Counting the Uninsured in the U.S.

by Tim Foley

category: Enemies of Reform

Published September 11, 2009 @ 04:27PM PT

We know from the Census’ report yesterday that there are 46.3 million total people as of 2008 who lack health coverage from an insurance company or a government-run program, including 36 million American citizens and 9.5 million people who are either legal immigrants, green card holders, or undocumented immigrants here illegally. But the closer we come to solving the problem, the more challenges you’ll hear to any and all of those numbers by those arguing against reform. Yes, there are larger questions of who we think should be covered in a responsible, just society and of what our methodology for counting is. These questions are worth discussion and debate. But it shouldn’t move us off a more fundamental question: how is a system in which millions and millions of people -- no matter how you count them -- lack basic health coverage acceptable?

So what are the distinctions? The largest one is documentation status. It’s not clear to me what the difference is between “more than 30 million American citizens”, to use President Obama’s formulation, or the “more than 46 million people” that is more frequently cited. It makes no difference in terms of public health or the economics of our unsustainable health care costs in which the burden of paying for the uninsured is borne by all of us. Communicable disease and emergency room trip-inducing calamities don’t care whether you’re insured or not, of what country you're a citizen, how much money you do or do not have, or your documentation status. It is a pure political wedge issue, agnostic to substantive health and economic concerns, and one on which I’ll have more to write about tonight.

But the strangest argument I’ve heard lately from Orrin Hatch and other conservatives is that we should also throw out any household making above $50,000 a year from the count. The argument is that those people should be able to afford insurance, because they’re solidly middle-class. That just shows how frustratingly naïve the conventional thinking on who is uninsured truly is.  It is precisely the middle-income working class that is being put through the ringer by our out-of-control health care costs. The income group between $50,000-$70,000 is actually the fastest-grown segment of the uninsured population. It accounts for most of the increase over the last decade. The reason why has been pointed out by many other writers today –- private, employer-based health insurance is already eroding because of escalating costs. Over the past seven years, we have seen a net loss of 5 million people covered by their job -- a fact usually ignored by those arguing that we shouldn't be in a rush to reform -- and the number of uninsured would, ironically, look much worse if it hadn’t been for the expansion of government-run Medicaid and SCHIP.

As someone who is in that income group myself, there is no mystery as to why these people who should have insurance (at least according to the Orrin Hatches of the world) don’t. The average family plan on the individual market here in New York is not that far off from the national average -- $12,254 according to America’s Health Insurance Plans. That represents 17-24% of income for a family in that range. For comparison’s sake, the Swiss and Japanese utilizing private insurance pay 8-9% of their income on premiums. Combine premiums that have nearly doubled since 2000, making an individual market plan increasingly unaffordable to the middle-class, with an increased likelihood that you will not have benefits offered by their employer, and the numbers explain themselves.

Now combine that with an economic crisis where unemployment shoots up several percentage points, leading to an estimated 6 million people have lost their insurance in 2009, and you have a recipe for disaster. No wonder those arguing against reform don’t want you to pay attention to this income group -- it’s the perfect snapshot of what’s going wrong.

So that opens the door to a different question. How many people should be uninsured in the United States of America, a land many of us to believe to be the greatest country on Earth, where we hold ourselves to a self-evident truth that all men and women are created equal? That answer is easy: zero.

(Photo credit: http://www.flickr.com/photos/aussiegall/ / CC BY 2.0 )

Conservatives Run Negative Ads on Republicans' Favorite Health Care Plan

by Tim Foley

category: Enemies of Reform

Published August 28, 2009 @ 05:01PM PT

This is one of those times when I wish I hadn’t been right.

One of the first posts I wrote for this site was a favorable analysis of the Wyden-Bennett plan, a universal health care plan with true bipartisan support in the Senate. These days, it’s the favorite alternative approach to the bills moving in Congress, largely because of said bipartisanship. However, as I cautioned a couple of weeks ago, “But anyone thinking Wyden-Bennett would be politically easier, either inside the Beltway or outside, doesn't seem to be listening.” Sure enough, we’re now seeing negative ads being run by the conservative Club for Growth against Wyden-Bennett – even though the bill isn’t even being considered!

It’s easy to see so many are turning to the bill, called the “Healthy Americans Act”, and imagining a clearer path to reform in Congress. When we’re looking at the realistic possibility of zero Republican votes in the Senate and the certainty of zero in the House, the adjective “bipartisan” takes on a magical air. This bill was co-sponsored by the liberal Ron Wyden of Oregon and the conservative Bob Bennett of Utah, and is almost evenly split between Republican and Democrat co-sponsors. But even more impressive, it solves a real problem in health care – the fact that benefits are tied to employment, creating job lock, freezing the individual out of making decisions about which plan works for him or her, and reducing direct competition among insurers. In the process, it would provide universal coverage and help reduce costs.  As such, it's a reasonable, responsible, free-market approach to solving health care, one more Republican Senators have signed onto than any other plan.

And none of that matters. The negative ads are already running.  The bill that the Congressional Budget Office scores as being completely deficit-neutral and which the Lewin Group estimates would decrease the deficit by $1.4 billion per year is lambasted as a big spending spree. The fabled bipartisanship becomes Sen. Bennett working “with liberals Democrats.” The provisions that free employers from having to deal with skyrocketing costs become “job-killing tax increases.” It is, frankly, the same old crap all over again.

I would like to believe conservative interest groups when they say they’re for reform but disagree about the methods. But when they run hatchet jobs on one of the most conservative Senators for his support of a free-market approach to universal health care, that excuse doesn’t hold water. They’re against reform – period.

Canada's Rebuttal to Our Health Care Ghost Stories

by Tim Foley

category: Enemies of Reform

Published August 25, 2009 @ 04:17PM PT

For the country that gave us William Shatner, Wayne Gretzky, and Celine Dion, Canada sure turns into a punching bag quickly whenever we talk about reforming American health care. All of a sudden, we hear about the horrors of Canadian socialized medicine (even though, since hospitals and doctors are mostly private, Canada doesn’t even have socialized medicine – they have single-payer, which only deals with financing.) Somehow, all the scary stories – most of them debunked long ago – surface even when we’re not talking about following the Canadian model at all. Well it seems our brothers and sisters to the north have a message for us about the difference between Canadian and American health care.

It can be summed up as, “Knock yourself out – as far as we’re concerned, the joke’s on you!”

Let’s make one thing clear. The health care bills moving in Congress would leave about 160 million Americans right where they are in employer-sponsored insurance, and add about 20-30 million more people into a transparent marketplace (the Exchange or the Gateways) where they’re given subsidies to purchase insurance sold either privately or publicly. That’s the structure that people are yelling about – one that leaves maybe 160, maybe 185 million Americans in private insurance. We can and will debate that, but let’s be honest: it really looks nothing like the health care system in Canada.

What does look like Canada is the health care system that every American over 65 enjoys – and which it seems Republicans are heavily resistant to change (today, at least). Who knew there’d be so much American love for single-payer health care?

Joe Lieberman Tries Out an Argument from December

by Tim Foley

category: Enemies of Reform

Published August 24, 2009 @ 07:56PM PT

In our health care debate, what’s old is new again. We scarcely gave a thought to Canada or Great Britain’s health care system, yet we’re daily confronted with bogeyman that had long ago been vanquished. Socialized medicine, a rallying cry that still invokes memories of a country that hasn’t existed for almost two decades, is the new black. Even the wishful thinking expression that America has the best health care in the world – a claim that has been debunked again and again – is in vogue. The older it is, the more it’s in style.

So leave it to Joe Lieberman to come up with an argument that’s only 8 months old – and never gained much traction at all: that the economic recovery requires that we put off health care reform. His bon mot from the Sunday talk show: “I’m afraid we’ve got to think about putting a lot of that off until the economy is out of recession.”

You don’t need to be Ezra Klein to realize what’s wrong with this statement – but Ezra does it with such panache:

First, we probably are out of recession. Second, health-care reform is scheduled to begin in 2013, by which time we will almost certainly be out of recession, and if we're not, we have bigger problems. Lieberman might be uncommonly pessimistic about our prospects for growth, but that would imply support for health-care reform, as it will pump a trillion dollars into the economy and thus stimulate demand.

Third, the costs of reform largely manifest in the later years of the decade, namely 2015-2019, by which point we may or may not be in recession, but if we are, it will probably be a different recession than the one we're in now. There is, in other words, no connection between whether GDP growth is slightly negative in the third quarter of 2009 and whether we should spend money between 2013 and 2019 building a universal health-care system.

Lieberman seems to be stuck at the start of the year, when every other blog post I wrote talked about how in this economic crisis, that actually created more of a need to reform health care. Health care costs per person are still scheduled to shoot past $8,000 and health care will be 20% of our economy by 2018 at the current trajectory. Runaway health care costs are the single biggest driver of both costs in the federal budget as well as that for large and small businesses. When the economy was shedding jobs, it was also dumping people out of coverage – at the rate of 1.1 million jobs for every 1% rise in unemployment. It’s no accident that as the economy inches back towards recovery, the impetus to get health care done – which felt like a “Please hurry up already” in February and March but has now settled to a “Hey, what’s the rush” – fades.

So if the Senator from Connecticut, the insurance capital of the world, wants to bring up economic recovery, by all means, go ahead. Maybe people will remember what a drag on the economy our mounting health care costs truly are.

(Photo credit:  MichaelTRuhl on Flickr.)

Moving the Goalposts: The Best of the Weekend

by Tim Foley

category: Enemies of Reform

Published August 23, 2009 @ 08:40PM PT

Every week, I feature the top three stories or videos from the weekend – the ones that best enhanced my own understanding of what’s going on with health care reform.

1.) The Rachel Maddow Show: “GOP Moving the Goalposts… Er, Basketball Hoops”

I’m cheating slightly by featuring a video that originally aired on Thursday but vividly demonstrates one of the more ludicrous refrains coming from Republican leaders in the Senate: specifically, that in order to be truly “bipartisan,” health care legislation would require an astounding 80 votes in the 100-member Senate. This isn’t anything I’d be likely to comment on, given that I’m on the record as saying I care less about a bill being bipartisan and more about it actually succeed at reducing costs, increasing access and improving quality. But I’m glad that Maddow and guest Sue Wicks are able to demonstrate what’s wrong with this picture.

2.) Washington Post: “Live or Die? That Was for the Panel to Decide”

The problem with the “death panels” lie is it’s a bogeyman designed to trample down debate. The reality is we could be having a more robust debate about issues of life and death, and what individuals and families can and should be thinking about to make sure when their time comes, we’re respecting their wishes, values and sense of dignity. But what I didn’t realize until reading John Buntin’s column was how much we’ve forgotten our own history on bioethics.

Something about the health-care debate gets people arguing about improbable scenarios, such as the United States turning into Canada or the government killing grandmas. But in the case of death panels, the overheated rhetoric has some historical truth. For a decade, there actually were death panels in this country. And it was big government that ended them.

Read the full article on WashingtonPost.com

3.) New York Times Editorial: “The Uninsured”

Most people are familiar with the notion of 46-50 million Americans being classified as “uninsured.” But how many of them would be helped by the current legislation? How many of them need to be helped? How many work? How many are young people who could afford it but don’t buy it? How many are undocumented workers? The NY Times tries to make the demographic breakdown of the uninsured easy to understand – while popping a few myths in the process.

No matter how you slice the numbers, there are tens of millions of people without insurance, often for extended periods, and there is good evidence that lack of insurance is harmful to their health.

Scores of well-designed studies have shown that uninsured people are more likely than insured people to die prematurely, to have their cancers diagnosed too late, or to die from heart failure, a heart attack, a stroke or a severe injury. The Institute of Medicine estimated in 2004 that perhaps 18,000 deaths a year among adults could be attributed to lack of insurance.

The oft-voiced suggestion that the uninsured can always go to an emergency room also badly misunderstands what is happening. By the time they do go, many of these people are much sicker than they would have been had insurance given them access to routine and preventive care. Emergency rooms are costly, and if uninsured patients cannot pay for their care, the hospital or the government ends up footing the bill.

Read the whole article on the NY Times Web site.

The Myth of Exceptional Quality in U.S. Health Care

by Tim Foley

category: Enemies of Reform

Published August 22, 2009 @ 04:10PM PT

You’ve doubtlessly heard of a 2000 World Health Organization study that ranked the U.S. as 37th in the world in terms of the quality of our health care. I have mentioned it before, but usually to trash talk Slovenia (ranked 38th… loser!) The problem is a lot of the numbers we toss around to wrap our arms around whether our health care system truly does underperform are numbers that don’t have meaning for people. It makes it that much harder to refute some nay-sayers who still maintain, in the face of the evidence, that the U.S. health care system is best in the world. A new report by the nonpartisan Urban Institute and Robert Wood Johnson Foundation aims to turn that around.

Because the report is so timely, it’s focused on a lot of the talking points you’re hearing from opponents of reform. The report’s reason for existence is to answer the question, Is American health care much better than care elsewhere (at which point we should be reluctant to change it) or is it truly lagging behind in one or more areas? In answering, they’re not afraid to answer the tough questions. They’re also not afraid to answer, “it depends.”

• Can you really compare data on health outcomes between countries? There’s plenty of concerns for methodology and bias, some of which is solvable. But all of it is colored by a big discrepancy between the U.S. and other countries: we let a fifth of our non-elderly citizens go without reliable health care entirely.
• What about big numbers like life expectancy and infant mortality? Most know that the United States does poorly in these factors, but some push back that the U.S. sees more accidents, homicides, etc. But we’re not doing great when it comes to amendable mortality – “the United States had the highest rates of deaths from conditions that could have been prevented or treated successfully.”
• How do we do on preventative care? Mixed. We’re excellent at cancer screenings like pap smears and other cancer screenings. We’re excellent, too, at vaccinating senior citizens against the flu (yay, Medicare!) But we stink at vaccinating our kids compared to other countries. Similarly, chronic diseases like asthma, diabetes, heart disease and hypertension – many of which are preventable – are not caught anywhere near as early or treated as aggressively as cancer.
• What about all these cancer survival rates where the U.S. does better than other countries? Credit where it’s due, the U.S. is as good or better. Why? The aforementioned push for early screenings. “Many cancers are more amenable to treatment when caught early. But it is also true that in countries with higher screening, more cancers will be diagnosed early, and survival rates in those countries will be higher simply because there are more patients in the denominator with less advanced disease.”
• We’re more at risk for overtreatment, including being put at risk for complications from treatment. We’re at greater risk of harm and death from inadequate patient safety. We’re also more at risk from hospital-transmitted infections. So we’ve got that going for us.
• Finally, what about the punching bag of Canadian health care? “Although studies findings go in both directions, the bulk of the research finds higher quality of care in Canada.”

So what does all of this research add up to: “[W]hile evidence base is incomplete and suffers from other limitations, it does not provide support for the oft-repeated claim that the ‘U.S. health care is the best in the world.’ In fact, there is no hard evidence that identifies particular areas in which U.S. health care quality is truly exceptional.”

Let me add my two cents – quality doesn’t exist in a vacuum. We spend twice as much as most other industrialized nations. So the question is less can you cherry pick a single health statistic to show we’re just as good as those who guarantee access to high-quality health care as a basic right.

The question is, are we getting twice as good care for our twice as much money? Of course not. That’s why we need reform.

(Photo credit:  the recent Remote Area Medical clinic for the uninsured in Los Angeles, from dhw20500 on Flickr.)

Betsy McCaughey, Meet Jon Stewart

by Tim Foley

category: Enemies of Reform

Published August 21, 2009 @ 08:11AM PT

Betsy McCaughey, the paid board member for medical device companies and former lieutenant governor of New York who has made her political career on doing “close readings” of health care legislation that scare the living bejeesus out of the general populace, was on Jon Stewart last night.  Those with a low tolerance for flapdoodle should avoid the following:

Two observations:

This absolutely was not the medium for the McCaughey style of argument. In a 700 word editorial for the NY Post, she can make a claim, cite the bill, and explain what it “really means” without ever being asked to explain how her assertion relates to the original. Hence she’s able to take a provision that’s intended to make sure that end-of-life directives are followed (including, as Jon Stewart notes, if that directive is “keep me alive by any means necessary”) connect to people on Medicare being denied or delayed on hip surgeries, living in pain, etc. It becomes absolutely clear that her citations in the bill are a means to the end. What she really wants to talk about is the emotional fear of being denied the care you need when you’re in pain, something those of us with HMOs are all too familiar with but Medicare beneficiaries generally are not. Finding a small provision in a bill that most people agree with – heck, if I had an end-of-life directive and the doctor didn’t follow it, you bet I wouldn’t want him/her to get paid full price – and using a leap of logic to get to an unconnected fear works in print, but it doesn’t work when you have someone in front of you saying, “Wait, that’s not what this says.”

Second, this is “mushroom cloud” logic. It’s all absolutes where all cuts to Medicare have equal weight and you’re left with a stark choice – invade Iraq or have St. Louis nuked. It turns out that wasn’t the choice there, and it isn’t the choice here, either. Cutting overpayments to insurance companies for Medicare Advantage will result in denied profit margins, not denied care. Reducing a payment rate for MRIs which was set when we believed they’d be in use half of the time because we now realize they’re in use 80% of the time or more won’t lead to my grandmother being denied her MRI when she needs it. (Indeed, the worry I’ve heard is that it will cause doctors to prescribe even more MRIs, whether necessary or not).

But let’s give McCaughey a taste of her own medicine. In this clip, she doesn’t want to see Medicare get cut at all, or any treatment denied at any time, no matter the cost and no matter the evidence. She also wants, as she says, for the uninsured to be subsidized. So the question is why does McCaughey want us to devote the entirety of the federal budget to unlimited health care for the entire population at a time of war? If you never deny any care for any reason and cover everyone, as she suggests, clearly health care will jump from 20% to 50% of our budget next year. I love this country too much to see our Department of Defense downsized so radically during a time of increasing danger around the globe. What good will our unlimited MRIs for every age and health condition be when North Korea launches nuclear missiles against us?

Yes, this is preposterous logic. So is McCaughey’s.

You can also watch Part 2 of the interview.