Dear Robert [I love you Robert, even though on the whole I don't agree with you!], from what I have read, Obama’s plan would reduce costs in numerous important ways, insure portability, and cover most Americans. He would do this by:

1. Reducing the cost of underwriting. If you eliminate the need for underwriting, you save a ton of money, insure everyone and eliminate the problem of becoming uninsured due to losing a job (aka you insure portability). Imagine the labor and money it takes to police this elaborate system created by private insurance companies whereby coverage is denied in a thousand ways due to “preexisting conditions.” I am assuming that this would mean that “preexisting conditions” would be a non-issue across the board, which should satisfy one of your criteria for insurance reform.

Interestingly, one of the most vehement opponents of the Obama plan that I know is my best friend who happens to be an insurance agent. She spends her days trying to figure out how to get someone to qualify for insurance one way or another, I presume by combating insurance underwriters that are simultaneously trying to deny these same clients coverage. Believe me when I tell you that she has advised me plenty of times on the wording to use on insurance applications. She’s good at what she does and she gets paid handsomely for it, as do a million other minions that do similar jobs. I love my friend and do not wish her ill, but I think that this is one of the duties of insurance agents that should become extinct due to a lack of demand/need.

2. Negotiating costs with pharmaceutical companies and doctors/nurses. Seems reasonable to not only me. In fact, these companies and the AMA appear more than interested in making concessions because they know what a mess our system is in and how much better off they’ll be (financially) if everyone is insured.

IMO, when individuals are attracted to a profession because of the money involved, and said profession is supposed to be governed by what is in the best interest of the patient and not by the financial incentives/upside involved (have you read the Hippocratic Oath lately?) there are going to be issues, big issues. Not all physicians, but plenty, have learned how to “work” the system (whether public as in Medicare, or private as in private insurance companies) for their maximum dollar benefit and have become hugely rich because of that. This has to end now.

On a personal level, another vehement opponent to Obama’s plan is another relative, an RN-phlebotomist that doesn’t want her income curbed due to Obama’s plan even though today ER docs come to work on weekends knowing they won’t be paid by the “weekend clientele,” which they appear to begrudge care. It just makes sense to take this emergency-room-as-dumping-ground out of the equation. I think everyone will be better off and doctors can go back to feeling empathy for their patients rather than anger.

3. Improving prevention. Amen. This should save a ton of money. Remember my comment about Blue Cross denying my son’s his Interferon treatments but telling me they’d pay for a liver transplant? How ridiculous and counter-intuitive is that (the Interferon was 100000 times less expensive and more ethical). Plus, think about the medical care that would be provided to the poor under Obama’s plan, which individuals now wait too long for care because they can’t afford it until a basic condition becomes chronic, which sends them to the emergency room for treatment that is outrageous in cost not to mention not what anyone had in mind when they use the word “preventative;”

4. Making sure that *everyone* is covered which again would reduce emergency room visits replacing them with regular and preventative (less expensive) doctors’ visits (see my friend’s blog about the out of control, illogical billing at hospitals due to treating the uninsured and various illogical reimbursement rules*) AND making sure that the 18 to 30ish crowd are required to pay into the system (too many of my friends’ kids are uninsured, many by choice, and I think this is one of those “free rider issues” (that is, these kids bets on not getting sick until a certain age and therefore opt out of insurance when they’re healthy, only to buy into the system when they’re more likely to be sick) that is one of those “choices” that is cheating the system and that dooms the health insurance system for all. It’s got to stop;

5. And, yes, turning back the Bush Tax breaks to folks who make more than 250K a year;

Sadly, I think our opinions come down to our income tax brackets, and our respective trust in government (me), distrust in government (you), or trust in the private sector (you) and distrust in the private sector (me). I think that you make more money than we do, and that you trust the capitalist system and distrust government, which thereby determines your views on this. Honestly, I have no idea why you would trust the capitalist system after the current bank, insurance and investment house disasters (most of which were caused by pure greed and not enough oversight, which were frankly preceded by the Savings and Loan crash, which everyone seems to have forgotten about now, but which I lived through has an attorney to credit unions). Businesses can’t self police when the public good is concerned because of their only mandate to increase returns to the stockholders, which just doesn’t consider/cover external costs to the public, or consider the public good. Think public transportation. Think paper mills and oil refineries. Think modern day agriculture.

I am considering a job with a very large private home health care and hospice care company, and have combed through their records for the last 25 years. I want to know their financial situation, how they operate and whether it is a good place to work. They have had their trials, let me tell you, and they have worked through them through various infusions of cash, selling off assets, acquiring other companies, and painfully moving toward an outcome based incentive system (which is where I come in). They have been lauded by Fortune Magazine as one of the best 200 small businesses over the last 10 years. I think that if you-all-folks that mistrust government so much were to look at their historical record and were told that they were run by the government, you-all would use their record to highlight that government can’t be trusted to run entities/concerns like a for profit concern could. But, in fact, I think that this type of organizational morphology happens all the time in various settings, not with just government run concerns, but with private concerns, as well. There is no panacea in private enterprise.

6. And Yes, Obama’s plan would limit “choice,” which will reduce costs. I think the concept of “choice” in today’s health insurance market is a pseudo concept to begin with, which has been reinforced and created by the PR firms and folks with communications degrees that are hired by insurance companies as a talking point against the public regulation or public option of health insurance (see my opinion below about where “choice” has gotten us **). The long and the short of it is that there really is no choice. We pick a policy with various provisions at a certain age never knowing which provisions we will need. And frankly, policies change, generally not due to a “choice” made by the policyholder (of course there is boilerplate in the insurance contract that says they can change any damned thing they want in your policy with notice). I remember a catastrophic health insurance policy from The Principal that I paid on for years that was expensive, that we never used, that was cancelled because they pulled out of selling insurance in the State of Washington. No refund. No nothing. Not my choice.

Interestingly, one of my best friend’s “greatest concerns” is that the bill would require doctors to talk to elders and those with life threatening illnesses about end of life care every five years, which she thinks brainwashes them to consider ending their lives prematurely, which of course, to her is “bad” because it would limit “choice.”… In fact, that is not the case under this bill, as these folks are only offered the opportunity for counseling by a doctor, which I think is good, as counseling been denied previously because doctors have not been “reimbursed” for it. Any education is good, considering the cost of health care during the last months of life and the fact that end of life health care doesn’t generally increase quality of life (or length of life much), and considering the fact that although we all have to die, we are just not that keen on talking about it in the US and would rather remain in denial, which makes us and our families request expensive procedures that are ultimately not very helpful to the person being treated and the public at large.

I also know that there is an argument against a Medicare type system because of the “lack of choice” issue. Let me say that having taken care of my elderly mother, who has lived in my backyard for the last 5 years, I have not found Medicare to difficult to deal with. She is glad she has it, as am I. She did have a stent put into her artery about 2 years ago, and when she first went to the hospital with chest pain, the doctor could only find a 60% blockage, and Medicare said they’d only pay if there was an… 85% blockage (or something like that). So, when I brought her in a couple of weeks later with the same symptoms, Medicare rules allowed the doctor to do the procedure (because there were various exceptions to the 85% rule, one of which was that the person has future life threatening symptoms). It seemed reasonable.

If it’s in financial trouble let’s fix it, not all systems stay healthy forever, even those run by private companies. We all deserve Medicare. I want to remind you and others that we had a surplus during the Clinton years he tried to put aside for SS, which we didn’t allow him to do. The current financial deficit has much to do with the Bush administration and not the previous Democratic administration, and the war….. Anyway.

I know folks in Canada, plenty of them. We lived in Seattle and Richard worked for a Canadian company for awhile. Plus, just our proximity to Canada resulted in us knowing so many folks there. They just have not complained about their health care [except for one silversmith Canadian friend of mine who can comment here if she wishes], and in fact the people I know that have moved there from the US are thrilled about it. Yes, there are waits, but for elective procedures. For non-elective procedures, there usually is not a wait. I have lived with an HMO policy for 25 years. My mother, a nurse, was vehemently against HMOs for most of my life, due to issues of “choice” with arguments much like I hear in opposition to Obama’s plan. Well, we have been very well treated by our HMOs. I have no complaints even through garnering various life saving procedures for both my son and husband.

I think that frankly what will happen is that people with money will buy additional health insurance policies which will allow us to have better health care than the basic universal care policy. In a perfect world this wouldn’t happen, but the world’s not perfect. However, I am willing to live in a less than perfect world where everyone has coverage, even if uneven. I think the people you know from Britain and Canada that come to the US for procedures are some of those folks in the upper income brackets.

Lastly, Robert, I’ve followed this recession/depression pretty closely for the last couple of years and have followed several economists from the time they were formulating their responses on how to deal with it. I know that for certain people with a certain political approach this stimulus measure seems counter-intuitive. In a family, for example, when you are in financial trouble you stop spending. In the larger macroeconomic environment, however, as we’ve seen from the recession in Japan in the 1980s and their delayed but finally successful stimulus response to it, and from Roosevelt’s response to the Depression, that is not how you come out of a financial situation like the one we were facing and face (where a reduction in the Fed rate and tax cuts will NOT do the job). In fact, you spend into it. I recommend you read Krugman with the NY Times, both his blog and his column. As to how to come out of it and get a grip on the deficit, I believe the theory is that once business is robust again spurred by an improved economy that increased taxes will pull you out of the hole.

Now I have to go to bed. I hope you had a wonderful night.

[My thanks go to my friend Robert-- he can identify himself if he wishes. He spurred me into putting my feelings down on paper because he was unimpressed with my first response because it was mostly emotional and wasn't substantive. I wanted to impress him. If I did not rise to the challenge, it wasn't for lack of trying. I do appreciate the alternative views of my friends and family even though to some it may not seem like it.]

* http://open.salon.com/blog/mishima666/2009/03/06/secrets_of_hospital_bills_revealed

** http://open.salon.com/blog/cindy_ross/2009/03/04/we_went_broke_paying_medical_bills--and_were_insured

** And my response:

I appreciate your post. It shows the community here on OS what normal, hardworking folks go through in this country every single day with our "free market" "health care" system which incorporates “choice" (whether you can afford it or not).

Our son has a chronic medical condition that he acquired from his first country at birth, which we didn't know about, but which surfaced during his middle school years. We are lucky that his very expensive treatment was fully covered by our HMO, which we "chose" during the "election" period at our large university employer. If we had "chosen" the non-HMO, typical Blue Cross option, which would have cost us much more, his "treatment" would NOT have been covered. But, his organ transplant WOULD HAVE BEEN covered.

He responded very well to the grueling treatment and has been healthy since. Lucky "choice" on our part.

He and his girlfriend, who has Type I diabetes, had a baby 2 years ago. Our grandson was "unexpected." Because they were both on their parents' respective health insurance policies, they couldn't marry because our insurances would drop them, and they are uninsurable due to their "pre-existing" conditions. Plus, although our son's girlfriend's parents both cover her with their large employer-based insurance policies, the pregnancy was not covered. Why? I'm not sure if they could have "chosen" such coverage. Even if they could have how many of us foresee our children's pregnancies and would choose a higher premium based on such possibilities?

Thankfully we had a very new Medicaid program in our state that covered the pregnancy, and our grandson's care after he was born. Both mom and baby have received excellent care from "Medicaid." Our son and his girlfriend are in graduate school now, and because they remain in school their parents' (our) health insurance policies will cover them until they are 24 years old. Apparently, that's the "standard" age that "kids" are dropped from parents' policies. We do not have any "choice" in the matter.

They will graduate before they are 24 by three months, and at that time will have to find employment from an employer that has a Group Health Insurance Policy, so that their "pre-existing" conditions do not "count" against them, so that they can be covered by health insurance.

What do I think their chances are of gaining such employment in this recession? I seriously don't know, but their "chances" of gainful post-graduation employment look dimmer every day. This is not their "choice" either.

This is what "choice" gets you.