Centerfield

I noticed the lack of policy specifics too. Kerry would say, "here's what I'm gonna do..." and then not really say anything specific. It was a fluff speech. But, I don't think that was anything outside of the norm for acceptance speeches. Long on promises... short on specifics. That's the way the game is played now days.

So far all the health-care proposals just seem to be different ways of shoveling money into the system. Nothing to address the basic problem of runaway costs, just ways to spread the pain of paying for them. The health-care lobby has nothing to fear from either party right now. Doctors, corporate providers, insurers, and pharmaceutical execs can go ahead and order their new Mercedes.

(Color me cynical.)

Tully,

I'm interested in what you believe are good first steps "to address the basic problem of runaway costs". (Not in comparison to Kerry, but what do YOU think?)

Cutting down on the administrative overhead would be a good start. At least 18% of overall health care spending is due to administrative costs related to our payments structure. Billing specialists to sort out (and fight with) insurance companies. Their counterparts at the insurance companies, bent on preserving insurance company overheads and profits. It all adds up to quite a chunk of change, in fact enough change to fund ALL the uninsured.

The obvious answer to that is single-payer. And there you run head-on into entrenched interests, and the fact that such a structural change would throw LOTS of people in insurance companies and medical offices and hospitals out of work. Asking Congess or the White House to do that just doesn't seem like a starter, does it?

Then there's tort reform--not the total gutting of the tort system, but some sane reforms to limit runaway punitive damage awards. Malpractice insurance is indeed driving some doctors out of high-risk fields. Restricting the number of practicioners can only send prices one direction. Gotta get by the tort lawyers on that one. But it would have other beneficial effects on prices and practices, such as relaxing the overuse of technology in the avoidance of niggling lawsuits. Doctors often throw the whole diagnostic arsenal at a patient, because NOT doing so can get them sued.

Of course, there's always the pharmaceutical companies. As American consumers, we subsidize new drug development for the rest of the world--and go on subsidizing it long after the rest of the world gets the drugs at much lower prices. Yeah, it inspires new product development of new wonder drugs. But why should we be paying two to five times as much as Canadians and Europeans for drugs we already paid to develop? Not to mention that the new drugs are often no more effective than the old ones--but the drug companies spend billions convincing doctors to rpescribe the newer and much more expensive ones. We pay those billions.

I could go on and on (and have on many occasions). Tax policy that favors stupid payment setups, and make people dependent on their employers for health care, afraid to change jobs and lose coverage. Unequal benefits that gaurantee the growth of "boutique" hospitals for the well-insured, while the underinsured and uninsured must depend on public charity (or die) and the resulting loss of revenue to public hospitals that must treat every patient. And so it goes.

The bottom line is that we created the world's finest for-profit health care system. Not the finest in producing overall results, but the finest in producing profits. And as Americans we demand everything possible, and damn the cost. It's an oligopoly producing a limited supply for an unlimited demand. The people making the money have enormous economic and political clout, and don't want reform.

People will talk about how changes will produce rationing--but we have rationing now. Health care is rationed by employment, by wealth, and by the government. The big squeeze is felt by those who don't have employer insurance (or don't have enough) and aren't poor enough for government coverage. It's fine and dandy to say, as Kerry has, that employers must offer access to insurance. But with premiums for a family of four at $800 a month or more, that doesn't do much good until you get to the middle class and above. So healthy younger people do without insurance rather than crippling their finances.

Make no mistake about it--almost every plan I have seen from the government for universal coverage has involved making the healthy young who now take their chances kick in to spread the risk pool. Not a one has involved actually addressing the problem of a politically powerful and extremely profitable oligopoly address the structural cost sinkholes built into the system. The Kerry proposal is no different, it just spreads the risk onto the entire taxpaying populace--as the Bush "solution" to the high cost of drugs did.

Great summary, Tully!

The only thing I'd add is that tort reform must go hand-in-hand with better accountability from physician/hospital boards. The assertion is that many mal-practice suits tend to concern a small group of physicians who seem to be able to transgress time after time without being disciplined. Remove the right to practice from a small number of crappy practitioners and that would have a major effect.

Although I tend to agree with you on the single-payer issue, I suspect we're more likely to take small steps rather than comprehensive reform (partly because of the failure of the Clinton initiatives). So we'll still have to choose from among non-optimal alternatives.

Even the Clinton approach didn't really have single-payer. Instead it proposed to carve up the goodies among the existing players and have the feds regulate 'em.

Which might be better than nothing--we're wasting almost one out of five health-care dollars fighting over what charges are covered. And as anyone who has had a major health catastrophe can tell you, one of the biggest stresses is having to fight the insurance companies to get them to pay for what they're supposed to. My foster uncle died of cancer over a year ago, after fighting it for three years. By the time he passed away the bills had run up considerable. Some of the charges, naturally, were not billed until after he died. The insurance company denied those claims on the grounds that the patient, being now deceased, was no longer insured....

(But I was on the insurance commissioner's campaign staff, and know every competent lawyer for a hundred miles. They paid. Finally.)

The routine denial of covered claims is stock-in-trade. The insurors know that a certain percentage of those bills will be paid out-of-pocket by people tired of fighting, so they stall as long as possible. I've often wondered if that isn't at least partially responsible for our outcomes being worse than countries where the payment is single-payer and there's no question of the billing. Stress kills.