I do not understand why we assume that more money (higher taxes) are needed. There are many countries in the world that do better than the US at much lower cost. If we do health care reform correctly, we SAVE money. Given that there are three main causes of high costs in the US healthcare system (high administrative costs; excess and unnecessary care; and high prices), this is not rocket science, although it might be rocket politics.
Barbara Starfield
-----Original Message-----
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On Behalf Of Shirley Johnson-lans
Sent: Friday, August 21, 2009 1:34 PM
To: [log in to unmask]
Subject: Re: Obama's moral sentiments
Stephen,
It seems to me that whether it is a zero sum game depends on whether there can be net gains from reorganizing the health care industries for great efficiency in the production and distrubtion of health care and whether voters will support higher taxes (not completely offset by lower private insurance costs).
Shirley
----- Original Message -----
From: Stephen Birch <[log in to unmask]>
To: [log in to unmask]
Sent: Thu, 20 Aug 2009 20:25:16 -0400 (EDT)
Subject: Re: Obama's moral sentiments
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<DIV dir="ltr"><FONT face="Arial" color="#000000" size="2">Looking from afar with a considerable level of ignorance about the details - is this a zero sum game, given the constrained real health care resources in US? So if access to health care is to be increased for some (many) does this also mean reducing access to care for others (e.g., increased waiting times for elective procedures for those currently with insurance cover)? I have no doubt that there is a strong feeling among the US population that something should be done about ensuring better access to care for the currently uninsured and underinsured but does this 'something' include accepting (longer) wait times for one's own care? </FONT></DIV>
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<FONT face="Tahoma" size="2"><B>From:</B> Anglo-American Health Policy Network on behalf of Marmor, Ted<BR><B>Sent:</B> Thu 20/08/2009 16:14<BR><B>To:</B> [log in to unmask]<BR><B>Subject:</B> Re: Obama's moral sentiments<BR></FONT><BR></DIV>
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<P><FONT size="2">To George/Shirley and others:<BR><BR>George,<BR><BR>The search for a single, powerful explanatory element is, I think, likely to be misleading. I share your view that Obama has been up to now technocratic in orientation and vague as to the reasons one should care about an overhaul of American health care and why any particular reform package serves those important ends. Instead, he and the Congressional leaders have been uttering slogans like affordable health care for every American even though the means to those vague ends are unspecified and, when suggested, are not very persuasive. <BR><BR>As Oberlander and I tried to argue in a recent piece for the New York Review of Books, the problems identified are very broad, but neither the priorities among competing values nor the basis for the hybrid plan have been communicated simply. Compare that with Medicare in 1965, where the target group was clear, the financing method (FICA) was fundamental and broadly legitimate, and the reasoning was easy to follow: the old use medical care more than other age groups, their access to insurance is either blocked or so expensive it is beyond the reach of all but a few percent. So, that mode involved a consistent portrayal of what group was to be the beneficiary, what sources of finance were legitimate (even if rejected by orthodox Republicans and conservative Democrats anxious to restrain public programs) and the goal was democratizing the retirees access to financial security that the working population largely had.<BR><BR>This current reform effort takes its message from the Clinton debacle and wanted to avoid it by reversing on all major counts. The Obama Administration--as illustrated by the Daschle book (Critical)--began with a public/private commitment, the avoidance of budget limits or caps on expenditures, and the embrace of cost control through quality improvement, not countervailing purchasing power. This effort at bipartisan consensus around problems and a search for common ground on remedies was bound to fail, given the ideological distance between core Democrats and anyone to the right of Olympia Snowe<BR><BR>Or so I believe. If you ask what it would have meant if social insurance reformers like Robert Ball had been Obama's strategists, it is likely they would have counseled a) there is no magic in the first year on this kind of issue; b)you need to elect the Congress that agrees with the core of your commitments, as happened in 1964-5; and even then surprises will arise, as with the addition of Medicaid and physicians' coverage Part B in 1965. But few in the current administration even know about these developments.<BR><BR>How does that connect to your solidarity concern or Shirley's emphasis on the worries of Americans about how big change will help or hurt them? The common element is the absence of a clear, concise statement of why it is necessary to change so much to get inflation under control, access expanded, and to do so without driving doctors, nurses, and hospitals to despair. That has not been done; it is not so much that we fail to hail solidarity as we have witnessed the weakness of technocratic reform in the face of ideological objection, material stakes that are willing to do anything to protect those interests, and a sophistication of distributing lies that we have come to call Swift-boating. That is quite enough, given this Congress, to make resorting to reconciliation necessary unless one is willing to take any despite many offered deals. <BR><BR>My slogan would be simple: if what is doable is desirable, do it. If what is worthy is not doable, wait until it is or take steps that move towards the goal clearly. If what is doable is not worthwhile, don't do it and try to fool the country that a good reform has taken place. The experiment in Massachusetts shows that subsidies and requirements can expand coverage; it does not show that cost control follows from insurance law reform.<BR><BR>George---you raise major issues, for which thanks. I do not think you simplistic at all, and would welcome further discussion.<BR><BR>Ted marmor<BR><BR><BR><BR><BR><BR>Message-----<BR>From: Anglo-American Health Policy Network [<A href="mailto:[log in to unmask]" target="_blank">mailto:[log in to unmask]</A>] On Behalf Of Shirley Johnson-lans<BR>Sent: Thursday, August 20, 2009 1:14 PM<BR>To: [log in to unmask]<BR>Subject: Re: Obama's moral sentiments<BR><BR>Dear George,<BR> I think your basic insight is sound. However, I am less optimistic than you about reforming the underlying social ethos, the "hearts and minds" and therefore think that other, more nitty-gritty, aspects of the proposed reform that middle-class insured folks are being made to believe will personally hurt them, need to be addressed.<BR><BR> Right now, most importantly, people need to know that the proposed reform is mostly about what kind of insurance options will be available and how insurance coverage for the currently un- or under-insured will be financed and that the provision of health care by physicians and hospitals (for those who currently have access through private insurance) will not change much, if at all. They also need to know that without reform their own employment-based insurance will become more expensive, less inclusive, and that their employers will undoubtedly shift more of the (direct) financial burden onto them. They need to know that for them, and for their employers (particularly if they are small or middle sized businesses......including non-profits like colleges and universities) the public option could provide better coverage at lower cost.<BR><BR> As a personal disclaimer re. where I stand politically: I'm personally persuaded that we also need to reform the way health care providers are paid and the way health is delivered, but that isn't a major part of what is currently being debated, though it may be aided by a reform of the insurance system. I've lived in the UK both as a grad. student and as a visiting professor with small children. In both cases, my family and I had excellent health care from caring physicians. But of course we were living in communities with university medical centers, which always helps! So I'm one of those "political centrists" who, when it comes to health care, thinks that a single-payer system is fine and that allowing private supplementary health insurance is also probably necessary. I also think that gradually moving to primarily salaried health care providers is fine. But that requires us to figure out a way to train physicians without them ending up with the levels of personal debt which then become the justification for high-priced fee-for-service medical care.<BR><BR>SJL<BR><BR><BR>----- Original Message -----<BR>From: George France <[log in to unmask]><BR>To: [log in to unmask]<BR>Sent: Thu, 20 Aug 2009 12:43:26 -0400 (EDT)<BR>Subject: Obama's moral sentiments<BR><BR>In an article by Jeff Zeleny and Carl Hulse in the electronic edition of the NYT of 20 August, President Obama is reported to have pleaded with a multi-denominational assembly of religious leaders to support his health care plan, describing the debate as a "core ethical and moral obligation".<BR><BR>Comparing health care financing systems in mature federations, one reading of the evidence is that the principal independent variable contributing to explain America's problem of uninsurance and under-insurance may not be the specific character of its political and governmental/federal arrangements nor how powers are allocated there between governments nor even poorly specified citizens' rights to health care. Rather the root problem may be the "qualified" character of sentiments of social solidarity still held by Americans and their representatives. Citizens of other nations tend to be less begrudging and more consistent in how they treat their fellows while US society is still prisoner of the (19th century) logic of "deservingness".<BR><BR>Referring to George W. Bush and his tax cuts, Uwe Reinhardt wrote scathingly of the "leadership's moral sentiments regarding the plight of the uninsured". If social solidarity is an important policy variable, perhaps convincing a majority of citizens to share the moral sentiments of the Obama administration is crucial for the success of health care reform.<BR><BR>Terms like "moral sentiment" and "social solidarity" are slippery and not very scientific, but in the last analysis they may be what the reform is about. If the President and his aides concentrate on tecnical questions in the public debate rather than on its ethical foundations, perhaps we shouldn't be surprised if the average man in his home entertainment room wearily switches off the news channel and reaches for a DVD and a six-pack.<BR><BR>I think my point is that we tend to appeal to ethics and social justice at the very beginning of the policy design stage and thereafter such considerations tend to be taken for granted. What do others think about this? Is there a change of strategy by Obama and even if there is, does it really matter? Or am I merely being simplistic here or stating the obvious?<BR><BR><BR><BR>Best regards,<BR><BR><BR><BR>George France<BR></FONT></P></DIV></BODY></HTML>
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