Health Care Debate
Thu, 08/27/2009 - 6:58am
Lies of Mass Destruction
The same skewed thinking that supports a Saddam-9/11 link explains the power of health-care myths.
Aug 25, 2009
Not being a complete idiot (contrary to the assertion of many readers I've been hearing from), I was not exactly surprised at the e-mails I got in response to my story analyzing why the myths about health-care reform—even the totally loony ones, like death panels—have gained such traction. One retired military officer called me "nothing more than an 'Obama Zombie' that has lost touch with reality," while a housewife sweetly suggested that I sign up for "socialistic medicine" and die, the sooner the better. (My kids get upset when people wish me dead, but hey, they'll survive.) But now I think I understand people who believe the health-care lies—and the Obama-was-born-in-Kenya lie—even better than when I wrote that piece.
Some people form and cling to false beliefs about health-care reform (or Obama's citizenship) despite overwhelming evidence thanks to a mental phenomenon called motivated reasoning, says sociologist Steven Hoffman, visiting assistant professor at the University at Buffalo. "Rather than search rationally for information that either confirms or disconfirms a particular belief," he says, "people actually seek out information that confirms what they already believe." And God knows, in the Internet age there is no dearth of sources to confirm even the most ludicrous claims (my favorite being that the moon landings were faked). "For the most part," says Hoffman, "people completely ignore contrary information" and are able to "develop elaborate rationalizations based on faulty information."
His conclusions arise from a study he and six colleagues conducted. They were looking at the well-known phenomenon of Americans believing that Saddam Hussein was involved in the 9/11 attacks. Some people, mostly liberals, have blamed that on false information and innuendo spread by the Bush administration and its GOP allies (by former members of the Bush White House, too, as recently as this past March). (As Dick Cheney said in June, suspicion of a link "turned out not to be true.") But the researchers think another force is at work. In a paper to be published in the September issue of the journal Sociological Inquiry(you have to subscribe to the journal to read the full paper, but the authors kindly posted it on their Web site here), they argue that some Americans believe the Saddam-9/11 link because it "made sense of the administration's decision to go to war against Iraq . . . [T]he fact of the war led to a search for a justification for it, which led them to infer the existence of ties between Iraq and 9/11," they write.
For their study, the scientists whittled down surveys filled out by 246 voters, of whom 73 percent believed in a Saddam-9/11 link, to 49 believers who were willing to be interviewed at length in October 2004. Even after the 49 were shown newspaper articles reporting that the 9/11 Commission had not found any evidence linking Saddam and 9/11, and quoting President Bush himself denying it, 48 stuck to their guns: yup, Saddam Hussein, directly or indirectly, brought down the Twin Towers.
When the scientists asked the participants why they believed in the link, they offered many justifications. Five argued that Saddam supported terrorism generally, or that evidence of a link to 9/11 might yet emerge. These counterarguments are not entirely illogical. But almost everyone else offered some version of "I don't know; I don't know anything"—that is, outright confusion over the conflict between what they believed and what the facts showed—or switched subjects to the invasion of Iraq. As one put it, when asked about his Saddam-9/11 belief, "There is no doubt in my mind that if we did not deal with Saddam Hussein when we did, it was just a matter of time when we would have to deal with him." In other words, holding fast to the Saddam-9/11 belief helped people make sense of the decision to go to war against Iraq.
"We refer to this as 'inferred justification,'" says Hoffman. Inferred justification is a sort of backward chain of reasoning. You start with something you believe strongly (the invasion of Iraq was the right move) and work backward to find support for it (Saddam was behind 9/11). "For these voters," says Hoffman, "the sheer fact that we were engaged in war led to a post-hoc search for a justification for that war."
For an explanation of this behavior, look no further than the psychological theory of cognitive dissonance. This theory holds that when people are presented with information that contradicts preexisting beliefs, they try to relieve the cognitive tension one way or another. They process and respond to information defensively, for instance: their belief challenged by fact, they ignore the latter. They also accept and seek out confirming information but ignore, discredit the source of, or argue against contrary information, studies have shown.
Which brings us back to health-care reform—in particular, the apoplexy at town-hall meetings and the effectiveness of the lies being spread about health-care reform proposals. First of all, let's remember that 59,934,814 voters cast their ballot for John McCain, so we can assume that tens of millions of Americans believe the wrong guy is in the White House. To justify that belief, they need to find evidence that he's leading the country astray. What better evidence of that than to seize on the misinformation about Obama's health-care reform ideas and believe that he wants to insure illegal aliens, for example, and give the Feds electronic access to doctors' bank accounts?
Obama's opponents also need to find evidence that their reading of him back in November was correct. They therefore seize on "confirmation" that he wants to, for instance, redistribute the wealth, as in his “spread the wealth around” remark to Joe the Plumber—finding such confirmation in the claims that health-care reform will do just that, redistributing health care from those who have it now to the 46 million currently uninsured. Similarly, they seize on anything that confirms the “socialist” label that got pinned on Obama during the campaign, or the pro-abortion label—anything to comfort themselves that they made the right choice last November.
There are legitimate, fact-based reasons to oppose health-care reform. But some of the loudest opposition is the result of confirmatory bias, cognitive dissonance, and other examples of mental processes that have gone off the rails.
Find this article at http://www.newsweek.com/id/213625
Business Week JULY 9, 2007
HEALTH
Michael Moore's documentary Sicko trumpets France as one of the most effective providers of universal health care. His conclusions and fist-in-your-gut approach may drive some Americans up the wall. But whatever you think of Moore, the French system—a complex mix of private and public financing—offers valuable lessons for would-be health-care reformers in the U.S.
In Sicko, Moore lumps France in with the socialized systems of Britain, Canada, and Cuba. In fact, the French system is similar enough to the U.S. model that reforms based on France's experience might work in America. The French can choose their doctors and see any specialist they want. Doctors in France, many of whom are self- employed, are free to prescribe any care they deem medically necessary. "The French approach suggests it is possible to solve the problem of financing universal coverage...[without] reorganizing the entire system," says Victor G. Rodwin, professor of health policy and management at New York University.
France also demonstrates that you can deliver stellar results with this mix of public and private financing. In a recent World Health Organization health-care ranking, France came in first, while the U.S. scored 37th, slightly better than Cuba and one notch above Slovenia. France's infant death rate is 3.9 per 1,000 live births, compared with 7 in the U.S., and average life expectancy is 79.4 years, two years more than in the U.S. The country has far more hospital beds and doctors per capita than America, and far lower rates of death from diabetes and heart disease. The difference in deaths from respiratory disease, an often preventable form of mortality, is particularly striking: 31.2 per 100,000 people in France, vs. 61.5 per 100,000 in the U.S.
That's not to say the French have solved all health-care riddles. Like every other nation, France is wrestling with runaway health-care inflation. That has led to some hefty tax hikes, and France is now considering U.S.-style health-maintenance organization tactics to rein in costs. Still, some 65% of French citizens express satisfaction with their system, compared with 40% of U.S. residents. And France spends just 10.7% of its gross domestic product on health care, while the U.S. lays out 16%, more than any other nation.
To grasp how the French system works, think about Medicare for the elderly in the U.S., then expand that to encompass the entire population. French medicine is based on a widely held value that the healthy should pay for care of the sick. Everyone has access to the same basic coverage through national insurance funds, to which every employer and employee contributes. The government picks up the tab for the unemployed who cannot gain coverage through a family member.
SAFETY NET But the french system is much more generous to its entire population than the U.S. is to its seniors. Unlike with Medicare, there are no deductibles, just modest co- payments that are dismissed for the chronically ill. Additionally, almost all French buy supplemental insurance, similar to Medigap, which reduces their out-of-pocket costs and covers extra expenses such as private hospital rooms, eyeglasses, and dental care.
In France, the sicker you get, the less you pay. Chronic diseases, such as diabetes, and critical surgeries, such as a coronary bypass, are reimbursed at 100%. Cancer patients are treated free of charge. Patients suffering from colon cancer, for instance, can receive Genentech Inc.'s (DNA ) Avastin without charge. In the U.S., a patient may pay $48,000 a year.
France particularly excels in prenatal and early childhood care. Since 1945 the country has built a widespread network of thousands of health-care facilities, called Protection Maternelle et Infantile (PMI), to ensure that every mother and child in the country receives basic preventive care. Children are evaluated by a team of private-practice pediatricians, nurses, midwives, psychologists, and social workers. When parents fail to bring their children in for regular checkups, social workers are dispatched to the family home. Mothers even receive a financial incentive for attending their pre- and post-natal visits.
A typical PMI can be found in Goutte d'Or, a poor neighborhood at the foot of Montmartre that has been home for the past 20 years to a swelling population of immigrants from Africa and Southeast Asia. On Rue Cavé, a tidy modern building is given over entirely to caring for expecting mothers, infants, and young children. The place usually is bustling with kids scrambling over toys, while mothers, often immigrants in colorful headdresses and with babies strapped to their backs, talk to their doctors as part of twice-monthly evaluations.
PMI and other such programs are starting to get attention in U.S. health-care circles. "If we really want to ensure that no child is left behind, then the PMI system is a good way to do it," says Daniel J. Pedersen, president of the Buffett Early Childhood Fund. "It's based on the practical idea that high-quality investments made at the start of a child's life will pay huge dividends to both the child and society in the future."
To make all this affordable, France reimburses its doctors at a far lower rate than U.S. physicians would accept. However, French doctors don't have to pay back their crushing student loans because medical school is paid for by the state, and malpractice insurance premiums are a tiny fraction of the $55,000 a year and up that many U.S. doctors pay. That $55,000 equals the average yearly net income for French doctors, a third of what their American counterparts earn. Then again, the French government pays two-thirds of the social security tax for most French physicians—a tax that's typically 40% of income.
Specialists who have spent at least four years practicing in a hospital are free to charge what they want, and some charge upwards of $675 for a single consultation. But American-style compensation is rare. "There is an unspoken and undefined limit to what you can charge," says Dr. Paul Benfredj, a gastroenterologist in Paris.
Many French doctors, in fact, earn more by increasing their patient load, or by prescribing more diagnostic tests and procedures—a technique, also popular in the U.S., that inflates health-care costs. So far France has been able to hold down the burden on patients through a combination of price controls and increased government spending, but the latter effort has led to higher taxes for both employers and workers. In 1990, 7% of health-care expenditures were financed out of general revenue taxes, and the rest came from mandatory payroll taxes. By 2003, the general revenue figure had grown to 40%, and it's still not enough. The French national insurance system has been running constant deficits since 1985 and has ballooned to $13.5 billion.
That's why France is gearing up to make changes. It already requires patients to register with a general practitioner before visiting a specialist, or else agree to a lesser reimbursement, much like many U.S. insurance plans. But France isn't likely to make major changes to a system most citizens say they like. Why would they? Says Shanny Peer, policy director at the independent French-American Foundation: "France gets better results for less money and everyone is covered."
For interesting readers' comments on this piece, see
http://www.businessweek.com/magazine/content/07_28/b4042070.htm
The White House expressed surprise last week that the "left of the left" had clung so forcefully to the public insurance option as a must-have element of health care reform. Some old hands in the administration were more likely surprised by the simple fact that, at this late stage, they still have to deal with progressives in Congress.
And who can blame them?
"We're the group that speaks to the righteousness of an issue, [but] inevitably the decisions about how that issue's going to be addressed are conducted somewhere else," said Rep. Raúl Grijalva (D-Ariz.), describing the traditional fecklessness of progressives in Congress. "The fact that we have stuck to our guns about the public option has surprised people."
A majority of the 81 Congressional Progressive Caucus members of the House have vowed to oppose any health care bill that does not include a "robust public option." That threat has kept it alive. With 256 seats in the House and 218 needed to pass a bill, Democrats simply can't move health care reform on their own without progressive caucus support.
The question facing the White House and congressional leadership: Just how serious are they? Interviews with CPC leaders and a look at the group's behavior suggest that leadership would be well advised to consider the threat real.
House Speaker Nancy Pelosi (D-Calif.) has repeatedly acknowledged the reality that the progressives can block the bill. In June, she was asked by HuffPost if she would allow health care reform without a public option to pass the House.
"It's not a question of allow. It wouldn't have the votes," she said. When the White House went squishy last week on the public option ("not essential"/"one sliver"/"a piece"), Pelosi returned to the basic calculus. "There's no way I can pass a bill in the House of Representatives without a public option," she said.
The strong House stand promises an end to the lower chamber's traditional role of Senate spectator - where the wise "centrists" in the august body craft compromise legislation and present it to the House as a fait accomplis.
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Until recently, reporters on Capitol Hill almost never found themselves typing the words "Congressional Progressive Caucus."
Raúl Grijalva's honed his politics in the Arizona desert, where he organized on behalf of the creation of community health centers.
"A good community organizer develops a high degree of codependency," said Grijalva. "You're codependent on the people you're working with. You're codependent on other organizations to help you. You're codependent on other members of the leadership team to do their part and so you learn to work both in the background and in front."
In March, Grijalva did something unusual for the progressive caucus: he began organizing. Caucus leadership sent a questionnaire asking members if they would be willing to oppose any health care bill that didn't include a public option. A majority said they would.
Attendance at caucus meetings - which had dipped to just a handful of members - began rising as the group hashed out what message to deliver to House leadership.
"I really felt that we needed to be righteous about the things that we believe in, but we also needed to practice the craft a little better," said Grijalva. "As a bloc we were getting beaten to the punch all the time."
If the CPC is the conscience of the Democratic Party, Rep. Barbara Lee (D-Calif.) has long been the conscience of the CPC. The only member to vote against using force against Afghanistan after 9/11, Lee has taken stand after losing stand on behalf of the dispossessed and disenfranchised. She stepped down as progressive caucus co-chair - where she had served alongside outspoken progressive Lynne Woolsey (D-Calif.) -- at the end of last year to take the helm of the Congressional Black Caucus.
Grijalva and sophomore Rep. Keith Ellison (D-Minn.) ran to fill Lee's spot. Both argued that the caucus needed to become relevant by taking strong and unified positions, a model that the Blue Dog Coalition had perfected since it formed in 1995.
"Quite frankly, we got motivated because there were other caucuses in the Democratic caucus who seem to get disproportionate attention based on their numbers," said Ellison. The Blue Dogs only number 51. "And we're like, wait a minute, we've got 80-plus members. How can we be ignored?"
Ellison's stature has risen quickly in House, where his sharp cross-examination of Bush administration officials' testimony and eloquence on the House floor has been quickly noticed.
Woolsey and Grijalva were elected co-chairs, with Ellison finishing third. "On an individual basis, progressive caucus members have always been a force within the caucus," said Ellison. "The difference here is how we have coalesced and hung together."
Like any institutional change, this one wasn't easy. "There was a comfort zone in being, 'Okay, we're going to do our alternative budget and that was the whole effort for the whole year. Wonderful, but at the end of the day, what?" said one member, who spoke not for attribution so as not to offend caucus members who are deeply invested in creating the progressive's alternative budget - an exercise that is almost completely ignored by the media and has no impact on the actual budget.
"The change to this attitude wasn't easy internally within the caucus," said the member.
For Woolsey, it's the issue that allows the caucus to stand unified. "It's the issue. We agree on this," she said. "We have never had the luxury of saying, 'Either go with us, or we'll go with the Republicans. We don't believe what the Republicans stand for at all. So it's been more difficult when Bush ran the White House. Nor have we had the majority of the progressives drawing a line in the sand as they are now."
Ilyse Hogue of MoveOn.org said that the ability of the progressives to identify the public option as the element to organize around has made their tough stand possible. "One of the things that we have typically seen from progressive members is a willingness to fight, but to fight on 18 fronts," she said. "They're unified around the public option. A single ask gives them legislative power."
In April, the message was delivered to leadership, which asked what elements of a public option must be included. Again, the progressives did something unusual: they turned to outside groups for help.
"Members of the progressive caucus began to hire people that were part of the progressive movement," said Ellison. "I got to congress in 2007. If you look at the level of connection between where we were when I got there and where we are now, I'm pretty hopeful about the prospects for a progressive future."
Ellison cited Rep. Alan Grayson's (D-Fla.) hiring of prominent blogger Matt Stoller. "He brings all of his perspective and his technical expertise with him," said Ellison.
The caucus also brought on Darcy Burner to help with outreach to progressive groups. Burner had twice run for Congress and is a hero of the Netroots community of bloggers and activists. She arranged for Jacob Hacker, the intellectual architect of the public option, and Diane Archer co-president of the Health Care for All Project, which is run by the Institute for America's Future, to brief the caucus.
With their help, the CPC developed a list of elements of a public option that must be included - and fit it all on one page, another feat.
On June 23rd, about two weeks after Pelosi said that health care reform wouldn't have the votes without a public option, the blog FiretDogLake.com began its own whip count of progressive members to put them on the record.
In July, an internal whip count was leaked to DailyKos that listed some 50 names of members who had taken the pledge to oppose a health care bill that didn't include a public option. Rep. Diane Watson (D-Calif.) is in charge of keeping the whip count for the CPC. Her spokeswoman, Dorinda White, confirmed to HuffPost that the list was accurate and had since only grown longer. FireDogLake, however, was unable to get the 50 members to confirm their position on the record, calling their commitment into question.
"We figured it was pretty unlikely they'd stand up for it in conference if they wouldn't even confirm it publicly," said FireDogLake founder Jane Hamsher.
The first test came in the Energy and Commerce Committee, where Blue Dogs held up a final vote in an effort to wrangle concessions from Chairman Henry Waxman (D-Calif.), himself a progressive caucus member.
On July 29, after days of delay, Waxman reached a deal to move the bill through the committee that would decouple the public option from Medicare's reimbursement rates - an element progressives consider crucial in getting the public plan on its feet.
Woolsey called the deal unacceptable. That evening 30 caucus members showed up for a meeting and decided to circulate a letter opposing the agreement and reiterating their stand. The next day, the letter was out, with 57 signatures (it would grow to 60 in a few days) - warp speed for the slow-moving CPC.
The caucus also reached out to MoveOn.org, which notified its members of the letter and encouraged folks to go to the press conference announcing it. "We let [our members] know there were people standing up for them," said MoveOn's Ilyse Hogue. "Looking from the outside in, I'm definitely seeing an increased understanding of the power progressives can wield on the inside working in coordination with outside progressive forces."
"There are certainly some of us who have come from those outside groups and have made a point in increasing communication with the outside groups," said Rep. Donna Edwards (D-Md.), a caucus vice-chair who previously worked for Public Citizen and The Arca Foundation, among others.
Three House committees have passed health care bills, which will be merged into one. Progressives are now pushing to strip the Energy and Commerce deal with Blue Dogs from the final package. Enough Blue Dogs back the public option that Democrats have enough votes to pass it on the House floor.
That's what Pelosi wants. "She told us," said Ellison. "'I myself am not in favor of a plan without a public option, so you guys we consider allies in this thing."
"I don't care what their deal was in Energy and Commerce," said Grijalva. "It's not binding on us and the difference between the progressive caucus and the Blue Dogs is that we deliver votes. They don't."
The conventional wisdom says that the public option will be removed in conference committee negotiations between the House and the Senate, perhaps replaced by a cooperative model. Progressives have reiterated in a letter signed by 60 members that their pledge includes the vote on the final conference package.
"We've done our compromising and we're not compromising any more. We've got our shot. Let somebody else show some flexibility now," said Ellison.
Hamsher and other bloggers are working to put the members' commitment on the record so that they can be rewarded if they follow through and punished if they don't.
"The key is carrots and not just sticks," said DailyKos contributing editor Joan McCarter, who broke the original whip list. "I am pleased to see them have this much backbone and probably like everyone else a little uncertain they can keep it up. But they're committed now."
The bloggers, with the help of MoveOn, launched a fundraising effort to thank the members who had taken the pledge. In just a few days, it raised more than $400,000 from nearly 7,000 donors.
"I think it's amazing," said Edwards. "I have been buoyed by the outpouring of support from outside groups."
Now that the progressives have dug in, they risk being rolled back into the wilderness if they cave. If they succeed in driving the bill left, however, they'll firmly establish their power in Congress.
Grijalva said he and others been eying the health care fight as a chance to establish the authority of caucus since the beginning of the year. "People have understood that this was not only a value statement that we had to stick to, but it was also, to put it in a really blunt sense, an opportunity to show that the caucus was going to be a real player in how policies get shaped and that's what we're trying to do," he said.
If they don't, watch out. "The progressives aren't actually bluffing," said Darcy Burner. But, she added, "If the House gets rolled, that sets a problematic precedent."
Individual members could be targeted. "Nobody ever talks about primarying progressives, but I could see it this time around," said McCarter. Hamsher said she would "absolutely" support primary challenges of progressives who broke their pledges.
As the prospect of a bipartisan bill fades, progressives hope their hand will be increasingly strengthened as Obama realizes where his allies are. "The White House does not know how to use the progressive community. They see us as kind of money in the kitty already," said Ellison. "The White House should be saying to the Blue Dogs and to the right wing, 'I cannot give you what you want because I have a progressive community that we're accountable to.'"
The key, said Ellison, is to keep that community organized. "We've got to get comfortable being in power and realize that power is not a bad thing," he said.
But even Edwards hedged a bit when asked by HuffPost if she was firm in her commitment to oppose a bill that comes out of conference without a public option.
"Let me just say this," she said. "I believe that there is widespread support for the public option, so I want to discuss how we get from the politics of where we are right now to achieving the thing that we know is widely supported in the Democratic caucus and also widely supported around the country. And I don't think you do that unless you get a bill out of the House of Representatives that has a solid public option in it, because you don't bargain the opposite direction in the Senate. So we need to make sure we have the strongest bill possible out of the House of Representatives. I know that there's support for the public option and I fully expect that to be a part of the bill that we pass out of the House. And that in itself will be the leverage to achieve it in the final product."
Ryan Grim is the author of This Is Your Country On Drugs: The Secret History of Getting High in America
September 29, 2009, 5:00 pm — Updated: 6:56 pm -->
Health Care Abroad: Germany
By Anne UnderwoodUwe E. Reinhardt is a professor of health economics at Princeton University and a former president of the Association of Health Services Research. He is also a member of the Institute of Medicine of the National Academy of Sciences, a board member of the Journal of the American Medical Association and a contributor to The Times’s Economix blog. His research has compared health care in the United States to that in other countries, including his native Germany. He spoke with freelance writer Anne Underwood.
Is it true that the concept of health insurance originated in Germany in the 1880s?
BY THE NUMBERS
Germany
Source: World Health Organization. U.S. statistics.
During the Industrial Revolution, workers who got sick didn’t earn money, so they formed what they called “friendly societies.” These were cooperatives into which workers paid monthly premiums, pooling their resources so they could continue the cash wages of workers who got sick. Those cooperatives became what are now called “sickness funds” in Germany.
Around the same time, Karl Marx and Friedrich Engels were stirring up the masses with their tracts, including “The Communist Manifesto.” To Otto von Bismarck, the so-called Iron Chancellor of Germany, it seemed that the only way to stop the growth of communism was to take the wind out of its sails by giving low-income people the things they craved — health care, education and a social safety net in general. So in 1883, he passed the Imperial Insurance Order — in German, the Reichsversicherungsverordnung, or R.V.O. — which made it mandatory that all workers up to a certain income threshold pay premiums to such sickness funds. The R.V.O. still governs German health care, although it’s had a thousand amendments in the meantime.
During World War II, Hitler exported the system to the Netherlands, Belgium and France. It’s now generally called the Bismarck Model, to distinguish it from other forms of social health insurance, such as the British National Health Service. The Bismarck model was so popular that after the war, even though it came from Hitler, these countries kept it.
So Bismarck’s system was the world’s first real insurance system?
It was the first formal social health insurance system, yes — the first government-regulated system. I believe it is still the best model there is, because it blends a private health-care delivery system with universal coverage and social solidarity. The financing is simple. It’s inexpensive and equitable. Coverage is portable. You’re never uninsured in Germany. No family goes broke over health care bills.
This is based in the workplace. Does it amount to an employer mandate?
Not exactly. Formally, employers pay half of the premium and workers pay the other half — although economists would argue that the premium is entirely taken out of the workers’ take-home pay. But the mandate to be insured is really on the individual. Each worker chooses a sickness fund.
In the United States, employers have a larger role. Employers pick the menu of health insurers from which employees can choose. German employees would take umbrage at that.
How large is the choice of funds?
The sickness funds were originally organized by craft or company or locality. Until 1992, you had no choice. If you were a carpenter, you belonged to the carpenters’ fund. But since 1992, people have been able to choose any of some 200 sickness funds.
What if you’re unemployed?
Unemployment insurance continues your premiums. If you’re poor, the community pays. If you’re retired, the pension fund pays. Children remain in the sickness fund with their parents, but the premium is paid by the federal government.
Does it achieve universal coverage?
100 percent.
What about illegal immigrants, who are the subject of so much debate in this country?
Once you’re in the country, you have rights to all social services.
Are the sickness funds run as for-profit businesses or nonprofit?
They’re all nonprofit companies. There is a separate for-profit industry to which you can belong if your income is above 45,000 euros [about $65,000]. If you’re 33 years old and have a high income, your premium in the private plan is much lower. However, premiums increase with age. And if your income declines, you could be in dire straits. Since 1992, individuals with an income above the threshold who choose to buy private insurance cannot get back into the social insurance system unless they fall below the poverty line. This makes people hesitant to leave the social insurance system.
Is there competition between private and public plans?
Yes, there is, but 90 percent of people are in the public plans. There is competition among the sickness funds, too, now that people can choose.
Many Americans are concerned that if we offer a public option, it will ultimately put private insurers out of business. What does the German experience tell us?
About 10 percent of the population is in for-profit plans, but most people who are entitled to choose such a plan don’t. It’s the same in this country with Medicare. Eighty percent stay in the traditional Medicare plan rather than choosing the private Medicare Advantage. Although the American people appear unaware of it, government is the only institution they really trust deep down.
That’s not what we heard over the summer in the town halls.
It’s utterly ridiculous to say they don’t trust the government. Where do Americans turn for help when they get into trouble? Do they run to the private sector? Even big bankers run to Washington. With a public plan, you would get something like Medicare. Just try taking Medicare away from the elderly. In the decades I have lived here, I have discovered this about America’s legendary rugged individualists: when the going gets rough, the rough run to the government.
Has competition between public and private plans in Germany made the system more efficient?
Competition in health care typically doesn’t make things more efficient. But the German system is more efficient than the U.S. system for other reasons. In Germany, the plans do not individually negotiate prices with individual doctors and hospitals. Instead representatives of each state (or Land) sit across the table from associations of doctors and hospitals and hash out uniform fees that every plan in that state will pay. They don’t waste a huge amount of resources by having each plan negotiate separately with every hospital and doctor.
Are administrative costs lower?
Much lower. I don’t have the exact figure, but it’s about half of what we spend. All billing is done electronically. You have a card, like an American Express card, that you take with you to the doctor. The physician codes in what he did for you, swipes the card, and in two weeks he gets a check. There is no haggling over bills. The patient usually pays a small co-pay. It’s 10 euros or so for the first visit in a quarter. After that, you pay nothing else for the rest of the quarter. It’s trivial.
How much government control is there?
The R.V.O. regulates the sickness funds to the point that they’re essentially uniform. But German hospitals probably have less regulation on them than U.S. hospitals. In the United States, there are multiple layers of regulators each imposing restrictions. The Medicare payment system alone is forbidding with all of its regulations.
Are drug prices regulated?
No. In principle, drug makers are free to price their products for the market. But the sickness funds group drugs into therapeutic groups. Patients have a choice between taking a low-cost drug for which they are fully reimbursed, or paying the difference between the low-cost drug and a higher-priced one in the same category. The system is called “reference pricing,” and it is much hated by drug manufacturers around the world — even though it’s a market system relying on the decisions of patients themselves. Isn’t that what the so-called “consumer directed health care” now being pushed in the U.S. is all about?
Of course, when patients can’t evaluate the different drugs, they tend to stick with the low-cost drugs. Apparently it happens often, because expenditures on drugs are much lower in Germany than the United States.
Are there long waits for service in Germany?
No, basically none.
How does Germany do at controlling costs?
They’re half as expensive as we are on a per capita basis, even though a much higher percentage of the German population is over age 65. Still, Germans lament that growth in medical spending is a problem. I say if we had problems like that, we would drink champagne.
What’s your biggest criticism of the system?
Every system has its weaknesses. I think, for example, lots of care [is] given in Germany — as it is elsewhere — for which we don’t actually know the effectiveness compared to other treatments. There is overutilization of the system. Also, the German system is a bit rigid in its structure, which makes innovation in organizing health care more difficult than it is here.
Is there medical bankruptcy in Germany?
That’s almost impossible. Germany’s benefit package is very broad and deep. If Germans were to go bankrupt on medical bills, it would be from purchasing drugs or services not in that broad benefit package. But I have not ever read of Germans going bankrupt over health care.
What is the most important lesson Americans should learn from the German system?
The K.I.S.S. principle — which stands for “Keep It Simple, Stupid.” If you can do something in a complicated way, trust Americans to discover it — certainly in health care. I was on the phone this morning with a hospital and insurer that were suing each other because the patient had gone to a hospital that was not in the insurer’s network. The hospital was charging the insurer two to three times the negotiated rate the insurer pays for in-network hospitals. Only lawyers can love this system. And it is a safe bet that whatever President Obama and the Congress comes out with this year will be so complicated, no one but a few consultants will understand it — and many of those consultants will be the Hill staffers who wrote the reform law. By comparison, the German system is very simple. Every German knows what health care costs his or her family.
http://prescriptions.blogs.nytimes.com/2009/09/29/health-care-abroad-ger...
Life in one of China's last communes
A look at life inside the Chinese commune village of Nanjie
As China prepares to mark the 60th anniversary of Communist rule, the BBC's Michael Bristow takes a look at one of the country's few remaining communes, a hallmark of the early Communist regime.
In the village of Nanjie in northern China, workers begin the day by singing in praise of the country's former leader Mao Zedong.
More than three decades after his death, Chairman Mao is still remembered fondly across China, but in Nanjie he has a special significance.
The village is one of the country's last remaining communes, where workers still abide by many of the former chairman's principles.
Most communes were disbanded years ago as China's leaders began to turn the country's planned economy into one governed by the market.
But the Nanjie commune is still going strong, providing its residents with their daily needs. Few people want to see it disappear.
Economic disaster
Mother-of-one Hu Xinhe is one of the commune's 4,000 or so permanent residents.
"I feel very relaxed and secure living in Nanjie. Whether we're talking about work or life in general, I'm very satisfied," said the 34-year-old.
As China's Communist Party celebrates 60 years in power this week, it is emphasising the country's bright future.
But this commune is a reminder that some people think the past had much to offer.
Nanjie lies in the rural heartland of Henan province.
Villagers have just harvested their crop of corn, which is currently drying on roadsides and in open spaces around Nanjie.
The commune also has a number of small food-processing factories that make products such as beer, chocolate, hot sauce and noodles.
Some noodles are even sold abroad - to Australia, the US and Canada.
Collective ownership
But there are reminders that capitalist ventures are not the main goal.
A statue of Mao takes pride of place in the village square. It is flanked by giant posters of other communist revolutionaries, such as Lenin and Stalin.
With its clean and tidy streets, Nanjie looks well-ordered and pleasant.
Communes were formed in the late 1950s as Chairman Mao tried to force rural people to live a more communist way of life.
Villagers had to pool their land, animals, tools and crops, and work for the collective.
In the early years, communes proved to be an economic disaster; they contributed to the deaths of millions of people through starvation between 1958-61.
They were finally abandoned in the early 1980s as villagers began to farm their own plots of land.
But a handful of communes - like the one in Nanjie - stayed as they were.
Wang Hongbin, the village's Communist Party secretary, said it had been the people themselves who had not wanted to disband the commune.
"They chose to have collective ownership. And if people want it, we - the party - have a responsibility to carry on with this system," he said.
Struggle to pay
In Nanjie, workers continue to toil for low wages, but in return are provided for in other ways by the commune.
"I earn about 400 yuan a month ($59; £37), but get very good welfare benefits," said Mrs Hu, who works as a quality control inspector in the village condiment factory.
"I get free medical care and housing - even gas, water and electricity are free."
Her son, nine-year-old Wang Haoyuan, also gets free education in the commune's schools. The collective will even pay for him to go to university.
It is this kind of security that makes life in Nanjie commune so attractive.
When China embarked on economic reforms in 1978, many benefits, particularly for China's farmers, disappeared.
They can now sell their own crops for profit, but some still struggle to pay school fees for their children or medical bills when they are sick.
Tens of millions of farmers have decided they cannot make ends meet and have left their villages to seek work in China's booming cities.
Uncertain future
Villagers who live near the Nanjie commune look on with envy at those inside.
One woman, surnamed Liu, said: "Living in Nanjie is so good - everything is supplied by the village. Although their salaries are low, they don't have to worry about other things.
"Our village doesn't give us many benefits, and I can't survive by farming alone."
Nanjie collective does have its critics, some of whom point out that it is not as communist as it makes out.
They claim the commune is in debt and does not treat its outside workers as well as it does permanent residents.
They also point out that it tries to trade on its communist credentials by encouraging tourists to visit.
There is a special hotel for visitors where workers wear military-style uniforms, presumably to reinforce the village's revolutionary history.
But while the commune may have its flaws, the people who live here say they genuinely believe in its aims.
At a time when the wealth gap between rich and poor is rising in China and life is uncertain for many, Nanjie offers the security and certainty of a bygone era.
http://news.bbc.co.uk/2/hi/asia-pacific/8278128.stm
Democratic leaders were forced to include a national public health insurance option as part of health care reform by progressive Democratic senators who refused to support anything less, Senate Majority Whip Dick Durbin (D-Ill.) said on Monday.
Durbin's assessment was made to a handful of reporters following the announcement by Senate Majority Leader Harry Reid (D-Nev.) that after weeks of talks with his colleagues he had determined that including a public option that states could opt out of was the best way to go.
For many years, it's been centrist and conservative-leaning senators who have been scoring legislative victories by digging in their heels, so this represented a quite dramatic turnabout. It is difficult to remember the last time that progressives won a legislative victory by laying down firm demands and sticking to them. In the House, the Congressional Progressive Caucus has found its feet, too, and is locked in a final battle with conservative Democrats over the shape of a public option.
At the end of last week, Sen. Olympia Snowe of Maine, the lone Republican that Democrats are still trying to woo, said that she couldn't support a bill that had a public option with an opt-out provision. Snowe preferred a public option that would be "triggered" into being by a failure by the insurance industry to meet certain benchmarks.
But Reid and the leadership faced this basic math: There is only one Snowe and there are 60 members of the Democratic caucus. If just a few Democrats abandoned the bill, it would fall short even with Snowe's support.
"It's a zero-sum situation," said Durbin, who is in charge of counting votes in the Senate. "If we thought that just putting the trigger in meant that we'd end with 61 votes," he explained, then that's what leadership would have done.
"But there were some [senators] that felt that that just didn't go far enough moving toward a public option," said Durbin, who is himself a backer.
"We have 60 people in the caucus," Reid said. "We'll all hang together and see where we come out."
Sen. Roland Burris (D-Ill.) had insisted he would oppose any bill without a public option and rejected the trigger as a compromise. Sen. Bernie Sanders, a Vermont independent and self-described democratic socialist who caucuses with Democrats, had come close to making such a threat but said he was "playing it day to day." Sen. Russ Feingold (D-Wisc.) said over the weekend that the lack of a public option was a "good reason" to vote against it.
Read more at: http://www.huffingtonpost.com/2009/10/26/durbin-progressives-force_n_334...
Kucinich: Why I Voted NO
Washington, Nov 7 -
http://kucinich.house.gov/News/DocumentSingle.aspx?DocumentID=153995
http://www.huffingtonpost.com/2009/12/14/liebermans-medicare-flip_n_3917...
Lieberman's Medicare Flip-Flop Leaves Democrats Fuming
I don't see Lieberman or any of the members of Congress complaining about or rejecting THEIR government health plans. That should be the test: give all Americans the same health coverage as Congress, period.
Miles Mogulescu
Entertainment attorney
Posted: December 23, 2009 02:32 PM
BIO
The Democrats' Authoritarian Health "Reform" Bill and the Ascendency of Corporatism in the Democratic Party
http://www.huffingtonpost.com/miles-mogulescu/the-democrats-authoritari_b_402146.htmldigg
(This
is the first of a series of blogs/articles that will try to put the
growing disappointment of many progressives at President Obama's
policies into a wider political and theoretical perspective about the
divide in the Democratic Party between progressives and corporatists.)
If Barack Obama and today's Congressional Democrats were passing Social Security for the first time, instead of a creating a public program, they would likely be mandating that every American buy an annuity from a private, profit-driven Wall Street firm like Goldman Sachs (who could keep 15%-20% of their payments for overhead, profits and executive salaries) with the IRS serving as Wall Street's collection agency. If they were passing Medicare today, they would be mandating that every American buy a health insurance policy from profit-driven companies like Aetna, Humana and Wellpoint that would start paying benefits with 40% co-pays and $10,000 a year deductibles when they turn 65.
Therefore, when Senate "liberals" argue that their health "reform" bill, while compromised, is like the first iterations of Social Security and Medicare and provides a "starter home" that can be added to later, many progressives respond that its foundation is built on quicksand and that it's not incremental reform but a step in the fundamentally wrong direction.
Democrats and liberals once stood for providing a social safety net through government programs like Social Security, Medicare and unemployment insurance, which were administered by government employees for the benefit of the American people and not by private companies for the benefit of their shareholders and executives who receive multi-million dollar salaries and bonuses. For over 60 years, they stood for the principal that health care should be a right and not a privilege and that Medicare should be extended to all Americans.
Democrats in Congress, under the leadership of Barack Obama, have now turned that principal on its head and made health care neither a right, nor a privilege, but an obligation for individual citizens and a government-mandated profit center for private corporations. For the first time in American history, Democrats are about to pass a bill that uses the coercive power of the federal government to force every American -- simply by virtue of being an American -- to purchase the products of a private company. At heart, the Democrats' solution to 48 million uninsured is to force the them to buy inadequate private insurance -- with potentially high deductibles and co-pays and no price controls -- or be fined by the federal government.
In effect, this represents an historic defeat for the type of liberalism represented by the New Deal and the Great Society and the ascendancy of a new type of corporatist liberalism. As Ed Kilgore recently wrote in an important and provocative article in The New Republic,
Or as David Brooks wrote in The New York Times earlier this summer,
The differences between progressive New Deal liberals -- what Howard Dean termed the "Democratic wing of the Democratic Party" -- and corporatist liberals or "New Democrats" were largely papered over for the past 8 years by common opposition to the free market absolutism and neoconservative foreign policy of the Bush administration. In terms of health care reform, they were papered over by the hopes of many progressive liberals -- who were willing to give up fighting for Medicare-For-All as politically "impractical" -- of achieving a robust public option as an acceptable compromise in the context of a larger health insurance mandate.
For many of these progressive liberals, the idea of the public option, at least at the beginning, was that it would be so large and successful that it would prove the superiority of government-run health insurance over private profit-driven health insurance and would eventually evolve into a single payer system. They watched, with increasing concern, as a large and robust public option was first turned by House Democrats into a small and puny public option that would insure only a handful of Americans and provide little competition to private insurers, and then as the public option was dumped entirely by Senate Democrats, with no help by President Obama to defend it.
And as they have seen the end result of the Democratic Senate's health care bill, progressives have started to get angry. Stripped of the public option, progressives could now look through the Democratic health care bill to its essence: the permanent entrenchment of the corrupt private health insurance corporation as the nexus of the American health care system; the authoritarian liberal solution of solving the problem of the uninsured by using the coercive power of the federal government to force citizens to buy inadequate private insurance sold by oligopolies with their profits subsidized by taxpayer dollars; and the increased political power of the of the private health care industry into the indefinite future, fueled by government money that can then be used to lobby the government for more private benefits.
As a result, the past two weeks have seen a revolt from much of the progressive base of the Democratic Party, articulated by people like Howard Dean, Marcos Moulitsas, Keith Olbermann, Ed Schultz, and by organizations like MoveOn, The AFL-CIO, SEIU, and Progressive Democrats of America. The ideological fault line between progressive Democrats and corporatist "New Democrats" has split wide open.
Obama campaigned, at least on the level of political imagery, as a progressive liberal. His campaign slogan was "Yes We Can", taken directly from the '60's era slogan of Cesar Chavez and The United Farm Workers Union, "Si Se Puede". He evoked the imagery of Martin Luther King and the civil rights movement. He talked about overthrowing the influence of special interests and lobbyists and transforming the way Washington does business. He promised transformative "Change" (although, as some critics pointed out at the time, he left the direction of "Change" so vague that voters of various stripes could read what they wanted into it). That's why a majority of progressive Democrats supported Obama over Hillary Clinton in the primaries, particularly after the more populist John Edwards withdrew. They didn't want to see a return to the centrism, corporatism, and triangulation of Clintonism.
But from the moment he was elected, Obama has governed not as a progressive liberal but as a corporatist liberal. Progressive liberals hoped Obama would be like FDR. Instead, he's been like Bill Clinton on steroids.
Obama's economic advisors, such as Larry Summers and Tim Geithner, were all drawn from the Wall Street wing of the Democratic Party. His foreign policy advisors were all liberal hawks like Hillary Clinton or even Bush administration veterans like Robert Gates. From day one, Obama continued Wall Street Republican Hank Paulson's financial policies of throwing money at the banks while demanding next to nothing in return in terms of making credit available to average Americans and small businesses or creating new jobs.
When it came to health care "reform", Obama's strategy was to cut deals with for-profit health care corporations. He cut a deal with big Pharma to continue banning Medicare from negotiating for lower drug prices and to continue banning consumers from buying cheaper drugs from Canada. He cut a deal with the for-profit hospital industry that there would be no effective national public option that might pay them lower rates that the for-profit insurance oligopoly. While he gave mild rhetorical support to the public option, he did nothing to actually fight for it , and, as Russ Feingold has pointed out, Joe Lieberman was really doing Obama's work in killing it.
Because of Obama's rhetorical and imaging skills, it has taken until the past week or two, with the death of the public option, for progressives to begin to wonder whether Obama was really their friend. And what's most remarkable, by teasing them with the hopes of a public option, he's so far held onto the vote of virtually every Congressional liberal for an essentially authoritarian corporatist health care bill.
So total has been Obama's success to date in defeating the progressive Democrats and enshrining the corporatist New Democrats, that even progressive talk radio veteran Al Franken and the closest thing to a European-style social democrat to hold national political office, Bernie Sanders, are not only voting for -- but are talking up the virtues of -- the Senate health "reform" bill. Although nearly 60 members of the House Progressive Caucus signed a letter promising to vote against a health care bill doesn't have a robust public option, unless, to everyone's surprise, there's a big enough revolt over the Christmas holidays among large progressive groups like the AFL-CIO (who's money and volunteers many Democratic Congresspeople need to get reelected), virtually all of those House Progressives will end up breaking their pledge and voting for a final Congressional Conference bill with no public option, a coercive mandate, and a tax on the "Chevy" health care benefits of union workers.
Only an African American President cloaked in the rhetoric and imagery of progressive change could have pulled off such a rout of progressives and such a virtually unanimous victory for the corporatists in the Democratic Party. The Clintons could never have pulled it off.
That helps explain why many progressive Democrats -- myself included -- are increasingly in a state of anger and despair. If after millions of progressives worked so hard to elect Barack Obama and a Democratic majority in Congress, the result is an almost total defeat of progressives in the Democratic Party -- or at least in the Congressional Democratic Party -- where do progressives turn? A progressive primary challenge to Democratic incumbents in 2010, or even to Obama's reelection in 2012, is probably futile and counterproductive. At the same time, as the 2000 Nader campaign so aptly demonstrated, the winner-take-all American electoral system makes the formation of a third party equally futile.
Historically, strong popular movements, like the labor movement and the civil rights movement, have pressured elected corporate Democrats to enact a measure of progressive change. And, as progressives come to understand the corporatist nature of Obamism, perhaps the best hope is that progressive organizations will be less anxious to be extensions of the White House and return to grassroots organizing. The question is whether Obama -- the one-time community organizer -- is susceptible to pressure from mass grassroots organizations. If not, the country, as well as Democrats and progressives, may be in for a hard time.
As it increasingly appears that Obama is the President of Wall Street, and not the President of Main Street, he is losing not only the left but the center. It's a myth that the path to winning the popular center in American politics is moving to the corporate center. If the only political choice given to American voters is using their taxes to help big government subsidize wealthy corporations, or the Republican message of shrinking the size of government and cutting their taxes, many who voted for Obama will return to the fold of the seemingly brain-dead Republican Party. Obama will likely face an even more conservative Congress after the 2010 election and even, like Jimmy Carter, could end up as a one-term President.
The hopes of millions of Obama campaign workers and voters that the Age of Obama would sweep in a new era of progressive change could be dashed. A generation of young voters could be turned off to politics instead of becoming permanent Democrats.
Let's hope, that with the defeat of the public option at Obama's hands, the Democratic wing of the Democratic Party wakes up and begins to realize that it has a fight on its hand against the corporatist Democrats, and that Obama might not be its natural ally.
As Kevin Baker wrote in Harpers Magazine last spring, warning of the dangers of a failed Obama Presidency,
That was spring. Now it's the winter of our discontent. The moment for Obama to "change direction and seize the radical moment at hand" is fast receding. Will he continue to move "prudently, carefully, reasonably towards disaster?" If not, I worry for the future not only of progressives and Democrats, but of the country. President Palin in 2012?