1. A Dialogue On The National Healthcare Debate
July 29, 2009
Arnold Birenbaum, Ph.D.
Professor of Pediatrics and Associate Director
Medical Sociologist and Health Policy Analyst
University Center for Excellence in Developmental Disabilities
Rose F. Kennedy Center
Albert Einstein College of Medicine

Tom: Well here you are wasting another perfectly beautiful Saturday morning listening to Health Care Systems Talk, the summer replacement for Car Talk.
Ray: Let’s take our first caller. Hello, you are in Health Care Systems Talk.

Arnie: Hi, this is Arnie from the Bronx.

Ray: You are the first caller we ever had from that county of New York State, which is also a borough of New York City.

Arnie: You are correct Ray.  I am sure you health guys heard the President’s press conference the other night, July 22nd, 2009 to be precise, where he compared our overpriced health care system to pay in excess of $5,000 for the same new car that was purchased by our neighbors to the north, Canada. I think the analogy is good but here is one that goes even further and fits into your day job as car experts. Our healthcare system is a clunker. It is ready to be taken off the road because it is dangerous to our health, expensive to fix, and is clearly broken.

Tom: That makes a lot of sense. We are on the verge of deciding that it is time to get a new car, I mean a new health care system. We may be attached to the old clunker because it is familiar and, well, the ashtrays still work, but we need to get us a new health care system. I’ll pass on comparisons with the reconfiguration of GM and Chrysler.

Ray: Yeah, I was talking with the actors who play Harry and Louise, then and now, and they are ready for the trade-in. You remember in 1993 they didn’t want to give up what they had for the unknown. You know what happened to them over the last few years? They watched the system break down.  Harry took me down the street of his hometown last week. The emergency department of his local hospital was filled with people without health insurance who waited a long time before bringing their kids for care.

Then we ran into Louise who was coming back from visiting an old friend, who had lost work because she had to care for an aged relative at home. Her friend’s brother was also in a bad way. He couldn’t get work because he had been in an automobile accident, suffered from back problems, and no employer would hire him.

The three of us stopped to think about what we might have to do to end this absurd situation where health care is a privilege of the well-insured and not a service that we all need access to. It is not a mystery why President Clinton’s bill, never subject to a vote in either chamber of Congress, was called “The Health Security Act.”

Arnie: You got that right. The United States is still trying to answer a question that other countries resolved long ago: Is it fair to make access to health care a privilege? No other country with comparable riches has failed to see that health care must come in the form of social insurance. Everybody has to be covered for insurance to work effectively.  Are we really like Homer Simpson, who complains about his children receiving inoculations against diseases that they never get?

Tom: Let me get in on this conversation. I think the Pres is on the right track. Harry and Louise, the real folks, are starting to see that it’s time to create universal coverage, allowing those who are happy with the insurance they have to keep it, and permitting those who want to use a public plan to do so. We can help transform a broken health care system into one that works for everybody. No more clunkers on the road!

The actors who now see the light--these two darlings of television --are simply answering the question that then-candidate Ronald Reagan asked in 1980 to gain an edge over his opponent, President Jimmy Carter. “Ask yourself: are you better off than you were four years ago?”

The answer today is clear! We are much worse off than in 1993 when Clinton was in charge. Wages and salaries are kept down to pay premiums for employer-based healthcare insurance. Applied to health care access and financing, we may be not in a position of need but we all know someone who avoided going to the doctor because they couldn’t afford the visit, or had hospital bills that they couldn’t pay. Even those with insurance may have co-pays, deductibles or claims denied that sunk a family into great debt.

Arnie: So how are we going to complete health care system reform?

Ray: We need to support the forward-thinking legislation. The health care system we have been sold is a piece of junk. This clunker has to be taken off the road. Yes, there are some excellent regional or local systems (e.g., Cleveland Clinic, the Mayo Clinic) but much of the time we are treated, or an intervention is recommended, as much to support the provider’s bottom line as to help us get well.At the same time, health plans and insurers are motivated to spend as little on care as possible. They focus on keeping what they call the “medical-loss ratio” low so profits can be high. We get questionable care at a high price and sometimes we are stuck with the bill when our claims are denied.

Arnie: Is this going to be the summer of change or just another summer re-run?

Tom:  Summer is usually a time for people to kick back and enjoy nature’s bounty, even have clambakes. That’s my New England heritage talking.

But this summer something transforming could happen. Since the days of Teddy Roosevelt and the Progressive Era, Americans have been struggling to get access to quality care at an affordable price.  Key committees in both houses of Congress are drafting legislation that will establish opportunities for working Americans who cannot afford premiums in the commercial insurance marketplace to receive subsidies to purchase policies that will afford protection against bankruptcy as well as allow people with serious health concerns to see appropriate health providers. Moreover, these subsidies will reduce the current cost-shifting to individuals with insurance and employers who help pay the premiums for their employees. This shared responsibility also means that everyone will have to purchase a policy and pay premiums even when subsidized. The young and healthy will be included in the insurance pool and their premiums help pay for care for those with serious acute or chronic illnesses. This kind of mandate is similar to state laws requiring that car owners carry liability insurance coverage.

Ray: You are leaving out some important concerns. The hard work is not done and the century of seeking health care reform is not over. This summer, advocates of universal access to health care coverage are also fighting for policies not only to be issued regardless of health status, that is, no exclusions for pre-existing conditions, but also that the plans have comprehensive benefits.  Coverage must not, as they say, “be a mile wide and an inch deep.”  Insurance benefits should cover interventions that help maintain functioning. This is extremely important for our aging population and to help youngsters with physical or speech disabilities improve their functioning.

And we definitely need a public option that would serve as a yardstick by which to measure the performance of the for-profit plans. The public option benefit-wise should be the same as what is found in commercial insurance plans. It will only require Federal funding for start-up costs which will be paid back. Individuals who receive subsidies because of low income or the unavailability of insurance at their workplaces will be able to purchase insurance from the public plan. Most importantly, it will demonstrate how to save money on marketing, advertising, and often-unnoticed administrative efforts of commercial insurers to deny claims and avoid financial risks.

Tom: let us take another call.

Max: Hi. This is Max from Montana. Do I want to know how we are going to pay for all of this?

Tom: A caller from the big sky country. Glad you asked.  Once we are all beneath the big umbrella of health insurance, we need to pay attention to how to pay for universal coverage in the short-term and the practices that must change in the healthcare industry that will lead to cost savings in order to pay for adding 48 million Americans to the insurance rolls.

First, we can add a small surcharge to the income taxes of families earning greater than a million bucks. Second, we can increase Medicare funding by taxing income from interest, dividends, and capital gains at a modest 1.45%, the rate that applies to wages and salaries currently, and use that additional income to make this form of social insurance more solvent.  Third, we can implement, over the long run, various cost-saving and health-promoting measures through comparative-effectiveness research, a step already underway via the stimulus package.

Next caller. Hello, you are in Health Care Systems Talk.

Hello, this is Nancy in California and I want to weigh in on my house. There are some roadblocks to change that we need to address.

Ray: You’re right, Nancy. Obama has not taken off the kid gloves. We need our President to be a top fighter, not a figurehead. If we are going to get meaningful reform, Obama has to deal with the red-state Democrats the way Lyndon B. Johnson did when he got Medicare enacted into law. The President has to bring his party into line. The rural states of America are dependent on public works such as dams and bridges. They also rely on military bases and missile silos to maintain their economies..\Threats to close them and build them in other states, and not to furnish money for public works, is the currency of presidents who want to get their programs through Congress.

Nancy: Yes, we can put the squeeze on those who want to hijack health care reform.

Tom:  Nancy, are you sure you aren’t from Massachusetts?  What you are saying fits my east coast strategy. It’s not only the president who can apply pressure to win votes for health care reform.

Ray and I love to go up to Maine during the summer and test out our jalopies. We note that many New Yorkers, friends from New Jersey, and folks from Pennsylvania take vacations, own property, or visit their grandchildren at camps (showing my age); some of us buy products such as lobsters from that state.  Economic boycotts do make a difference.  We need to let the residents of Maine and their senators know that we want them to get behind health care reform that guarantees affordable health care for all, establishes a public option, and will help pay for itself over the next five to ten years.

And like cooking a lobster, something I do well, health care reform has to have a decisive quality to it. You can’t toss the critter into warming water because it will crawl out. You have to wait until there is a rolling boil and then go for it. This summer is the time to get health reform done. You know how I will celebrate. You all can join me since lobster prices are down.

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