Hi Barbara
 
Thanks for your message. I provide some answers below, which I'll copy to the whole list in the hope that people far better informed than me will be able and willing to contribute to the discussion. 

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From: Anglo-American Health Policy Network on behalf of Starfield, Barbara
Sent: Sun 25/01/2009 5:41 PM
To: [log in to unmask]
Subject: Re: Obama's pre-election plan



Hi Adam:

Thanks for sending your commentary, which was very in formative.   I too have written one---for JECH---and attach it for your interest.(It is a pdf of the proof so it has some editorial stuff at the beginning, which I cannot figure out how to delete--sorry)  I believe that our agreement is substantial.

Your paper repeats what I recently read in a Lancet commentary on 'chronic illness'---that Obama is proposing to  improve primary care, public health, and prevention.  I failed to find these in anything I read about his proposals and wondered where you got it from?  I'd love to see how he phrased it, as the only thing I am aware of is the focus in 'disease-management' (which is the antithesis of primary care).

I think I read these in a table provided by the Kaiser Family Foundation. I think (but am just guessing) that Obama's public health proposals are tied in to libertarian paternalism. This is convenient, as his former colleague, Cass Sunstein, has just been appointed to a very senior position in the Adminstration, and I believe that his other former colleague, Richard Thaler, is serving as an informal advisor (I could be wrong about this last point though).    


Other questions, for my information.
1. I was  glad to have the reference to your paper on the VA. Do you know what is the Administrative overhead for the VA?
You may be aware that there is a campaign to discredit the Woolhandler/Himmelstein figures on administrative overhead in the US health services system; everyone agrees that insurance company overhead is about 7%; to this, Steffie and David add the huge costs associated with individual billing, to come to a total of at least 20% and as much as  third of total costs. What is it in the VA?  Also, at the end of your second paragraph of Controlling Costs, you refer to 'elsewhere' and the reference is to your VA article. Does 'elsewhere' mean the VA?

I'm not sure about admin overhead in the VHA, but it is a good question. You might ask Paul Schekelle at UCLA. I would be surprised if it much exceeded 5%. I personally think that the W/H figures are a bit extreme, although I do sympathise with their sentiment. The reason I think they are a little extreme is because their estimate for 'excess' admin in the US exceeds the total NHS spend - that is to say that the US may be able to give their uninsured an NHS-type service (if appropriately organised and priced - like the VHA for example), if they removed excess admin costs. This doesn't sound quite right to me, although admin costs in the US, I'm sure anyone outside the Wharton School might agree, are excessive. 

On the point about league table competition (the 'elsewhere' bit), the NHS has also had some success here. I personally believe this is one of the great overlooked potentialities for improving health care systems (it involves supply side competition, but not demand driven choice - most people seem to inaccurately bundle competetion and choice together). Gwyn Bevan has written some things about it vis-a-vis the NHS. 

2. In the second paragraph of Expanding Coverage, you mention two things, the second one as a "moreover'. Isn't this "moreover' part of the mechanism of the National Health Insurance Exchange idea, since how else (besides instituting a competitive  government program) could one persuade insurance companies to participate in an 'exchange'?

Not sure which bit you mean here. The second para 'moreover' bit of the expanding coverage section relates to the catastophic cost coverage proposal does it not? - this could stand outside the National Insurance Exchange idea I think. 


Very best wishes, 

Adam

 


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