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== Angles ==
What are the basic angles to explore in this segment, from left, right or other?

'''Focus on core questions, not technical details.''' Tell your audience what they want to know, not what the campaigns want them to hear. Tell your audience something new. 

This is being covered exhaustively everywhere, so you should give WNYC listeners something unique directed at them that they won't get elsewhere. 

You have two kinds of listeners. First, the ordinary informed public radio listener who trusts you. Second, a surprising number of academics, activists and policy experts, and you should tell them something they don't know too. 

The details of health policy are mind-numbing, so you can only deliver a few well-selected good simple ideas. (David Cay Johnston said, "ask the core questions, not the detailed ones around the edges."[http://www.poynter.org/forum/view_post.asp?id=13611][http://www.onthemedia.org/transcripts/2008/09/26/02])

After you've done a lot of research, you have to write it down, think it out, and ask yourself, "Does this make sense? Or is there something wrong here? Are there any obvious questions nobody else has answered?" That's your story. 

Here's how Trudy Lieberman did it. Part [http://www.cjr.org/campaign_desk/mccains_health_proposals_under.php 1][http://www.cjr.org/campaign_desk/mccains_health_proposals_under_1.php 2][http://www.cjr.org/campaign_desk/mccains_health_proposals_under_2.php 3][http://www.cjr.org/campaign_desk/mccains_health_proposals_under_3.php 4][http://www.cjr.org/campaign_desk/mccains_health_proposals_under_4.php 5]

(BTW, this approach follows a book, The Art and Craft of Feature Writing, by William E. Blundell, which was based on the Wall Street Journal style book.) 

Your listeners don't need another comparison of the Obama PowerPoint vs. the McCain PowerPoint. They've clearly been telling you, in the calls and on the message boards, both ordinary citizens and experts, that they want a single-payer system. For them the untold story is Obama, McCain, and single payer. 

They've been [http://www.pnhp.org/img/cartoons/29tomo.gif saying repeatedly] that single payer would be better and cheaper. They want to know why we don't have it. Why is it so "difficult to achieve," as Hillary Clinton said? Some of them believe that the health care industry has simply bought off the politicians, as the the millitary-industrial complex did. Is this true? 

That's the way I would frame the story. Since you asked. [[User:Norman|Norman]] 19:57, 25 September 2008 (UTC)

''''''Why does the U.S. lack the political will to adopt single-payer universal care?''''''  People fear they will be "denied" care, but the truth is that (1) we have rationing now (how long does it take to get an appointment?) and (2) we will have to make hard choices, perhaps about end-of-life and neonatal care. --[[User:Jmandelker|Jmandelker]] 15:24, 2 October 2008 (UTC)

'''Health insurance itself is the problem.''' By nature, health insurance is a temporary thing that's lost when you change jobs, lose a job, and  move from one state to the other.  The Institute of Medicine reported that each year 42 million Americans are at risk of losing coverage for part of the year -- almost as many people as there are uninsured. [http://www.iom.edu/CMS/3809/4660.aspx Institute of Medicine, Consequences of Uninsurance (2004)], [http://www.iom.edu/?id=17759][http://www.iom.edu/Object.File/Master/17/742/Fact%20sheet%202%20Continuous.pdf Uninsurance Facts and Figures: Fact Sheet 2] With so many health care dollars spent on treating chronic diseases like diabetes, an interruption of insurance and therefore medical care, will cost the system more as well as being cruel. --[[User:Jmandelker|Jmandelker]] 15:24, 2 October 2008 (UTC)

:You see? I told you they want single payer. [[User:Norman|Norman]] 10:52, 4 October 2008 (UTC)

'''Do we have a democracy?''' When the people want something that's possible and practical, and the politicians tell them that they can't give it to them because the political system doesn't allow it, said David Himmelstein, M.D., co-founder of [http://pnhp.org/ Physicians for a National Health Program], "you don't have a democracy."

*''Critical point: Do we have a democracy?''

== Candidate Positions ==

What have McCain and Obama said or done on this issue? Do their actions match their words?

''Here's an article from the New England Journal of Medicine that compares the McCain and Obama health plans. The NEJM is subscription-based, but this one is free. There are innumerable articles comparing the plans, but this is one of the best. Your listeners can get the basics by reading an article like this. The challenge for you is to give them something more.''

[http://content.nejm.org/cgi/content/full/359/8/781 NEJM, 21 Aug 2008, 359(8):781]Perspective: Election 2008: The partisan divide -- the McCain and Obama plans for U.S. health care reform, Jonathan Oberlander. In summary: 

Oberlander says, "The candidates' opposing visions of health care reform reflect fundamentally different assumptions about the virtues and vices of markets and government." 

*''Critical point: How well does the '''free market''' work in health care? What's the evidence?''

'''Key Elements of John McCain's Plan for Health Care Reform'''

Elimination of current tax exclusion for employer-paid health insurance premiums

Using revenues generated from eliminating tax exclusion, provision of refundable tax credits ($2,500 for individuals, $5,000 for families) for all persons obtaining private health insurance; if insurance costs less than the value of the credit, remaining funds can be deposited into health savings accounts

Creation of guaranteed access plan to provide insurance pool for persons who are medically uninsurable on the individual market

Promotion of individually purchased insurance and less comprehensive insurance policies

Deregulation of insurance markets

Reform of Medicare to make bundled payments for episodes of care and to pay on the basis of outcomes

Other proposed measures to control costs and improve quality: 
*Enhanced competition
*Faster introduction of generic drugs
*Emphasis on prevention and better management of chronic conditions
*Greater use of health information technology
*Medical malpractice reform

The biggest problem with McCain's proposals, says Oberlander, is his reliance on the individual insurance market, which is administratively expensive, and excludes sick people and the elderly. McCain's "guaranteed access plan" is a high-risk pool like the state pools that have worked badly. There's no evidence that these cost-saving measures (in either plan) would work. 

'''Key Elements of Barack Obama's Plan for Health Care Reform'''

"Play or pay" employer mandate requiring businesses either to offer workers insurance or to pay a tax (very small businesses would be exempt)

Creation of a new national health plan (similar to Medicare) for the uninsured and small businesses

Estabishment of new national health insurance exchange that would offer choice of private insurance options for the uninsured and small businesses

Mandate that all children must have coverage

Subsidies for lower-income Americans to help them afford coverage

Expanded coverage financed through the payroll tax, letting tax cuts for families making over $250,000 expire, and savings from electronic medical records, disease management, and other system reforms

Regulation of all private insurance plans to end risk rating based on health status

Establishment of federal reinsurance program to insure businesses against the cost of workers' expensive medical episodes

Other proposed measures to control costs and improve quality: 
*Reduction in the administrative costs of private insurance
*Accelerated adoption of electronic medical records
*Promotion of disease management
*Emphasis on prevention and public health
*Payment of providers on the basis of performance and outcomes
*Reduction in excessive payments to private plans contracting with Medicare
*Allowing Medicare to negotiate with drug companies
*Establishment of a comparative-effectiveness research institute 

A problem with Obama's plan, says Oberlander, is the cost. It assumes cost savings through reforms, like electronic medical records, that haven't been controlling costs up to now. And the OMB doesn't support his tax calculations. [[User:Norman|Norman]] 18:12, 5 October 2008 (UTC)

'''Cost to government.''' McCain's plan is budget-neutral (and so would cost consumers more money), whereas Obama's plan increases government spending (and so would cost taxpayers more money). The [http://www.taxpolicycenter.org/ Tax Policy Center] estimated that Obama's plan would cost $1.6 trillion over 10 years and cover 34 million more people ($4,700 per person per year), according to [http://online.wsj.com/article/SB122315505846605217.html Laura Meckler in the Wall Street Journal]. McCain would pay for his health plan with cuts to Medicare and Medicaid that the Tax Policy Center estimated at $1.3 trillion over 10 years, which [http://www.leighbureau.com/speaker_documents.asp?view=article&id=344 Douglas Holtz-Eakin] [http://www.leighbureau.com/speakers/dholtz-Eakin/essays/healthcare.pdf], McCain's senior policy advisor and a policy expert on health care, acknowledged. Both candidates have said that they would solve budget problems with "cost savings," but neutral analysts say that these cost savings would be insignificant. [[User:Norman|Norman]] 14:27, 6 October 2008 (UTC)

'''Prevention.''' Both candidates are depending on prevention to save money. But as Gil Welch of Dartmouth wrote in the NYT, [http://www.nytimes.com/2008/10/07/health/views/07essa.html "Campaign Myth: Prevention as Cure-All"], most studies find prevention costs money rather than saves money, and often does more harm than good. 

:'''Critics.''' There are three main categories of critics of the plans: [http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.6.w462 Republican critics] of the Obama plan, [http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.6.w472 Democratic critics] of the McCain plan, and [http://www.pnhp.org/ single-payer critics] of both plans. [[User:Norman|Norman]] 14:09, 24 September 2008 (UTC)
::[http://www.latimes.com/news/nationworld/nation/la-na-campaign5-2008oct05,0,2863079.story Here's an Oct. 5 story from the LAT] on Obama's attacks on the McCain health plan, and McCain advisor Holtz-Eakin's response. [http://online.wsj.com/article/SB122333750424809705.html Here's an Oct. 7 Op-Ed from the WSJ by David Gratzer] defending McCain's plan. (I don't think you can make sense of "debate" articles like this unless you read them along with NEJM and Health Affairs -- but here they are.)

::Journalism professor Gary Schwitzer discussed fact-checking the candidates' statements on his [http://blog.lib.umn.edu/schwitz/healthnews/146345.html  Health News Blog].

::[http://www.factcheck.org/elections-2008/health_care_spin.html FactCheck.org] evaluates the accuracy of each candidate's charges about the other candidate. 

'''Last night's debate ''' crystalized the difference between the candidates. McCain views health care as a ''responsibility'' while Obama views health care as a ''right''. What does that difference mean? How does that influence policy? How can Obama reconcile a mandate for children's health insurance with Americans' "right"  for health care? (Good audio clips from the debate available for this angle.)--[[User:Jmandelker|Jmandelker]] 15:31, 8 October 2008 (UTC)

The debate about health care being a "right" or a "responsibility" may be framed the wrong way between the candidates.  Perhaps we should see it as an entitlement.  We came to a consensus as a society that senior citizens have an entitlement to health care which was Medicare.  A right is something you are born with, not something you gain through someone else's labor.  Free speech is a right as is the right to privacy.  Perhaps what we need to do is not state that health care is a right, but instead state that as a society we have a moral responsibility to see that everyone has access, just as we should make sure everyone has access to housing and education.  The services are not free of charge because the providers need to be paid.  Martha

== Possible Guests ==

Who would help guide this discussion? This could be reporters familiar with the topic; academics or think-tankers who know the issue; people to talk on behalf of the candidates; or more "outside-the-box" guests who may have an interesting perspective.

''I would recommend '''Jonathan Oberlander''' and '''Robert Kuttner'''. They are the two people who understand the McCain plan and Obama plan, and the reasons why we don't have single payer, better than anyone else I can think of. They both write for the NEJM. But Kuttner, like many of your listeners, believes that single payer is possible, while Oberlander believes that it isn't. They are the two best people to answer the question your listeners are asking: why don't we have single payer? Is it possible?'' [[User:Norman|Norman]] 18:59, 5 October 2008 (UTC)

'''Jonathan Oberlander.''' Your standard smart liberal academic, who understands the system very well but, like Trudy Lieberman, doesn't think single payer is possible. He's written for the NEJM (above), been interviewed on [http://www.npr.org/templates/story/story.php?storyId=11826524 Terry Gross], etc. so you know what he's going to say and you can be ready with a good followup. My question for Oberlander would be: If Angell is right, and single payer would be [http://www.openmedicine.ca/article/viewArticle/8/1 cheaper with the same quality and universal coverage], and Kuttner is right, and it's popular with the American public, why can't we get politicians who will give us single payer? Is Himmelstein right -- we don't have a democracy? Is Krugman right -- the health care industry owns our politicians, like the military-industrial complex? 

My line of questioning for Oberlander (on behalf of the listeners who believe in single payer) would be: 

Q: In my understanding, you believe that single payer would be better, right? (Or what kind of reform do you think would be better?) 

Q: But you also believe the wealth, power and campaign contributions of the health care industry makes single payer, or any significant reform, impossible. 

Q: So we don't have a democracy? 

Q: Is there any way that people could organize into a political movement to get single payer? 

Q: Is there any hope of reform? Is it really that hopeless? How certain are you of that conclusion? You've been wrong before, right? 

Here are the notes I took while listening to [http://www.npr.org/templates/story/story.php?storyId=11826524 9 Jul 2007, Fresh Air, Terry Gross. Jonathan Oberlander, political scientist, U. North Carolina, Chapel Hill, author Political Life of Medicare, discusses U.S. and Canadian health care and Sicko.] Quotes have not been checked. 

This is the standard liberal academic analysis of the health care problem. The question I'd like to hear him argue with Kuttner is: Is it really this bad? Or can can we get single payer if we organize and educate people? Is he pessimistic or realistic? 

Oberlander: Political barriers to single payer are very strong. It's very unlikely. That $3 billion we spend on health care is income to the providers, who are deeply indebted to the status quo. One of the poigniant part of Sicko is when Michael Moore puts price tags on Congressmen's heads. The pharmaceutical industry pays contributions and expects obligation from it. The AMA, who coined the term "socialized medicine," fought against reform, but now they're more involved in malpractice liability and reimbursements, and don't care about the uninsured. [The AMA is one of the largest single political campaign contributors.]

Health care reform is like [http://www.youtube.com/watch?v=pPFxBzlFe94 "Bambi vs. Godzilla."]

Germany and Australia use private health insurance in their public system. Germany's system has sickness funds, which are nonprofit and highly regulated. Those mixed models are much more feasible in the U.S. In Germany, if you're unemployed, the government buys you in. The U.S. system, where you lose your insurance when you lose your job, is unique. Administrative costs are 30% U.S., 17% Canada, according to Kinsey & Co. report. 

HMOs started in 1930s and 1940s as a liberal idea, to coordinate care and have physicians on salary, like Kaiser Permanente. In the 1970s prepaid group practices were renamed HMOs and reinvented as a cost control mechamism. For-profit replaced non-profits. But HMOs have flatlined. Most Americans are in PPOs which don't manage anything. 

"Consumer-driven health care is badly named, because it's certainly not driven by consumers." Very high deductible, and pair them with health savings account, which is a tax preferred savings account. Much worse than manged care. Consumer driven health care is really just shifting the cost of health care onto the backs of patients. You'll notice they renamed patients to to "consumer." People who have chronic illness will be hurt. When you raise that deductible to $3-4,000, an individual with chronic illness is never going to be able to save anything in their savings account. Employers like it because they're going to save money, but they're not going to fund these health care accounts. 

Conservatives tend to support consumer-driven health care. They believe, as do a fair number of health economists, that people use too much health care and use too much health care of little value. If you move to high-deductible plans, people will think twice. If I have a sore throat, instead of going to my physician, I'll have a cup of tea instead. 

Bush has a plan to change the tax system. The employer system is heavily subsidized by the federal government. I don't pay any taxes on my employer-sponsored health insurance. The government foregoes $200 billion a year, so it's very expensive, and very regressive. Bush proposed a substitute, a standard deduction that anybody buying health insurance could take, of $15,000 family, $7,500 individual. 

Clinton plan failed because of the sin of ambition. Universal coverage, employer mandate, control costs, change delivery system towards managed care. It alienated people who already had health insurance. Now candidates are trying to build on existing system. 

"It seems like Groundhog Day." [[User:Norman|Norman]] 00:25, 3 October 2008 (UTC)

'''Robert Kuttner.''' Co-editor of The American Prospect, and has written for the New England Journal of Medicine. Kuttner says that the Clinton and Obama health plans were both variations on a plan by Jacob Hacker, Yale University, "which is an attempt to get to universal coverage without having national health insurance, and it's not bad, if you can't have the first best, which is national health insurance."[http://www.democracynow.org/2008/2/8/examining_clinton_obamas_stances_on_the]  But it keeps the paperwork and bad incentives, and doesn't get the cost efficiencies of universial health insurance. Kuttner opposes mandates, because "a mandate turns the problem of the system into the problem of the individual," and is an extremely regressive tax. "If Obama and Clinton "had gone all the way and said, 'Let's just to do this right and have national health insurance,' I think they could have used this as a teachable moment. They could have bought public opinion around. Medicare is phenomenally popular. Medicare is national health insurance for seniors. Let's have national health insurance for everybody." In the New England Journal of Medicine ([http://content.nejm.org/cgi/content/short/358/6/549 7 Feb 2008, 358(6):549, Perspective: Market-based failure -- a second opinion on U.S. health care costs]) he wrote that the free market in health care has been a failure, because the incentives are backwards. True national health insurance, without the private insurance industry, has been "at the fringes of the national debate," because of the "immense power of the insurance and pharmaceutical industries ... the intimidation of politicians, and the erroneous media images of dissatisfied patients in universal systems." He's going on talk shows because he's promoting his new book, "Obama's Challenge," which argues that the Democrats should blame not just Bush and the Republican party, but "the whole rightwing ideology." (Kuttner identified the seriousness of the mortgage crisis in January.) Kuttner is the most political and furthest left of the journalists, and I think he is correct. Kuttner would be my first choice. 

The tough questions I would ask Kuttner are: 

Q: If single payer is so popular, why doesn't it get more political support? 

Q: Harris Wofford won the 1991 Pennsylvania Senate race on a platform of universal health care. Why haven't candidates been trying this again? 

Q: If it's so popular, why isn't the [http://thomas.loc.gov/cgi-bin/bdquery/z?d110:HR676: United States National Health Insurance Act] going anywhere? 

Q: If it's so popular, why didn't Dennis Kucinich do better in the presidential primaries? 

Q: If it's so popular, why can't candidates win elections with it? [[User:Norman|Norman]] 01:11, 26 September 2008 (UTC)

'''Marcia Angell, M.D.''' is former editor of the [http://nejm.org New England Journal of Medicine] and now a lecturer at Harvard. As editor, she commissioned a series of articles on health care reform [http://content.nejm.org/cgi/content/full/340/1/48 The American Health Care System Revisited -- A New Series. 1999 Jan 7;340(1):48.] by experts on all sides, and then wrote an editorial[citation needed] which concluded that incremental change was doomed to fail, and the only reform that could work is a single payer system. [http://content.nejm.org/cgi/content/full/342/22/1663 Patients' Rights Bills and Other Futile Gestures, N Engl J Med. 2000 Oct 26;342(22):1663], [http://www.nytimes.com/2001/06/23/opinion/23ANGE.html A Wrong Turn on Patients' Rights, By Marcia Angell, New York Times, June 23, 2001], [http://www.prospect.org/cs/articles?article=placebo_politics Placebo Politics, The American Prospect, 11(23) 6 Nov 2000], [http://www.prospect.org/cs/articles?article=health_reform_you_shouldnt_believe_in Health Reform You Shouldn't Believe In; What the Massachusetts experiment teaches us about incremental efforts to increase coverage by expanding private insurance. The American Prospect, April 21, 2008]. She is a member of [http://www.pnhp.org Physicians for a National Health Program]. 

In "The Truth About the Drug Companies: How They Deceive Us and What to Do
About It" Angell argues that drug companies charge too much, engage in deceptive research, produce inferior products, borrow their best ideas from government-funded scientists, and improperly influence physicians with trips and gifts. The pharmaceutical industry is "now primarily a marketing machine to sell drugs of dubious benefit." 
[http://www.commercialalert.org/relmanangell.pdf How the drug industry distorts medicine and politics: America’s Other Drug Problem, By Arnold S. Relman and Marcia Angell, New Republic, December 16, 2002], [http://bulletin.aarp.org/yourhealth/medications/articles/the_dope_on_drugmakers.html The Dope on Drugmakers, 2004-09-15 AARP Bulletin Today]

The Wall Street Journal editorial page is a good place to find Angell's free-market critics. For example, Richard A. Epstein ("Drug Crazy," March 26, 2008, and "Patients' Risk/Return Trade-Off on Drugs," April 5, 2008) and Benjamin Zychner ("One-Size-Fits-All Rules will Hurt Drug Quality," April 4, 2008) debated with Angell ("Those Newly Approved Drugs Are A Lot Like the Old Ones," April 2, 2007). Epstein and Zychner argued that the FDA should have allowed Vioxx and Bextra to be sold, because the evidence of the market was that doctors and patients were weighing the risks of increased heart attacks and preferred the COX-2 inhibitors over aspirin and ibuprofin (Advil), because COX-2 inhibitors relieved pain better. Angell responded that, according to the randomized controlled trials, ibuprofin relieves pain just as well as COX-2 inhibitors. The advantages of COX-2 inhibitors is that they have fewer gastrointestinal adverse effects than ibuprofin, but you can also get the same fewer GI adverse effects by giving ibuprofin with omeprazole (Prilosec) at a much lower price and without the heart attacks. Zychner said that, if the evidence of free market sales contradicts the evidence of randomized controlled trials, doctors and patients could be guided by the market. [[User:Norman|Norman]] 16:52, 30 September 2008 (UTC)

*''Critical point: '''Free market vs. RCTs.''' The fundamental political debate is between academic doctors like Angell, who believe that the only way to tell that a treatment works is by randomized controlled trials, as evaluated usually in government-sponsored panels, and economists like Epstein who believe that, if a drug succeeds in the free market, that  proves it works, and individual consumers and their doctors can make the best decisions. Doctors have many examples like Vioxx of drugs that sold well but were harmful; they ask the economists, "where is your clinical data to prove that the market works?" The economists reply, "Sales figures, and our brilliant insights, are sufficient data." This free-market argument is based on an ideological faith in the market and antipathy to government regulation, and these economists have been trying to find data to support it for decades. This is a theme that repeats through the entire health care debate: Who makes better decisions, government-supported panels of medical experts, or consumers and their doctors in the free market?''

'''Stephanie Woolhandler, M.D.''' Woolhandler is a good alternative to Angell, and Woolhandler is a designated press contact at [http://www.pnhp.org Physicians for a National Health Program], which she founded with her husband, '''David Himmelstein, M.D.''' Woollhandler is distinguished for having over 100 articles on health policy in [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term=woolhandler+s every major peer reviewed medical journal]. If accuracy is important, then you want people who can support their claims with peer-reviewed evidence. 

'''George Lundberg, MD''' editor-in-chief of [Medscape http://www.medscape.com] and author of "Severed Trust" would be an excellent guest, knowledgeable about health policy, clinical care, and how our culture often determines what is funded and not funded in health care.  Prior to joining Medscape in 1999, Dr. Lundberg was for 17 years editor of ''JAMA.''  He was fired by the AMA for publishing, during the impeachment hearings over Bill Clinton, a peer-reviewed article about a Kinsey Institute study. The study found that 60% of college women would not consider oral sex "having sex." 
Lundberg successfully sued the AMA over the firing. -- peter frishauf, new york, ny (disclosure: I founded Medscape in 1995 and recruited Lundberg in '99; I left the enterprise in 2002.)

'''[http://query.nytimes.com/search/query?frow=0&n=10&srcht=s&query=health+care&srchst=nyt&submit.x=19&submit.y=6&submit=sub&hdlquery=&bylquery=krugman Paul Krugman.]''' New York Times colunnist, and economics professor at Princeton. Supports single payer. Particularly good at understanding, explaining and debunking the false claims of free-market efficiency. He compared the drug costs in the Veterans Administration system to private insurance. Krugman pointed out that Medicare Advantage, the privatized version of Medicare, costs 15% more than standard Medicare. So if the free market is more efficient, he askes, why do we have to pay them 15% more? (The insurance industry group AHIP challenged this claim, although their [http://www.ahip.org/content/pressrelease.aspx?docid=18217 press release] doesn't tell where the supposed $2.1 billion savings comes from.) Krugman understands the economics better than the politics, and sometimes just observes how money flows from the health care industry to politicians like Billy Tauzin and assumes that it's a quid pro quo. Krugman supported Hillary Clinton's plan, because, with mandates, it would have covered more people (45 million) at lower cost ($2,700 per person) than Obama's plan, without mandates, which would have covered fewer people (23 million) at greater cost ($4,400 per person). [[http://topics.nytimes.com/top/opinion/editorialsandoped/oped/columnists/paulkrugman/index.html Link to Krugman's columns]] [[User:Norman|Norman]] 01:05, 26 September 2008 (UTC)

'''Trudy Lieberman.''' Lieberman used to work at Consumer Reports. She's head of the health care and medical reporting program at CCNY graduate school, and she has a [http://www.google.com/search?q=site%3Acjr.org+trudy+lieberman&btnG=Search blog] at Columbia Journalism Review. Here's one about the [http://www.cjr.org/q_and_a/the_new_healthcare_debate.php half-hearted NPR coverage]. Consumer Reports actively supported single payer when Rhona Kapartkin ran it, but since then they've become discouraged about its practical possibility and so has Lieberman. 
My question for Lieberman would be, "Do you think the fight for single payer is hopeless? If not, how could we get there?" 

'''Georganne Chapin''' is President & CEO of the [http://www.hcheq.org Hudson Center for Health Equity & Quality], a not-for-profit institution that advocates universal health care and other policies to broaden access to high quality health care. She argues that health insurance itself is the biggest barrier to obtaining health care. "We don't need more programs, we need fewer programs that cover more people," says Chapin in a cover story in Managed Healthcare Executive. ([[http://managedhealthcareexecutive.modernmedicine.com/mhe/article/articleDetail.jsp?id=363693]]). In an editorial video on Medscape ([[http://www.medscape.com/viewarticle/559758]]), Chapin says insurance is only temporary, which is fine for auto policies, but not for human lives. She adds that insurance companies make more money preventing care than by keeping people healthy. She should know -- she's also the President and CEO of Hudson Health Plan, a not-for-profit managed care organization based in Tarrytown, NY. Now, wouldn't a health insurance executive who is against health insurance make an interesting guest? -- Jeannie Mandelker --[[User:Jmandelker|Jmandelker]] 19:06, 25 September 2008 (UTC)

'''Maggie Mahar''' ([http://www.healthbeatblog.org Blog]), author of "Money Driven Medicine" which is an exhaustive look at how we got into the predicament we are in and all the threads and players involved. She gives good evidence of why costs are so out of control, who is profiting and how the region you live in determines the amount of money spent on health care. There is an atlas put out by the Dartmouth Medical school that shows that costs do not follow real estate prices or general costs of living in the different regions, but instead the amount of technology and the number of specialists in a particular region.  Thus:  supply and demand are turned on their head, instead of more supply=less demand it is more supply=more demand. Martha 

'''Robert Laszewski'''[http://healthpolicyandmarket.blogspot.com/] is president of Health Policy and Strategy Associates, LLC (HPSA), a policy and marketplace consulting firm specializing in assisting its clients through the significant health policy and market change afoot. Before forming HPSA in 1992, Mr. Laszewski was Executive VP and COO, Group Markets, for the Liberty Mutual Insurance Group. Gerard 19:20, 24 September 2008 (UTC)

Here's an [http://blogs.webmd.com/election-2008-expert-view/2008/07/interview-robert-laszewski-author.html interview] with Laszewski at WebMD. He has lots of good numbers that Obama and McCain are vague about, debunks a few pat solutions, and he's easier to understand than Health Affairs. He says that ultimately doctors, hospitals and insurance companies must get paid less. His solution is Sen. Ron Wyden's (D-OR) [http://www.standtallforamerica.com/content/health_care_reform Healthy Americans Act], which would (like McCain) transfer the responsibility for insurance from the employer to the employee, who would buy insurance from a more efficient market. Wyden's bill has many of the problems Lazewski identifies with the other two plans. And here are some more [http://www.cjr.org/campaign_desk/mccains_health_proposals_under.php critics] of Wyden's approach. [[User:Norman|Norman]] 00:20, 25 September 2008 (UTC)

'''David Gratzer, M.D.''' Actually, I think Gratzer is the kind of guest you should ''not'' have on a program that has to be concise, accurate and focused. (1) He gets his facts wrong. For example, he claimed that Rudolph Giuliani's chances of surviving prostate cancer in the U.S. was [http://www.city-journal.org/html/eon2007-10-31dg.html 82 percent, but in England, "only 44 percent under socialized medicine.”]  This was wrong. [http://voices.washingtonpost.com/fact-checker/2007/10/rudy_miscalculates_cancer_surv.html][http://voices.washingtonpost.com/fact-checker/2007/11/four_pinocchios_for_rudy_the_r.html] (At the risk of oversimplification, many people who are diagnosed and treated for prostate cancer in the U.S. would never actually develop prostate cancer. Healthy people have very good survival statistics.) Everybody makes mistakes, but the culture of academic medicine is that you have to admit when you're wrong. (2) Gratzer publishes very little in the [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term=gratzer+d peer-reviewed literature]. (3) The Manhattan Institute doesn't routinely disclose its [http://www.sourcewatch.org/index.php?title=Manhattan_Institute_for_Policy_Research#Funding funding sources]. There's an overwhelming consensus in science and academic medicine today that if you're getting money from a source that could profit if the policies you recommend were adopted, you have an ethical obligation to disclose it. Gratzer can contribute in other settings, but not in a quick-paced program where credibility and accuracy are essential and you're trying to get a focused point across.

Gratzer supports the McCain plan. In [http://online.wsj.com/article/SB122333750424809705.html McCain is the real health-care reformer; the right prescription for what ails our system], Wall Street Journal, 7 October 2008, he argued that McCain wants to give the tax deduction for health insurance to the employee, not the employer. Employees would have choice to join any health plan. Employees could continue with the same plan after they left their job. Employees wouldn't have to stay at their jobs to keep their insurance. McCain's worst omission is provision for the chronically ill. The Obama proposal merely regulates insurance companies, subsidizes small business, and grows government programs. (And then he cites articles in Health Affairs to support his case.)

'''votevets.org.''' I recommend a representative from the organization [http://votevets.org votevets.org]  -- someone who can explain the importance of sharing the rehabilitative and health care costs for our returning military and all veterans.   Maybe then, people will understand how a huge war impacts the economy, the budget, health care and 
just about every other taxpayer funded program. (User: proudfoot)

== Opening Copy ==
How should Brian frame the issue at the beginning of the segment?

#'''Two candidates, single payer.''' According to the Institute of Medicine, ten thousand Americans die every year because they can't afford health care. Medical costs drive half a million Americans bankrupt every year. America is the richest country in the world. Why can't we help [http://www.post-gazette.com/pg/06339/743713-84.stm these people]? Experts say that our political system is deadlocked. Now we've come to the election. How do each of the candidates propose to end the deadlock? Can they succeed? Will they really make us better off? How does McCain's proposal compare with Obama's? And what about a single-payer system, which many WNYC listeners think is the solution? [[User:Norman|Norman]] 13:27, 25 September 2008 (UTC)
#'''Bipartisan support.''' As Robert Laszewski suggests at http://healthpolicyandmarket.blogspot.com “The real question that needs to be put to these candidates: Just how will you achieve bipartisan health care reform in the face of the reality of needing to deal with a Democratic Congress (McCain) and a crippling budget challenge (Obama)?” [[Special:Contributions/65.119.245.254|65.119.245.254]] 19:41, 24 September 2008 (UTC) Gerard
#'''Veteran's healthcare.''' Nearly every discussion about health care focuses mostly on civilian Americans and fails to address a key component of taxpayer funded healthcare -- veterans and the military.   In an election year in which our country is fighting a two front war, neither candidate has done anything to explain to the country just how important this issue is to the entire discussions about budget, the war, and yes, TAXES.  You cannot talk about health care or the war or the budget without talking about how our taxes relate to all of this.  (User: proudfoot)

== Questions ==
What are the key questions? What order should they be asked in?

''Health care policy is extremely complicated, the sources often have vested financial interests, and they are skilled at giving pat answers, evading the question and lying. To interview them in live radio, you must not only prepare your questions in advance but also know their likely answers, so you can fact-check them and prepare your followup questions in advance too. You can't just think on your feet; it's too complicated. This American Life has a great example of what happens when you're not prepared. ([http://www.thisamericanlife.org/Radio_Episode.aspx?sched=1068 What I Should've Said. Act Two. In the Bush Leagues.])''

'''Is single payer better?''' Would a single-payer system be better than the system we have? Would it be better than the Obama and McCain proposals? The evidence is that (1) Medicare works well for people over 65. (2) The Veterans Administration system provides better care than private care, according to good scientific comparisons. (3) Medicare Advantage costs 15% more than standard Medicare, so the free market is more expensive. (All that according to Krugman) (4) The Canadian system offers equal or better quality, at lower cost, for everyone, according to [http://www.openmedicine.ca/article/viewArticle/8/1 Guyatt], Himmelstein and Woolhandler. (5) Americans favor single-payer, "Medicare for all," government-run insurance by pluralities or majorities, in the polls, according to [http://www.democracynow.org/2008/2/8/examining_clinton_obamas_stances_on_the Kuttner] and others. What is the ''peer-reviewed'' evidence against single-payer? [[User:Norman|Norman]] 01:38, 28 September 2008 (UTC)

'''Is single payer possible?''' If single payer is better, why is it so "difficult to achieve," as Hillary Clinton says? Exactly what are the forces that prevent it? If, the two Democratic candidates, or a Democratic president, supported single payer, what would have happened? Would it have been as popular as Kuttner and Himmelstein say it would be? Is it so easy for the insurance industry to foil popular choice by $100 million worth of "Harry and Louise" TV spots and scare tactics? Is that the kind of democracy we have? [[User:Norman|Norman]] 01:38, 28 September 2008 (UTC)

'''What are the objections to single payer?''' (1) Americans don't want single payer. They want freedom to choose, and single payer would take away their freedom. (2) The quality of single payer would be worse. (3) Single payer is economically inefficient. (4) Powerful interest groups oppose it, so it's impossible. Arguments 1-3 are challenged by good data in peer-reviewed journals. The story is whether (4) is true. 

''If single payer isn't possible, move on to the specific features of the McCain and Obama proposals. The fundamental problem with free-market systems is that some people can't afford to pay for health care. The free-market or mixed public-private systems try to solve that problem with subsidies for poor people, and for middle-class people with large expenses. How does each proposal try to solve that problem, and can it succeed? That's what your questions should probe.''

'''Premiums for chronic illness.''' It's easy to give health care to healthy people; the problem is to give health care to people with chronic or expensive diseases. Suppose a 30-year-old waitress is making $25,000 a year, and she develops multiple sclerosis, which costs $30,000 a year to treat. Under your plan, how much would she pay? How much would the government pay? Would every insurance company have to accept her? Would the insurance company have any limits on the premium it could charge? (This is modeled on a question by Uwe Reinhard.)

'''Equity.''' Should health insurance be like fire insurance, where everybody pays according to individual risk, or should it be like the fire department, where everybody pays progressive taxes, and gets all the services he needs? If the average cost of providing health care is $6,000 a year, how much should a person pay who has an income of $12,000 a year? $25,000 a year? $50,000 a year? $100,000 a year? 

'''Donut hole.''' In Medicare Part D, the prescription drug program, people who need $5,100 worth of drugs a year (as many cancer patients do) must pay $3,600 of that every year. Medicaid covers people with very low incomes and assets, but most people don't qualify. Would you keep the donut hole? If a doctor prescribes $5,100 worth of drugs a year for a cancer patient, how much of that should she pay? How much would she pay under your plan? 

'''Insurance companies.''' What [http://www.pnhp.org/img/cartoons/01tomo.gif purpose] do insurance companies serve? They take 15% of our premium dollars directly in administrative costs and profits (the most efficient plans, like HIP of New York, report a "loss ratio" of 85%, which means they keep 15%). Paul Krugman says that Medicare Advantage, which is administered by insurance companies, costs about 15% more than traditional Medicare directly from the government, or the Veteran's Administration system. In addition, doctors have to pay up to 15%  of that 85% for administrative costs in dealing with insurance companies. (A 6-person medical office would typically have one full-time employee dealing with insurance company billing.) Most other developed countries, like Canada, don't have health insurance companies at all. Do we have health insurance companies because we need them, or because they've successfully lobbied to keep politicians from cutting them out? [[User:Norman|Norman]] 00:30, 25 September 2008 (UTC)

'''Campaign financing.''' According to Robert Steinbrook, M.D., in the New England Journal of Medicine ([http://content.nejm.org/cgi/content/full/359/13/1313 Campaign Contributions, Lobbying, and the U.S. Health Sector -- An Update], Sep. 25, 2008) the "health sector" contributed $54.5 million to Democrats, and $46.1 million to Republicans, to this year's candidates, as of July. That includes $8,841,124 to Obama and $4,681,148 to McCain, according to [http://www.opensecrets.org Open Secrets]. (Dennis Kucinich got $40,000 from the California Nurses Association.) Cynics say that if you can't contribute money like this you have no meaningful influence on policy. Can you prove the cynics wrong? [[User:Norman|Norman]] 18:41, 23 September 2008 (UTC)

'''Co-payments.''' In Medicare managed care plans that charged women co-payments of $10 or more, 8% fewer women had mammograms than in plans without co-payments. ([http://content.nejm.org/cgi/content/full/358/4/375 Trivedi, Effect of Cost Sharing on Screening Mammography in Medicare Health Plans, NEJM, 358:375-383, January 24, 2008], [http://content.nejm.org/cgi/content/full/358/4/411 Cost Sharing for Health Care — Whose Skin? Which Game? Bach, NEJM, 358:411-413, January 24, 2008]). When employers imposed co-payments on employees, more than half of their employees with rheumatoid arthritis stopped taking medication because it was too expensive ($26 a month), and the cost of increased disability was greater than the cost savings on medication. ([http://www.nytimes.com/2007/06/27/business/27copay.html Scant Drug Benefits Called Costly to Employers, by Milt Freudenheim, New York Times, June 27, 2007]). The consistent result of [http://en.wikipedia.org/wiki/RAND_Health_Insurance_Experiment over 30 years' research] is that cost sharing reduces inappropriate health care, but it also reduces appropriate health care. Do you accept the NEJM study that $10 Medicare copayments reduced mammograms by 8%? Do you think insurance companies should be free to charge those copayments? Do you believe that states should be able to prevent insurance companies from charging co-payments for mammograms? [[User:Norman|Norman]] 16:27, 27 September 2008 (UTC)

'''Paying Providers''' Doctors in private practice rarely accept Medicaid and more and more are withdrawing from Medicare and HMO panels, because the reimbursement rates are too low, they are not rewarded for excellence, it is difficult if not impossible to negotiate as a single provider or a small group practice vs the third-party payors (making it easier to go off-network), and the bureaucratic obstacles for submitting claims and obtaining approval for treatment are difficult to navigate. How would a single payor provide fair reimbursement to providers? How would you establish appropriate payment rates? Would you repeal the restrictions on physicians grouping together to negotiate price?

'''Malpractice''' Doctors as a group are unlikely to support any plan that does not place limits on malpractice lawsuits. Would nationalization of malpractice coverage under the single payor and provision for arbitration panels that would take judgments away from juries (and trial lawyers) be fair trade to get physicians to participate in a single-payor plan, specially if they in turn agree to submit outcome measures to better define quality? I for one would prefer to have a nurse in my office monitoring how my patients are doing (helping to take care of them at the same time) and generating the outcomes data, than a clerk sitting on hold on the phone with an HMO employee (usually a nurse NOT taking care of patients) for hours, attempting to get approval for a test.

'''McCain's plan.''' How can McCain say that "you will get a $5000 tax credit for your health care deduction." 
# If you are an individual you can only deduct $2500. Isn't this less than a self-employed individual can already deduct?
# Isn't this really a huge TAX INCREASE for the average American? 
# What percentage of companies will just drop their healthcare coverage rather than deal with the taxes?
# How many individuals will not be able to afford the increase in overall cost of their healthcare insurance and end up uninsured?
# Doesn't the lack of national health insurance continue to cripple our employers when competing with foreign employers with lower cost from national plans?
# Why not adopt the single payer Medicaid plan -- which has the lowest administrative cost per patient?
# What is the average profit margin of health care insurers in the United States?
# What currently available plans (if any) could someone afford with the money McCain proposes to give to each individual/family?

== Audio Clips to Use ==
Are there any audio clips out there that we should include? Or particular music we should include? Be specific.

*SEN. HILLARY CLINTON (at the Democratic debate): We cannot get to universal healthcare, which I believe is both a core Democratic value and an imperative for our country, if we don’t do one of three things. Either you can have a single-payer system, or [applause] —which I know a lot of people favor, but for many reasons is difficult to achieve—or you can mandate employers—well, that’s also very controversial—or you can do what I am proposing, which is to have shared responsibility. [http://www.democracynow.org/2008/2/8/examining_clinton_obamas_stances_on_the Democracy Now]

*Take Away, 10/9/2008 morning ... had a quote from a listener ... along the lines of "Should we be PROFITING from someone's CANCER?" This simple statement changed MY WHOLE VIEW of health care (and I nearly finished an MBA in Health Care Admin, back in 1982) ... We SHOULD NOT be profiting from people's illnesses, sure, we can wash our hands more often, and reduce risk in other ways, but from a social / societal view, that is NOT gonna cut it.

== Links to Research Materials ==
Do you have any readings, videos or any other relevant material to recommend?

'''In a nutshell:''' The best place to start is: [http://www.prospect.org/cs/articles?article=placebo_politics Placebo Politics, Marcia Angell, The American Prospect, 11(23) 6 Nov 2000 ], which explains why the Democratic and Republican insurance-based reforms are failing.

'''[http://www.health08.org/ health08.org] Kaiser Family Foundation''' resources and information about health policy issues in the 2008 election. Comparisons and analysis of McCain and Obama policies. New section, [http://www.kff.org/uninsured/h08_7813.cfm Covering the Uninsured: Options for Reform] discusses options (including single payer) and questions to ask about each one. 

'''[http://www.nejm.org New England Journal of Medicine.]''' In the hierarchical world of medicine, the NEJM is at the top of the hierarchy. Its mission is to inform doctors and medical students about everything they need to know in medicine, primarily clinical medicine but also social issues such as the health care system, including extensive coverage of politics and reform, both by peer-reviewed academics and by M.D. journalists. It is well-indexed both on its own web site and on [http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed PubMed]. While access is limited to subscribers ($159/year, $69 students), many of their articles are free online, including their [http://content.nejm.org/cgi/collection/health_policy Health Policy collection]. Or you can ask a college student with library access to get an article and email it to you. 

'''Paul Krugman''' critiques [http://query.nytimes.com/search/query?frow=0&n=10&srcht=s&query=health+care&srchst=nyt&submit.x=19&submit.y=6&submit=sub&hdlquery=&bylquery=krugman health care] in his New York Times column. 

'''"Money Driven Medicine"''' by Maggie Mahar.  A look at how we arrived at our current predicament and an exhaustive explanation of why just eliminating the insurance companies and going to a single-payer system will not fly because of the runaway costs.  She examines the reasons for the runaway costs, and they are not caused by the insurance companies themselves. Martha

'''Douglas Holtz-Eakin,''' McCain's senior policy advisor. One of his areas of expertise is health care. He explained his ideas on the role of insurance, economic incentives for patients, and other market-oriented approaches in a policy paper [http://www.leighbureau.com/speakers/dholtz-Eakin/essays/healthcare.pdf Health Care Reform in the United States: Why, When and How?] A good source to understand market-oriented thinking. [[User:Norman|Norman]] 14:32, 6 October 2008 (UTC)

'''[http://en.wikipedia.org/wiki/David_Cutler David M. Cutler.]''' Obama's health adviser. 

'''[http://healthaffairs.org/ Health Affairs]''' is the major peer-reviewed academic journal on health policy, and they're quoted in the media all the time. Some content is free, but with a New York Public Library card you can get it all free online in the Ebsco database, at [http://www.nypl.org/databases/index.cfm?act=3&id=131 NYPL connect from home]. When you're trying to figure out a policy debate, Health Affairs is a good place to find out what the facts (if any) are to support each side's position (for example, they've had comparisons of cancer survival rates in different countries). But it can get technical. You can start with the [http://www.healthaffairs.org/1360_press_room.php press releases]. The [http://www.healthaffairs.org/press/mayjune0801.htm May/June] issue was on health reform. [[User:Norman|Norman]] 04:50, 23 September 2008 (UTC)

'''[http://online.wsj.com/public/page/news-opinion-commentary.html Wall Street Journal editorial page.]''' Not to be confused with the WSJ news section. Op-Ed articles by big business <s>lackeys</s> advocates and free-market ideologues. This is a good place to understand the thinking behind conservative health care ideas, which have lots of money and power behind them. Often thought-provoking (what if you abolished the FDA and let people buy prescription drugs on the free market?) As Cicero said, you don't understand your own argument until you understand your adversary's argument. Conversely, they print great letters debunking the Op-Eds. Free online.

'''[http://www.metrohealthcare.org  Metro New York Health Care for All Campaign.]''' Local New York group organizing for single payer health care. 

'''[http://www.ahip.org/content/default.aspx America’s Health Insurance Plans (AHIP).]''' Trade group of insurance companies. Formed by merger of American Association of Health Plans (AAHP), and the Health Insurance Association of America (HIAA), which ran the "Harry and Louise" ads that helped to sabotage the 1993 Clinton health plan. President of AHIP is Karen M. Ignagni, who used to work for AFL-CIO to get a Canadian-style system, then went to the corporate side. Ignani makes a reported $1.2 million a year. 

'''[http://www.phrma.org/ Pharmaceutical Research and Manufacturers of America (PhRMA)]''' is the trade association of the pharmaceutical industry. President and CEO Billy Tauzin was Senator from Louisianna when he shepherded through Congress the Medicare Part D pharmaceutical plan, which prohibited the government from negotiating prices with the industry, and established the donut hole, which, according to the NEJM, seems to have been designed to benefit swing voters. After Medicare Part D became law, Tauzin retired from the Senate and assumed his job at PhRMA. Tauzin said he was not engaged in talks with PhRMA over the job while he was working on Medicare Part D. He took the job, he said, because he learned about the important work of the pharmaceutical industry when his mother got cancer. Tauzin makes a reported $3 million a year. Ask PhRMA if you want to know why drugs cost $100,000. PhRMA's web site has a directory of members, in case you want to work in the pharmaceutical industry and need a list of prospective employers. 

'''[http://www.democracynow.org/ Democracy Now.]''' Amy Goodman created this as an independent offshoot of WBAI-Pacifica, during some disputes over editorial control. While Goodman was recently in the news for getting arrested at the Republican National Convention in Minnesotta, she was also beaten and shot at during a mass killing by Indonesian soldiers in East Timor. Democracy Now uses journalism-school standards of objectivity and balance, with frequent quotes (or refusal to comment) from mainstream politicians, except their balance point is further to the left.[http://www.pbs.org/ombudsman/2006/10/a_fair_analysis.html] Democracy Now has substantial coverage of health care, and is one of the few news sources with substantive coverage of single payer, with interviews of Kucinich, Nader, Kuttner, and Woolhandler. Most useful of all for research purposes, Democracy Now is transcribed and the full text is available free [http://www.democracynow.org/search online]. According to Democracy Now's tax filings, Goodman makes $40,000 a year.

== What Else? ==

=== Single Payer ===

Marcia Angell, former editor of the New England Journal of Medicine, wrote in many editorials that incremental change is doomed to fail. Incremental changes make the system more administratively complex, and therefore more expensive, and more people fall between the cracks. The only system that will work, said Angell, is a single-payer system, like Medicare or the Canadian National Health Service. Administrative costs and insurance company profits are 30% of all health care costs, compared to the Canadian system, which spends half as much as the U.S. system for equal or better outcomes, according to [http://www.openmedicine.ca/article/viewArticle/8/1 Guyatt et al.] Pluralities or majorities of Americans tell pollsters that they favor government-run insurance. Yet most American politicians say that they can't create a single-payer system. When the people want something, and the politicians tell them that the political system can't give it to them, said David Himmelstein, M.D., co-founder of [http://pnhp.org/ Physicians for a National Health Program], "you don't have a democracy." Would we have a better health care system if Medicare was extended to everyone? If it's not politically possible, why not? 

What is to be done? There are two strategies, say Kuttner and Himmelstein: 

*The top-down solution would be for Democratic candidates, like Clinton and Obama, to come out for single payer, which is very popular among voters, and would give them an advantage over the Republicans. The problem is the influence of money on American politics. 

* The bottom-up solution, they say, is to (1) educate and (2) organize people to demand single payer from our politicians. The problem is the influence of money and power on the corporate media, which is biased against progressive solutions ([http://www.fair.org Fair.org]). So advocates must develop alternatives to the corporate media. Alternatives like you, Brian. [[User:Norman|Norman]] 19:39, 26 September 2008 (UTC)

:I think that not enough discussion has been held on why medical costs rise at a rate of twice to three times inflation.  I love the Physicians for a National Health Program, but I question their numbers.  I saw a pie chart from 2005 whose source was the National Institutes for Medicare and Medicaid, a division of the US Dept. of Health and Human Services.  It shows on 4.5% of expenditures are for the profits and administrative costs of private health plans.'''[Citation needed]''' 4.236.177.143 15:18, 26 September 2008

::Take for example the Health Insurance Plan of New York. In their [http://69.74.106.39/downloads/AboutHIP/annual_report2006.pdf 2006 Annual Report], go to Consolidated Statement of Operations, PDF page 15, their page 13. It says: 

:::Expenses:
:::Cost of benefits provided 4,201,614 
:::General and administrative 638,926 

::$638,926/$4,201,614=15.2%. (That's a loss ratio of 84.8%.) [[User:Norman|Norman]] 22:28, 26 September 2008 (UTC)

===Regional variations and rationing===

<font color="red">BL Show Note:</font> ''The below discussion between Norman and Martha and others is fascinating, and respectful. Thank you. But remember, one of the goals here is to collaborate on a script that Brian can use on the air. It has to be short, to the point, and fair. So, how do we condense the below into a few key, fully formed questions that can go into Brian's hands?''

Maggie Mahar, the author of "Bull," wrote a great book called "Money Driven Medicine.  She demonstrates using research from the Dartmouth Medical School that costs are driven by a glut of technology.  The logic is thus:  If a cardiologist buys a CT scanner for  million dollars, he/she has a huge incentive to use it all the time in order to make it cost effective.  So there are many scans that are ordered that may not be necessary.  Moreover, the effectiveness is not proven.  Many times a CT scan is inconclusive, requiring more tests to confirm or clarify results.  My point is that it is not enough to get rid of the insurance companies; something has to be done to take the incentive out of ordering procedures that are expensive and not proven effective, new drugs that are expensive and not proven effective and new devices that are expensive and not proven effective.  Otherwise we are doomed to a 6% rise in costs every year, because just changing to a government single payer simply shifts those costs from the private to the public sector. 4.236.177.143 15:18, 26 September 2008

:Yes, this pattern was discovered by John Wennberg 40 years ago[http://en.wikipedia.org/wiki/John_Wennberg][http://www.ncbi.nlm.nih.gov/sites/entrez][http://www.dartmouthatlas.org/][http://www.ncbi.nlm.nih.gov/pubmed/4750608][http://www.sciencemag.org/cgi/reprint/182/4117/1102.pdf (Science 1973)] and has been the subject of thousands of studies and millions of research dollars. In June the New York Times had a story on this as it played out in CT scans of the heart ([http://www.nytimes.com/2008/06/29/business/29scan.html The Evidence Gap: Weighing the Costs of a CT Scan’s Look Inside the Heart]). This is an ongoing policy debate without an easy answer. One simple solution is for Medicare or the insurance companies to decide which treatments are effective, which are ineffective, and only pay for the effective treatments. That was managed care. When people tried to put that into practice, they found that a small number of treatments had been proven effective, a small number of treatments had been proven ineffective, and a huge number of treatments were in the middle. For example, some [http://www.cochrane.org/reviews/en/ab001877.html respected medical authorities] believe that mammography does more harm than good. Should "we" stop mammographies? Who decides? 

:In the UK, like most countries with government-funded health care, they set up an independent organization, the [http://www.nice.org.uk/ National Instituite for Clinical Excellence], which evaluates treatments for cost-effectiveness, and sets guidelines that doctors usually follow. They figure that if a treatment can extend a patient's life by 1 year for $70,000 or less, it's worth it. This system works reasonably well, especially when the evidence is clear, but there are constant public debates over whether a patient with hopeless, metastatic ''breast'' cancer should get an expensive American drug which has been shown to extend the lives of patients with hopeless, metastatic ''colon'' cancer by 6 months for $100,000. The NHS usually caves in and gives the drug. 

:In this country, guidelines are written by professional organizations such as the American College of Cardiology. Insurance companies love guidelines. It gives them a good reason to say "No." Wennberg also has some policy proposals. 

:I'm not sure how this would be affected by decisions at the Presidential policy level. You could frame this issue as a question: 

:Suppose a woman has metastatic ''breast'' cancer. A new drug costs $100,000 and extends the life of ''colon'' cancer patients by 6 months. She wants the drug. Her oncologist says it's a slim hope but he's philosophically opposed to giving up. (Oncologists routinely give patients with one cancer drugs that have been proven to work in other cancers -- but these prices are a recent development.) Should she get the drug? Who should pay for it? Medicare (if she's 65 or over)? Her insurance company (if she's under 65)? Should she get it only if she's willing to pay for it herself? Would a copayment of 5% (which is what Medicare does now) solve the problem? Who decides? How do they decide? [[User:Norman|Norman]] 15:20, 27 September 2008 (UTC)

This is a great question.  In addition to that question we should be asking why the new drug costs $100,000 and is it proven to be as many times more effective as the old drug it purports to replace?  How do we ration care for the elderly?  Or the terminally ill?  This are hard questions that no one in the US is ready to face.  Martha

:Marcia Angell explains why drugs cost so much in the New Republic article above, including the industry arguments that she finds unconvincing. You can get industry response to Angell on the WSJ editorial page web site. Basically they say (1) High-tech drugs involve great risks, and every effective drug has to pay for the 99 they tried that failed (2) It costs $300 million to develop a new drug, but if that drug is for a rare disease that only affects 1,000 people a year, you have to split the cost among those people (3) Value pricing (how much is your life worth?) 

:I'm sorry to have to inform you that some day you will die. If you talk to elderly (70s and 80s) people, or the doctors who treat them, you'll find out that they are usually not afraid of death. They worry about being in pain, or losing their independence (with a stroke, for example), or losing their savings. Most middle-class elderly people would rather leave $100,000 to their grandchildren for college than spend $100,000 on a Tier 4 cancer drug that ''might'' keep them alive for another four months. This is not really a problem. 

:The WSJ editorial page frames health care as a commodity that you can buy on the free market -- as much health and life as you can afford. That works well for them. They're rich. In a free market, they don't have to pay taxes to help the poor. I believe (on the basis of published evidence, for example [http://www.cfah.org/pdfs/Promises%20and%20Pitfalls%20in%20Consumer%20Decision%20Making.pdf Jessie Gruman], who interviewed 200 patients about how they made decisions after devastating diagnoses) that most Americans don't want to make those "consumer" decisions. The WSJ editorial page is framing the question the wrong way. In most industrial democracies (with government health plans), doctors establish treatment standards ("guidelines") and bring everybody up to those standards. If you have a functioning democracy, you can with some effort decide whether you want to spend $70,000 to extend a year of life, or $100,000, or $120,000. That's what the Department of Transportation does (with conservative blessings) when they calculate the cost/benefit ratio of auto safety regulations. 

:Would you rather pay more taxes to keep an unconscious 80-year-old man alive in an ICU with a tube in his throat on a breathing machine for a week ( $2,000 a day), if his family insists on keeping him alive until his blood pressure sinks? That's a social decision. State law usually determines "futility" policies. Hospitals have medical ethicists for this. It's a solved problem that you can look up in ethics textbooks. Sometimes a right-to-life doctor insists on resuscitating a dying infant who will go on to live 40 years unable to sit up or know what's going on around him, but that's rare. 

:As David Cay Johnston said, focus on the core questions: Is Marcia Angell right about single payer? Or does Obama or McCain have a better solution? [[User:Norman|Norman]] 00:17, 28 September 2008 (UTC)

I don't buy the drug industry's reasons for why new drugs cost for an instant.  I think they cost what they do because they can get us to pay the prices.  All the more reason to question they prices.
I disagree that the ethics of rationed care is a solved problem or we wouldn't still be having an argument about it.  I may have my own opinion but the country as a whole needs to decide how much health care is enough and how much it should cost.  I like the above core questions, but I think we miss something if we don't have a larger discussion about what we think universal access would look like in terms of the actual care.  We clearly cannot do everything for everyone.  Where will the lines be drawn and who will draw them?  Martha

:It would help me if you could explain what your problem is. 

:In the UK NHS system, their decision-making is straightforward. 

:First, they decide how much they will spend on health care overall (a global budget). Under Thatcher it was less. People started complaining so they raised it. 

:Then they have an organization called [http://www.nice.org.uk/NICE NICE] that creates guidelines for every major condition. They decide what treatments are cost-effective, what treatments aren't cost-effective, and what treatments don't work at all or are harmful. (Our FDA has similar panels but they just consider effectiveness, not costs.) 

:If a treatment reaches a cost-effective threshold of $70,000 a year, or its equivalent, they provide that treatment. Here's how they treat [http://www.nice.org.uk/guidance/index.jsp?action=byID&o=12069 chronic kidney disease]. They adopted the guidelines of the U.S. National Kidney Foundation. They give dialysis and kidney transplant when appropriate (according to U.S. standards), but they aggressively pursue prevention (drugs for high blood pressure, etc.) because that's better for patients and saves money in the long run. 

:Most of the time it's a straightforward decision. Everybody gets the treatments that reach that cost-effectiveness level. Sometimes people with particular conditions complain that they can't get certain treatments either because NICE doesn't think it meets the cost-effectiveness guidelines (often using U.S. guidelines), or because it doesn't work at all. They debate it and if the treatment is indeed effective the decision is usually to let them have it. 

:Most people seem to accept this because they believe it's fair. They don't have rich people with good insurance getting $100,000 drugs and poor people without good insurance doing without. 

:That's what universal access looks like, and that's how they draw the lines, in the U.K. and Canada, the two countries whose journals I read. 

:I'm puzzled. What are you objecting to? Is the UK system as I described it acceptable to you? [[User:Norman|Norman]] 22:23, 28 September 2008 (UTC)

I'm not talking about a problem that I have.  I am saying that in this country any talk abut rationing care in any way at all is politically toxic.  I would like to see that change.  I think the BL show might be a good place to start raising the issue.  The UK system would be a great place to start?  Could such a method fly in the US?  If not, then what might?  It's not a matter of what universal access looks like in the UK - it's what it would look like here. People have a hard time talking about how much care we should really provide and I think it gets in the way of a serious discussion about reform.  Also, while we are talking about the UK it might be interesting to explore the recent news stories about people paying for care outside the system when it is convenient for them and going back inside when it is not.  For example:  instead of waiting in line for a test, they get it outside the system.  If the test shows a condition that needs serious treatment they go back in.  It is putting stress on the system.  Martha

:I don't think it's politically toxic, It just doesn't sell books. I did a Google search on "health care rationing" and found lots of articles in the New York Times, and lots of books that are policy-oriented and technical. 

:I also found this article, which I actually read when it was published, during the health care debate around the time of the Clinton health care plan. Now it comes back to me. 

:[http://www.sciencemag.org/cgi/content/abstract/247/4941/418 Rationing health care]: the choice before us, H Aaron and WB Schwartz, Science 26 January 1990:Vol. 247. no. 4941, pp. 418 - 422. 

:Aaron and Schwartz say that rationing is a problem in the U.S., not in European countries with comparable economies, although they do discuss rationing in the U.K., of kidney dialysis, implantable cardiac defibrilators, factor VIII for hemophilia, AZT for AIDS, CT scans, etc. 

:This confirms my impression that rationing was a fashionable issue with policy wonks in the 1990s, but has been resolved in socially acceptable ways since then, both in the U.S. and U.K. Most of those examples above are now standard treatment in the U.S. and U.K. We give AIDS patients even more expensive drugs than AZT, in the U.S., U.K., and even Brazil, and (unlike derivative mortgage financing and the Iraq war) that didn't drive us bankrupt. As you can see in the NICE standard for chronic kidney failure that I cited, the U.K. uses exactly the same National Kidney Foundation standards and recommendation that we use in the U.S. (for those who can pay). 

:I subscribe to the [http://bmj.com BMJ] and I've followed their discussions of what they would call "allocation." Their first concern is whether the global budget is big enough. (Thatcher cut it and encouraged privatization.) Give them a pot of money, and they can allocate it very efficiently to get the most benefit out of it. They usually use U.S. guidelines. The big debates among doctors are over whether a particular intervention is supported by the evidence, and they answer that question with less politician interference than we do. To take that NYT story about CT scans in cardiology, they do use CT scans for acute myocardial infarction, when it's appropriate. They don't use CT scans for screening the population, when (the NYT said) it's inappropriate. They'll do a randomized, controlled trial to see whether an essentially cost-free ultrasound will save as many patients as a $500 CT scan, and once they find out which saves more patients, that's what U.K. doctors will use. That's a good way to save money. 

:They do have big public controversies about (1) the scientific basis behind the standards and (2) patients with a human face who are denied treatments because they don't meet the guidelines. As Aaron and Schwartz said, when U.K. doctors are faced with a few patients who needs an expensive treatment, like Factor VIII, they give in and pay for it, although they try to hold the line on budget-busting treatments like total parenteral nutrition which can keep elderly people alive in bed for a few more months. (3) "Gaming" the system, when for example patients pay for tests in the private market to "jump the queue," then return to the public system. The U.K. newspapers have been writing short, sensational, oversimplified stories, but if you want to understnad what's really happening you have to think out the long-term policy consequences of each proposed solution, which gets very complicated and requires lots of reading. 

:What we learn from this is that there are 2 ways of allocating medical resources: (1) Expert panels of doctors who decide what treatments are effective and ineffective, subject to political oversight from the voters, as they do in the U.K. (2) The free market, where medical consumers decide as individuals whether a mammogram is worth $10, or whether an ambulance to the ER is worth $150 when you're having chest pains. Which works better? This is a case history that gets to the heart of the broader public/private debate that plays out between the Wall Street Journal editorial page and the left. 

:Having said that, I see on Google that there was also an entire program on [http://archives.onpointradio.org/shows/2006/01/20060109_b_main.asp On Point: Rationing Health Care] -- with our old friends, Henry Aaron, David Himmelstein and Stephanie Woolhandler. I'd suspend judgment until I've heard it. But I'd check out their facts and claims too. Even if you believe in single payer, you don't serve the interests of your listeners by letting PNHP bullshit you either. If someone can make a good case for the free market, I'd like to hear that. I've already given you some questions. 

:Everything I've said here has the caveat that I've written it off the top of my head, and I still haven't figured out how to get Citation Manager working. I'd (obviously) be very interested in a program that checked out what I've said to see if I'm correct. Some people tell me that I idealize the U.K. system too much. I'd like to hear from some of the U.K. doctors who have written about it for BMJ and Lancet. 

:If you were to block out 10 1-hour programs on health care over the next year, this would be a good (difficult) one. On Point spent 1 hour on rationing, but they had to simplify it by tossing the free-market conservatives off the bus. I don't see how rationing could fit into a 1-hour program on health care in the 2008 election. 

:I couldn't condense this discussion into a few key, fully formed questions on rationing that can go into Brian's hands. I could however work up a short bibliography of 10 books and journal articles to get you started on understanding it. [[User:Norman|Norman]] 15:44, 30 September 2008 (UTC)

::On rationing, here's a story from the WSJ in which people argue that Lilly was creating a phony ethics debate about "rationing" in order to promote the use of an expensive drug. Sales were disappointing, "only" $100 million a year, and an assessment in the NEJM concluded that there wasn't enough evidence to demonstrate effectiveness. 

::Perry Communications Group Inc., Sacramento, Calif., a PR firm, lined up patients who will say that Xigris saved their life when they had sepsis, and doctors who will say that they can't use Xigris as much as they want because of rationing, in case you need a guest for a program on the subject. 

:::To Sell Pricey Drug, Eli Lilly<br>
:::Fuels a Debate Over Rationing<br>
:::It Rallies Doctors, Patients to Speak Out<br>
:::For Xigris, Even as Some Hospitals Balk<br>

:::By ANTONIO REGALADO<br>
:::The Wall Street Journal<br>
:::September 18, 2003<br>

:::In the war over how health care should be allocated in the U.S., one of the big new battlegrounds is an expensive drug called Xigris.

:::A committee of doctors and academics was convened this year to study "ethics and rationing" in intensive-care units after debate erupted over who should get Xigris. The drug, used to treat severe sepsis, a deadly syndrome associated with severe infections, costs $6,800 per treatment. Some doctors and patients, concerned about reluctance to prescribe the drug, are questioning whether patients are dying because of tight-fisted hospital policies.

:::"It's amazing. This is a new, lifesaving technology that works," says Jay Steingrub, director of Baystate Medical Center's medical intensive-care unit in Springfield, Mass., who has begun speaking out on the issue. "Yet it's been rationed without the American public being aware of it."

:::Behind the scenes, an unconventional campaign by Xigris's maker, Eli Lilly & Co., is fueling the debate. With Xigris's sales far below expectations, Lilly is stoking a controversy over who should get expensive treatments in times of limited resources.

:::It gave a $1.8 million grant for the study of health-care rationing practices. It successfully lobbied for a special reimbursement of half the drug's cost for Medicare patients. It hired public-relations firms that helped the drug maker shape a rationing-debate strategy. And it has rallied patients and doctors who believe in the drug....

::[http://en.wikipedia.org/wiki/Xigris#Marketing_controversy Wikipedia] also had a good writeup on the Xigris promotion. [[User:Norman|Norman]] 14:33, 10 October 2008 (UTC)

:::For the record, BMJ (formerly British Medical Journal) has [http://www.bmj.com/cgi/content/extract/337/oct10_2/a2047 three articles on rationing] in the 10 October 2008 issue. So you can see whether I know what I'm talking about. Subscription only, I'm afraid. [[User:Norman|Norman]] 17:06, 11 October 2008 (UTC)

=== Martha's questions ===
In addition to the question above:  Is single payer better?  I would like to see a discussion of costs.  I recommended Maggie Mahar as a possible guest.  She points out that 85% percent of the premiums we pay to health insurance companies is paid out in claims.  If you take the total $2.2 trillion spending on health care in the US, insurance companies' administrative costs and profits only add up to 4.5%.  More than the government's overhead which accounts for 2.3%.  Almost half of the health care delivered in the US is already funded by taxpayers.  These figures come from the Centers for Medicare and Medicaid Services.  There has been research done by the Dartmouth Medical School and John Wennberg (mentioned above by Norman), and others, that shows that spending on health care is driven by regional differences, the accessability of technology to those who have insurance, the profit incentive to use the technology by doctors and hospitals, and the lack of good information on the effectiveness of such technology on patient outcomes.  A partner to this problem is the lack of primary caregivers in the US because they are not compensated as well as specialists. The system now encourages expensive care after someone becomes ill; it does not encourage prevention.  So we spend more and the outcomes are worse. If we decide to change to a single payer, already a hard sell apparently, we have to have a discussion on how not to keep paying a health care inflation rate of 6-12% a year or we will rapidly run out of money and political will.  So here are my questions for Brian Leherer to consider when putting this segment together: 
# If we change to a single payer system, or even just a system where access is guaranteed, what method will we use to make sure we are not paying for unneeded or excessively expensive care?  Unneeded to one person may be considered life-saving by another, so we need a mechanism for determining this.  In the 90's the HMO's took a lot of heat for this, so clearly they did not do it right. Perhaps a study of the UK model is a good place to start.
# How do we make it more worthwhile for medical school graduates to specialize in primary care?  Should public money be spent doing that?
# How do we make sure everyone participates?  If people are able to opt in and out of the system it leads to adverse selection; only the sick buy in because they see a need for it, the healthy stay out.  That leads to a higher risk pool.  Should we do it with a broad-based tax or should we require that everyone buy in?  How do we enforce that?
# How should we fund effectiveness studies?  Right now the FDA is defunded, so most of the studies on new drugs are paid for by the drug companies themselves, an obvious conflict of interest that has led to some terrible outcomes recently.  
# How much are we willing to pay for all of this?
# An obvious question that must be asked because it is not in the US Constitution and is not a settled question for that reason:  Is access to health care a human right?  Believe it or not we have political actors in this country who say it is not.
# How do the candidates weigh in on all of the above? 
Martha

:This is an excellent list of questions. The most important question for a journalist is, "What does my audience want to know?" so he can frame a story that will answer those questions. The Internet is a journalist's dream, because it gives you a sense of your audience. (Although I know medical writers who listen to talk radio for that.) 

:Of course, no single radio broadcast could answer every one of those questions. The hard part of journalism is brutal winnowing. But you can always have another broadcast. [[User:Norman|Norman]] 00:37, 3 October 2008 (UTC)

===Markbnj's proposal===
---oo--- markbnj ---oo---

Here's a big question:  from my blog (sorry guys, I've got a LOT of stuff...)

[http://sos-newdeal.blogspot.com/2008/03/proposal-health-care-for-all.html my-full-health-care-proposal]

  Proposal: Health Care for ALL
Health care for all. A single payer system, which will be phased in over a 20 year period of time.

To start:

If you are employed and have health insurance, you may stay in it.
If you don't have it, you will be able to sign up. (Initially a Medicaid type system)
If you can't afford it, you will get assistance.

A 20 year phase in is necessary, so that insurance companies are involved in moving the plans forward.

Next, there will be plan mobility, so everyone can eventually get the new national plan (that our Congressmen and Senators currently have!)


Next: cost of medical plans will need to be moved from employers to government, and a tax credit might be a means of doing so.

Next: forbid companies from "slimming down" their health plans year after year.

Next: make sure drug companies are no longer allowed to sell directly to consumers...
(reduce costs)

These ideas are where we need to start.


Eventuallly, (say after 3 years) some of the employee plans will be taken over by the insurers (as opposed to by the employer (At&T/IBM/etc.) as a step to merging to several large national plans.

In the beginning, every X years, the government will put out a bid for management of the health plan.

eventually we might wind up with 4-6 national plans, that are similar, but run by different companies. this will help to unify them.

Notice that in this plan we do NOT
privatize or nationalize the Doctors
Reduce health care allocations.

We do save from
larger pools of insured people
less managerial costs, and NO PROFITTERING motives!

This is a key plan... Without nationalized health care, we will have problems with all other parts of the Real New deal

===Ruben Safir's Answer to the McCain Campaign on Healthcare ===

:The best thing I can do for you guys at this point is to tell you your making a HUGE mistake in the campaign strategy.   You can't win with the current message and Obama is tricking Dick and personel attacks can't work.

Obama has to be attacked on the economic front.  He has to painted as the "New" Jimmy Carter, an elitist academic with a bunch of well thought ideas which can NEVER work because the deficit is too big to absorb all absurd promises he says he can keep.  This is especially true with regard to the Health care boondoggle which not only can we not afford TODAY, but we can afford even less tomorrow.   His plan avoids the only real solution to the health care crisis which is a genuine downward economic pressure on prices.  A government run health care system  assures generations of rapidly rising costs with Washington "inside the beltway" lobbyists pork barreling the system for the rest of our lifetime.

Also, much as to be made of Obama's Chicago machine past.  Give him the Jim Daily Smear.  He deserves it and add to it the fact that he almost never shows up for a Senate vote.

Then show this New "Jimmy Carter" and compare him to McCain, a Man with a RECORD.  McCain-Fiendgold, Immigration, a man who can reach across a divide.  The only  Moderate in this election.

"Barrack, there you go again".

Ruben Safir RPh

in response to:

Bill Bloomfield, McCain-Palin 2008 wrote:
>
> Dear Supporter,
>
> The McCain-Palin campaign is now recruiting volunteers for the final weeks of the campaign and your help is needed.

== Existing Models==
The first attempt at a national health care system by the federal government was during the Taft administration almost 100 years ago. Even Richard Nixon, whose policies at the time were considered quite conservative, had proposed a health care policy somewhat resembling the current Canadian system, which would today be called 'socialist' by the same people that idealize Nixon as their ideological forebear. 

Most of the developed (and many of the non-developed) countries of the world have some form of social health care policy, including Japan, Germany (which has used the same model consistently since Otto Von Bismarck in the 1800's), Britain, and Sweden. The issue is not a new one on the world or even national stage, although most pundits would have you believe that the very notion of a national health care policy did not exist prior to Hillary Clinton's proposal back in the early 1990's. 

Would you please examine some of the existing models from other countries, as well as the proposals pre-dating the Clinton administration that originated in this country, just to give us some sense of perspective, and to bring to bear existing ideas which may have worked, what has not worked, and what could be used here int he US in the modern day based on existing data? It would add more strength to an argument that has so often failed because people mistakenly believed that the whole thing was being made up as we went along. [[User:Rain City Blues|Rain City Blues]] 18:48, 25 October 2008 (UTC)