Part one, the history of the whole thing, is, on the one hand, useful as a refresher, even if you followed the news reporting during this time, and, secondly, provides a window into the point of view of liberals on healthcare reform.<\/p>\n
Brill starts with the context, and the \u201cneed\u201d for reform, citing the (debunked) claim that 60% of bankruptcies are due to medical bills. \u00a0He gives some background on Obama\u2019s initial unpreparedness on the topic, and his later insistence that he\u2019d differentiate himself from Clinton by opposing the mandate she supported. \u00a0At the same time, members of Congress, including Max Baucus and Republican Chuck Grassley, were already talking about reform, and Baucus himself prided himself on his ability to make deals across the aisle. \u00a0Hence, the initial plans were bipartisan, and the Romney model in Massachusetts was the basis.<\/p>\n
Because Baucus and other players in the Senate and House had already been busy, Obama continued to let them take the lead, for good or bad. \u00a0Grassley continued to provide input, and the Dems hoped to get Olypmia Snowe on board as well for some measure of bipartisanship. \u00a0At the same time, the Cornhusker kickback, the Louisiana Purchase, and a multitude of other special deals brought reluctant Democrats on board. \u00a0And dealmaking of all kinds occured with the industry players: \u00a0getting each of hospitals, insurance companies, and drug makers to agree to concessions, on the rationale that they\u2019d get more customers, and that half a loaf is better than none, or, rather, that agreeing to support limited concessions would be better than even more onerous taxes that the bill-writers threatened them with.<\/p>\n
A window into the presidency: \u00a0true to other reports, Valerie Jarrett is here portrayed as controlling the president, insisting that he be provided a \u201cconsensus\u201d report from the various advisors, with any conflicts among them seemingly ironed out (due, in reality, to one or the other of them having won any given battle), with simple checkbox-type choices laid out. \u00a0Obama also went \u201coff-script\u201d by casting the insurers as the bad guys in speeches, even though they weren\u2019t the ones raking in the money; their profits weren\u2019t that exceptional.<\/p>\n
In the end, after the summer break, it became clear that the Senate bill would be passed by the 60-senator Democratic majority, with no GOP support. \u00a0More horse-trading, and manipulation of the CBO \u201cscoring\u201d process. \u00a0The House passes their version of the bill, but then Scott Brown wins the Senate seat formerly held by Teddy Kennedy, meaning that the usual conference process was foreclosed. \u00a0The House would have to vote on the Senate bill as-is, and then the Senate, using the Reconciliation process (no filibuster required), could vote on a set of changes limited only to financial components of the bill.<\/p>\n
So there you have it. \u00a0Well, Brill then continues into the disastrous implementation of the exchanges, the court battles, the real-world feel-good stories of people with new coverage, and so on \u2014 but let\u2019s skip ahead.<\/p>\n
Throughout this story, Brill makes his opinion clear. \u00a0To begin with, he simply doesn\u2019t understand insurance.<\/p>\n
Insurance plans offered by large employers, called group plans, do not screen individuals for their health history or even their age. \u00a0That\u2019s because the \u201cpool\u201d of people to be insured is large enough that the risks among them average out \u2014 which is what insurance is supposed to be about: \u00a0large groups of people paying premiums in order to share hte risk that some of them will need help.<\/p>\n
But . . \u00a0the individual market was premised on the insurer gauging the risk \u2014 which is called underwriting \u2014 of each person applying for insurance.<\/p>\n
In that sense it was not really insurance at all, because it was not about a large group covering for the losses of one of its members. \u00a0Rather, it was about the insurance company making a bet on [an individual\u2019s] risk of getting sick. \u00a0Only it was making a bet using data about [her] age, her health history . . . and her lifestyle and circumstances.<\/p>\n
All that data \u2014 all that underwriting expertise \u2014 gave the insurers [and unfair advantage] . . . like card counting in blackjack. (p. 38)<\/p><\/blockquote>\n
So \u2014 what do you do with that? \u00a0He has it completely backwards. \u00a0Insurance is completely about determining an individual\u2019s risk of filing claims, and pricing premiums accordingly. \u00a0You\u2019d be pretty upset if, as a careful driver, you paid the same auto insurance premium as someone with frequent accidents for which they were at fault, or a history of speeding tickets. \u00a0And of course you expect that your home insurance premium will reflect such features as proximity to the fire department or fire hydrant, overall crime rates in the neighborhood, or other elements. \u00a0You\u2019d also be pretty irritated if life insurance had the same premium rates for everyone, regardless of age. \u00a0Yes, an insurance company can ultimately stay in business even when its customers file claims, only when it has a large enough customer base to balance out the claims that some file, but that\u2019s not what makes it insurance.<\/p>\n
Brill also makes no secret of his preference for a single-payer system like the UK, and uses the analogy that a healthcare plan that preserved the main outlines of the existing system \u2014 predominantly employer-provided, via insurance copmanies \u2014 is like \u201cadding ornaments to the hood of a jalopy\u201d (p. 66). \u00a0 He also makes his disappointment clear that proposals for a \u201cpublic option\u201d were dropped. \u00a0 And he strongly suggests that the Republicans had no real grounds for opposing Obamacare, other than a plan to oppose anything Obama supported, and were hence acting in bad faith, because, after all, the plan kept the general insurance-company-based structure, and had its antecedents in Romneycare and a Heritage proposal (side note: \u00a0from what I understand, though I haven\u2019t looked at this in-depth, \u201cRomneycare\u201d was based to a considerable degree on demands from the Democrats who controlled the Massachusetts legislature, and the Heritage proposal was not something that had previously gathered particularly much support, but was a single policy proposal by a staff member).<\/p>\n
The other thing that you start to realize is this:<\/p>\n
The core elements of Obamacare are pictured as a three-legged stool, with each element indispensable \u2014 but that\u2019s because its backers start with the elimination of the ability of insurers to underwrite based on pre-existing conditions. \u00a0When this is the starting point, then it\u2019s clear that a mandate is necessary, and subsidies follow. \u00a0But it doesn\u2019t work in the reverse: \u00a0it is entirely possible to provide a set of subsidies (or a complete voucher program) without upending the concept of insurance underwriting.<\/p>\n
So that\u2019s the history part of the book. \u00a0And the two-books-in-one aspect? \u00a0Because after all of this, and all of my gripes about his attitude about insurance, he actually, when it gets to the last section of the book, the \u201cwhat I\u2019d do to fix the system\u201d part, he actually ends up where I\u2019ve ended up: \u00a0with a staff-model HMO as the predominant form of healthcare delivery. \u00a0Hospitals are already buying up doctors\u2019 practices, and building extensive networks, and in some cases are already sponsoring their own insurance plans. \u00a0This concept has a lot to recommend it: \u00a0putting together the medical expertise of doctors and hospitals with the cost control perspective of insurers ought to mean that, if each such doctor\/hospital\/administrative entity competes against others in a given city, that they\u2019ll fight for market share based both on price and quality of care.<\/p>\n
Of course, in larger markets, Brill envisions there being as many as four or five such entities, but in medium-sized cities, there may be only two, and in smaller towns, a monopoly \u2014 and in the\u00a0last of these cases, he\u2019d treat this entity as a utility with utility-like regulation. \u00a0He\u2019d also impose such regulations as an 8% operating profit cap, a salary cap at 60x the lowest-paid doctor, an ombudsman\u2019s office, and regulated prices for the uninsured. \u00a0Interestingly, he shops his idea around to some of the experts he interviews, and one, an executive at UnitedHealth Group, says, \u201cwell, that\u2019s pretty much we do in Brazil\u201d \u2014 which is interesting to me largely because I was reading about Brazil\u2019s healthcare system for a project at work today.<\/p>\n
So this is particularly interesting to me because a while back I was asking, \u201cwhy didn\u2019t the Staff Model HMO work?\u201d \u00a0It still continues, in California with Kaiser, but it\u2019s not as if they\u2019re such an extraordinary cost savings compared to other insurance options that others are emulating them. \u00a0And yet you\u2019d think it ought to<\/em> work, though with some difficulties, as when you\u2019re travelling and need medical care, and simply can\u2019t access the provider network. \u00a0What\u2019s more, this system would, in many cases, really require leaving the current employer-based system; employers want nationwide insurance options, for the most part, and don\u2019t want to make arrangements with multiple providers in each town, especially in the ideal scenario in which consumers have their choice of multiple competing hospital\/doctor options in their particular area.<\/p>\nSo there you have it.<\/p>\n<\/body><\/html>\n","protected":false},"excerpt":{"rendered":"
This book is a bit of a bait-and-switch; you all know about the famous \u201cBitter Pill\u201d article Brill wrote for Time magazine (now behind a subscriber paywall \u2014 and, wow, that was two years ago!) and the title grabs you, in browsing the new book shelf at the library, on that basis, but this book, […]<\/p>\n","protected":false},"author":2209,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[10,133],"class_list":["post-1603","post","type-post","status-publish","format-standard","hentry","category-uncategorized","tag-from-the-library","tag-healthcare"],"yoast_head":"\n
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