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Why I Do Not Support Obama-Care

To be honest, I had a hard time paying attention to anything President Obama said Wednesday night after he said this, let alone taking him seriously on the subject. From near the beginning of his speech:

"There are those on the left who believe that the only way to fix the system is through a single-payer system like Canada's -- (applause) -- where we would severely restrict the private insurance market and have the government provide coverage for everybody. On the right, there are those who argue that we should end employer-based systems and leave individuals to buy health insurance on their own.*

"I've said -- I have to say that there are arguments to be made for both these approaches. But either one would represent a radical shift that would disrupt the health care most people currently have. Since health care represents one-sixth of our economy, I believe it makes more sense to build on what works and fix what doesn't, rather than try to build an entirely new system from scratch."
And what I say, then, is, I believe it makes more sense once you've said that to put it off until we have an actual Democrat, or gods help us even a liberal Republican like Richard Nixon, in the White House. Someone who would actually support Medicare for All, instead of some god-awful patchwork of public-private partnerships that's going to be an even bigger handout to already malevolent and wealthy corporations than Medicare part D and TARP were.

If nothing else, I insist that this makes more sense than the President's approach because the President's approach just plain flatly will not work. Contrary to what he claims, the reason that medical expenses in the US are skyrocketing is not inefficiency and waste. Nor, contrary to what the Republicans are claiming, is it malpractice insurance; this was solved at the state level two years ago, and malpractice insurance rates are down across the board. The main reason that health care costs have skyrocketed is honest-to-gods scarcity. And that scarcity is entirely artificial. And his approach does nothing to address the artificial scarcity of doctors, or the artificial scarcity of newly (wrongly) patented drugs. And the other reason why health care costs have skyrocketed is flagrantly corrupt profiteering in both the insurance and pharmaceutical industries.

Come back to me, either after the President has smartened up or after we get a new, smarter President with a plan that does these things:

  1. It should flat-out ban private health insurance. Private health insurance companies, without exception, cost 17% more than government-run systems do. They try to gain lock-in of doctors, hospitals, and practices and thus competitive advantage through incompatible billing and other paperwork systems. They have more layers of bureaucracy than even the most bloated bureaucracy in Washington, and they pay their managers way more, dozens or hundreds of times more for the top layers. They rake off yet more to funnel to stock market speculators who provide no health care at all. And because they're stuck competing for the scarce resource of medical specialists, they don't negotiate prices at all well, getting into bidding wars with each other over the most profitable specialists, which ends up driving up costs. The supposed "competitive efficiency" that we have repeatedly been promised that was supposed to make up for all of these administrative and overhead costs just plain doesn't exist. That the insurance companies keep insisting that any kind of a public plan, even one like Obama has proposed which would receive no subsidies and be funded entirely by its competitively priced premiums, would put them out of business is all the proof we ought to need that they should be put out of business. There. There's 17% savings, right away.

    And unlike private insurance companies, a government that takes your premiums and then denies you the benefits you paid for is accountable in the next election. If taxpayers paid for coverage and then got cheated out of it, it'd be a national scandal. But if you pay your premiums to Aetna, Cigna, or Kaiser Permanente and they then manufacture bullcrap excuses to deny you the benefits you paid for, all you can do is cry ... and no, this bill isn't going to change that, either. It'll just make them come up with new excuses to deny coverage. And they're highly incented to do so; they're not answerable to anyone when they do, and it's the only way they can keep raking off the maximum possible amount of all of that lovely free money that President Obama proposes to require us to give them.

  2. It should at least double the number of students admitted to medical and dental school, immediately. This will, within 8 years, bring doctors' salaries in the US down to where they are in the rest of the developed world, about 30% lower. There's another 30% savings, right away. Even if this was the only thing we did, it would solve the problem. People are entirely right to worry that increasing the number of people who can afford a doctor, without increasing the number of doctors, means more people will die on waiting lists to see a doctor. And if we what we have now were all of the doctors that it's possible to have, that would provide some economic justification (if not moral justification) for rationing who can and can't see a doctor. But medical schools turn away as many qualified applicants as they accept, because the AMA and the ADA have flatly opposed letting the number of doctors and dentists who graduate each year increase at the same rate that the population has increased. Solve that problem, and Republicans' entirely slanderous hypothetical "death panels" don't have to ration health care: nobody rations something if it isn't scarce.

    At its heart, Obama-Care is about price controls. It isn't supposed to look like price control because it's supposed to increase volume and decrease costs at the same time it (entirely unsuccessfully) attempts to control prices, but it is still a price control scheme. Price controls don't bring costs down. Eliminating scarcity, not dictating prices, is how you bring down prices, and all of the scarcity in our health care system is artificial. All of it.

  3. Speaking of scarcity, patents are an entirely legal way of enforcing scarcity. And that's why the government should immediately fund comparative effectiveness research for all patented pharmaceuticals. Where the drug companies can prove that their treatments are actually more effective than the drugs that are in the public domain, they would be allowed to bill Medicare for All for them. Where they can't, those drugs should just flatly not be covered until and unless the patient has tried the public domain alternative first. To pick an especially egregious example, we could have saved an awful lot of people an awful lot of heart attacks if more arthritis sufferers had been told, as we now know, that Celebrex doesn't work any better than aspirin for 999/1000 arthritis sufferers, and we would have all saved a ton on our insurance premiums if we'd known that, too. Or leave the heart attacks out of it: the best comparative-effectiveness study out there, the gold standard, is the one that compared plain old so-cheap-they're-free diuretics to "state of the art" patented blood pressure medicines, and found out that for every single patient tested, the diuretics controlled their blood pressure better. Where the science actually shows that the patented medicines work better, we should be finding some way to make them affordable for every patient that needs them. Where the science shows that the patented medicine works worse than the public domain alternative, we should be prescribing the public domain alternative and funding it, no matter how high the patented drug's manufacturer's advertising budget is.

  4. And speaking of patents, while we're at it, reform patent law. The metabolites of a drug with an expired patent are not a new invention. Adding time-release coating to a drug with an expired patent is not a new invention. Adding an extraneous ion or two to the end of the molecule that doesn't actually interact with the targeted cells, just to change the brand name, is not a new invention. Patent law requires that an invention be non-obvious before it qualifies for a patent; on all of the above, the courts have just plain gotten the law wrong. It's long past time for Congress to clarify the law.
That? That would be health reform. It would extend life and health for all Americans, and it would do it at a cost of 25% to maybe even 60% or 70% less than we're spending now. And it would do it without forcing people to just hand the insurance companies however much they ask for, and leaving the taxpayers on the hook for the "tax credits" to cover the difference between what Washington lobbyists decide you could afford to spend and what the insurance companies conspire to charge -- something that, not incidentally, candidate Obama and Senator Obama promised to oppose, that now President Obama boneheadedly supports.

As I said to someone else this morning, Democratic primary voters turned down John Edwards because he was too combative, too uncompromising, and too liberal. So instead we ended up with Barack Obama, who won't fight for anything worth fighting for, compromised away single payer before the negotiations even began, and has consistently been, on economic and health care issues, perceptibly to the right of Richard Nixon. I'm with Howard Dean, who said weeks ago on Rachel Maddow's show:

"It‘s just about—it‘s about money. It‘s about money, because when you have 72 percent of the American people thinking that they should have the choice instead of Congress, this is about money. And the insurance industry gives out of a lot of money. And, you know, this is going to be a hell of an issue in 2010 because—you know, honestly, what‘s the point of having a 60-vote majority in the United States Senate if you can‘t produce health insurance reform out of it? I don‘t—or excuse me, health care reform. You can get health insurance reform.

"This bill is going to cost a lot of money and isn‘t going to do anything if this compromise, this so-called compromise is true. This compromise does nothing except it will reform insurance. That‘s a good thing to do, but they ought to strip the money out of it because we reformed insurance like this in Vermont 15 years ago. It‘s a fine thing to do, but it doesn‘t insure more people. It‘s not worthless because it makes it fair, but it‘s not health care reform, and nobody should pretend that it is."
But then, I'd think so, wouldn't I? I voted for Dean in the primaries. And I'd do it again. I'd trust Howard Dean with health care reform; unlike Barack Obama, Howard Dean knows what he's talking about and his heart and his head are in the right place. Give me Howard Dean in the White House, or somebody else more like him than they are like Barack Obama, and then I'll be ready to talk about health care reform.

* Footnote: Straw man argument. And not for the first time. They let you graduate from Harvard Law, arguing like that?



( 71 comments — Leave a comment )
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Sep. 10th, 2009 04:47 am (UTC)
It may not be true health care reform, but I'm not convinced it's worthless to do. I want single payer, but I also want to have everyone covered.

Fresh Air did an interview not too long back with a fellow who wrote a book about different health care systems throughout the world. It's actually very interesting to listen to, though I now forget the author's name. Other civilized countries actually have quite a mix of social insurance systems, but I think US is the only one with the for-profit system. Some have all doctors working directly for the government, some have government social insurance that pays the doctors but doesn't keep them on payroll, and others have private non-profit insurance that works quite well for them.

I don't know what the "best" of them is, but I certainly know what we have now is the worst. We're afraid of rationing, but we actually have rationing in effect right now -- the rich get care and the poor don't. Getting everyone covered, and forcing insurers to cover regardless of conditions, would immediately start putting the squeeze on insurer's windfall profits at our expense. Not extending coverage to everyone now is pretty inexcuseable in my opinion.

I also totally support a public option... not having a public option might make me think twice, but frankly it's less important to me than extending coverage to everyone. The argument "oh noes, what if public option puts private insurance out of business" doesn't fly with me... my answer is "If it does? Great!" So this is probably my second biggest thing apart from covering everyone.

Anyway I think I totally agree with your four main points, but I don't agree that the plan NOT doing those things should be rejected out of hand.
Sep. 10th, 2009 04:48 am (UTC)
*sigh* You have fully articulated my concerns about this whole clusterfuck.

Sep. 10th, 2009 04:56 am (UTC)
It appears to me(from what I've followed) that Obama has tried to compromise based on what the American people say they want. Unfortunatly there are so many differnet conflicting things that everyone says they want I think Obama is trying to make everyone happy. While I don't think that is a good idea I can understand where he's coming from. He's trying to do something where both the left and right are happy rather than just trying to appease one side. I agree with the idea that Brad brought up but I see the flaw being that there aren't enough Americans who would want to go that route as they either like what they have or are too afraid to try something different. Personally I've always been of the mindset that some programs and ideas shouldn't be decided by the public mainly because a lot of our fellow Americans will shoot down a perfectly viable idea for some of the stupidest reasons. So while I do agree this idea might not work you got to cut the guy some slack for trying to come up with something designed to please everyone.
Sep. 10th, 2009 05:11 am (UTC)
I don't want a guy who would try to come up with something designed to please everyone. That's a crippling character flaw.

Franklin Roosevelt did not pass Social Security by trying to please everyone. He swept into office at a time when Herbert Hoover and Calvin Coolidge had as thoroughly discredited the Republican Party as George Bush did, but unlike Barack Obama, he knew that. And so he made one or two conciliatory noises, but then he set about kicking butt and taking names. This was so popular that it won him an even bigger Democratic congress, and an even more sweeping mandate in his re-election race, and that is how he passed Social Security.

Lyndon Johnson did not pass Medicare by trying to please everyone. He inherited a Democratic majority in Congress. But he spent years making absolutely sure that every Democrat in Congress was afraid to cross him, making them 100% sure that you did not cross the leader of your own political party, on an issue that was important to him, without suffering dire consequences for your district and in your next race for re-election. Period.

Barack Obama's single biggest problem, both with the Republicans and with the "Blue Dog" right wing Democrats, is that they have both learned by now that they don't even have to stab him in the back. They can stab him in the face, and he won't even object. There is no penalty in Washington right now for crossing, or even double-crossing, Barack Obama. And if he doesn't toughen up and impose some party discipline, soon, that's going to make him the most ineffective President we've had since Jimmy Carter.
(no subject) - bemused_leftist - Sep. 10th, 2009 11:47 am (UTC) - Expand
Sep. 10th, 2009 05:54 am (UTC)

With regard to point 3, in Australia, the Pharmaceutical Benefits Advisory Committee (the government body that decides whether a drug should be subsidised by the government) has often been attacked by "Big Pharma" because the industry has to show that the new drug has a qualitative improvement in therapy over existing drugs. And a drug that doesn't get on the Pharmaceutical Benefits Scheme is uncompetitive in the Australian marketplace, regardless of the amount of advertising you spend.

Sep. 10th, 2009 05:59 am (UTC)
View from Oz.
The way we (theoretically) manage things in Oz is that you can buy all the Private Health Insurance you want. Just like you can buy a solid gold toilet seat, if you feel you absolutely must have one.

The theory is, though, that you should never need to buy it. That you can walk into a hospital with an injury, and walk out again when you are well enough to, and not have to worry about debt collectors chasing you down the street. Our Medicare Bulk-billing system is that you could walk into your GP's office, have a consultation, and he would take the details from your Medicare card, and you walk out again: the government has just paid for your visit.

What this means is that if you think you need a check-up, you go and have a check-up, you don't need to wait for an Insurance Company approved GP, you don't need to put cash down up front (at least, you didn't use to...), you don't need to cover the excess, you don't need to stress that the very results you're after will negate your coverage.

Alas, the Howard administration kicked a lot of this in the head. They obeyed the dictates of the Medical Associations, and restricted the number of Medical places in universities. The resulting decrease in the number of GPs has meant that the number of GPs willing to put up with the inconvenience of bulk billing has decreased as well, and surgeries are now more commonly group clinics, with up-front payment over the Medicare rate (which means you take your receipt to the Medicare office and get a refund, but not a complete refund, and you've lost an hour waiting in line for the privilege).

Dentistry has never been part of Medicare, and always should have been. Many people get Health Insurance just for the dental coverage, especially when for all other things the public hospitals are as well or better appointed as the private, with equally or better trained and experienced doctors, and as good or better care. And for less patient payment. And less overhead.

Howard also started this bullshit idea of taking the strain off the public health system (strain of too little funding, and of too few doctors, qv the restrictions on medical student places), by encouraging people to go private -- to take private health insurance and use private hospitals. Alas for that, first: Howard being the neoconservative he is, he did this by financially penalising people who did not do so at tax time (with what are essentially fines which increase the older you are until you take out private coverage), and he managed to miss the part that even with more people in private insurance, they were still using the public system, because that way they skipped the whole ‘excess’ and gap thing. Which meant that the public system had more stress put on it, with the expectation of dealing with smaller budgets.

If Rudd hadn't won the last election, I suspect the public system would have had even more attacks on it, and be close to collapse in Oz. It's not doing well as it is, and Rudd has a lot of work to do to bring it back from the brink.

Where was I? Oh yeah: There's nothing wrong with allowing people to buy private health insurance, or buy a bed in a private hospital. The trouble comes when people are expected to do so, and when public hospitals are forced to act as if they're private, by demanding credit cards before admission.
Sep. 10th, 2009 06:45 am (UTC)
What you said here. Although you can get free/cheap dental care from some dental hospitals, can you not? People keep telling me that that is possible, but I am lazy and never get around to it.

Other neat things: Most optometrists bulk-bill for eyesight stuff. A system whereby psychologists are free (I'm on it!) recently got introduced- 12 visits a year, with the option for a further six.

Queensland also gets everyone to pay for ambulance cover with a cheap surcharge on one's electricity bill. This means that ambulances are free for everyone. Hooray! [I now live in NSW, and no-one seems to know how it works down here.]
(no subject) - catsidhe - Sep. 10th, 2009 06:55 am (UTC) - Expand
(no subject) - goblinpaladin - Sep. 10th, 2009 07:04 am (UTC) - Expand
(no subject) - fluffydragon - Sep. 10th, 2009 11:03 am (UTC) - Expand
Sep. 10th, 2009 06:13 am (UTC)
What I wish I had heard..
"So, in order for the members of this august body to see the issues with our current health care system, I've just signed an executive order directing that the health care funding for congress be halted effective at midnight tonight. To the men, women, and children watching at home, this means that your Senator and Congressman/woman will now share your struggle to find quality health insurance at a reasonable price."
Sep. 10th, 2009 06:58 am (UTC)
Sounds like he wants to "reform" health insurance to make it more like car insurance.
Sep. 10th, 2009 07:17 am (UTC)
Yes. Exactly. It is the exact comparison that most supporters of "individual mandate" make. As if that were a good thing.
Sep. 10th, 2009 08:24 am (UTC)
I agree with all four of those points, but there's absolutely no need to ban private health insurance. All we need is a good system of public health insurance to compete with private insurance, that way, in a decade or so private insurance will likely be dead because almost everyone will have switched to public insurance, and there's less economic disruption in the meantime.

Fortunately, the House & Senate look ready to pass a bill that contains public health insurance as one of the options. If they actually manage this, and it isn't crippled by conservatives within the Democratic Party (since this bill will likely be passed with 0 Republican votes), then the entire system of US insurance will change, not instantly, but soon. Also, most people who currently lacks insurance will be able to get the public health insurance as soon as it exists.

I don't know what the final bill will be, but a public option to compete with private insurance looks likely, and that's really all that's needed to change the system. In general, gradual change works better than instant revolutions, and this sort of gradual change will work because private insurance sucks, and eventually most people will abandon it, but they won't be forced to stop using it, which could get lots of people up in arms, and thus Congress would risk a lot by passing such a bill.
Sep. 12th, 2009 01:56 pm (UTC)
the House & Senate look ready

The House I'll grant you, but the Senate?
Sep. 10th, 2009 11:44 am (UTC)
how mandate works in Massachusetts - forced to buy a defective product
“It will basically be a government law that says you have to buy their defective product,” says Dr. David Himmelstein, a professor at Harvard Medical School and a founder of Physicians for a National Health Plan. [ http://www.pnhp.org/ ]

“[ In a similar program in Massachusetts. ] For someone my age who is making $40,000 a year you are required to lay out $5,000 for an insurance premium for coverage that covers nothing until you have spent $2,000 out of pocket,” Himmelstein said. “You are $7,000 out of pocket before you have any coverage at all. For most people that means you are already bankrupt before you have insurance. If anything, that has made them worse off. Instead of having that $5,000 to cover some of their medical expenses they have laid it out in premiums.”

Sep. 10th, 2009 12:45 pm (UTC)
The reason the insurance companies are concerned about a goverment plan is not that they can't beat the prices today, but because (later) the government could just fix the price artifically below market which would cause the providers to raise rates to have the insurance companies subsidze the government plan.

I'm also pretty damn amused that people are so bent out of shape over the 3 cents of each healthcare dollar that's profit for the insurance companies. I'd think it would be better to focus on the other 97 cents we're spending on healthcare.
Sep. 10th, 2009 03:57 pm (UTC)
I'm curious as to where you've gotten that 3% figure; the overhead for non-healthcare healthcare-related spending that I hear is between 20 and 40% in the US, depending on the provider. Many other countries have much, much, much smaller overheads. This Fresh Air interview (http://www.npr.org/templates/story/story.php?storyId=112172939&ps=cprs) with T. R. Reid covers some of it, which is the most recent place I remember hearing those figures bandied about. This is also the story mentioned in another comment about the author who took his bum shoulder around the world to see how different healthcare systems would take care of it.
(no subject) - bradhicks - Sep. 10th, 2009 04:43 pm (UTC) - Expand
(no subject) - pentane - Sep. 10th, 2009 05:44 pm (UTC) - Expand
(no subject) - pentane - Sep. 10th, 2009 05:27 pm (UTC) - Expand
(no subject) - pentane - Sep. 13th, 2009 01:53 am (UTC) - Expand
Sep. 10th, 2009 01:43 pm (UTC)
i wish he would just flat-out fight for single-payer but i understand (not approve) why he's not. while i'm unhappy with what he's proposing.....i want health care reform, not health insurance reform.....i still think it's a step in the right direction. what we've got now is broken, and a few toddling steps down the road to real reform is better than the tharn state the right wing wants to keep us in.
Sep. 10th, 2009 01:54 pm (UTC)
And what I say, then, is, I believe it makes more sense once you've said that to put it off until we have an actual Democrat, or gods help us even a liberal Republican like Richard Nixon, in the White House. Someone who would actually support Medicare for All, instead of some god-awful patchwork of public-private partnerships that's going to be an even bigger handout to already malevolent and wealthy corporations than Medicare part D and TARP were.

This Conservative agrees with you 100% on this. Especially what a clusterfuck this can't-make-up-our-minds public/private partnership is. It is the worst of both.
Sep. 10th, 2009 03:24 pm (UTC)
It should at least double the number of students admitted to medical and dental school, immediately. This will, within 8 years, bring doctors' salaries in the US down to where they are in the rest of the developed world, about 30% lower.

Thank you for saying this. I've been saying EXACTLY this ever since this entire farce of a debate started: that there is an obvious supply problem. Every place I've lived there are FEWER hospitals than there were twenty years ago.. and the population has increased, so that has never made any sense to me.
Sep. 10th, 2009 03:33 pm (UTC)
Banning Private Health Insurance
Banning private health insurance, while I agree it's the right thing to do, is a political non-starter, even if Howard Dean, or the ghost of Ted Kennedy ended up in the White House.

There are many millions of Americans with private health insurance who have not yet realized how bad it is. These people are fertile ground for any smear tactics by the health insurance industry, so that their well financed lobbying efforts to kill any such bill in congress would be backed by massive popular support.

You can't tell a drunk that you're taking his alcohol away, and expect him to be OK with that. You can't tell a conservative office worker you're taking his private health plan away and expect him be OK with it.

The thing I like about a "robust public option" is it's the only serious health care proposal that can plausibly move us towards single payer without further legislation, as people start to realize their private insurance is crap and move to the safer public option.

PS: there are those who argue that we should end employer-based systems and leave individuals to buy health insurance on their own.*Straw man argument.

That's not a straw man, that's almost exactly what Governor Romney proposed in Massachusetts when it became clear that the momentum for health care reform in MA was unstoppable, and if he didn't lead he'd have political repercussions. The final bill didn't come out quite like that, but I've heard a lot of talk from conservative/libertarian types that individual health care plans are the only sane way to go (in spite of the financial difficulties MA is having with their system)

I may disagree with their opinion, but it's a real view, not a straw man presented by Obama.
Sep. 10th, 2009 03:38 pm (UTC)
Every time I hear someone complain that a public option would essentially destroy private insurance, I'm left with my mouth hanging open in surprise. My response is, typically, "So? Good riddance!" What have insurance companies done beside make clever commercials and get their brand of legalized robbery regulated into law? How have they managed to bamboozle the very people they steal from into defending them?

All of which is completely besides the point that no such failure of private industry would happen. There are numerous examples of private companies in competition with government programs that succeed and enhance the market.
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