Ezekiel Emanuel Appointed as Healthcare Advisor

This is from the Wall Street Journal’s Washington Wire:

“Ezekiel J. Emanuel, a prominent bioethicist at the National Institutes of Health–and the brother of incoming White House Chief of Staff Rahm Emanuel–will serve as a senior counselor at the White House Office of Management and Budget on health policy, two Democratic officials said Thursday. 

“Zeke Emanuel will work closely with Department of Health and Human Services secretary-nominee Tom Daschle to formulate a national health insurance program and to try to curb the swelling cost of health insurance without adversely impacting health care.

“Two Emanuels in the White House might sound like a voluble combination, given Rahm Emanuel’s penchant for yelling, but his brother is known for being suave and soft-spoken”

As regular readers may remember, I’ve written about the plan for universal coverage that Zeke Emanuel outlines in his book Healthcare,Guaranteed in two posts: The first post begins:

“Imagine a proposal for health care reform that guarantees free, high quality health care for all Americans.

"No premiums. No deductibles. Under this plan, the government insists that all insurers offer the same comprehensive benefits to everyone including: office and home visits, hospitalization, preventive screening tests, prescription drugs, some dental care, inpatient and outpatient mental health care and physical and occupational therapy.

“These benefits are more generous than Medicare’s and more comprehensive than what 85 percent of all employers offer their employees. (Individuals who want to purchase coverage for additional services like concierge medicine, experimental drugs for serious conditions, complementary medicines or more mental health benefits could do so.)

“If this all sounds too good to be true, you need to read Health Care, Guaranteed by Dr. Ezekiel Emanuel..." Part 1 of the post is here and Part 2, here.

The plan, originally developed by Emanuel and health care economist Victor Fuchs, remains the best proposal for healthcare reform that I have seen. Granted, it lacks a public sector “Medicare for All” option which observers like Jacob Hacker believe is important. (See the paper that Hacker just released here)   But Emanuel has told me that he sees no reason a public sector insurance option couldn’t’ be included. He just doesn’t think it is necessary if private sector insurers are regulated as described in his book.

Former CBO director Peter Orszag (who I have quoted on HealthBeat) will be heading the Office of Management and Budget, where Emanuel will be advising him on health policy. This is a brain trust that bodes well for sustainable, affordable and effective healthcare reform.

Comments

[Barry Carol]

Nate,

I just want to clarify my earlier comment about my employer’s administrative costs. My reference to $15-$20 per month for claims processing, wellness and disease management was per member per month (PMPM), not per employee per month (PEPM) and only applies to the active employees. The charges for the retirees are at least twice as high because of the higher medical costs they incur and the more numerous claims they generate, along with, probably, their greater need for disease management. Nevertheless, the basic point remains that our plan’s administrative costs are quite low – about 5% or so of combined healthcare claims costs plus associated administrative costs.

I work on the investment side for a large corporate pension fund. Part of my responsibility includes covering the publicly traded managed care insurers, the PBM’s and the drug retailers.

[Barry Carol]

Nate,

Thanks for the detailed discussion of insurer administrative costs. My employer has something over 20,000 active employees in the U.S. and north of 70,000 retirees. We pay between $15-$20 per month for the actives including claims processing, wellness and disease management.

I wonder if you can provide a reasonable “all-in” administrative cost estimate per member for Medicare which includes applying for benefits upon age in at 65, which is currently done through the Social Security Administration, raising capital to fund their operations which is done for them by the IRS and Treasury, and office occupancy costs which may be provided by the General Services Administration as well as any other administrative services that may be provided by other government agencies and are not reflected in CMS’ budget.

Also, perhaps you could provide us with an update on the status of private sector real time claims adjudication technology that allows providers to both verify coverage at the time of service and determine the patient’s responsibility amount, if any, based on contract rates, not list price.

Finally, I’ve mentioned in the past that the best and most thorough discussion of administrative costs throughout the entire healthcare system that I’ve ever seen was a paper published in Health Affairs by Ken Thorpe of Emory University back in the early 1990’s. It was titled: “Inside The Black Box of Administrative Costs.”

[Maggie Mahar]

Don--

You write: "Actually, Medicare's pockets are deeper than any private sector insurer, for the government can continue issuing debt, borrowing from itself, and, for accounting purposes a corresponding asset is created."

I think those days are coming to an end. We'll no doubt need some deficit spending to get through this recession/depression to pay for extended unemployment coverage, Iraq, infrastructure, creating jobs etc.

But once we get unemployment down--and some economic growth--we're going to have to re-think the whole idea of printing money.

The dollar is no longer viewed as a totally"safe haven" by the rest of the world. We're on a slipper slope and the fact we are the the world's larger debtor will catch up with us before long. If the rest of the world cuts its purchase of our Treasuries, we are in deep trouble. Inflation, a dollar worth signficantly less than it is today, oil no longer priced in dollars (and so much more expensive for us) and a lower standard of living throughout the U.S.

Those who say the deficit doesn't matter are living in a dream world.

[Patrick Schoenfelder]

Thanks Maggie.

One last note on doctors and private insurers.

Polls show that 55% of doctors nation wide support adoption of a national single payer plan. In my own state the state Medical Society did a poll and found that 65% of doctors in the state supported single payer, including majorities of every specialty except general surgery.

I would like to believe that this is because doctors have an altruistic concern for their patients and for the uninsured as well as concerns about the economy, and to some extent that is true. But I have never talked to a doctor for or against single payer who did not mention that a significant advantage would be being able to stop dealing with private insurers.

[Don Levit]

Maggie:
You asked if the insurers' profits from investments give them deep pockets that Medicare lacks?
Actually, Medicare's pockets are deeper than any private sector insurer, for the government can continue issuing debt, borrowing from itself, and, for accounting purposes a corresponding asset is created.
Doesn't that sound a bit farfetched, particularly when even the loan interest is not being paid back? Or, is this a real loan, just like the trust fund is not a real trust fund, and the reserves are not real reserves, as we know them in the private sector?
From the same recent GAO report I quoted which speaks of the intragovernmental borrowing to fund Medicare:"Intragovernmental transfers arise in the form of borrowing/lending between the Government accounts. Interest credited to the trust fund arises when the excess of program income over expenses is loaned to the General Fund. The General Fund has to credit interest on the loans from the trust fund programs just as if it borrowed the money from the public. The credits lead to future obligations for the General Fund. The credits increase trust fund income exactly as much as they increase credits (future obligations) in the General Fund. From the standpoint of the Government as a whole, at least in an accounting sense, these interest credits are a wash."
It is important to note these are all notional accounts, filled with IOUs.
How can private insurers compete with this?
Don Levit

[Maggie Mahar]

Patick, Barry, Don Levit and Nate--

Thanks for your comments.

Patrick-

I, too, like the idea of adding a public sector option to Emanuel's plan-- and having it compete on a level playing field--same regulations, no co-pays, etc.

Barry--

If insurers were not able to make money by "cherry-picking"--and by selling Swiss cheese policies filled with hidden holes, or high-deductible polices that most people cannot afford to use (because deuctibles so high) they probably would not be able to pay health care providers any more than the public sector plan pays.

Though both the public sector plan and private sector insurers need to redistribute their reimbursment dollars, paying doctors at the bottom of the ladder more and some at the top less, with all changes in payments based on just how much the patient benefits from the treatment.

Private insurers do have much bigger costs in a few areas: marketing, advertising and lobbying Congress.

When it comes to lobbying the health insurance industry is second only to Pharma in the amount it spends.

Also, it is not just top excecutive salaries, but many upper-management salaries that are much higher than the salaries civil servants earn.

And under our current system, insurers spend a fortune marketing themselves to thousands of employers--even in those cases where employers are self-insured and the insurance company provides on administrative servcics.

There is no evidence that private insurers do a better job of investigating fraud. Most of the biggest, most successful investigations have been done by the FBI.

There is some evidence that some private-sector insurers simply close thier eyes to fraud, knowing they can pass the cost along in the form of higher premiums. (See the story I quote from my book and the WSJ in my comment to Patrick below)

Finally, as for-profit companies, insurers have costs in addition to providing profits to investors. They also must court them (investor relations) and in some cases wine & dine them.
"Lobbying" Wall Street is not cheap.

Some very good insurers could compete against Medicare, but not most. It would be interesting to see what happened.

Patrick--
You are right about cost-shifting, Medicare and Medicaid.

Medicaid pays about 30% less than Medicare, and it often costs providers significantly more than Medicaid pays to provide the services. So they must shift the costs to someone else.

What you say about Medicare paying about 10% less than private insurers squares with national figures. The difference varies regionally and based on the service, but overall Medicare pays somewhat less.

On the other hand, doctors confirm what you say about Medicare being Much Less Hassle. For one, Medicare pays in 30 days--it doesn't try to play the float with your money.

Secondly, Medicare's reimbursement forms are not filled with tricks that make it easy to make a mistake.

Third, with Medicare you are dealing with one set of forms, not 12 different insurers.

Fourth-- you don't have to call Medicare to get permission; you don't have to have lenghty conversations with Medicare's clerks to get paid.

On fraud--you are right. I, too, have never seen any evidence that private insurers are better.

In fact, in Money-Driven medicine, I quote a Wall Street Journal story which asked the question: "Why didn't private insurers act sooner against NME, a company that had bilked them out of hundreds of millions?".

Insurers sued NME only after the FBI raided the company.

Louis Parisi, director of the New Jersey insurance dept. fraud division told Congress that "health insurance companies, with some exceptions, are content to pass the cost associated with fraud along to their customers in the form of higher premiums. In the testimony, quoted in the Journal, he explained that workers who process claims often are paid on vollume. This gives them an incentive to let questions slide, some even take to "plugging things in to make the claims fly."
Robert STuckey, former medical director at a NME hospital backed the story, saying that when he informed The Prudential Company of possible insurance fraud, company executives merely laughed, saying that for them, large bills meant large premiums and big bonuses."

Barry--
On the argument that the value of vouchers wouldn't keep up with rising healthcare expenses . .

A voucher system funded solely by VAT taxes would find its funding rising in tandem with the economy as a whole. But no faster. This would allow for growth while putting a cap on health care spending--it wouldn't be able to grow faster than GDP.

You are right about CEO compensation--But I wonder if one added up compensation, bonuses, options for all executives,from mid-management on up, and compared it to civil servant salaries in Medicare, from mid-level management on up, wouldn't the difference be large enough to put private sector insurers at a disadvantage?

I honestly don't know the answer, but it would be interesting to find out. In general, those enormous CEO salaries do create a culture where many others are overpaid.

Don Levit-- You make good
points about differences in accounting, though I'm not sure how they effect the competition for customers . . . .though if private sector insurers carry liabilities, that would affect what they could spend on networks that would attract customers. .
One other difference occurs to me: Insurers are free to invest premiums as they please. There are serious constraints on what Medicare can do with its money. Wouldn't insurers' profits from investment sometimes give them deep pockets that Medicare lacks . . .

Nate--
Please see my comments above, covering many of your points, particuarly on fraud and how much Medicare pays vis a vis private insurers.
I'm not sure where your numbers are coming from.
Also, on this blog we try to avoid saying things like "You have absolutely no idea what you are talking about . ."
.

[Maggie Mahar]

Dr. McCanne-

Thanks for coming back to the blog --and thank you for the kind words.

I suspect that you and I do agree in our ultimate goals.

As I have said many times, I am not opposed to single-payer (though recent experience with the Bush administration does make me somewhat wary of having no alternative to
public-sector care--see my recent post "Insurers Expand Primary Care--An Argument For Obama's Plan." )

Nevertheless, what I like about the Obama plan--which offers both private sector and public sector insurance-- is that I think it offers a back door to single-payer. If Medicare-for-All is as good as it could be,
people will choose it and the for-profit insurance industry would wither away.

That said, let me address a few specific points.

You write: "Regardless of how many hundred billion dollars the recoverable administrative waste is (between one hundred billion and four hundred billion), we should attempt to recover it and spend it on health care,

Since rougly $700 billion is wasted, I would guess that at least $400 billion is recoverable, and I'm not convinced it should all be spent on health care.

Certainly not on the kind of health care we have today. I would invest much of it in pubic health-- gyms and gym teachers in all public schools, safe playgrounds, safe parks in poor neighborhoods, subsidized greenmarkets in poor neighborhoods; free smoking cessation clinics; more, fully funded drug rehab clinics; bus children from poor neighborhoods to suburban schools, where they are spread out among classrooms, 4 or 5 to a class (this is alread working in some cities).

In other words, I think that adressing poverty, and education would do more to improve the nation's health than pouring more money into acute care.

You write: " a VAT alone is not adequate for financing health care because we will require a much greater transfer from the wealthy than a VAT would enable."

Having read Emanuel's book I am not persuaded that is true. Keep in mind this is a 10 percent VAT on everything-- no exclusions. And he is not trying to cover Medicare or other govt programs that have separate funding (the VA, etc.)

You write:" basing reform on a social insurance model of European-style private plans that are designed to help people pay medical bills would be very different than the current proposals to base reform on U.S.-style private plans that are designed to enhance business performance by reducing access to health care (just ask institutional investors why they invest in U.S. plans)"

Germany, France and other European countries also have for-profit insurers--but they are tightly regulated. That is the difference.

We could tightly regulate our private insurers the way we once regulated utilities. (See recent post I mentioned above.)

Like utilities, insurers are providing a necessity, and thus the interests of their shareholders cannot be allowed to interfere with the interests of their customers.

If we did that, manly for-profit insurers would drop out of the business. But some of the best would stay--which includes not-for-profits.

[Don Levit]

Patrick:
I think it is a good idea to provide competition with private insurers through a government-run program.
If that is done, however, it needs to be a fairly level playing field.
The way the federal government can use the "reserves" of the "trust funds" for general government expenses has no equal in the private sector.
Here is some especially frank verbage from a recent GAO report entitled "The Complete Fiscal Year 2008 Financial Report."
"The Government does not set aside assets to pay future benefits associated with earmarked funds (such as Medicare). The cash receipts for an earmarked fund are deposited in the Treasury, which uses the cash for general Government purposes. Treasury securities are an asset to the Federal agencies and a liability to the Treasury, and therefore, do not represent an asset or a liability."
So, when the government borrows from itself, it is a wash for accounting purposes.
That sounds like the type of manipulation of the numbers in which private sector entities placed themselves in financial jeopardy.
Don Levit

[Patrick Schoenfelder]

Barry and Don --

I agree that compensation of execs is a very small part of overhead for private insurers. But profit, payment for sales people, advertising, and higher costs of claims management are not. I have read that actuarial expenses and underwriting account for only 30% of the total overhead.

I also agree that the cost of retaining assets for fiscal reserves to assure future financial solvency for paying claims is an expense that private insurers are forced to carry but that public insurers do not have to , since they are backed by the full faith and credit of the government. I can't say how to deal with that, or even if it can be changed.

As you can probably tell, I am a bit frustrated with the claim programs of private insurers. There are a few things they could do to improve things:

1.) create industry wide standards for claim documentation and filing so that each company does not require providers to re-invent the wheel.

2.)Electronic submission of bills and requests for reconsideration would be useful, especially again if it were uniform throughout the industry.

3.) Much greater clarity in the communications sent to patients regarding their bills would help a lot too. A large number of patients who do not understand their bills call or come to the provider for explaination rather than wade through the swamp of insurance company claims offices. The explaination is often quite simple for people who understand the system, but it costs time and money and leads to unfortunate situations dealing with people who are very frustrated not with us but with the insurance company, but have only us to complain to.

4.) Finally, and very important, the companies need to work on being much quicker at processing, paying, or challenging bills. Medicare takes about half as much time to pay a bill as private insurers. Prompt payment is not only gratifying to providers, but also helps clarify the situation for patients and prevent confusion. I am very suspicious that this is a habit companies fell into back when interest rates were very high and it was very profitable to delay payment, but continue to follow today out of habit. As a person who works in a field where there is a constant daily stream of new work and who learned long ago that delaying today's work until tomorrow does not make the work load lighter but just frustrates the people we are serving, I have to say that I cannot understand a system that does not have a policy of dealing with all of each day's work today, since if you don't it just gets in the way of tomorrow's work.

[Barry Carol]

Perhaps Maggie could ask TypePad if its hosting technology could be enhanced to allow more than 50 comments. It would be nice, and potentially quite useful to researchers and others, if the Archives contained a complete record of comments, along with the original posts.

[Don Levit]

When Patrick writes about private insurers and public insurers, we need to take into account that the 2 insurers do not recognize assets and liabilities similarly.
Medicare uses a cost basis, and private insurers use an accrual basis.
Liabilities extending beyond one year are not considered liabilities to Medicare, while they are considered liabilities to private insurers.
"Reserves" in the Medicare trust fund cannot be converted into cash, while the reserves in a private insurer, can be converted into cash.
At least from an accounting perspective, public insurers have many advantages over private insurers.
Don Levit

[Barry Carol]

Patrick,

Thanks for the detailed response. I always learn the most from the doctors on the blog. A voucher system is my preferred reform approach, and I’m a believer in choice and competition, even if it means that administrative costs are somewhat higher than under a single payer system. At the very least, it’s reassuring to know that you have someplace else to go during the next open enrollment period if you are not satisfied with your current insurer whether it’s public or private.

I do agree with you that there is much more that insurers could do to streamline and simplify their product offerings. Hopefully, real time claims adjudication technology will continue to develop and mitigate much of the administrative burden that you currently face. Large self-funded plans probably contribute to the current confusion as they pick and choose what they are willing to cover and pay for. On the plus side, since large employers are not paying for medical underwriting, broker commissions, marketing, advertising, and state premium taxes, their administrative costs are quite low as they only reflect the cost of claims processing and, if they choose to buy it, disease management, health coaches, nurse hotlines and the like.

If I remember correctly, the commission formed to study Medicare when Bill Clinton was President recommended a voucher or defined contribution approach which they called “Premium Support.” Opponents feared that, over time, the value of the voucher would not keep pace with the growth in healthcare costs due to budget constraints. That implies that consumers would either bear steadily increasing out-of-pocket costs or benefits would have to be scaled back. I expect that argument to resurface during the upcoming debate.

I also want to make one point on executive compensation. While I agree that CEO’s across corporate America are paid more than they need to be, driven mainly by the value of stock options and other stock based compensation, if the top five executives from all of these companies worked for $1 per year and the savings were passed through in lower insurance premiums, the impact would be a small fraction of 1% at most. So, while it makes a nice soundbite, sharply cutting the CEO’s compensation won’t have any impact in mitigating our excessively high healthcare costs.

[Patrick Schoenfelder]

Barry --

1.) Conservatives always like to talk about "cost shifting in Medicare and Medicaid" since the lion's share of the cost shifting is actually due to Medicaid. Medicaid would effectively cease to exist under this program, since no enrollee in their right mind would choose Medicaid with all its hassles and humiliations over the voucher system. "Cost shifting" in Medicare is much less of a factor since today most insurers mirror Medicare rates. (In my practice private insurers never have paid us more than 10% more than Medicare and some actually paid less. The difference in payments is almost completely swallowed by the fact that dealing with private insurers costs us SEVEN times as much per bill on average as dealing with Medicare. I would REALLY like a reform that would make private insurers get their acts together in their claims offices.) Some large health care providers do collect a lot more from private insurers because they are powerful enough to force the insurers to negotiate. Medicare never negotiates, but many health providers do not have the power to negotiate with private companies either.

2.) Doctors and other providers can refuse to accept Medicare now and some do. Some providers bargain away that right in exchange for other trinkets, but only if they see it to be to their advantage. True emergency care is an exception to this of course, but I do not foresee anyone staking out the position that people with life threatening conditions can be thrown out the door because of insurance coverage. I see nothing in Emanuel's plan that changes that.

3.)Coverage of all costs by the voucher is implied by what I propose. The value of the voucher will be SET to the cost of the public program, at least when the voucher program begins. If the private insurers can actually undersell Medicare then Medicare would probably go out of business eventually because the value of the voucher would tend to be reduced over time to below their costs.

4.) I assume that the system would include a method for redress of complaints. The only proviso I would add to this is that if an insurer filed a complaint and it turned out to be unfounded, they should have to bear the expense of the investigation process and pay some penalty for the economic burden to the system of their frivilous complaint.

In my mind, bidding for drug prices and for equipment prices is implied in this system or any rational system, and will almost certainly be extended to existing federal health programs as soon as George Bush and his veto pen leave the White House.

The expenses for private insurers you are not mentioning are profit and very high payments for executives. Private insurance will have to find ways to improve their efficiency enough to cover those costs.

As far as fraud and so on, I have never really seen anything either in my own experience or in the media to suggest that private insurers are better at preventing fraud than public insurers. The public insurers are charged with pursuing fraud and with publicizing the results. Private insurers tend to be secretive if they are doing anything. Certainly in my experience I never saw the private insurers doing anything to be more aggressive about fraud, and if I were to speculate I would suggest that private insures are actually "cost shifting" fraud investigation to the public programs, which of course do have the advantage of having the power of the government behind them when they launch investigations.

Care coordination is usually in the hands of provider systems, with HMO's clearly a big player as well as actually an insurer. Public and private systems both would be responsible for mandating various cost savings, and a public system would have a power advantage in doing so because of its huge size.

If as I suggested the value of the voucher were set to the cost of the Medicare system, it would be impossible for congress to enter into a conspiracy to destroy the private insurance industry. Such a conspiracy would be unlikely anyhow, since even in the new congress "friends" of the insurance industry will outnumber its "enemies." Important Democrats, some very high in the leadership, are closely allied with insurance industry.

Supporters of public insurance would probably be paranoid that some private insurers would use reserves or borrowed money to engage in predatory pricing in order to gain advantage over public insurance and other private insurers, planning to make up the losses once they attain a strong market position and drive competitors out. Obviously all such bad behavior, whether from public or private insurers would have to be prevented, probably by extending audit rights to the National Health Board.

I totally agree that for my proposal to work it cannot be stacked against the insurers any more than the lower operating costs and superior power of Medicare stacks it naturally, nor can the insurance industry be offered the chance to muddy the waters with false issues and claims or by predatory pricing. If private insurers can provide better health care for less money they should and will win out. If not they won't. That's what I mean about an "empirical" answer to the question.

I am talking about pure Adam Smith here -- may the best player win.

[Barry Carol]

Patrick,

I think insurers would be perfectly willing to compete with a public option under the following conditions:

1. There can be no cost shifting to the private sector as there is with Medicare and Medicaid.

2. Doctors, hospitals and other providers can refuse to accept the public option insurance if the reimbursement rates are deemed inadequate while continuing to accept Medicare patients if they want to.

3. The public option must cover its costs out of premium revenues alone with no subsidies from general tax revenues.

4. There would need to be a mechanism for redress if any of these conditions are violated.

The only inherent costs that private insurers incur but Medicare and a public option doesn’t are for medical underwriting, which would disappear under community rating and guaranteed issue, broker commissions, marketing and advertising. If private insurers are subject to state premium taxes, the public option should be as well.

Insurers probably do a better job of mitigating provider fraud. Insurers could put durable medical equipment out for bid whereas Congress will not currently let CMS do the same despite a successful pilot project which suggested potential savings of at least $1 billion per year nationally.

If the Medicare Payment Advisory Commission (MEDPAC) issues recommendations against payment for certain drugs, devices and procedures based on cost-effectiveness, it could provide the political cover and moral authority to allow private insurers to refuse to cover them even if lobbyists prevail upon Congress to force CMS and/or a public option to continue to pay for them. Private insurers may also be able to outperform Medicare or the public option on providing care coordination for chronically ill people with multiple co-morbidities.

All things considered, I think it is quite likely that private insurers could compete effectively with a public option if the playing field were truly level. If the Congress is determined to put them out of business, however, it wouldn’t be hard to deliberately under price the product, perhaps significantly, and make up the difference with general revenue. If that happens, what’s the industry’s recourse? Under those circumstances, their opposition is understandable.

[Patrick Schoenfelder]

Thought about this off and on over the holiday.

Here is a proposal that I think could strengthen the Emanuel plan.

Adopt the plan as he has conceived it, except:

Create a national public insurance option, either as a direct buy in to Medicare or as a seperate program to be co-administered through the Medicare administration system. Bring the program and Medicare itself into compliance with Emanuel's standards (no premiums, no deductibles, very low co-pays, use of the national health board and the medical injury and malpractice board.)

Set the values of the vouchers at the level of the cost of the public option based on the same actuarial assesment of costs that Emanuel advocates for setting his values. Enrollees would get the public insurance for no cost. Private insurers who can match the costs of Medicare will compete on an even field based on the attractiveness of their programs. Private insurers who cannot match that price or who wish to offer premium coverage will have to charge enrollees an extra premium but the voucher will cover a large part of the cost. Private insurers who can beat the cost of Medicare will be allowed to collect the surplus money and use it as they wish, including refunding part of it to customers as an incentive to choose their coverage.

Cherry picking would be prevented by Emanuel's "no rejected applications" rules and by accurate setting of the value of the vouchers.

Allow the public and private entities to compete for market share. If one or the other is more successful at reducing costs while improving care, in the long run they will dominate the market and the others will fade away.

This allows us to answer the question of single payer vs private plans and their application in the US in an empirical way using the marketplace as the judge.

May the best system win.

[Don McCanne, MD]

Although I'm reluctant to add this one last post because it will knock someone else's message off the bottom, I feel that it is important to express my profound respect for Maggie Mahar and her work. I subscribe to her messages and find them all to be highly credible - the same level of credibility that we attempt to maintain at PNHP. Although I'm usually already familiar with the topics she discusses, I find that her perspective often adds to an understanding of the issues.

As far as reposting my prior comments, I didn't keep copies of my postings since I assumed that they would be archived on this website (and I now understand why they aren't). But, very briefly, a couple of my points: 1) regardless of how many hundred billion dollars the recoverable administrative waste is (between one hundred billion and four hundred billion), we should attempt to recover it and spend it on health care, 2) a VAT alone is not adequate for financing health care because we will require a much greater transfer from the wealthy than a VAT would enable, 3) basing reform on a social insurance model of European-style private plans that are designed to help people pay medical bills would be very different than the current proposals to base reform on U.S.-style private plans that are designed to enhance business performance by reducing access to health care (just ask institutional investors why they invest in U.S. plans), and 4) since single payer is the least expensive, and most effective and equitable model of ensuring that everyone has affordable access to all necessary health care it is premature to abandon it merely because AHIP, PhRMA, USCOC, and conservative Republicans are opposed. Their opposition to providing a public option within a market of private plans will be (and already is) just as intense as is their opposition to single payer.

Anyway, we're all on the right side in our fundamental goal: we want high quality, affordable health care for everyone. Let's hope that all of our efforts together will bring it to us in 2009.

Peace.

[Maggie Mahar]

Merrill--

My vote is Ringo, and I know how he felt!

Merry Christmas to you too.

Best, Maggie

[Maggie Mahar]

Patrick & Barry--

Patrick--Thanks for your support and understanding.

Barry-- I understand your concern. Typepad (the platform that the Century Foundation chose when we started this blog) allows a maximum of 50 comments.
I've put it on that setting; beyond that, there is nothing I can do.

The good news it aht this blog tends to attract thoughtful, lengthy comments, so we rarely get more than 50 on a post

[Barry Carol]

“Second, as the page fills up (and this thread is now 62 entries long with some very long entries) the older comments gradually roll off the bottom of the page and, as far as I can tell, are no longer accessible.”

I never realized this before, and I think it’s unfortunate. Other blogs that I read from time to time which attract numerous comments including The Healthcare Blog and Ezra Klein’s blog maintain access to all comments both while the thread is fresh and in the archives. From time to time, I like to go back to the archives and reread an entire discussion of a thread of interest to me, and I suspect others may do the same. Considering the very knowledgeable people who comment on Health Beat, (especially doctors and Maggie) I think it would be useful and helpful if all comments were maintained and archived, at least if it is not cost prohibitive.

[Patrick Schoenfelder]

It bothers me that Dr. McCanne and Ida Hellander seem to be suggesting the Maggie is not acting in good faith running this blog and is removing posts she disagrees with. I think those who are saying this do not understand how the mechanics of the blog work.

First, the original article we are all commenting on stays at the top of the page permanently.

Second, as the page fills up (and this thread is now 62 entries long with some very long entries) the older comments gradually roll off the bottom of the page and, as far as I can tell, are no longer accessible.

That rule applies to everyone's comments, including Maggie's. The only thing of Maggie's that gets preferred treatment is the original article, which makes sense since that is what everyone is talking about.

There may be a way to get at older comments, but I can't find it. I am uncertain if it necessary to be able to find them, since blog comments, by their very nature, are ephemoral. If you believe your comments are so important that they should be preserved, as some people have already said you should repost them. If they are that important you certainly kept copies.

Some blogs do have a way of paging to previous pages to see old comments, but this policy is probably not Maggie's policy but the policy of her host, which is probably trying to conserve bandwidth and associated costs.

I think that the operation of this blog is fair to everyone, regardless of their position in relation to Maggie's ideas.

[Merrill Goozner]

I just wanted to wish you a happy holiday season, and hope that neither of us find ourselves screaming in the new year, like one of the Beatles on "Helter Skelter" (was it John? was it Ringo?) "I've got blisters on my fingers!"

best wishes,
Merrill
http://www.gooznews.com

[jamesd]

Maggie,
Happy Holiday's. I'm glad to see you'll be unwinding the next few days. Take Friday off too. (We all should) I know there is much to do, but it will keep till Monday. You've certainly earned it. Enjoy, and we will renew the debate on Monday

[Maggie Mahar]

Everyone--

Thanks for your comments.

Today I'm stuffing a turkey, wrapping final presents adn getting ready for Christmas Eve dinner with my family.

(We celebrate on Christmas Eve.)

Tomorrow I plan to go to movies all day (probably see two.) I haven't seen a film in months--too busy working. And I love movies, so this will be a treat.

I may not get back to blog until Friday, but will reply to comments then.

Best, Maggie

[Maggie Mahar]

Anon--

You make a good point. Since I said that I did not delete Dr. McCanne's comments (making it clear that they were welcome), I
wonder why he didn't repost them?

I also wonder why he never replied to my numbers and specific argument about how, in fact, insurers' administrative costs are only a small part of the total cost of healthcare?
As we can see from the example of Taiwan (an example single-payers often cite) a single-payer system is not cheap-- see the facts in my comments on premiums,co-pays and deductibles in Taiwan as well as contraints on access. . .

That said, I went back to typepad to see if I could figure out what happened to Dr. McCanne's comments.

It turns out that there is a default setting that limits the number of comments that you can see on a given thread

I changed the setting to the maximum-- 50-- see Dr. McCanne's comments should now be visible.

[Don Levit]

Lisa:
I live in Sugar Land. Can you provide some more information about the event?
My E-mail is donaldlevit@aol.com.
Thanks.
Don Levit