Love it. Just love it.

Today are the Texas and California county Democratic conventions (with one Texas exception, happening tomorrow), and some of my twitter buds are liveblogging via Twitter. Here’s an excerpt from @lnewcomer’s (web site here) live stream:

• Compared america to a burning house. He repeats the unity stuff
• Obama will bring us todether, heal us & lead us to the future. Obama crowd way louder. 2 minutes ago from txt
• Slow start. Obama crowd gets into it. 5 minutes ago from txt
• Ron kirk for obama. 6 minutes ago from txt
• Repeats hillary wont be getting out. 7 minutes ago from txt
• Biggest crowd response so far. Ends w/ more unity stuff 8 minutes ago from txt
• Wow. Terry mccauliffe here to talk for hillary. Sounds hoarse as always 10 minutes ago from txt
• M&m break 11 minutes ago from txt
• They want us to sing ‘Happy Days are Here Again’. A little bit of camelot. We’re ignoring the suggestion 14 minutes ago from txt
• Judge Charlie Baird to the front. Must have a defendant that needs a ridiculously light sentence 18 minutes ago from txt
• Lol. They’ve asked for Huggies diapers 20 minutes ago from txt
• We’ve started the wave 21 minutes ago from txt
• Also they’ve brought in more port a potties & opened another conc stand 21 minutes ago from txt
• They’re asking for a travis co. Dist jtdge for some reason. 23 minutes ago from txt
• All affected precincts w/ probs have to narc on themselves before we can proceed 24 minutes ago from txt
• Chaos about to ensue 26 minutes ago from txt
• Chaos about to emsue 27 minutes ago from txt
• Still dealing w/ too many credentials given out than allotted. 28 minutes ago from txt
• Tx senate dist 14 still dealing w/ credentials challenges 29 minutes ago from txt

Momocrats Socalmom (Donna) and Glennia are at the California State Convention (which you can also view via webcast at their web site) are also liveblogging:

Glennia:

• Speeches seem to cover the same topics: education, Iraq, global warming, healthcare. Beat McCain. about 2 hours ago from web
• John Garamendi gave a good speech. Hit the highlights. No body has beaten Jerry Brown. He rocks AND rolls. about 2 hours ago from web
• Next up: Cal Controller John Chiang. about 3 hours ago from web

Donna is sending updates to the blog.

It’s all very interesting and in the case of Texas, in particular, is a real exercise in civics. We never learned stuff about the kind of efforts at voter suppression that have gone on in Texas in school. Eye-opening stuff. JavaJenn will be blogging her experience at Collin County’s convention — the only one postponed until tomorrow because of issues with venue and accessibility.

Technorati Tags: conventions, state, caucus, delegates, Texas, California, Momocrats

This is, of course, the message of the Clinton campaign. Hope doesn’t pay for $3/gallon gas, hope doesn’t pay for medical bills, hope doesn’t pay overdue mortgages, hope doesn’t fill the prescriptions at the drug store, hope doesn’t pay. Bill Clinton restated this again at a campaign stop where he appealed to supporters for — you guessed it — hope.

Hope that supporters would vote and attend the caucus Tuesday night, hope that Hillary could hold onto her candidacy via the Alamo, hope that her message would resonate with voters.

This, from the man who came from the “town called Hope”. How sad that ambition springs so eternal that the Clinton campaign would be nothing more than a massive effort to tell voters in this nation that the status quo is all that matters, hope is dead, and screw all the people sacrificing time, effort, money and talent to get that hope message heard, because what really matters is ‘experience’.

Another irony coming out of the Clinton campaign: 16 years ago, a little-known governor from Hope, AK was challenging another Democratic party stalwart for the nomination, and ultimately framed his entire candidacy and election around…hope.

At the turn of this century, those hopes had been dashed by the Whitewater investigation, the constant rumors and leaks about womanizing and the final blow of seeing my hopes impeached on the floor of the House of Representatives. The real hope-killer was Bill Clinton, who forgot he had enemies waiting for DNA on a blue dress.

But then, there’s the work of his foundation, the good work. And inside of that work is hope. It gives hope, endeavors to improve lives. Out of that hope, Bill Clinton’s reputation began to be rehabilitated (at least, with me), until this campaign, when once again, the selfish strategy is to dash the hopes of millions to give his wife the opportunity to restore the Clinton name to the White House. This too, is a hope. A hope predicated on the destruction of others’ hope, born out of arrogance.

Having Hillary Clinton appear on Saturday Night Live and reverse-whine about press bias, hearing her scold me for daring to hope, watching her try to hijack the “grass-roots movement” which can only be attributed to the hard work of others, is certainly enough to confound hope. It’s a dissonance, a minor chord in a major opus. There is the sense of unreality, as though the true goal is to force voters to make a commitment to hope or despair. Which of us wants despair?

The video I posted earlier really is the answer to the Clinton mantra of hopelessness. The Obama campaign is not about what HE can do alone, but about what WE can do together. Consider this: Over 1 million donors in 2008. Over 1 million phone calls made to Ohio and Texas by volunteers, before the big phone party that just began a few minutes ago. A goal of 1 million doors canvassed by March 4th. Do you suppose those 1 million donors, callers, canvassers are hopeless? Do you suppose that when they hang up the phone, make their donation, walk another block their ownership ends?

Of course not. Because for us (yes, I am one of them), the hope isn’t that Barack Obama will fix everything. That’s Hillary’s message. No, the hope is that WE will be what WE hope for. That WE will be heard. That WE will be permitted to take action, to mobilize, to create the change we all hope for. That my veteran son without a home of his own will have a future where he can hope, where there is opportunity, where he isn’t wondering where his next dollar will come from, where the only opportunity is a minimum-wage job at Blockbuster. He doesn’t want a hope-killer, he wants a hopemongerer. He’s looking for opportunity, and maybe a little bit of recognition for his military job well-done.

Hillary Clinton’s message is a hypocritical one, because she doesn’t really want to kill hope. She just wants it to be hope in her, placed in a cynical, selfish way. The kind of hope where we hope Republicans don’t shred what’s left of her character in an effort to block her election. The kind of hope where she triangulates in order to move the bar milli-inches forward. The kind of hope where white is black, up is down, down is up, and everything spins differently depending on the press cycle. That kind.

If today measured tomorrow, there would be no reason to hope. If yesterday measured tomorrow, there would be no reason to hope. What the Clintons don’t understand is that there is no anointing here. There are no entitlements, not even to nominations. They can’t kill hope and expect to raise hopes. They can’t ‘get real’ and ask us to imagine — hope for — a time where healthcare will be available to everyone, where education is reformed, where THEY do it all for US.

What they miss is this: We really ARE what we hope for. Not THEM. Not HIM. US. That New American Majority who clearly understands what sacrifice means, because we are already sacrificing our time, resources and energy toward an investment in our ability to reframe the future in a brighter, better way. If we’re making this sacrifice now, we’re willing to do it later, long after President Obama takes office, it’s because we understand that hope isn’t just emotion and pretty thoughts. Hope energizes, spurs action, mobilizes and inspires individuals to understand what it means to participate — indeed, to OWN — instead of standing idly by.

That’s bigger than the Clinton ‘hope is dead’ message or the McCain ‘be afraid’ message. It’s the same resolve that put men on the moon. It’s the same resolve that brings a candidate to the fore who is the unlikeliest candidate in the history of this nation and it’s the same resolve that will put him in the White House along with a mandate for that change we all hope for. The manifestation of hope is action — positive action which proves hope DOES pay.

Technorati Tags: hope, action, obama, clinton, mccain, newamericanmajority

The Pew Research Center released the findings of a voter survey conducted around the Presidential candidates today, specifically analyzing their perceived strengths and weaknesses in various policy areas when compared to each other. Voters believe that Barack Obama will win the nomination by an astounding margin — 70% believe he will win it versus 17% who believe Hillary Clinton will win it. However, when pure voter preference is measured, the margin decreases — 49% Obama; 40% Clinton.

I don’t want to spend too much time on the specifics — it’s all available on the Pew Research site — but one area worth noting is where Obama measures up next to McCain. When voters were asked whether the candidates had provided enough information on their policies, 36% said Obama had and 56% said he had not, compared to 67% who said Clinton had and 28% who said she has not. Further, they perceive Obama as “not tough enough”.

In the debate on Tuesday night, Hillary Clinton mentioned withdrawing 1-2 brigades per month from Iraq. The typical size of a brigade is 4,000-5,000 troops. There are approximately 180,000-200,000 US troops in Iraq right now, roughly the same number that were sent to Vietnam. That was the extent of her specifics.

Jeffrey Feldman has written an excellent three-point plan of how he believes the Democrats need to frame Iraq. For Barack Obama, sooner is better than later in this regard in order to begin to demonstrate his command of the specific facts and his specific policies around Iraq. The three points are:

1. End the Occupation – The key word here is ‘occupation’. Changing the frame from war (a justifiable freedom-fighting act) to occupation (an aggressive, unwanted intrusion) pushes back on McCain’s attempt to frame this as a struggle against Al Qaeda which we will “lose” by withdrawing. When it’s framed as an “occupation”, withdrawal becomes a moral act, an act of strength and respect to the Iraqi people. It also calls it what it is — an unwelcome incursion into another sovereign nation. It is an occupation.
2. Move Toward a Diplomatic Summit – By calling for a diplomatic solution and discussion with Iraq’s leaders, the Iraq problems are framed in terms of peaceful solutions and mutual agreement, instead of “cutting and running”, which is how McCain will attempt to frame it. As Feldman points out, if the Bush administration decides to initiate a summit to pre-empt the Democrats, the Democrats can still take credit for it as the ones forcefully pushing the idea to the American people, not to mention getting the Bush Administration to do something besides use force.
3. Approach Iraq as Part of a Bigger Picture – Feldman suggests a frame like “Smart Security”, where Iraq is framed into a larger plan for regional security, which would include Iran, Pakistan, Afghanistan, and other players in the region. There is no better time than now for this to happen, with the Pakistani election result effectively deposing the Musharraf regime in favor of a completely new government. As Feldman points out, by placing Iraq into a larger perspective, the electorate begins to understand the stark differences between the McCain-Bush doctrines of remaining in the region and using force for 100, 1,000, even 100,000 years and comparing that to a shift in solutions from military to diplomatic.

Barack Obama has some unique qualities in the area of foreign policy that work to his advantage, and he should begin to emphasize these inside of his more specific discussions of the plan for Iraq. He understands the value of knowing the cultural and societal values of a region. He lived in Indonesia during a time of unrest, he is well-regarded internationally for his desire to end the occupation of Iraq and begin to rebuild relationships based on solid diplomatic footing, and he is the polar opposite of George Bush in terms of his approach to conflict. He’s demonstrated an even temper and firm approach to conflict, and has the ability to see a bigger picture. And as trite as this may sound, he does have the ability to inspire, and that is true abroad even as it is here.

One final point. A study was done by Nobel-winning economist Joseph Stiglitz on the true cost of the Iraq occupation. Conservative estimates say that it will cost 1 TRILLION dollars. Stiglitz reports that the true cost is 3 Trillion Dollars to the US alone, and that’s a conservative estimate. Obama should hammer that number home, along with what didn’t happen as a result:

By way of context, Stiglitz and Bilmes list what even one of these trillions could have paid for: 8 million housing units, or 15 million public school teachers, or healthcare for 530 million children for a year, or scholarships to university for 43 million students. Three trillion could have fixed America’s social security problem for half a century. America, says Stiglitz, is currently spending $5bn a year in Africa, and worrying about being outflanked by China there: “Five billion is roughly 10 days’ fighting, so you get a new metric of thinking about everything.”

Recently President Bush tried to justify the costs of the occupation by claiming that the economy was stimulated by the goods being manufactured in the US for the military (the old military-industrial complex). But Stiglitz found otherwise, stating:

Thus, any idea that war is good for the economy, Stiglitz and Bilmes argue, is a myth. A persuasive myth, of course, and in specific cases, such as world war two, one that has seemed to be true – but in 1939, America and Europe were in a depression; there was all sorts of possible supply in the market, but people didn’t have the cash to buy anything. Making armaments meant jobs, more people with more disposable income, and so on – but peacetime western economies these days operate near full employment. As Stiglitz and Bilmes put it, “Money spent on armaments is money poured down the drain”; far better to invest in education, infrastructure, research, health, and reap the rewards in the long term. But any idea that war can be divorced from the economy is also naive. “A lot of people didn’t expect the economy to take over the war as the major issue [in the American election],” says Stiglitz, “because people did not expect the economy to be as weak as it is. I sort of did. So one of the points of this book is that we don’t have two issues in this campaign – we have one issue. Or at least, the two are very, very closely linked together.”

Stiglitz’ recommendation?

Far better, he suggests, to leave rapidly and in a dignified manner, and to spend some of it on helping Iraqis reconstruct their own country – and the rest on investing in and strengthening the American economy, so that it can retain its independence, and have the wherewithal, at least, to play a responsible role in the world.

This is an economist speaking — a highly respected one. An economist who is analyzing the risk-benefit of an unwelcome incursion into a sovereign country over a span of time longer than World War II. He has some scathing indictments of the Bush administration, saying that there has been no coherent policy, just a Bush “policy of convenience”. His bottom-line message is this: The economy and the occupation are inextricably linked, and the economy will continue to spiral downward until the occupation ends. Therefore, end it.

The Democrats need to take hold of this and clearly explain it to the blue collar workers, the moms, the dads, the seniors, the college students, everyone. They need to own this piece of the debate by being clear and specific. I could even imagine a policy speech or podcast or video which explains this. The Obama campaign has been so creative with the video that I’d really love to see them communicate a clear and cogent and very specific plan for Iraq using this method.

Technorati Tags: Election2008, reframing Iraq, three trillion dollar war, occupation, invasion, democrats, policy, foreign policy

Go away, Ralph Nader. We don’t want you to run. We don’t need you to run for President. You’re the past, not the future. Go away. Please. Wasn’t 2000 reason enough?

There are representatives in the Congress actively pursuing impeachment. Single payer health insurance isn’t the answer, for reasons like these.

Side note to Sen. Obama and Sen. Clinton: It’s not enough to expand availability of health insurance and make it affordable. Reforms of the insurance industry and a stop to pharma price-fixing have to be addressed, too.

Technorati Tags: Ralph Nader, healthcare, pharma

I have spent the past 28 years administering employee benefit plans covered by the Employee Retirement Income Security Act of 1974, commonly known as ERISA. Your 401(k) plan, your profit sharing plan, even your employer-provided health insurance are all covered under ERISA in one form or another. Broad-sweeping, progressive, and even radical for its time, ERISA has come to be one of the most solid pieces of social legislation passed.

Were it not for some leaders with passion and vision, it would never have happened at all.

A Brief History

Employer-provided pension plans were in much the same condition as our current health care system. Before ERISA, pension plans were minimally regulated and were not viewed as a social obligation, but as a gift from the employer to the employee. Enjoying tax-favored treatment from the early 1900’s on, by the 1950’s financial abuse of the plans was rampant. Benefit definitions were discriminatory and fluid, assets were used and abused to the benefit of the employer and very often, the detriment of the employee.

The monumental failure of the Studebaker plan highlighted the abysmal state of the pension industry and abuse taking place within union pension plans and outside. At the point of the plan’s termination, the group who had reached age 60 received full benefits (this included the executives of Studebaker, by the way), the group aged 40-59 received 15% of their earned benefits, and the rest of the employees received nothing, despite having funded part of their benefits through union contributions made during the course of their employment.

A more personal example of this happened to my grandmother. My grandfather worked for the Southern Pacific Railroad for 51 years. He was murdered either on the job or just after leaving his job in 1971. He had worked past his normal retirement date with no corresponding increase in benefits. A loyal union member, he had also contributed many thousands of dollars to that pension plan over the course of his employment with SP. When my grandmother went to claim his Railroad Retirement benefits as his surviving widow, she was denied all benefits. Because he was still an active employee and had not begun to receive payment of his benefits, she was denied survivor benefits which she would have received if he had been retired and paid his earned pension. My grandmother was forced to live the rest of her life with the tragedy of his death in an extremely precarious financial situation. She only had her own Social Security benefits that she earned during her years of employment (he was a Railroad employee and therefore exempt from Social Security), and a very small life insurance policy that paid double indemnity. When she passed away, she still owed 5 years of her 30-year mortgage on the only asset she had left.

Her story was not unusual. Similarly, we’ve arrived at a time where health care is controlled by insurance companies, pharmaceutical companies and litigators. Like pensions, health care benefits for employees have been regarded as a gift rather than an extension of the compensation package for employees, and like pensions, rampant abuses and profit-taking abound. Health care policy is determined on a state-by-state basis with no overall federal mandate and no consistent policy. As a consequence, insurance companies are able to tailor their policies to the state’s rules and regulations, which is to their benefit in some states; to their detriment in others.

What ERISA Accomplished

ERISA laid the foundation for broad reform of pension plan operations and responsibility. It established four basic principles:

1. Required Reporting and Disclosure of Financial and Operational Information
2. Required Standards of Conduct for Fiduciaries and Related Parties (and penalties for non-compliance)
3. Defined Internal Revenue Code provisions to govern the operation of pension plans and preserve tax-deferred status
4. Established the Pension Benefit Guaranty Corporation (PBGC) to insure certain guaranteed pension benefits

Although the PBGC (Title IV of ERISA) is probably the most controversial prong of ERISA reforms today, for the most part, all four prongs have withstood the test of time to the benefit of every employee who has been covered by a qualified pension plan. Every few years Congress amends various provisions to meet their tax goals, but still, for the most part, ERISA is a solid and significant law that benefits each and every American. Despite those amendments, the basic principles of ERISA remain inviolate 34 years after its passage.

Why ERISA Succeeds

Here are the fundamental reasons that I believe ERISA has withstood the test of time:

• It established broad-based principles for the establishment and maintenance of employee benefit plans: disclosure, responsibility, compliance and benefit guarantees.
• It split the regulatory oversight responsibility between three different agencies: the IRS, the Department of Labor, and the PBGC, allocating specific responsibilities to each agency.
• It was not an attempt to amend the status quo, but instead approached pension reform from the standpoint of what should have been implemented at the start.
• Compliance was phased in over a short period of time in reasonable increments, which minimized the economic disruption.
• Because ERISA was drafted with a broad, sweeping reform brush, amendments made subsequent to its passage have remained largely within the letter and spirit of the law. I can think of one exception which was repealed shortly after its passage and was specifically intended to reduce employer tax deductions in a budget bill. But most legislation passed which touches on or amends ERISA remains within the constraints of the original intent — to ensure that employees’ retirement funds are inviolate, prudently invested, and benefits are available and earned in a non-discriminatory fashion to all covered employees.
• ERISA pre-empted individual state pension laws and brought the universe of pension plans under a federal umbrella, ensuring consistent treatment no matter what state one lived in.

Why Health Care Reform Should Follow The ERISA Model

I believe any health care reform plan will also need solid foundational pillars to its foundation in order to succeed. They are:

1. Universal Availability, Portability and Choice of Plan Defined by Federal Law, pre-empting state laws.
2. Federal limits on malpractice claims
3. Mandatory reporting, disclosure and transparent operations of insurance companies and related entities (including pharmacy benefit providers)
4. Broad minimum benefit and funding requirements
5. Parity in incentives for employers and individuals in the form of tax deductions and/or credits for Health Savings Accounts and payment of health insurance premiums (currently available only to employers)

The Democratic candidates have all put forward meaningful health care reform proposals. However, I don’t believe they go far enough, because they don’t define an overall policy going forward which will guide future legislative bodies when considering reforms. Further, they don’t assign clear lines of responsibility for enforcement and accountability that I can see. I believe it’s essential for the candidates to begin the process with a clean slate and clear vision rather than trying to reshape what is in place now for the future.

The architects of ERISA, led by John Erlenborn and John Dent, were passionate about their belief that the only pension reform worth making would be lasting reform, and lasting reform meant beginning with a clean slate and clear-cut principles. Any effort at health care reform that does not follow these same principles is doomed to fail in the long run, because it will be the domain of all of those who lobby for their own interest at the expense of those most in need. What health care reform needs is a leader who is willing to take risks, define broad policy-based principles for implementation and administration, create carrots for compliance and participation and sticks for exploitation. Anything less will be no reform at all.

Resources:

• Edwards Plan for Universal Health Care
• Barack Obama’s Plan for Health Care
• Hillary Clinton: The American Health Choices Plan
• Overview and comparison of all candidates’ plans

Technorati Tags: health, insurance, health care, health care reform, pensions, law, legal, history, ERISA, employee benefits, tax reform, social policy

I’ve been following the discussion surrounding universal health care and Sicko closely over the past couple of weeks. It’s interesting to me to see the polarity of opinion around the question of how best to deliver health care in this country.

One thing is sure: Reasonable, open discussion of the issues with solutions attached is nearly non-existent. Reactions range from “Universal Health Care will doom this country” to “Universal Health Care is the solution to all of our ills, physical and otherwise.” Where is the middle ground here? Is there a starting point? For me, there is.

dn lpnsk, via Flickr

The three-pronged profit pitchfork of our current healthcare system:

1. Pharmaceuticals: Rising costs associated with medications and delivery
2. Malpractice Lawsuits and uncapped damage awards
3. Insurance Companies – Profit-taking Enterprises posing as non-profits with extraordinarily costly administrative layers

Starting with a reasonable dialogue about how to limit the financial and political control that the three groups associated with the three prongs named above have on the reform process is a good place. Three of the most powerful lobbies in Congress are represented there. It seems to me that to have a reasonable dialogue about access to healthcare at a reasonable price, there needs to be a commitment (or revolt) that excludes any interest other than the national interest; that is, the citizens of this country and their need to receive healthcare at some sort of reasonable price.

Michael Moore drives home how loudly the money talks. When he points out that there isn’t a single person in Congress who hasn’t received funding on some level from the companies with a vested interest in the status quo, I was tempted to throw my hands in the air and give up before even beginning. But I think we can make this work.

The following links all came by way of Kevin, MD, who does a great job of linking yeas and nays alike, though he tends to lean away from the universal healthcare system proposed by Moore. (I’m not sure I’m sold on it either, at least not if the administrator is the federal government). Here are some of the ‘nays’ I’ve read in the past few days:

USA Today, June 21st:

Sicko uses omission, exaggeration and cinematic sleight of hand to make its points. In criticizing politicians, insurers and drug makers, it says little about the high quality of U.S. care. In lauding Canada, Great Britain, France and Cuba, it largely avoids mention of the long lines and high taxes that accompany most government-run systems.

In fairness to the authors of this op-ed piece, they do make an effort to present a balanced view, but overall this quote states the premise of the author’s opinion. However, what they miss is that the quality of health care in the US isn’t relevant to people who have no access to it. This is the crux of the issue to me — we have to find a way to open the lines of access to healthcare and do it without bankrupting individuals or the country.

WizBang writes:

I do not believe that we have a health care crisis in the United States.

I do believe that we have a serious problem with the financial aspect of the health care industry.

I also believe that the biggest contributor to the health care financing crisis has been lawyers.

Personal injury lawyers like John Edwards, who can claim a large portion of the credit for crippling the obstetrics field in his home state.

The cost of health care has skyrocketed in the last few decades, while the actual income of physicians has not kept pace. In some cases, it’s declined tremendously. That means that a lot of money is going into the system is getting sucked out before it reaches those who actually provide the services. Some of it is leeched out by the personal injury lawyers, both directly (through lawsuits) and indirectly (through malpractice insurance premiums).

Some of it is sucked up by the tremendous bureaucracies instituted by the insurance companies, whose purpose is to minimize how much money gets through them to doctors and other health care providers.

Some of it goes into the increased overhead of doctors, who have to comply with zillions of regulations from health insurance companies and the government.

While I agree with some of what Wizbang writes, I disagree with the statement that we are not nearing a health care crisis in this country. We surely are heading in that direction. Less students are applying to medical schools. More doctors are leaving active practice for academics, consulting, and other areas of practice which relieve them of the need to pay exhorbitant malpractice premiums, expanding their payroll to include employees to manage the administrative red tape involved with insurance companies, and being paid less to do more. The students who do go to medical school are heading for specialty practices more often than not, leaving our family practices without general practitioners.

Yes, we are heading toward a crisis, Wizbang. But you’re right about the contributors to it, for sure.

On the other side of things, The Health Care Blog rightly points out that making a change is hardly as easy as snapping our fingers and making a new system:

A big problem I have with those who now advocate moving to a single-payer system is how really poorly thought-out their proposal is. Proponents seem to presume that you can get from Point A to Point B in one easy move.

The problem is that since 1965 those who operate in the the U.S. health care system have become something akin to drug addicts–they are addicted to all the incentives we have–good, bad, and perverse.

Both are excellent points. In the 1970’s a similar dialogue was taking place around pension and retirement security, and how best to reform the pension system in a way that was fair to employers and employees and would provide some measure of retirement security to all. Sen. John Erlenborn led the way to the passage of ERISA — a sweeping reform of how benefits were to be administered and delivered, how retirement assets were to be protected, and minimum requirements for the operation and administration of pension plans.

Despite Congress’ addiction to amending the pension laws every 2 years or so, the foundational spires of ERISA remain intact: No discrimination against employees; trust assets must be for the exclusive benefit of participants; vesting and benefit accruals must be earned over a limited number of years, and employees must receive annual disclosures and statements related to their benefits. There are other provisions, but these are the basics. By stripping retirement security down to the most basic level and starting there, a plan could be developed for implementation that actually delivered results.

We need to do the same thing with our current health care system. Take what we have, figure out the most basic requirements going forward, and then find a way to deliver those basics fairly and economically, which may mean forming some sort of foundation (non-profit) outside of the government but accountable to administer it.

There’s much more to be said. This is just the beginning. I’ll be posting updates with opinions pro and con as I have time. Or you can save me some and post a comment here to start things off.

Technorati Tags: Sicko, health care, universal health care, policy, reform

Michael Moore’s new film “Sicko” is a must-see for everyone, regardless of party affiliation, regardless of how you feel about Moore, and regardless of where you stand on the state of health care in the United States. He presents a picture of health care in our country that strikes a chord and resonates in one way or another. For me, his call-out of insurance companies and pharmaceutical companies’ incessant rape of the health care system in the name of higher profits got a high five and then some. He does a great job of choosing out the inequalities in the current system without flinching.

After a stellar job of beating down the current system in the US, viewers are given selective glimpses of health care delivery in four countries: Canada, France, the UK, and Cuba. If we are to believe Moore, these other health care systems are specimens of finely-designed social policy in motion, offering free health care to all at no cost and no limit. This is where the film begins to falter for me.

Let’s start with this: When filming a documentary anywhere with a clearly visible camera and well-known filmmaker, the subjects would be idiots if they didn’t paint themselves in the best possible light. Moore uses that to his advantage, choosing archival footage to prove the brokenness of the American system and live footage of the four other systems. While he uses some live interviews to illustrate the inanity that is American health care, he carefully builds his case for why the system is broken with archival footage, including some eye-opening footage of a meeting between Nixon and Haldeman concerning Kaiser Permanente and the idea of private, for-profit health organizations. There is no question that his point is driven home with the combination of statistics and never-before-seen footage of a private Nixon-Haldeman meeting.

Moore was interviewed by Amy Goodman today.  This excerpt sums up his argument against our current system:

And these health insurance companies are — they’re just — they’re the Halliburtons of the health industry. I mean, they really — they get away with murder. They charge whatever they want. There’s no government control. And frankly, we will not really fix our system until we remove these private insurance companies.

On the candidates’ proposals for reform:

Kucinich is closest to the right idea, and, of course, he keeps, you know, saying “nonprofit,” or whatever. But I kind of don’t want to use that word anymore, and I wish that Dennis wouldn’t use that, because Kaiser Permanente is a nonprofit. Blue Cross is a nonprofit.

That’s why I say that essentially you don’t want any private insurance companies involved and that whether they’re for private or nonprofit, because — but when I say “profit,” you have these huge nonprofits that are under the guise of nonprofit, but they’re all about profit. They’re all about making money for themselves and for their executives, and what they make is obscene. And so, I favor the removal of all private insurance companies.

I agree with everything he says. It’s a sick joke to call these organizations “non-profit”. Of course they’re about profit. It’s just that the profit goes into the pockets of suppliers and managers and executives at the expense of patients and doctors. I argued in an earlier post that the reason the Pharmacy Benefit Managers remain for-profit corporations is to line the pockets of the executives who sit on the boards of the non-profit health insurance corporations. I haven’t seen anything to convince me to change my mind, and the statistics tell the story:

First Quarter Results for the Top 3 PBMs:

• Caremark: Up 24%
• Medco: rose 29%
• ExpressScripts: 28% rise in profits, despite the body blow it took fighting to out-proxy Caremark for the purchase of CVS

So Michael, now that we know it’s broken, how should it be fixed?

Moore takes us on a short, worldwide odyssey to look at four other systems in action. In each case, health care access is universal, unrestricted, does not appear to have the bureaucratic red tape of other systems, and delivers better end results.

As I watched, I kept asking myself the same two questions:

1. How is it administered?
2. How is it funded?

You will not have the answers to these questions at the end of the film.  So I went looking for my own, in Moore-esque fashion.  In each case, I tried to go either to the source itself or a respected organization.  Because I do not speak French, for example, I relied on the English-language reports of Civitas.org, which appeared to be an objective analysis of the French health care system. If there are flaws in these reports, please post a comment with suggestions for more objective reports that I can actually read.

Canada
WHO Core Statistics

In a comment to my initial post about this film, Stephen Downes challenged me to ask Canadians whether they’d trade their health care system for the one in the US. So I’m asking — Canadians, would you trade? And if not, why not? And beyond that, it would be great to read about what you like, what you don’t like and what you’d change about your current system, too, assuming you would keep it.

Health care benefits in Canada are paid for through a combination of taxes (public sources), supplemental insurance, out-of-pocket expenditures, and donations (private sources). According to the Canadian Institute for Health Information, the split of public/private expenditure in 2005 was 70% public, 30% private. However, the Canadian healthcare is struggling with rising drug expenditure costs, long wait times for some health services (See Wait times for treatment in Canada), and rising drug expenditures, which are rising at a nearly-exponential rate.

When Michael Moore was asked about these flaws in the Canadian system, he responded with this:

And, you know, you’ll hear the critics of the Canadian system here talk about, “Oh, the Canadians, you have to wait in line, you know, before you can get a knee replacement, or you have to wait x-number of number of weeks, you know, where you don’t have to wait in America.” You know, when I hear that, I think, well, that’s what you do when you have to share the pie. Sometimes you have to wait.

I agree — sometimes you have to wait. The problem is, there are some conditions that don’t wait. They worsen with time. But what Moore misses is this: Canada’s health care system is threatened by the same gremlins that haunt ours. The issues of cost containment and out-of-control pharmaceutical costs are global — they affect the Canadian system, the UK system, and the French system. These problems have not gone away, despite the universal access to health care offered by these other countries.

France
WHO Core Statistics

France has an amazingly complex system. The best illustration of its structure is this page, excerpted from the full Civitas.org report cited below. As close as I can tell, France employs a hybrid payer system which largely funded with public funds and supplemented to a small degree with private funds. France also has one of the top-rated health care systems in the world, yet this country is also grappling with similar questions on how to maintain excellence while containing rapidly rising costs.

From Civitas.org¹:

The organizational structure of the French health care system makes this goal [cost containment] difficult to achieve. It is difficult to control expenditure in a system where the freedom of patients and providers is unrestricted, where care is largely publicly funded and retrospectively reimbursed and where health insurance funds have no real financial responsibility. Not surprisingly, therefore, the French health care system is relatively expensive by international standards, and the slowing down of expenditure growth which most countries achieved during the 1980s has only recently occurred in France, in the second half of the 1990s.

Although relatively high levels of expenditure on health care result in patient satisfaction and good health outcomes, cost containment remains a permanent subject of debate, since many of the measures taken to reduce expenditure growth have been ineffective and have always been strongly opposed by professional associations, particularly doctors’ associations.[emphasis mine]

and this, from the conclusions:

Finally, the financial sustainability of the health care system is a perpetual source of concern, particularly due to the fact that actual expenditure consistently exceeds the targets set. Until now, the high cost of the health care system has been accompanied by high levels of access to health care, but the demographic change expected within the health professions may lead to an increase in explicit rationing in future years.

Great Britain/NHS
NHS Core Statistics

Great Britain’s system is completely funded by public funds. It is widely regarded as one of the most accessible and patient-friendly systems in the world, and yet, reforms are being considered for this system as well.
From a 2005 NHS document², a description of the NHS today:

• the NHS has achieved a lot
• there are both public and staff concerns
• the NHS has been underfunded for decades
• a 1940s system in a 21st century world

According to the report, decades of underfunding are now coming home to roost. Some of the reforms the NHS are weighing include: empowering patients, decentralizing services, more focus on wellness, preventive care and self-care, increased funding and yes, managing the cost of pharmaceuticals and facilities.

Wait time is also an issue in Great Britain, and the initiative seeks to implement procedures which will ultimately reduce the wait time and improve overall delivery of healthcare services.

Cuba

Cuba’s health care system is completely nationalized and controlled by the government. According to the Journal of the American Board of Family Medicine, Cuba’s health care system is “notable for achieving developed country health outcomes despite a developing country economy.”³  Despite the stark differences in economic models and per capita income, Cuba has health outcomes that rival those in the US for a fraction of the cost.

The central framework of the Cuban health care system rests on the family practice, an emphasis on wellness and disease prevention.  As Moore points out in Sicko, there is a clinic on nearly every block, with doctor or nurse who live in the community they serve.  Cuban physicians practice traditional and complementary medicine, and interface with the specialists serving those in their patient-community. 

Here is a comparison of the Cuban health care system to that of the United States:

Cuba has the highest family physician-to-population ratio in the world,¹¹ and it has a family physician-per-patient ratio of approximately 1:600.⁸ In the United States, the average family physician-per-population ratio is approximately 1:3200.¹⁵ In 2001, only 35% of Cuban residency graduates specialized further (including 8% who graduated in general internal medicine and pediatrics).¹⁶ In the United States, only a third of physicians are primary care physicians (ie, family practice, internal medicine, and pediatrics physicians).¹⁷ Only 11% are family physicians.¹⁸

Other features of the Cuban health care system include holding physicans accountable for health care outcome measures in their community, evaluation of patients within the context of their family and community, and combining traditional pharmaceuticals with the complementary treatment methods by doctors trained in their use and implementation.

The conclusion to this report is one worth noting:

Despite political differences, Cuba and the United States share a passion for baseball and for family medicine as an important component of the health care system. At a structural level, the Cuban and US health systems differ drastically: Cuba provides universal health insurance and every physician completes a family medicine residency. In contrast, the United States has more than 46 million uninsured residents, and only 11% of its physicians practice family medicine.

So What?

Michael Moore gets more right than he does wrong with Sicko. He hasn’t convinced me that universal health care will work in this country without a radical takedown of some long-revered and powerful institutions. To accomplish any meaningful reform, Americans will have to dismantle the insurance and pharma lobbies at a minimum, and begin to tackle the question of how to deliver universal health care without tying it to employment, marital status, or other qualifiers (and figure out how to put all those unemployed pharma and insurance reps to work, too). Once those lobbies have been set aside, the questions of how to implement a healthcare system which avoids the pitfalls faced by Canada, the UK and France, embraces the positives in the Cuban system, and essentially folds a socialist system into a capitalist society will have to be addressed.

One thing is sure: This will not happen overnight. I do believe it can happen, but only if it’s done as part of the largest social, non-partisan debate we’ve ever had in our country about something which is truly universal. Health care may not be a right, but it is a fundamental need and without a method to deliver it effectively, we are dooming ourselves to a stunted economic outlook where the mega-rich become richer at the expense of public health. What cannot happen is the application of a political, band-aid solution that gives the appearance of reform but carries the stench of the profiteers underneath.

¹Health Care Systems in Transition, 2004, Simone Sandier,Valérie Paris,Dominique Polton
²The NHS Plan: a plan for investment, a plan for reform
³Family Medicine in Cuba: Community-Oriented Primary Care and Complementary and Alternative Medicine

Technorati Tags: Michael Moore, Sicko, health care, cuba, france, great britain, canada, socialism, capitalism

Part II of a series on healthcare reforms

Adam J. Wolfberg wrote an excellent commentary for the Boston Globe today on “Hippocritical Doctors”. The issues he describes in his column go right to the heart of the issues at the heart of the PBM problem in my previous posts and deeper to the heart of the overall brokenness of our healthcare system.

Dr. Wolfberg’s daughter has cerebral palsy. The best treatment for her condition is physical therapy which was denied by his insurance by two separate doctors paid to review and deny claims. Describing his experience, he notes the following:

While one of these doctors has no expertise with cerebral palsy, the second one does. In his other job, he cares for children with severe physical disabilities and is a proponent of therapy for disabled children. As he wrote to me in an e-mail, “my personal view is that children with [cerebral palsy] benefit from therapy services.” However, in his review of my appeal, he wrote a careful explanation justifying why the health plan should not pay for the therapy.

So two doctors, one with NO expertise in the area of treating children with cerebral palsy, and one with extensive experience in the field and who holds the personal opinion that children benefit from physical therapy, are charged with saving the insurance company the cost of covering the therapy. Dr. Wolfberg definitely has an opinion about this:

This doctor and others like him are making money denying care – and they might as well hang up their white coats. They may believe that their administrative decisions are medically justifiable. However, it often appears that they are hired because their MD degrees lend a patina of legitimacy to administrative decisions that are based on interpretation of a health plan’s policies, not a chart, lab test, or CT scan.

This is the dark side of our healthcare system: There is only incentive to deny claims, not to evaluate them fairly and approve or deny based upon facts, expertise and the best interest of the patient. The ones who are harmed are the patients, with real conditions, some life-threatening, others not. Dr. Wolfberg concludes with this:

Individuals are harmed when medical care is withheld. Many of these health plan doctors, whose job it is to reject claims, end up being paid to violate the Hippocratic oath they took when they graduated from medical school – to “first, do no harm.”

That is the heart of the matter: There is an irreconcilable conflict when insurance companies place physicians, bound by oath to do no harm, in a position where their decisions are driven by the bottom line instead of the patient’s needs. The most qualified individual to determine a patient’s needs is their own PHYSICIAN. What we have here is a system where the decisions of treating physicians are disrespected in favor of an arms-length review and denial by colleagues who sold their white coat for a paycheck.

Anyone seeking a career as a doctor (particularly one in general practice) today would have to be certifiably insane.  Assuming they make it through medical school, their internship and residency, they come away with tremendous debt.  Then they are injected into a system where their decisions are second-guessed by insurance company physicians, their malpractice insurance costs equal more than they pay for their homes, their rates are dictated by arbitrary price-fixing and they have to navigate a maze of red tape and paperwork to see patients at all.

Contrast this with one person’s recent experience in an emergency room in France:

…there’s no paper needed anywhere, no forms, no signatures. The French have developed what I would call the USERNAME system of medicine. Just like many web sites who just want you as a user and don’t really care about your real identity, the French Emergency Health care system is the same. They would like to know who you are but they do not need to know who you are when you are in a medical emergency.

…there’s absolutely no paperwork. I had never seen anything like that. You tell them your name, they believe you, you tell them your address, they believe you. They don´t ask you for medical insurance nor for any kind of payment and the whole admission takes at most 45 seconds.

… the legal system is mainly absent from French medicine. When it was all done it was shocking for me to leave the hospital without having to sign any release forms. The surgeon herself notified the administrative staff that I was done and she released me simply saying that I could go home without seeing anybody.

This author concludes:

But what’s wrong with the American health experience is that it is invaded by a lot of elements that are foreign to medicine. The result is a cost so onerous that the percentage of GDP Americans spend on medicine is much higher than in France but the results are very disappointing.

Indeed.

(Hat tip to Kevin, MD for the link to Dr. Wolfberg’s article)

Technorati Tags: medical benefits, claims review, health insurance

An illustration of why PBMs are such wonderful cash cows for the insurance boys:

For the year ended Dec. 31, Caremark reported that its profit grew 15 percent to $1.07 billion compared with profit of $932 million in 2005. Caremark’s revenue grew 11 percent in 2006 to more than $36.7 billion from revenue of nearly $33 billion in 2005.

Keep in mind that Caremark was being courted by two suitors at the end of 2006: CVS and ExpressScripts. CVS won, just last week.

What those profits mean to the insureds: Denied claims and substandard claims review.

What those profits mean to employers: No reduction in the overall burden of providing pharmacy benefits.

What those profits mean to the healthcare system overall: Erosion of the quality and standard of care available to all insureds, and in particular, insureds who are covered by Medicare or Medicaid.

Did I mention that the CEO of Caremark’s predecessor (AdvancePCS), David Halbert is a good buddy of our esteemed President? Did I also mention that he was one of the key drafters of the current Medicare pharmacy benefit laws? Follow the money.

Technorati Tags: Caremark, AdvancePCS, Medicare, pharmacy benefits, PBM