available in Central Oregon.

  • (Show?)

    Thanks Kari, I will be very interested to hear what Senator Merkley had to say.

    Carla, I think you are quite right that we have no idea what a public plan option might look like, so many ideas have been floated.

    As I said to a fellow single payer advocate the other night, our immediate prospects remind me of an old Gary Larson cartoon, similar in concept to this more recent one from The New Yorker; the prospects for a genuinely "robust" public plan with requisite regulation of private insurance to constrain e.g. dumping & cherry picking only somewhat more likely; the most likely prospects for some variety of government insurance plan being a "fake" or weak so-called "public option" that will be so constrained against using its potential advantages that it won't do much except maybe become another cudgel to be used against the word "public"; and piecemeal marginal reforms probably the most likely of all. Cf. what happened to Oregon health care reform since Spring 2008.

    However, I don't buy the "once in a generation" argument about this summer. The whole set-up is in too much of a crisis. At the April 16 Town Hall at the Unitarian Church also involving Earl Blumenauer and a PNHP doc, Dr. Alan Bates, one of the health fundis in the state lege said something along these lines:

    (paraphrase)

    At this juncture something like 60% of people are satisfied enough with what they've currently got that they're at least afraid of losing it, and in those circumstances single payer won't go through. But if there aren't big changes in the current system, the dynamics are such that more and more people will lose insurance, and the insurance others have will offer less and less at higher and higher costs, that somewhere not too far down the road, maybe 5 years, maybe 10, than 60% becomes 40%, and at that point we get single payer.

    (end of paraphrase)

    N.B. that most polling questions about satisfaction do not adequately distinguish between satisfaction with doctors/ treatment/ other practitioners and satisfaction with insurance.

    It wasn't my impression that Dr. Bates was particularly for or against single payer in saying this. He has been working at the state level for things that would count as big changes, though I'm skeptical they would work (the Spring 2008 model was essentially Massachusetts plan for Oregon & the Massachusetts plan is failing dismally).

    And it might be that a "robust public insurance plan" model would be enough of a change to extend the current array of political forces blocking single payer for a longer time, despite its probable limits particularly in cost control (other limits would vary with specifics of plan) past the horizon Dr. Bates suggests.

    And maybe it would even expand and reform actual health care and the way it is practiced that the improvement could be reasonably argued to have been "worth it," even if fuller reform would have produced still better outcomes, had there been the political will among the political classes. But that's several steps of maybes.

    But if all that comes is marginal changes in the private system, or a weak, artificially constrained, fake "public option" intentionally poorly designed because otherwise private insurance can't compete, then Dr. Bates' observation remains cogent and relevant, and the pressures for reform will only grow.

    Another argument that leads to the same conclusion against the "once in a generation" meme is the trend graph for mean "health care costs" (i.e. insurance costs, not all for care, plus out of pocket costs) as a % of mean income.

    Since that definition of "health care costs" is rising at several times the rate of general inflation and of income inflation, some time around 2025 mean "health care costs" = !00% of mean income.

    Now there's a lot that can be slanted here: family vs. personal vs. per capita income, same for costs, and the ever popular focus on the mean without dealing with the distribution underlying it.

    But the basic point remains: more and more people are not going to be able to afford insurance as premiums keep rising, and another more and more will be forced into really expensive plans with deductibles so high that they are little more than "catastrophic" plans with bits of "annual check-up" and partial drug coverage fig leafs. This already is happening to many people I know, and indeed to myself.

    And of course that process cuts exactly against what all serious thinkers focused on health improvement say: we need a massive shift from specialist treatment of developed illnesses to primary care, prevention, early stage disease management through socially supported health behavior change and lower cost treatments, and extensive capacity for contact with health practitioners (in a wide sense) to support all of that.

  • Bill Bodden (unverified)
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    "At this juncture something like 60% of people are satisfied enough with what they've currently got ..."

    And many people who were not only satisfied with their health plans but thought they had really good plans found themselves bankrupt when a serious illness came up against the fine print and exclusions.

  • (Show?)

    Michael M.'s statements about doctors "running away" from Medicaid and Medicare patients is grossly overgeneralized. With Medicaid, the system varies highly from state to state as do reimbursement rates, which also in turn vary with specialty. Budget pressures due to balanced budget requirements may deepen such differentials. With Medicare there also is a degree of geographic variation but the problem areas have tended to with particular kinds of doctors and those problems have to a degree been redressed in the last couple of years.

    The argument that the U.S. subsidizes the rest of the world in pharmaceutical development is not persuasive. As is typical Michael M. relates high U.S. prices to research & development costs. This formulation leaves out both profit margins and marketing expenditures. A huge proportion of pharmaceutical company expenses & the prices they charge do not go into R&D but into marketing. And the prices likely are calculated not as involving a profit margin based on R&D costs (including failed efforts) & other basic overhead, but based on those items PLUS the enormous sums put into marketing to get people to buy more expensive newer drugs.

    And it is just nonsense to say that new drug research and development only goes on in the U.S. In fact European pharmaceutical companies have always had a huge role, e.g. Swiss Hoffman-LaRoche and a number of British companies. Most of the really large companies that compete now are mergers of former U.S. and European companies.

    A properly reformed health promotion system would in the first instance re-expand publicly funded non-profit academic medical and pharmaceutical research through the NSF, whose fruits would start in the public domain and thus avoid the frenzied search for "blockbuster" drugs that can be hurry-up marketed and then tweaked to take advantage of and extend patent-based monopolies.

    Secondly, it would seek a different solution to the problem of private investment in research conducted at great expense that doesn't pan out in a highly marketable drug. Such a solution would exchange a mitigation or limitation of the risks for a limitation on the monopoly pricing and the hyperbolic marketing, i.e. smooth the downward spikes of losses to unsuccessful research and the upward spikes of prices for successful hypermarketed research. It might be possible to achieve this (oddly enough) through some kind of insurance mechanism. It might be possible to do it through an indemnification against losses beyond a certain point after drug development reaches a relatively advanced stage in return for agreements on terms of licensing. Either of these ideas could be tied to giving the government an ownership stake in the intellectual property involved.

  • Ms Mel Harmon (unverified)
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    I was at the town hall today, but I was having trouble hearing some of the questions/answers. Here is what I do know:

    Merkley stated that the plan is to get the bill out onto the floor by week after next with the public option on it. Said this is critical so we can have the debate about the health care issue. Says they have 20 that will vote for the public option.

    Kari (or anyone else)----Jefferson Smith, Mitch Greenlick and Michael Dembrow were there as well as Ted Wheeler. One of them can probably fill in some of the blanks here...and I'm sure they are in your rolodex!

  • Bill Bodden (unverified)
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    "And it is just nonsense to say that new drug research and development only goes on in the U.S. In fact European pharmaceutical companies have always had a huge role, e.g. Swiss Hoffman-LaRoche and a number of British companies. Most of the really large companies that compete now are mergers of former U.S. and European companies."

    Then, there is the fact that pharmaceutical companies don't go near illnesses where there is no profit. Very callous, but that is the attitude they have for increasing profits.

    As for Medicare reimbursements, I wouldn't be surprised if politicians on the list of insurance-pharmaceutical campaign donors rig the system to run Medicare into the ground. Don't blame the "government" for Medicare's shortcomings. Blame the politicians in Congress who control Medicare's budget and policies.

  • Bill Bodden (unverified)
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    "As for Medicare reimbursements, I wouldn't be surprised if politicians on the list of insurance-pharmaceutical campaign donors rig the system to run Medicare into the ground."

    The Center for Responsive Politics at www.opensecrets.org has the numbers.

  • The Libertarian Guy (unverified)
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    Rather interesting article on cancer in the N.Y.T. which tells us a lot about money and medical research. Perhaps this will help explain why medical care is so costly in the U.S. http://www.nytimes.com/2009/06/28/health/research/28cancer.html?_r=1&hp

    "The cancer institute has spent $105 billion since President Richard M. Nixon declared war on the disease in 1971. The American Cancer Society, the largest private financer of cancer research, has spent about $3.4 billion on research grants since 1946.

    Yet the fight against cancer is going slower than most had hoped, with only small changes in the death rate in the almost 40 years since it began.

    One major impediment, scientists agree, is the grant system itself. It has become a sort of jobs program, a way to keep research laboratories going year after year with the understanding that the focus will be on small projects unlikely to take significant steps toward curing cancer."

  • George Anonymuncule Seldes (unverified)
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    TLG, the issue is that, thanks to corporations, we refuse to look upstream at cancer much -- we'd rather think about treatment than at establishing a precautionary principle or even forcing corporations to deal with their own wastes. That's the bottom line on cancer -- as long as you're trying to chase what is actually a whole host of pathological cell behaviors with different causes after the fact, you're not going to make much progress.

    The War on Cancer and the War on Drugs have an awful lot in common ---- both are incredibly expensive, both lead to a lot of unnecessary suffering, and both are failures from the start because they are founded on an incorrect physical and behavioral model. Treating drugs as a criminal issue has been an extraordinary failure, but very rewarding to certain powerful sectors of society. Pretending to hold a "War" on cancer while requiring science to satisfy a very high burden before a compound can be labelled a carcinogen and removed from use --- if the lobbyists and the bought-off politicians ever let it get that far --- is very similar.

  • The Libertarian Guy (unverified)
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    George I understand that corporations have a lot to do with the problem, but they are not the only group in society that bears that burden. Government also has been responsible, or irresponsible on this issue. Corporation don't pass laws. Governments do and politicians have been on the receiving end of money for years.

    But cancer isn't the only problem that has run up the costs. Organized medicine lobbied to prohibit midwives and that prohibition resulted in higher costs for births and as well higher maternal deaths and greater infant mortality.

    The passage of the McCarran-Ferguson Act resulted in each state regulating insurance and the Balkanization of the insurance industry. That resulted in unneeded entry barriers that drove up the costs of insurance for consumers.

    Then there are the games played with the drug industry and those relating to medical appliance and the licensing laws.

    And let's not forget the state medical boards which have been captured by the medical organizations for years. They are pretty much a scam.

  • Bill R. (unverified)
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    Everything I have read puts medicare admin costs around 12%. That's why the insurance industry and their surrogates in the senate and the house are fighting it so desperately. They can't compete and still exact profit for their stockholders and to pay corporate bonuses and CEO salaries. And it is the only way to provide real cost control.

    The Rs keep referring to a study that predicts a huge flight from corporate insurance to Medicare if we give it as a public option for everyone. The AMA is fighting it both as public option and as single payer because it will put a real control on the fees they can charge, and their privileged status in our country will decline.

    Right now we could without too much trouble give medicare to everyone, providing a ground floor of medical service to everyone, and support it by shifting the money presently paid into the private insurance system by employers and individuals, and add additional taxes if need be. Private insurance could have a chance to compete through medicare-plus programs, people like AARP, Kaiser, and those who presently provide medicare plus programs.

  • The Libertarian Guy (unverified)
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    Question. What is defined as adminstartive costs?

    There was a piece in the N.Y.T. a few weeks ago that suggested that docs in private practice run up the costs significantly and if they would move to hospital or group practices those costs would drop.

  • Bill Bodden (unverified)
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    "Government also has been responsible, or irresponsible on this issue."

    Let's quit using the right-wing term of "government" when it comes to laying blame. The government consists of the politicians elected by the people to govern. They go to the national or state capital to govern, not to sit around on their butts or hustle campaign donations while the "government" runs things. Let's get real. The United States government that rules the people consists of the elected officials in Congress and the corporations that have bought them to do their bidding to enhance corporate profits. (By Mussolini's definition, that is fascism.)

    Then there are the people who keep returning these bought politicians to Congress so they can screw them for another two, four, or six years.

    If we want a health care system that will work for all (or almost all) of the people, then there is one step the people must take. Wake up from their apathy and slumber and tell their representative, senators, AND president that if they don't deliver by the next election, they are out of office.

  • Kurt Chapman (unverified)
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    Bill and Kari both bring up excellent points. I was not deliberately obtuse in my statement; I just did a poor job of framing my concerns. Specifically:

    1. Medicare reimbursement is typically at such a low rate as to only cover 80% or so of 'true' costs.
    2. Medicare procedure reimbursement is driven by geographic considerations rather than quality of health considerations. The same procedure performed in Seattle, Atlanta, Miami, Portland, Sacramento, Roseburg, and Wenatchee is reimbursed at vastly different levels.
    3. Administrative requirements in the medical provider office for Medicare are vastly different and often contradictory to other providers.
    4. Due mainly to numbers 1 and 2 above; medical providers pass on unreimbursed medicare costs to the rest of the population seeking medical care.
  • The Libertarian Guy (unverified)
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    Bill I think most people on here understand what you mean, but at the same time most of the public has little, or no time to spend researching these issues in depth so that they can vote for the right person.

    Example Coley's Toxins. I have spent a lot of time on this one and still don't have all the facts down, but in the early 1900's Doctor Coley developed a toxin, or series of toxins that killed tumors of some types of cancer. When the FDA was created aspirin was grandfathered in, but Coley's toxins were not.

    I don't think the average citizen has the time to research this or any number of issues in the news and relies on the news and politicians to give the some degree of straight information.

  • Assegai Up Jacksey (unverified)
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    I think Chris put it well, without qualification.

    I do have to wonder why people use the Post Scriptum in a medium that is not synchronous or serial, though! At least I assume you didn't plunk it out on an old Smith-Carona...

  • Bill Bodden (unverified)
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    "Bill I think most people on here understand what you mean, but at the same time most of the public has little, or no time to spend researching these issues in depth so that they can vote for the right person."

    This falls into the category of getting priorities right. Most people do have some time to get an idea of what's going on, but a large percentage prefer to watch their favorite television programs and be clueless about what is going on. A few years ago I was collecting signatures for campaign finance reform. I stopped a couple of people to solicit their signatures and was taken aback when they said they didn't know an election was coming up.

    I agree that the majority of people are not in a position to do in-depth studies of the issues, but given the availability of data they can get enough information relatively easily so they can make responsible judgments.

    For example, if they listen to a politician who makes a series of promises, it doesn't take a lot of research to discover whether that politician is keeping or reneging on those promises. But the tragic point is that a vast number of people don't care or are content to let some demagogues do their thinking for them. Then there is the problem of tribal loyalty that is almost as bad as the tribal loyalties shown in Northern Ireland, the Balkans, and Iraq where you have people voting for whatever hack their political party gives them.

    I was just watching a conference on health care on C-Span and listened to a representative from the Association of American Physicians and Surgeons describe how horrible it is for doctors working with Medicare. She sounded Kafkaesque in describing what could happen to a doctor if he or she checked the wrong box on a form. To the contrary, note my reference above to the Clear Choice health plans that obviously refute that. Clear Choice is basically a doctor-initiated plan working with Medicare supplemented by premiums paid by plan members. Given that information you don't need to go to the library of Congress to do some research to get the idea that this spokesperson from the AAPS might be tossing out BS for public consumption. I did a brief search on the internet and was not surprised to note that Wikipedia referred to the AAPS as a conservative organization.

    In the case of health care, it won't take a lot of research when the next elections come up. People will only need to look at their own situation to see if there is any improvement. If their insurance premiums and deductibles go up and they are less secure, then they need to check up on how their representative or senator or president voted. But more likely many will take their cues from the likes of Limpbag or O'Lielly and vote accordingly - if they vote at all.

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    AUJ,

    Well, in synchronous, serial media, to use your terms, a p.s. can reflect either news added following an originally fixed letter, or an afterthought in the sense of something less important or somewhat related but not really integral to the main point, or a related thought not yet fully developed to be integrated into the preceding whole.

    In this medium, I think it can still function as visual rhetorical device indicating similar things, a bit like parentheses but more clearly marked off as distinct from the main body.

    In this case, Senator Merkley's letter drew my attention both for his reiteration of his previously stated stance and commitment, and for the confusion of the letter's formulation, I suppose by a staffer, regarding single payer, "public option" and Medicare analogies. The main things I wanted to say concerned the former. The second seemed important enough that I wanted to mention it, but also to indicate that it was of lesser concern.

    BTW, thanks for your nom de keyboard. I think in my youth I may have seen Batsmen of the Kalahari on a U.S. Monty Python rebroadcast, but at the time I did not know enough about either cricket or southern Africa or anthropology or David Attenborough to understand just how funny it is, and I'd forgotten it until trying to figure out your reference. (In a previous life I taught African history with a research focus on South & southern Africa.)

  • acerbic p (unverified)
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    It will be a surprise to the French (and all other reasonable people) that single payer doesn't work. Only Democrats and Republicans can be so stupid.

    Paul Krugman, not a radical, has it right:

    "The point is that if you’re making big policy changes, the final form of the policy has to be good enough to do the job. You might think that half a loaf is always better than none — but it isn’t if the failure of half-measures ends up discrediting your whole policy approach.

    "Which brings us back to health care. It would be a crushing blow to progressive hopes if Mr. Obama doesn’t succeed in getting some form of universal care through Congress. But even so, reform isn’t worth having if you can only get it on terms so compromised that it’s doomed to fail." (Not Enough Audacity, http://www.nytimes.com/2009/06/26/opinion/26krugman.html)

  • backbeat (unverified)
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    Meanwhile what do we get from Wyden? Why hasn't his lousy positions been covered on this site?

    crickets

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    Backbeat, stay tuned. I've got several things in the pipeline, but am putting first priority on a couple of items related to positively influencing the shape of the debate.

  • Bill Bodden (unverified)
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    "Meanwhile what do we get from Wyden? Why hasn't his lousy positions been covered on this site?"

    There was a discussion about Wyden's pro-insurance corporation plan recently, but it would be a good idea to have another session on it.

  • backbeat (unverified)
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    I've got several things in the pipeline, but am putting first priority on a couple of items related to positively influencing the shape of the debate.

    excellent. I've called his office more than once to find out if there are any town hall meetings slated for west of the Cascades during this recess. If so, you'll see me there filming it. Just can't make the trip to Baker/Malheur this week. Maybe I'll hold a poster with Grandma Dina, whose 100th birthday party he attended as a photo op when he ran for office the first time.

  • chris #12 (unverified)
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    Re: Wyden

    Check out this great photo from a recent health care protest.

  • David from Eugene (unverified)
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    Regarding Wyden:

    He does not support real health care reform. What is needed is for a real health care reform Democrat to announce a run for Wyden’s Senate Seat. The more prominent and well known the better.

  • fat loss 4 idiots (unverified)
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    If President Obama has to declare a NATIONAL STATE OF EMERGENCY to rescue the American people from our healthcare crisis, he will need all the sustained support you can give him.

  • perfect golf swing (unverified)
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    Merkley said that although some preliminary proposals include more publicly funded health care, support for such plans will be hard to find, especially in the face of opposition from insurance and pharmaceutical companies.

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