Monday, December 28, 2009

Watching the storm from the porch of civility

Tiny bubbles…
In the wine…
Make me happy…
Make me feel fine.

I was looking for a quiet place to stand, safe from the storm. I usually find it in a silly song… or sometimes a Christmas carol this time of year.

In my youth I was more… political. About thirty years ago, as a matter of self preservation, I stopped talking, listening, reading or even thinking about anything remotely political—until healthcare reform forced itself into my field of view. So, I plugged back into the political milieu and, predictably, I did not like what I saw.

I am worried about our shining city on a hill—the short experiment in human political organization known as the United States of America. The dialectic continues apace but the debate has definitely dumbed down. We now have Olbermann and Maddow on MSNBC versus O’Reilly and Beck on Fox News where once we had Hamilton and Jefferson. I am not saying that our forefathers’ motives were necessarily more altruistic, but it would be true to say that the Hamilton-Jefferson debate elevates while the Beck-Maddow “debate” depresses. Hamilton and Jefferson had their share of lust for power and money. Beck inspires fear in order to boost ratings and the price of gold. Maddow’s on-air craving for approval and popularity with the liberal intelligentsia is palpable. Does that mean we can stop worrying about the current state of American political discourse because it really is just “same old, same old”? I think not. Can we at least get more articulate noise? I must be listening in all the wrong places. For goodness sake, do not tune in CNN and listen to actual speech-making by our elected politicians. It is more depressing than Beck-Maddow.

I can hear the objection: “They are not politicians; they are not even political media; they are in the entertainment business; no one takes them seriously.” That rationalization is in wide circulation as an effort to marginalize Limbaugh, Beck, O’Reilly, etc. It is a patently foolish thing to say. Millions of people listen and are stirred to passion. No other criteria or credentials matter in the face of that fact.

Beck and Maddow seem on such opposite sides of the political spectrum it is easy to forget that they are really two sides of the same coin. Beck and Maddow were both raised Roman Catholic—both on the west coast: he in Washington; she in California. They both entered the national scene after relocating to New England states: he in Connecticut; she in Massachusetts.

Beck is a high school graduate. He was divorced from his first wife amid struggles with substance abuse. He admits to being a recovering alcoholic and drug addict. He cites the help of Alcoholics Anonymous, attending his first AA meeting in November 1994, the month he states he stopped drinking alcohol and smoking cannabis. In 1995, Beck was co-hosting a local four-hour radio morning show in Hamden, Connecticut, billed as the Glenn and Pat Show. During a broadcast of the show, an Asian-American listener called to complain about a comedy skit speaking fake Chinese. Beck made fun of the caller who subsequently contacted a number of human rights organizations. The station manager read an apology on the air and the station issued a written pledge to refrain from offensive activities and instituted cultural sensitivity training for employees. Soon thereafter, while working for a New Haven, Connecticut radio station, Beck was admitted to Yale University through a special program for non-traditional students. One of his recommendations for admittance came from Senator Joe Lieberman. Beck took one theology class, “Early Christology,” and then dropped out. After he remarried, he became a Mormon.

Maddow earned a degree in public policy from Stanford University in 1994. She is a recipient of a Rhodes Scholarship and completed her PhD in politics from Oxford University. Her doctoral thesis was titled “HIV/AIDS and Health Care Reform in British and American Prisons.” She was the first openly gay American to win a Rhodes scholarship. Her first radio hosting job was in Holyoke, Massachusetts. The station held a contest for a new on-air personality and Maddow won.

As I said: two sides of the same coin. Both parlayed their fifteen minutes of fame on local radio stations into a national television audience. Maddow is certainly better educated, or, more accurately, Maddow is educated and Beck is not. To me, that fact only makes Maddow’s on-air rhetoric all the more frustrating. I can almost forgive Beck for being an ignorant buffoon. He is what he is. Maddow should know better.

Here is a synopsis of the dialectic as expressed by Hamilton and Jefferson:

Hamilton: Can a democratic assembly who annually [through elections] revolve in the mass of the people, be supposed steadily to pursue the public good? Nothing but a permanent body can check the imprudence of democracy. Their turbulent and changing disposition requires checks.

Jefferson: Men are naturally divided into two parties: those who fear and distrust the people and those who identify themselves with the people, have confidence in them, cherish and consider them as the most honest and safe depository of the public interest.

Hamilton: Take mankind in general, they are vicious—their passions may be operated upon. Take mankind as they are, and what are they governed by? There may be in every government a few choice spirits, who may act from more worthy motives. One great error is that we suppose mankind more honest than they are. Our prevailing passions are ambition and interest; and it will be the duty of a wise government to avail itself of those passions, in order to make them subservient to the public good.

Jefferson: I have such reliance on the good sense of the body of the people and the honesty of their leaders that I am not afraid of their letting things go wrong to any length in any cause.

Hamilton: I have an indifferent [low] opinion of the honesty of this country, and ill foreboding as to its future system. I said that I was affectionately attached to the republican theory. I add that I have strong hopes for the success of that theory; but in candor, I ought also to add that I am far from being without doubts. I consider its success as yet a problem.

Jefferson: Whenever the people are well-informed, they can be trusted with their own government; whenever things get so far wrong as to attract their notice, they may be relied on to set them to rights. I am not among those who fear the people. I have great confidence in the common sense of mankind in general. My most earnest wish is to see the republican element of popular control pushed to the maximum of its practicable exercise. I shall then believe that our government may be pure and perpetual.

Hamilton: Your people, sir, is a great beast.

Jefferson: The mass of mankind has not been born with saddles on their backs, nor a favored few booted and spurred, ready to ride them legitimately, by the grace of God.

We have been having this debate for over two hundred years. When Rush Limbaugh and Glenn Beck rely on politics of fear for ratings, power and money, are they conscious of the Hamilton-Jefferson dialectic? The answer is complicated. They subscribe to the superficial view of Hamilton as a proto-liberal, big government Democrat in contrast to Jefferson as a proto-conservative, small government Republican. Yet, power derived from a politics of fear depends on a Hamiltonian view of human nature. Ironic, isn’t it? But then, effete intellectuals tend to find irony in everything.

Irony is interesting—even pleasurable—but it is not an answer to anything, and I can not go to sleep until I tuck some kind of answer in a drawer somewhere in my mind. So, what is really bothering me? We have had civil war and civil unrest but it is the current lack of civility that concerns me most. If I were a weatherman, I would say there’s a storm blowin’ gonna make Katrina feel like a soft, summer shower.

Blow, winds, and crack your cheeks! rage! blow!
You cataracts and hurricanoes, spout
Till you have drenched our steeples.

Lear did not have a quiet place to stand. It’s hard to find the eye in the storm with all the screaming and howling.

I was about to say we all need a calm center to make sense of the chaos—otherwise we risk losing our eyes and becoming as blind as King Lear—but then I remembered the man that corrupted Hadleyburg. Mark Twain was a profound moralist about our “get rich quick” culture, not because he stood apart but because he was so susceptible to it. There is no such thing as “the ethical choice” unless made in opposition to a compelling corrupt choice.

The Becks and Maddows are not going to stop shouting at us. The always-on connection to public media through television, internet and cell is not going to fall silent. Maybe we can learn to turn it into a strength.

Wednesday, December 16, 2009

Another way...

The healthcare reform drama has become a medieval morality play. Shakespeare could have had some fun with this material. I have decided that the real problem is pie. Everyone loves pie. The players strut and fret upon the stage in order to protect their individual pieces of the healthcare pie. No one believes it is possible for everyone to get enough to eat; so, they each lay claim to a separate piece and guard it jealously.

Who knows what tomorrow will bring, but at this moment, the debate is focused on contracting the uninsured piece of the pie, expanding the Medicare and Medicaid pieces of the pie, and maybe, just maybe, contracting the commercial insurance piece of the pie by creating a new piece called “public option.” I don’t know about you but I would not want to be in a pie-eating contest with eaters as strong and as voracious as commercial insurance companies. Yet, that is precisely the nature of the contest currently being waged.

I have a pie-shattering, paradigm-shifting idea. What about doughnuts? Doughnuts are meant to be shared. If you have an early morning meeting with a group of your fellow employees and you want to bring something that says, “We are all in this together,” you don’t bring pie—you bring doughnuts.

What is the pie? The pie is the cost of providing healthcare to everybody in the country. The following chart is meant to be representative of the players holding pieces of pie but it is not meant to be statistically accurate. The economic size of the piece is not as significant as the political strength of the hand holding on to it. The players are likewise a bit different than the usual suspects. The uninsured piece is not based on the actual market force belonging to the consumer-patient responsible for payment because that market force does not exist except as a negative pressure, a kind of anti-piece. The pieces belonging to Medicare and Medicaid are easily recognized but should carry subtitles as a reminder of the federal and state political processes that respectively exert pressure. The piece labeled on the pie chart below as belonging to “provider contract” is not usually recognized as such. The pie is usually divided into “employer provided” insurance and individual purchased insurance, but the fact is employers do not really control a piece of this pie beyond an indirect influence similar to the role of the taxpayers who fund governmental insurances. The “provider contract” piece refers to contracts negotiated by healthcare providers (primarily if not exclusively the large hospital systems in a given market) and commercial insurance companies (primarily if not exclusively the mega companies that dominate a given market). The “provider contract” piece also refers to direct contracts between providers and employers or other groups cutting out the insurance middleman.

Each piece contains a distinct population at any given time. The insurance industry refers to them as “covered lives” meaning that the unlucky millions in the uninsured piece would therefore have to be “uncovered” lives. If you are paying close attention, you might notice that there would be many more lives contained in these pieces than there are people living in this country. A person covered by commercial insurance would also get counted in the provider contract piece. That is as it should be. There is a cost based on the provider contract and a separate cost associated with the commercial insurance “middleman.” This doubling effect also holds true if the Medicare or Medicaid covered life is a commercial insurance hybrid such as Medicare Advantage. These, then, are the principle pie-eaters holding a significant piece of the total cost of providing healthcare to people in this country.

Thus far, healthcare reform has focused on reducing the size of the pie (or, more accurately, slowing the rate of the pie’s increase in size) by shrinking/enlarging some of the pieces relative to the other pieces (or, in the case of the public option, introducing a new pie-eater to the contest). It is difficult to shrink the overall size of the pie using that kind of strategy. Thankfully, there is another way. Bring doughnuts!

There is no hole in this doughnut. Americare is a basic benefit package covering everyone. In order to determine the cost of Americare, the total cost of providing care for everyone in the country for one year is calculated at Medicare rates and is divided by the total number of lives, creating a “single payer” annual premium for every individual life. It would be a low premium for three reasons:
1. By including all lives, the premium is based on the low cost of covering the “young invincibles.”
2. By forcing the cost of care to the Medicare allowable, the profit margin of the commercial insurers is eliminated.
3. While there are no deductibles, Americare has an across-the-board “co-pay” of 40% and the premium is based only on the 60% of cost actually covered.

The thing that makes this approach a doughnut instead of a pie is that the remaining 40% of the cost would be covered by the traditional pie-eaters. In that way, we can eat our doughnut and they can have their pie, too. In fact, since Americare would function like Medicare by utilizing commercial insurance companies as fiscal intermediaries to process and pay claims, the commercial insurance players would maintain multiple opportunities to feed themselves. The Medicare program would function as it does now but would provide coverage under its terms only as to the 40% co-pay. Likewise, the Medicaid programs would provide coverage for the 40% co-pay for covered beneficiaries—with coverage determined through a combination of federal and state mandates. Employer-funded groups would cover the co-pay through traditional commercial insurance. Self-employed persons would be required to purchase insurance (perhaps through a newly created insurance exchange) to cover the 40% co-pay. Individuals would also be allowed to “self-fund” the mandated insurance requirement through individual HSA investments.

I discuss this Americare version of healthcare reform in more detail in my whitepaper posted on this blog. In order to control the cost of care, it is important to include economic incentives for patients to reduce over-utilization and to maintain healthy lifestyles. Therefore, the premiums for the cost of covering the 40% not covered by Americare would be based on individual rate factors. Insurers would still have incentives to offer innovative programs. There would be healthy market competition between insurers. Providers would compete on a level playing field but there would be remain opportunities for synergies in well-integrated systems.

It should be obvious as to the pay sources of the 40% co-pay, but who pays for Americare? The answer is that much of funding would come from those same pay sources. The “new” payers would be those uninsured persons mandated to pay the Americare premium. There would also be “new” monies made available from that part of the premium dollar now being paid to commercial insurance companies. That dollar would no doubt cover more lives under the Americare system. Providers—particularly the mega systems built on heavy utilization by a saturation of specialists—will howl that they cannot survive on Medicare rates. It will probably be necessary to phase in the program over four years, but providers will adapt and they will survive.

Don’t Bogart the pie. Pass the doughnuts.

Wednesday, December 2, 2009

Healing Hands: An OCH Gravette documentary

This is the trailer for a compelling story about healthcare in small town USA. This story documents the trials and tribulations of the community of Gravette, Arkansas as they fight to gain access to healthcare.