#45 Health INSURANCE Reform

On September 8, 2009

Hello Everyone,

After a long hesitation, I think it is time to weigh in on what has been mistakenly called the “health care” debate.

I know enough about health care to be dangerous. My mother and a couple of aunts were nurses. I served three years as an officer in the hospital administration section of the Army, working on bringing information technology to its largest hospitals. When I was a Merrill Lynch investment banker, two of the country’s largest hospital supply companies were clients. I also worked with some medical device manufacturers. Our daughter-in-law is a fellowship-trained radiologist. I have been a beneficiary of both government and private-sector health insurance provided by the Army, Merrill Lynch, and now Medicare. And, I’m eligible for Veteran’s Administration benefits, too.

But this is a vast topic, and I’m no expert. At an estimated 16% of GDP, healthcare spending is an enormous subject that defies easy comprehension. It is also emotion-laden. So, I will only attempt to shed some modest light on a few aspects of the current debate in this first of what may be a handful of installments.

The Debate and the President

It seems to be that much of the debate so far, and the media coverage of it, have been focused on the entertaining aspects of the political process, with surprisingly little on the substance of the issues.

The bills drafted so far have been largely about health insurance reform, not health care reform, which would involve fundamentally changing the delivery system as well. That system will continue to be overwhelmingly in the private-sector hands of doctors and hospitals.

Despite declining poll numbers (my long time readers know my skepticism about the validity of polls), my faith in President Obama’s capabilities, temperament, moderation, and effectiveness is unwavering.

I have quoted Doris Kerns Goodwin’s Team of Rivals many times before. In the latter stages of the book, she talks about President Lincoln’s attempts to negotiate peace with representatives of the Confederacy, quoting Harper’s Weekly:

“Indeed, nothing but the foolish assumption of four years ago, that Mr. Lincoln was unfit for his office,” could explain the fatuous predictions that he would “flinch and falter” before the Southern delegates…We venture to say that there is no man in our history who has shown a more felicitous combination of temperament, conviction, and ability to grapple with a complication …than Abraham Lincoln.”

It is worthwhile to recall how the country repeatedly underestimated Lincoln’s capabilities only to see them fully displayed in the end. Likewise, I believe that we will see President Obama’s “felicitous combination of temperament, conviction, and ability to grapple with complication” on full display as this process proceeds.

As I have written in an earlier Obamagram, from time to time during the campaign, candidate Obama was getting “flak from all sides” (see item 2, “Flak from All Sides – 7-16-08” at: http://obamagrams.com/category/group-4/). That is because he is more measured and moderate than the left wing of the Democratic Party would like and more liberal than most Republicans would like. It’s happening again now, and I think that’s a good sign.

This debate also reminds me of a favorite quote from Niccolò Machiavelli’s The Prince (published in 1513) about the difficulty of achieving change:

And one should bear in mind that there is nothing more difficult to execute, nor more dubious of success, nor more dangerous to administer than to introduce a new order of things; for he who introduces it has all those who profit from the old order as his enemies, and he has only lukewarm allies in all those who might profit from the new. This lukewarmness partly stems from fear of their adversaries…and partly from the skepticism of men, who do not truly believe in new things unless they have actually had personal experience of them. Therefore, it happens that whenever those who are enemies have the chance to attack, they do so enthusiastically, whereas those others defend hesitantly…

It also brings to mind Daniel Goleman’s interpretation of neurological research in his book Emotional Intelligence:

In humans the amygdala…is an almond-shaped cluster of interconnected structures perched above the brainstem…The amygdala is the specialist for emotional matters…Incoming signals from the senses let the amygdala scan every experience for trouble. This puts the amygdala in a powerful post in mental life, something like a psychological sentinel, challenging every situation, every perception, with but one kind of question in mind, the most primitive: “Is this something I hate” That hurts me” Something I fear”” If so—if the movement at hand somehow draws a “Yes”—the amygdala reacts instantaneously, like a neural tripwire, telegraphing a message of crisis to all parts of the brain…The amygdala’s extensive web of neural connections allows it, during an emotional emergency, to capture and drive much of the rest of the brain—including the rational mind [emphasis added].

Goleman calls this “amygdala high jacking” – when primitive fears permit the emotions to override reason. Like “road rage”. Sometimes when people want desperately to win an argument, they resort to fear tactics. Think “death panel” lies now or scary “Harry and Louise” commercials in 1993. If they can activate your amygdala, it will override the rational parts of your brain.

Looking it up

One other observation I have made in past Obamagrams involved my continuing dismay at voters’ reluctance to “look it up”. That is, their unwillingness to find and read primary source documents in order to come to their own fully-informed judgments. Due to lack of time or inclination, we mostly rely solely on the opinions of others, and are, therefore, easily manipulated. When I write these essays, I try to rely on original documents whenever possible, as I will below.

In this instance, I will admit to my own frustrations in trying to find the proposed legislation. Evidently, there have been a number of bills introduced in the House of Representatives, but there have been no bills formally introduced in the Senate. No bills have been brought to the floor of either chamber for a vote.

While I am still unclear about what other bills are in committee in the House, the tension in the air seems to be focused on HR 3200. If you want to look it up yourself (which I encourage you to do), go to http://thomas.loc.gov/ . Enter HR 3200 in the box under “Search Bill Summary & Status”, click on the “Bill Number” button and click on “Search”. I have found the best way to read this document is to click on “Text of the Legislation”, then click on the “Printer Friendly Display” tab, but there are a variety of other ways to peruse the bill on that site.

The first thing that will jump out at you is that the bill is 478 pages long, not the “1000 pages” waved in front of opponents to inflame them. (Of course, the number of pages depends upon margins and font size.) To a Tweeting public that is unlikely to wade into Goodwin’s 750-page Team of Rivals, this bill may seem daunting. But, most major legislation is.

This is health INSURANCE reform

I will get into more details in subsequent Obamagrams, but let’s begin with two critical observations.

First, the President and Congress are proposing health insurance reform, not comprehensive health care reform.

I have included as the first attachment what amounts to the table of contents for HR 3200. As you will see, the bill is divided into three sections (Divisions A, B, and C). Over 80% of the document focuses directly on health insurance reform. Division A, which accounts for about 22% of the bill, concerns tightening private health insurance standards and protections, much like those provided by the Consumer Product Safety Commission, the Securities and Exchange Commission, and the Food and Drug Administration. The recent credit card law is another good precedent. Division B, which accounts for about 60% of the bill, pertains to changes in

Medicare and Medicaid, the wildly popular single-payer government insurance programs for the elderly and the indigent.

Division C is the remaining 20% of the bill. It focuses on public health and workforce development. Hardly “health care overhaul.”

If you take a few minutes to look at the website and/or the first attachment, you will likely agree with me – this bill is not about health care reform – it is overwhelmingly about health insurance reform. Much less scary and much more difficult to demagogue. Unless you simply want to see this president fail.

Sarah Palin’s “death panel” lies

I will end this first installment with a second critical observation. Naysayers are using fear tactics to stop any and all reform. The prime example is the incredible lies being circulated about non-existent “death panels.” The actual text contained in HR 3200 pertaining to “Advanced Care Planning Consultation” is included as the second attachment. That five-page provision, originally proposed by a Republican Congressman in the recent past, is thoughtful and anything but invasive.

We Americans are reluctant to discuss what we deem to be highly sensitive topics – including sex or personal finances – or how to care for ourselves and our loved ones as we near the ends of our lives. Most of us don’t want to even think about it.

Let me personalize this a bit. My family finds itself increasingly in “advanced care planning” conversations these days. Two weeks ago, my 93-year-old father went into cardiac arrest. Because of the alertness of my stepmother, good medical care paid for by Medicare insurance, and incredible resiliency, Dad is recovering.

My father and stepmother are fortunate enough to live in a very nice continuous care retirement community in Florida. That was the first step we collectively took several years ago to do advanced care planning. The next step was to work with their family physician, lawyers, and other health care workers to write living wills and all of the other advanced directives covered by the bill. While these are never easy conversations to have or plans to make, I have come to appreciate how important thoughtful planning is for this stage of life, just like it is for other, seemingly happier, stages – like marriage, family, and college.

Spend a few minutes reading the second attachment. You will readily see how thoughtful this provision is and how wrongheaded those who demagogue it are. Moreover, I challenge you to find any hint of government intervention in this process other than proposing health insurance coverage to pay for counseling and document preparation should people choose to do such planning and proposing some innocuous standards to promote clarity and consistency.

The exclusion of insurance coverage for this type of consultation from the bills would neither surprise me nor weaken these insurance reform efforts to any meaningful extent. And, it would remove an easy target for the fear mongers who are trying to activate your amygdala.

Prescriptive Leadership

In my view, the President has been wise to let the Congress take the lead in drafting legislation, as uncomfortable as that must have been for him. I’m sure that he knew it would be so.

I suspect that starting with his speech to the Joint Session, he will become substantially more prescriptive. I appreciate the irony in the usage of that term in this situation. And, the irony that many in Congress are now clamoring for him to be prescriptive even though they would have mightily resisted him if he had tried to be so at the outset.

That’s probably enough for now. I am confident that President Obama will succeed in shaping significant health insurance change by the end of the year. As the debate proceeds over the coming days and weeks, and as I study the topic more thoroughly, I will no doubt be back in touch.

Please, as always, pass it along.


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adobe pdf file Attachment: America’s Affordable Health Choices Act of 2009


adobe pdf file Attachment: America’s Affordable Health Choices Act of 2009 Sec 1233


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