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What does it mean to 'start over' in healthcare reform?

ScottBrown Lots of folks, particularly conservatives, want to cast the special Senate election in Massachusetts ON Tuesday as a referendum on Obamacare. I'm not close enough to Massachusetts politics to say how big a factor that is, but clearly Republican Scott Brown is emphasizing his opposition to the Democrats' healthcare reform proposals. "As your senator, I will insist they start over," he said on the campaign trail Sunday.

But what would a do-over mean, policywise?

If the goal is to slow healthcare inflation -- seemingly the one problem in the system that everyone can agree on -- Congress has a couple of options:

  • Try to impose national spending caps, but that's a political non-starter as well as constitutionally questionable. Spending caps = rationing by government. The public may be comfortable having private insurers ration care, but not with government doing it. (Witness the looming train wreck at Medicare, a testament to Congress' inability to curb the public's appetite for healthcare.)

  • Attack the roots of the growth in healthcare costs, particularly the wacky incentives the system provides to let people get sick, then perform as many procedures on them as insurers will pay for. That means finding ways to reward individuals, doctors and hospitals for preventing illness and injury, and to discourage the use of expensive new treatments and drugs that produce no better results than previous approaches. It also means providing more incentive to improve the quality of care, rather than simply paying for services rendered.

That's a Hobson's choice, yet there's no easy way to fix the problem of misaligned incentives. The government's main leverage is over Medicare and Medicaid, and there are plenty of good ideas for how to change the way those programs deliver and pay for care. The assumption is that the most successful efforts will migrate into the private insurance market. But it's hard to say which changes will work until you implement them and work out the kinks.

There's no question that the pending legislation could do more to "bend the curve" in healthcare costs. Even if Congress were to focus only on cost control, though, its success would be limited unless it sharply reduced the number of uninsured Americans -- particularly those who can't afford to pay for their own care. That's because their costs are passed on to everyone else in the system.

The ranks of the uninsured were growing even before the recession hit because private insurers have been denying or canceling coverage for the riskiest consumers (something they can do easily in the market for individual policies). One response would be simply to bar insurers from cherry-picking customers. But that would create a powerful incentive for people not to carry insurance until they needed medical care. This form of adverse risk selection would not only raise the cost of coverage, it would neuter the efforts to shift incentives from treatment to wellness.

The solution to that problem is not just to bar cherry-picking, but also to require people to obtain insurance. As soon as you impose an individual mandate, though, you have to provide subsidies for the working poor. Otherwise, you'd be ordering millions of people to purchase something they can't afford. To help make the coverage affordable, you'd also want to create a way for those individuals to pool their risks and shop as a group. That's where the concept of an insurance exchange comes in -- a new marketplace that effectively creates a pool for uninsured individuals.

One Republican alternative to an individual mandate is for each state to set up an insurance pool for applicants whom insurers didn't want to cover (e.g., those with pre-existing conditions or risky occupations). Providing coverage to members of this group, however, would be an extremely expensive proposition, so premiums would be quite high. Without subsidies to make the coverage affordable, the new pools wouldn't do much to pare the number of uninsured.

Other GOP proposals could help cut healthcare costs in the short term, but don't really address the forces that are rapidly driving up those costs. These include allowing insurers to compete across state lines and limiting damage awards in medical malpractice lawsuits. Malpractice insurance premiums have risen sharply over the past 20 years, so they certainly are a factor in healthcare inflation. But it's not clear that damage caps will rein them in.

In sum, it's hard to obtain the improvements in the system that seemingly everyone wants without a comprehensive (and costly) effort that includes healthcare delivery and reimbursement reforms, an insurance mandate, and new pools and subsidies for individual buyers. Otherwise, you're either tinkering around the edges or creating powerful and destructive new incentives to game the system.

The Democrats' approach is far from perfect, and it's to both parties' discredit that they haven't incorporated more of the Republicans' ideas for bringing market forces to bear on the healthcare system. But it seems unrealistic to think that lawmakers could start over on healthcare reform and produce a dramatically different measure unless they abandoned the intertwined goals of controlling costs, expanding coverage and improving quality.

So where does Brown stand on all this? Here's what he says on his website:

I believe that all Americans deserve health care coverage, but I am opposed to the health care legislation that is under consideration in Congress and will vote against it. It will raise taxes, increase government spending and lower the quality of care, especially for elders on Medicare. I support strengthening the existing private market system with policies that will drive down costs and make it easier for people to purchase affordable insurance. In Massachusetts, I support the 2006 healthcare law that was successful in expanding coverage, but I also recognize that the state must now turn its attention to controlling costs.

The centerpiece of said Massachusetts law is a requirement that almost all residents obtain insurance. The measure also creates an insurance exchange and provides subsidies to help lower-income residents buy policies. If that's what Brown supports, he's on a much different page than most Republicans in Congress -- they prefer to characterize the Massachusetts effort as a total failure. But the state wasn't trying to fix the skewed incentives in the healthcare system, and it took few of the steps that reformers in Congress have proposed to restrain costs.

Democrat Martha Coakley, meanwhile, supports a comprehensive reform similar in outline to the bills approved by the House and Senate. From a healthcare white paper on her website:

We can no longer afford to wait for meaningful health care reform. I believe that national health care reform should have three principal goals: expanding health insurance coverage to those who today lack it; improving the quality of health care for all; and containing costs. The legislation currently working its way through Congress takes steps toward these goals, but is only a starting point. Even if President Obama signs a final health care reform bill, federal and state governments will need to work with doctors, hospitals, nurses, insurers, and consumers to improve a complex system that badly needs repair.

Good thing she said "if" Obama signs a bill. After all, she's the one casting the most doubt about the outcome.

-- Jon Healey

Photo: Scott Brown campaigning Monday in Boston. Credit:  Robert F. Bukaty / Associated Press

 

Comments () | Archives (24)

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andrew nelson

Democrats should do some serious thinking about the meaning of the bullet that just whizzed by the liberal bastion of Ted Kennedy's seat in Mass. The fact that this seat is so seriously threatened, despite who wins on Tuesday, is not simply a referendum, but a scathing indictment on the healthcare legislation, the Obama administration, and the lack of bipartisan representation in anything these tyrants do. This administration and these democrats have completely disenfranchised Republican and Independent voters. There is NO Republican and Independent representation in the way they attempt to govern over us. It would be a serious and violently reckless mistake to try parlimentary tricks in order to jam this bill through, after Tuesday. Forget Cap and Trade. Forget any attempt to tax us after Climate Gate. Our nation was born in a revolt against the tyranny of a distant, disconnected, and deaf elite. It would be a very serious mistake to continue down this path, whatever the outcome of Tuesday's election in Mass.

Jon Healey

@Andrew -- It takes two willing sides to compromise. Republicans talk about healthcare reform, but they've run away from things they used to support (e.g., the individual mandate) rather than work with Democrats. I think the Senate Finance Committee's experience last summer is most instructive -- while Sen. Grassley was supposedly negotiating a bipartisan bill with Chairman Baucus as part of the "Gang of Six," he was sending out fundraising letters pledging to defeat the bill.

The way politics is played in Washington these days, there seems to be zero interest in tackling major problems in a truly bipartisan way -- one where the best ideas get support no matter where they come from. On some issues, there's a partisan split over whether a problem even exists (e.g., climate change). And on health care, where everyone acknowledges a ruinous problem with costs, there's been no move to solve it from the middle. You have the GOP pretending that interstate competition among insurers and tort reform are the answers, knowing full well the Democrats won't support either one -- and, if they're honest, knowing they're Band Aids at best. As I said in the post, they don't get at the root of the problem. And on the other side you have the Dems focusing on top-down approaches and whacking away at Medicare Advantage, which Republicans had promoted as a way to give private insurers more influence over Medicare.

If Republicans manage to kill healthcare reform and retake control of Congress, they'll have to deal with the looming insolvency of Medicare. Then, perhaps, we'll see a bipartisan approach to healthcare reform. But my guess is that Democrats will find a way to push the bill through this year -- in a worse-case scenario, by having the House approve the bill the Senate passed. Then the question will be whether Republicans will be willing to support refinements to the law, or if they'll just hope to retake Congress and repeal the thing -- which, of course, would leave the nagging problem of Medicare insolvency in 2017. But hey, that's two presidential elections away....

andrew nelson

@John -- Look at what you wrote in your response to my post. The context of your argument relies totally on an elitist 'progressively left' accepted belief, coming out of left field, that is simply not grounded in the reality of our constitution. The two 'bandaids' as you call them, goes to the heart of the one, and only-- legal -- thing that congress is constitutionally allowed to do in this instance, in regard to national healthcare - to regulate interstate commerce. Why won't Democrats support either one? The only conclusion one can make is that they don't understand the constitution, they don't understand interstate commerce, and they certainly don't understand the United States. And I will point out, that their primary job, domestically, and what they have failed at so dramatically, is to regulate interstate commerce. They have allowed and GROWN monopolies that have killed commerce and competition. They have allowed and GROWN blood sucking vampire taxes that have killed commerce and competition. They have allowed and GROWN blood sucking vampire Unions that have killed education and gov't services, both locally and nationally. The fact that the Soviet Union collapsed from government entropy and inertia should have been the premier lesson of this new century. And yet - even our local congress people have touted the benefits of the Cuban public healthcare system. They have railed against big banks and yet give MILLIONS in salary to Fannie May and Freddie Mac, the institutions that the U.S. government now owns, thanks to board members like Rohm Emmanuel. The Democrats need to wake up. It's the economy, it's the economy, it's the economy.

Jon Healey

@Andrew -- FIrst off, we'll have to disagree on the constitutionality of Congress mandating that people carry health insurance. I've written about that before and won't repeat myself here, other than to say that I think it's a close call. But if you think individual mandates are a "elitist, `progressive left'" idea, you've got an awfully short memory. Republicans were the original champions of individual mandates. To borrow a phrase, they were for it before they were against it.

Second, to suggest that tort reform (which, by the way, you should object to on federalist grounds because state courts, not Congress, have traditionally set their own tort rules) and interstate insurance competition are the *only* thing Congress can do on healthcare reform is to ignore the problems in Medicare and Medicaid. There's much that Congress can do to promote more efficient and higher quality healthcare delivery in those programs, while also fixing the skewed incentives in the reimbursement system.

andrew nelson

@John -- Check. We disagree on the constitutionality of the mandate to require someone to buy something from a monopoly. Short memory? I think you have me confused with a Republican. Before the Tea Party Conservative movement, an Independent's only chance to navigate politcal waters here in the U.S., was to keep both parties equal and at each other's throats. A two party system is not enshrined in the Constitution, I want to also point out. Second, you mix apple and oranges. If you think Federal Medicare and State Medicaid require extra constitutional tools to remain solvent, then do the right thing and call for a constitutional convention. Otherwise, stay in the framework of the constitution.

Jon Healey

@Andrew -- The constitutional issue isn't whether it's legal to force people to buy something from a monopoly, because the insurance industry isn't monopolized. The issue is whether the mandate goes beyond Congress' enumerated powers. The argument in favor of the legality of the mandate holds that Congress clearly has the power to regulate the insurance industry, and the mandate is just one element of that regulation. See http://www.healthreformwatch.com/2009/08/25/is-it-unconstitutional-to-mandate-health-insurance/

As for Medicare and Medicaid, that's my point exactly. These are federal programs (or rather, one purely federal, one a joint federal and state effort). I don't see any constitutional issue raised by Congress overhauling Medicare and Medicaid. You seemed to be arguing that Congress couldn't do anything on the healthcare front other than tort reform and interstate competition among insurers, and that overlooks a slew of things that can and should be done in Medicare and Medicaid. The assumption is that successful reforms will migrate from public insurance programs into private ones, so there's an indirect benefit as well.

andrew nelson

@John -- We'll have to agree to disagree on whether the insurance industry, because of individual state laws and rules, aren't carefully protected individual state monopolies. Congress's only -correct- role, according to the constitution, in regulating the insurance industry, is to remove state imposed barriers to free trade, and the free exchange of those insurance policies across state lines. I can get a hundred car insurance policies, standardized for minimum coverages, across any state line. Health insurance is a protected state monopoly. The powers enumerated in the constitution to the congress (and they only get enumerated powers - see the 10th Amendment), does not give them the power to make me buy anything. They can tax me, when I volunteer to work. They cannot make me work to pay for service from a private, state imposed private monopoly.

As for Medicare and Medicaid what exactly is your point? States (all 50 states - no two the same) each manage their Medicaid differently. If you want to bring both under the federal umbrella, then do so. But no state, and no free citizen of a state (where that power actually resides, if it isn't enshrined in a state constitution), is going to allow unfunded mandates to their Medicaid programs rammed down their throats.

George Walls

Some other alternatives you might consider: more broad use of HSA's should enable patients to help control costs through "shopping." Tort reform might reduce defensive medicine. Perhaps cost shifting should be made illegal. This practice inflates costs to individuals and insurance companies as a way to subsidize Medicare and Medicaid. Also, any reform needs to be sure that healthcare provides can still make a living lest they leave the profession through early retirement, jobs in industry, ... A reduction in "supply" will bend the cost curve the wrong direction.

In my experience government solutions frequently have unintended consequences that either make the exisiting problem worse or create new problems.

It might be worthwhile to investigate Switzerland. They have one of the best systems in the world. I have heard (but can not prove) that they are 100% private and 100% covered. I have not seen an article on this.

My observation from travel to European healthcare systems is that Germany and France are very good. The UK is at the very bottom and the others are in between. In all cases there is defacto rationing as caregivers are often "budgeted" on the number of procedures they can perform irrespective of who walks through the door.

andrew nelson

@John -- The constitutional arguments, in the link you provide, are interesting. Note: Regulation and mandates are two different things. Regulation restricts action. A mandate forces action. This is why modern double-speak is so dangerous. Take for example the invention of a “right” to healthcare. If it's a “right”, then how is a doctor not automatically made a “slave” because he is a provider of that service? Additionally, rights are not a function of need. Natural rights are the rights we have enshrined in the constitution. Life, liberty, pursuit of happiness. Liberty, Liberty, Liberty.

“ … The only possible constitutional restriction is an archaic provision …” What bearing does the age of a provision have on anything? If something is old then we can ignore it? The constitution itself is pretty old. By the “logic” you site in that URL, a mandate to purchase a GM vehicle to support the American auto industry is just as constitutional as a mandate to buy health insurance. What about religious belief in regard to health care? Holistic Medicine? The question is not “do I have a right to be uninsured?” The question is, “Do I have a right not to purchase insurance”. Do I have a right not to purchase a GM or Chrysler car?

Jon Healey

@Andrew -- Not to prolong this debate, but consider these two things:

There are a bunch of differences between a mandate to buy a GM car and a mandate to buy health insurance. Most obviously, one rationale for requiring you to buy health insurance is to reduce the costs you would impose on others if you were hospitalized and unable to pay the bill. (Considering the cost of fixing a broken leg, treating cancer or fighting heart disease, there aren't many people who can reliably self-insure.) It's not to prop up a brand or even promote a lifestyle choice. In that sense, it's really like a tax designed to cover the cost of services that are guaranteed to be delivered to you if you need them. (Remember, federal law *requires* hospitals to provide emergency care to everyone regardless of ability to pay.) What service are you entitled to that would justify the government requiring you to buy a GM car? There is none.

The federal government maintains a safety net that's financed through taxes. But federal employees aren't delivering many of those safety-net services; instead, they're delivered by doctors, hospitals, nursing homes, mental-health clinics, job trainers, etc. etc. Often, it does so through vouchers, such as food stamps. In the Democrats' healthcare reform proposal, instead of taxing people and handing the money to 3rd parties, the government would impose what amounts to a tax (by requiring them to pay insurance premiums) and have the money flow directly to those 3rd parties (the insurers). It's not the same thing, I'll freely admit. But it's not a huge stretch, IMHO.

andrew nelson

@John -- Thanks for prolonging the debate but arriving at the inevitable conclusion. It was worth it. It is a tax. Simply put. A tax is the only constitutional way to do it. And since there is no free lunch, the only way to pay it.

Why all the subterfuge? Why the smoke and mirrors? Why the lies? Why the BOGUS constitutional advice and elitist proclamations? Because it's not a right, because you can't pass it in the open, in the light of day, and because it only benefits a limited special interest. But what is absolutely horrendous and very sobering is that they would risk the Constitution of the United States to pay off their core constituencies, their hard core voters.

This, alone, has cost them the right to govern.

andrew nelson

@John -- Apparently, I'm not the only one that disagrees with your assertion that the individual mandate is unconstitutional.

Florida Attorney General Threatens Lawsuit Against Health Care Mandate


Making a delicately nuanced argument about the U.S. Constitution, former Republican congressman and Florida Attorney General Bill McCollum said Tuesday that provisions to force Americans to buy health care or pay a fine are not legal and he will file a lawsuit if they become law.


Making a delicately nuanced argument about the U.S. Constitution, former Republican congressman and Florida Attorney General Bill McCollum said Tuesday that provisions to force Americans to buy health care or pay a fine are not legal and he will file a lawsuit if they become law.

In a memo sent to the House and Senate leadership, the attorney general called the mandate requiring Americans to get health care a "living tax" that unconstitutionally penalizes people for being inactive.

"Never before has Congress compelled Americans, under threat of government fines or taxes, to purchase an unwanted product or service simply as a condition of existing in the country (a 'living tax')," McCollum wrote to Senate Majority Leader Harry Reid, R-Nev., Minority Leader Mitch McCollum, R-Ky., House Speaker Nancy Pelosi, D-Pa., and Minority Leader John Boehner, R-Ohio.

According to the attorney general, a citizen's choice not to buy health insurance cannot rationally be construed as economic activity subject to the Commerce Clause.

"The Commerce Clause gives no authority for Congress to transform a citizen's individual choice to be inactive in the marketplace into a compulsion to purchase apparently unwanted insurance or be penalized," he wrote.

McCollum also said that taxes that are directly applied across the citizenry have to be "apportioned by the population of each state."

McCollum wrote that as attorney general of Florida he is in a position to file suit.

"While affected citizens of every state may pursue judicial relief from the individual mandate provisions, states have standing to sue the federal government to protect their sovereign and quasi-sovereign interests," he wrote.

Mitchell Young

@Androo

For Pete's sake, the man's name is Jon!

Jerry Klein

So Andrew, consider this situation - I have a workplace insurance and a health problem. If I lose my job, I won't be able to switch to an individual insurance even if I could afford it, even with the same provider I currently have. There is COBRA of course, but it's really expensive and has a limited duration. So, if healthcare is not a right, you're basically saying if I lose my job my health problem will remain untreated. The only other choice is if I have bought and carried the individual insurance years ago, in parallel with the one at my workplace. That's just not working in the current insurance market - it relies on your ability to get the insurance from your workplace and offers no viable individual option. The Republican proposal is basically saying it's too bad - be employed or be sick with no treatment options. Not exactly a humanist position. We need to remove the workplace dependency in order to fix this system and create communal insurance pools. But then we are back to what Jon is saying in his article - where is the incentive to buy the insurance until you're sick?

Dyck Dewid

Great stimulation and background your article. I have a lot to learn and also some ideas. Thank you.

Rationale to support my rights and freedoms that I so vehemently defend (I am capable of outrage and daring).

Trying to solve Everyone's problems will necessarily infringe on rights of many, if not all, and create new problems. Diagnostically, it is most sensible to isolate and determine (understand) cause. Then treat the cause.

If I were to begin isolation I would start with significant costs of being sick:

1. Intervening of Insurance (a middle man who takes profit out) and which causes secondary costs of claim disputes, heavy admin requirements on everyone, illogical unnecessary procedures, errors from complexity, incorrect care decisions, etc.. In other words, it managing by averages to maintain profits... a business model with a captive customer base (shared monopoly?).

2. Intervening of Pharmaceuticals which is linked to Insurances 'allowed' treatments. Any scrutiny on the Insurance-Pharma relationship? High profit drugs replacing older low profit drugs or non-drug therapies. There is a constant pressure for profit and no incentive to produce and distribute cheap drugs or herbs in favor of 'faster acting' or 'more powerful' or 'without a particular side affect'. Although these often product many adverse reactions and then can in fact exacerbate dis-ease calling for more medical treatments. The often dubious rationale of a 'better' drug appeals to society weakness for 'immediate relief' or 'not having to change'. So, if one smokes, over eats, eats poorly, eats things that aggravate, has stress, etc., they can get rid of the problem symptoms with a drug. On some level this is unethical to pander to those needs. That is why ethics versus profit is so important in medicine. People are vulnerable here. There appears to be no advocate that promotes lifestyle changes to cure disease except Alternative Care. And Alternative Care is predominately Not Covered by Insurance.

3. Medical treatments and equipment. I don't understand deeply this category but read that advances in procedures and equipment are very beneficial and often reduces pain and cost. However, I have seen that the relationship between Insurance coverage and procedure is dubious and cloaked. For example, Medicare won't commit to paying or not paying for an MRI until after the patient receives it. So, this category introduces the fact that patients cannot have control or even understanding of what they are being charged medically nor what will be reimbursed. This surely is the kiss of death to any cost containment process-- no control or knowledge.

4. People who are now sick or at risk cost a lot. From an insurance point of view these are not the kind of policy holders desired. Why? Because those who must be paid are bad, and those who have no claims are good-- because we need to make money to run a large company and for our investors who want to make lots of money- as much as possible-- whatever the market will bear!

The sick and at risk are minority and represent high cost patients. Some of these people are in need and some are not. Some are wealthy and some are indigent. It is obvious, as a society we must be compassionate. We must also be wise so as not to remove consequences that instruct human behavior toward happiness and away from pain or undesirable condition.

5. Oh, I almost forgot the ballooned costs charged to those without health care insurance to pay for the artificially lowered prices insurance companies and Medicare have coerced from medical providers.


A non-cost consequence of our medical system I call the assembly line care. It is de-humanizing and disrespectful. It demeans the patient and the well-intended doctor. It places selfish motive and profits between my self determination and my health, making it stressful and often inefficient or ineffective the cure. It introduces First Doing Harm into what was sacred.

I'm getting old and my mind has let loose of some other points I wanted to make. But, I can still say it doesn't seem necessary for us all to suffer hardship and loss of freedom to accommodate a universal answer to an ill-defined problem. I've mentioned several problems. It seems they can each be tackled with a right-minded attitude. But, these can not be tackled with selfish-mindedness or greed.

Who among us can see with integrity-- without selfish motive (including me)?

andrew nelson

ooops, Mitchell, you're right. Sorry Jon, I was so caught up in the debate, I was inadvertantly rude. My apologies.

For Jerry, I cannot understand an attempt to frame your argument as a humanist position. You seem to feel no humanist remorse when it comes to enslaving the provider of health care, to enslave me - as a taxpayer, or to enslave someone who is forced to buy insurance, or enslave all of your fellow citizens - by the obligation to fulfill your personal individual needs. I cannot be very sympathetic to your plight when you are so callously willing to destroy my rights and my freedoms in order to satisfy CONVENIENCE to your own personal health care requirements.

No one forces you to make your decisions, for the situation you find yourself in. There are several options, and you've stated them, already. And there are several good charities, and several state and federal solutions already provided for those in dire need.

tucanofulano

Independents in Mass. went 3 to 1 for Brown, e.g. against Obama and Obamacare. Let there be no mistake or spin - Obama is a lame duck and Democrats are running for the exits. This message is countrywide, local, and far bigger than Obama.

tucanofulano

Best medicine for Obamacare is lethyl injection.

Mitchell Young

We need to remove the workplace dependency in order to fix this system and create communal insurance pools.

The basic principle behind 'communal insurance' is that everyone pays something, hence the mandate to be covered. Supposedly this will help lower costs of things like emergency room visits by the uninsured, as they will have access to more cost effective channels of treatment. Also, the uninsured will

In California something like 18% of drivers are uninsured, despite an easily enforced mandate that every driver carry insurance. Does anyone think that compliance with the healthcare insurance mandate will be higher? Let's face it, the uninsured tend to be marginalized, irresponsible, and feckless. Add to that the illegal immigration dimension -- I suspect a lot of uninsured California are either illegal immigrants or the citizen children of illegal immigrants . Why would folks unconcerned with immigration and work eligibility laws suddenly comply with another government mandate?

Those who think that mandatory health coverage will help recover a significant cost of treating the uninsured are likely to be deeply dissappointed.

Dean Coonradt

Though the article made passing mention of putting caps on malpractice awards--and even then questioned it's possible effectivness--it is clear there is too little consideration of legal reform as a way of reducing health care costs. Lawyers (and greedy clients) need to be reigned in. If you have not been the victim of a frivolous lawsuit, you certainly know someone who has. It didn't used to be that way. Insurance companies are seen as targets out of which to wring the largest possible awards for real or imagined wrongs. Everyone pays for this in the form of higher premiums and unecessary lawsuit-shielding medical procedures ordered by doctors who (understandably) don't want to be sued. We all know why this issue is left out of the national health care bill: personal-injury lawyers are a lucrative source of campaign contributions for democratic politicians who don't want to kill the golden goose. The fact that legal reform is not addressed in the health care bill makes the effort cynical and insincere. The whole thing should be scrapped.

Jerry Klein

'Communal insurance' is about access, not cost containment. I agree that the mandate shouldn't be enforced by the federal government, but by the healthcare industry. If you have no insurance and go to a doctor you should be charged so much that you'd actually prefer to have insurance. Leave it up to the industry to figure out the cost details, just enforce the no denials policy on the federal level. If you lose one kind of coverage and get another you shouldn't be penalized, but if you never carry any kind of coverage you deserve to be bankrupted when you need expensive healthcare.

Jerry Klein

Andrew, you seem to ignore the fact that a sick person who loses employment today has no viable coverage options. You call it an inconvenience, as if it's that person's fault for getting ill. I repeat, not exactly a humanist position. No one is asking to enslave anyone, just decouple medical insurance from employment.

Jon Healey

@Dean -- California has tough caps on malpractice awards, so why isn't healthcare cheaper here, or healthcare inflation lower than in other states? That's what I meant by it not being clear that damage caps are the answer.

andrew nelson

@Jon -- California's HUGE underground economy (that has been employing illegal aliens for decades) has never, ever, provided employment insurance. The simple fact is that the reason health care is so expensive, here, is because of the cost shifting necessary to provide health care to those here illegally, or irresponsibly.

@Jerry -- Democrats coupled medical insurance with employment because, back in the day, everyone worked, and it was the constitutional way to regulate interstate commerce (i.e. that was the way to constitutionally force a large segment of the population to do it). You have COBRA, expensive, in between jobs, as an incentive to find work. If you are long time unemployed you can go on welfare, and receive medicaid, until you find a job. Or people work, without insurance, all the time. They simply factor in their private policy insurance fees in their negotiations with their employers.

I am extremely comforted that you don't want to enslave anyone. I am comforted that you are not asking to enslave health care providers by forcing them to take lower fees, but still do the same work, 'voluntarily'. I am also comforted that you are not going to force me to buy insurance if I don't want to work. I am also comforted that you will not send the IRS after me to monitor my individual health care decisions. I am also comforted that you will not fine me, if I don't want to buy insurance. I am also comforted that you will NOT JAIL ME if I don't pay the fine for not buying the insurance. So then I will not have to be a slave to your idea of convenient health care.


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