Which health care reform process do you prefer?

As a public service, Cascade Policy Institute offers the following comparison between two approaches to the health care reform process.

Which process do you think best serves Oregon? Consider the alternatives, and then comment if you’d like about the pros and cons of the two approaches presented below.

Which health reform process do you prefer?

“Insanity: doing the same thing over and over again and expecting
different results
.” “”Albert Einstein

Insanity                                           Sanity

Glorify ourselves                                   Define the problem

Assure status quo to Medicare             Insist on all-inclusiveness     &nbsp        and public employees

Process focused                                     Performance focused

Appoint commissions,                            Request competing proposals
committees, focus groups

Negotiate and compromise                    Vet, compare and contrast

Talk big, act small                                  Encourage innovation

Attack the “guilty parties”                     Reposition the interests and                                                                 incentives

Create new bureaucracy                         Select “best” alternative(s)

Dependency / control                             Self-reliance / determination

Obscure accountability                           Test, evaluate, adjust

Tell people what they get                       Win customers with what                                                                  they want

Perpetuate mediocrity                            Succeed or shut down

Change governors: Start over                 Move on to solving other                                                                           problems

You can view, print and forward a formatted color version of this comparison here.

In January 2007 Cascade Policy Institute began a series of one-page Insights to address various health care reform issues. They’re published in BrainstormNW magazine and online in the Health Care Policy Insight section of Cascade’s Health Care research page. This comparison is the February 2008 Insight.

Steve Buckstein is Senior Policy Analyst and founder of Cascade Policy Institute, a Portland-based think tank.

  • Jerry

    I vote for the self-reliance path.

    Also, isn’t it a bit too much that Hillary would not answer the question, when asked, if her campaign workers got health coverage????

    Think about this people when you climb on these silly bandwagons.

  • Steve Plunk

    Steve’s illustration not only exposes our current problems with health care reform but it also shows us what is wrong with pretty much all government decision making. The process currently used fails us too often and should be replaced with the more sane choice.

    Let’s face it right now we’re doin’ it wrong.

  • Bo

    I prefer the system that actually works!

  • dean

    Steve….I usually have higher regard for you than what you present here, which is a straw man chart you don’t even bother to mask. Why don’t you compare the actual proposals of the 2 leading Democrats with whatever other serious proposal you can find (the Republicans don’t seem to have any,) and ask some truly objective health policy experts to critique them for how well they meet a reasonable set of goals, perhaps as follows:

    1) number of people expected to be covered
    2) cost to taxpayers, businesses, and individuals (and future cost expectations)
    3) expected quality of care and innovation
    4) Level of freedom of choice
    5) Limits to the care one can expect (i.e. longer waiting lines for some procedures)

    • Stephen Gregg

      Think the add was intended to be a critique of the rather the ‘wrong headed” reform discussion going on in Oregon. The “insane” column is pretty much what we have been doing, perhaps a tad bit cynically stated. Certainly Oregon is guilty of “glorifying itself”, far beyond what would be sustained by any empirical analysis. As for the national proposals, the essence of their problem and indeed their fatal flaw is that they are long on universal coverage strategy, and woefully short on a credible cost containment strategy. When challenged on this, Obama suggests cost control will come from “prevention”; Hillary suggests better electronic records, and insurance premium regulation. To be fair, neither is a complete description of what might be their cost containment programs, but out of their own lips this is what they chose to suggest as the most important features. The inadequacy is pretty self evident to me. If I were to place bets, the left may very well “win” on the uninsured and fail on the cost front leaving effective reform considerably more intractable, and most likely on a track of either incurring more debt, or a long run of tax or tax equivalent increases. Too bad it has to be painted as a partisan issue, when everyone loses if we don’t control health care costs.

    • Anonymous

      Dean, This post is about “process”, not the specifics of any particular proposal. Discussing specifics is important, but if we use a flawed process I’m afraid no specific plan has a chance of turning out as its author might intend.

      • Steve Buckstein

        Sorry, the “anonymous” comment above is from me. Using a different broswer left off my identity.

        • dean

          Steve and Stephen…I tend to agree that the Dem’s proposals are fuzzy and perhaps optimistic on cost containment. But they are not without it altogether, and at least they are serious proposals that could pass. In looking at my own list, I would say they do well on 1, 3 and 4, are fuzzy on 2, and don’t mention 5 at all. But any serious reform will have to tradeoff amongst these 5 items and serve some better than others, don’t you agree? I suppose we should add a number 6: can it get enough political support to pass? Otherwise the French single payer model with supplimental optional insurance is the objective way to go. The Canadian system’s flaws (as I understand them) are in large part due to the inability of people to buy additional insurance to avoid long waits for some underfunded procedures.

          I truly think state by state solutions are not going to work because of the inability to manage costs at the state level, as Massachussetts is finding out. So whatever Oregon is up to may not matter one way or the other, but thanks for the clarification.

          • Stephen Gregg

            Dean, I tend to believe that the uninsured and cost elements of the problem need to be engaged credibly and contemporaneously. “trying hard” on costs is not a “deal maker” for me. Supplemental insurance options, does not have much to do with the underlying costs. Proposing to regulate insurance premiums while allowing costs to be largely unregulated is very analogous to what happened in California with the Enron crisis, where retail rates were regulated and wholesale rates ran in the “free market”. Seems to me that the “right” and “left” share a common behavior trait for a distaste of either regulating the costs or allowing the pain associated with “free market” pressures of people simply not buying the service. The result is looking for all manner of deferral on the economics. The rest of the stuff are sideshows to this conflict….because if it is not economically sustainable we continue to decline. It could be argued that we already have fewer teachers in the classrooms, marginal improvements to transportation infrastructure, flat middle class personal income, because of health care inflation. Answer can’t be to come up with a better method of allocation or targeting some minority class for assessment. We can decide to engage this or not. Clearly we are on a path of avoidance in the near term.

            On first pass, I agree with you that State by State solutions are undesirable, but if we accept Obama’s rhetoric, then we would believe change needs to come from the bottom up and not the top down. I also believe if we are honest about this subject, local initiatives have greater prospect of serious engagement than the gauntlet of untested national reforms. If we accept the “smartest people” really are confounded by the problem, then simply prescribing an untested solution and imposing it on all from the get go, just because we wish to “believe”, is particularly irresponsible.

            I appreciate those who in their hearts are only interested in the uninsured component of the problem can find satisfaction with what is on the table. I just think those “good intentions” are going to get us in a lot more trouble with largely irreversible expectations.

          • dean

            For me it is as much head as it is heart. Our system costs way too much and denies care to too many, which as you suggest is costing us in all sorts of ways we are not accounting for. And our system leaves many of us who have insurance (including me) teetering on the edge.

            Obama’s rhetoric aside, I can’t see how we can reform the system from the bottom up in this case. Opportunities to do so were squandred long ago by stiff resistance to any change by insurance companies, doctors, and the Republican establishment, as well as by failed Democratic efforts like the Oregon Health plan.

            As one “on the left,” I assure you I am not against regulating costs. The question is how one does that without overly stiffling innovation, or creating long waiting lines, and without generating so much political opposition that one can’t pass the program in the first place.

            I think Obama and Clinton go way beyond increasing access. I don’t think either goes far enough to control costs, but if what either proposes is passed I expect that more serious cost containment will be added as we “test, evaluate, and adjust” to borrow a phrase.

            For example, if the new government offered medical insurance begins to out compete in cost and quality private insurance, then we will see private insurance get more competitive. Or if public costs exceed estimates, then we will see cost control measures added bit by bit Since the Dems proposals both build upon the existing private-public mixed system, they are not radical departures and probably should be viewed as an “adjustment” of what we already have.

  • Stephen Gregg

    Unlike the proposals we are discussing, I am on record with a specific model that calls for “all inclusiveness”, the overt creation of a public system in competition with the private system…on a level playing field; enabling people to chose what they want. I don’t think either Hillary or Obama will seek to include Medicare in the mix (both the third rail, and deadly omission); and when it comes to crunch time, will they agree to “level the playing field” by normalilzing the unilateral cost shifts the govt imposes? Other than the absence of will to engage the cost issue, there is nothing that stands in the way of getting on with it, other than the perennial excuse of “politics” and the self rationalized view of only adopting “solutions…that represent what can be done”. It also commits us to the assumption that we must embrace some kind of national consensus when profound change does not usually happen that way. What we need is highly aggressive and innovative models of change which likely only 10% of the population (early adopters) would accept from the get-go. The point is many so-called reformers will not accept a carve out of such a population, because they fear impact on their own interests. As an example the typical union ideology would clearly oppose my desire to be insured by catastrophic insurance, even if I could demonstrate that as a reasonable solution. Providers would generally oppose “systems” that enabled consumers to exercise free choice of specialists outside of their “consumer as captive” models. Everyone has their self interest in this discussion.

    I find the logic in all this as circular. Bottom line is none of these proposals have a credible strategy to control costs which is a deal breaker for me. I would not give them a pass on this, and hope we would have better leverage on the subject later. If we were to go down that road, better political odds that we would just borrow ourselves into self destruction. Quite frankly, can’t see how a rational being could expect otherwise given our track record.

    None of this is partisan by the way. Just can’t see how this strategy is driven by the “head”.

    • dean

      Stephen..I’ve seen your proposal and I like it. But unfortunately it is not really on the table as an option, for whatever reason I don’t know.

      What we have on the table are 2 proposals from the leading democrats that differ a bit in one having mandates and the other having choice. We have the current system as is. And we have the state by state experimentation, such as the Oregon plan, the Massachussetts plan, the Hawaii plan, and so forth.
      Given the 15% of our GDP presently spent on health care, our lousy results (37th in the world,) our lack of access for nearly 50 million and climbing, and given the likelihood of a strong Democratic majority in congress plus the presidency in 09, the chance of getting this done is probably as good as it is going to get.

      To be fair, both Clinton and Obama acknowledge the cost of their program, at least at the outset, and have identified funding sources. Yes, over time costs could outstrip our willingness to finance this, as is presently happening on other fronts.

      I don’t see anything in their proposals that stops people like yourself and others from still opting for catostrophic only coverage, do you?

      • Stephen Gregg

        First of all, “what is on the table” by two presidential candidates is almost certainly not the likely outcome of the gauntlet any proposal is to face in the legislative process. All of us should fear that exercise. Indeed, some speculate national reform proposals are for political show, as simply a fundamental requirement of being a candidate, with no expectation of massive change. I consider it “insane” that we are not outraged by $1000 per month in today’s dollars going out for a Portland school teacher. The idea that we view costs as something to deal with in the future when the frog is boiling now is not a proposition I accept. I have a good number of professional friends who chose to define the “come to Jesus” event as hitting some kind of wall in the future that causes us to get real about the costs. I used to share this speculation as logical but have grown to believe the more likely scenario is one of “finding more money” either by evilizing some minority or simply taking on more debt. Honestly, don’t you think that is the more likely behavior? That can only mean attrition of other priorities, especially when as much as half of all health care is considered ineffective.

        As far as catastrophic care is concerned, my guess in the broader reform context it is likely doomed. Certainly Obama’s position of not insisting on a mandate, affords the possibility for some to buy catastrophic insurance, pending the “details”. However on the “mandate” track(Hillary’s proposal) the immediate follow on issue is “mandate what?”. You must understand already where that goes. In the early days of “HillaryCare”, I was told Clinton floated a national policy of catastrophic coverage for all, and absolutely was clobbered politically by those interests with rich benefits who feared this would become the new national standard. Clearly, one has not been in the mandate discussion if we don’t appreciate that it is basically all about “what I have now, plus more preventative benefits, and perhaps with some tweaking of the rules pertaining to more provider choice”. “Now lets talk about who is going to pay for that expectation”.

        I have been promoting that we should have a discussion about “what is likely to happen”, rather than “what should happen”. Perhaps in this way we would do a better job exploring the unintended consequences of our “good intentions”.

        Generally don’t think people appreciate that successfully finding a new source of funding health care is not a victory, as it more than likely will inflate underlying health care costs. We seem to be going into this exercise pretending that if we find more money to subsidize the purchase of services it will somehow reduce the underlying costs. That is clearly Swiss cheese logic.

        As to why my plan does not have more traction, there could be anyone of several answers. 1) It does not afford the obvious opportunity for the key players to make more money; 2) It invites everyone to consider change, when most feel more security with what they have; 3) Reluctance of financial sponsors (government, employers, etc) to give up control; 4) Tactical deficiencies on my part beyond program content; 5) Lack of ability to identify a disruptive force for change; 6) We need to experience repetitive failure before facing up to the task. (Do you know any impartial thought leader that believes the Mass Plan is sustainable as designed?)

        Good talking to you.

        • dean

          Stephen…the Mass plan is probably not sustainable because it can’t or won’t control costs. And you are absolutely right that at the end of the day, unless cost control is serious NO PLAN is sustainable with an aging population, including our current mixed bag.

          The current Dem plans are much better vetted than the old Hillary care plan. The Dems have had all these years to lick their wounds, re-crunch numbers, and create the new approach. As I understand it, costs are addressed in 3 ways. First, increased competion by creating a new, optional Medicare for non-seniors and opening up the existing Federal Health employee options to everyone. Second, by hastening the computerization of medical records. Third, by allowing the government to directly negotiate with the pharmecutical companies, as they do in every other nation. There is also discussion of increased preventative care, but I’m not convinced that buys any actual savings, as a recent Netherlands study suggests.

          Is this enough? I doubt it. Will it break the bank? I’m not smart enough to know, but given what we are spending in Iraq it is the least of my worries to tell the truth. Would I prefer a single payer system that limits cost increases by budgeting? You bet. But it ain’t gonna happen. Will catostrophic only premiums still be part of the mix? I think so, if there are enough people who want them.

          I’m not sure that new funding will further inflate things. It basically subsidizes premiums for those who can’t afford the full cost, and to the extent these folks are already a drag on the system (emergency room care) it could be a wash. Bottom line, we will still have 20% of us using up 80% of the total care out there at any given time. That suggests the true “savings” if there are any are in the real serious cases, which are usually the elderly, but also includ long term chronic illnesses and serious injuries.

          Thanks for the usual enlightenment you offer on this issue.

          • dean

            Stephen…the cost control details of the Clinton plan are summarized at: https://www.hillaryclinton.com/feature/healthcare/

            I would be interested to hear you take on what she proposes.

          • Stephen Gregg

            Re: Hillary Plan

            Following down her list of strategies

            1. Prevention…already discussed…bogus impact on costs. Probably inflationary as a basis for enriched benefits. Incredibly foolish thinking from a cost perspective.
            2. Automation of Records…huge savings…Ask yourself how much your premium has been reduced so far by the “huge” investment that has already been made over decades in IT technology. Where’s the proof?
            3. Improve treatment of chronically ill: This likely means a “more tightly managed patient” which means more provider encounters, testing, intervention, drugs, and more cash flow to the industry. If “better care” is successful in shutting down one source of cash flow, there is an army of managers responsible to replace lost revenues with something else.
            4. Insurance reform….In the political context private insurance cannot be challenged at its core, when perhaps it should be. The central conflict is that insurance is about “selecting favorable risk” as a means of keeping premiums down for clients. This is in conflict with the social goal of covering everyone regardless of risk. The “single payer” crowd could benefit from a more nuanced approach calling for a government run risk pool, administered by competing claims processing and medical management companies compensated based on “performance”. That said, I would pursue this strategy cautiously. Nothing to be gained by making a political concession to leave carriers in tact while trying to regulate them into not doing any risk selection.

            5. Create a “Best Practices” Institute….high impact? are you kidding me!!!
            6. Pharmacy…Drugs are typically about 10% of premium costs. In some cases higher in others not even an offered benefit. Let’s imagine an aggressive strategy to cut this revenue flow by an incredible 25% after any incremental admin costs to get there. That is a one time savings of 2.5% on premiums. That is equivalent to about 2-3 months of inflation in health care premium costs.

            Appreciate, I believe just about all of these “ideas” have merit to pursue, but all combined they are a total glass of water when it comes to the reality of the task in front of us. We should expect a better proposal…but we must not offend!!

          • Stephen Gregg

            I have spent a career in health care cost containment. Made a ton of money selling protocols of almost all types to reduce costs. Believed intensely that we were promoting the right things…but in the end they did not deliver the goods on a sustainable basis. I could write essays outlining the fallacy of each of the leverage points you hold hope for outlined above. As stated previously, my generation of cost control cut rates of hospitalization and length of stay in half to no sustainable consequence. It makes no sense that automated medical records will have more force. What people do not appreciate is that an increase in efficiency from whatever action you wish to speculate about, invariably does not transmit itself to a lasting reduction in premiums, if at all. The overwhelming force that we have to address is the full context of the personal income earned by the industry. If a “savings” is installed, one cannot assume that the industry or individuals simply stand still and take a loss of revenue. That applies to the CEOs of profit or non profit organizations. Pharma is a glass of water when compared to the economics of hospitals. To control costs, the strategy must mitigate what a nurse, doctor, hospital administrator earns…and that is a virtual impossible assignment for the “political process”. If we don’t understand those linkages, we don’t understand the nature of the problem…or we do, and simply chose to defer.

            As far as “negotiation” goes, I personally led the efficacy of negotiating provider fees in Minneapolis during the 1970’s when such matters were considered quite odd. While I believe in the benefits of such exchanges for a lot of reasons, you need to appreciate as that practice matures it migrates to a simple matter of differential pricing practices with little impact on underlying costs. Someone’s discount is another’s price increase. When we pitch the government is going to save tons of money by negotiating with pharma directly, in all likelihood it will simply result in another cost shift to those outside of that negotiation, similar to what takes place with hospital and physician reimbursement. Then we can argue that everyone should have access to such pricing advantages in which case we end up with a utility model with one buyer setting a universal price to be paid. No logical reason why that thought process should not apply to everything. This should then be followed by such questions as what is the point of private hospitals with independent revenues, expenses, and capital expenditures. Obviously other countries have made those transitions decades ago. Personally, I have a lot of push back on promoting the concentration of power that comes from single anything. Invites bureaucracy, lack of innovation, protection of status quo, mediocrity, etc. That said, my proposal allows that ideology to develop in competition with private sector alternatives, driven by the free will of individuals with varying sources of financing.

            If we view “regulation” as an important characteristic to think through, I would suggest that the government’s ability to cost shift, and otherwise impose unique costs on the system needs to be regulated. In other words, the regulators need to be regulated!!

            I believe dispassionate economists would predominantly assure you that providing increasing subsidies, improving access, etc will be inflationary, after any consideration of flipping “free care” to compensated care. Good issue to refer to an “expert” if we could find one without an agenda. We do understand the “vast savings” associated with “prevention” is “bunk”.

          • dean

            Stephen…why is the economics of health care so different from the economics of everything else? A cost savngs in manufacturing would either increase profits or decrease product price right? Why wouldn’t a cost savings in say, medical record keeping translate into a premium or delivery price reduction, particularly if there is competition between providers? Is the answer that any savings will be reinvested in an expensive medical device that generates more profits elsewhere in the system?

            I tend to agree on the false hope of cost savings asociated with prevention, though Clinton’s analysis (by the Rand Corporation, not a bastion of liberal thinking) states otherwise. I think with prevention we do get better health and longer lives, but end of longer life care will eat up all the savings. At least that is what the Netherlands study, a computer modeling of weight loss and smoking cessation predicted. Basically healthy people live longer and a lot of them get Alzheimers, which is more expensive to treat than diabetes or heart disease.

            Nontheless, what we are still left with is that nations with single payer systems have better overall results at far lower cost. Why?

            What we know for certain is that none of us are getting out of this alive.

            And good night all.

          • Stephen Gregg

            Not sure I know the methodology of how Rand came up with their numbers or whether the “savings” would translate to a premium savings. There is an MIT academic with seemingly outstanding credentials, that studies this stuff, that says, “I know of no credible data that supports the view that investment in prevention reduces health care expenditures”. I know from my own experience, that Kaiser has struggled with this conclusion from an operational perspective since I was in graduate school. Prevention is an emerging “business line” for much of the industry, as I am sure you already sense. Many are actively campaigning to incorporate those services as covered benefits.

            My broader message is to be more critical of whatever the current populist thinking is. I could dig out a quote from as long back as the 1958 (may be off by a year) Democratic Platform that speculates “the reason why we have unacceptably high health care costs (they did not appreciate how high it could go), is because we have too few hospitals and doctors”. This thinking was the economic basis for policies that more than doubled medical school enrollment and greatly expanded hospitals via a program known as Hill-Burton. In the following generations we realized that if you produce more providers, the pathology of the community is relatively infinite. Supply and Demand theory would have seemingly supported this logic.

            I do believe any “savings” from cost containment is generally retained by the industry, at best making next year’s “intolerable” increase a percentage point or two less than it would otherwise be. Why does this happen? We don’t have third party reimbursement in other transactions where the consumer is insulated from the price or has the discretion not to buy the service. Nor do we appear to have the political will to either seriously curtail access, or more obviously vary the terms of access based on an individual’s ability to pay. This is further aggravated in more recent decades by the market effectively moving to an oligopoly structure where demand must be focused on suppliers that control the market. Even more recently excess provider capacity has largely disappeared further marginalizing buyer influence. Another way to answer your question is with another question…If there is a 3 fold variation in Oregon in what hospitals charge for the same diagnostic problem, why is it that this variation makes no discernible difference to where patients seek health care? Perhaps another difference is the effect of the governments purchasing role in this industry. In general, all providers are “entitled” to participate in this reimbursement without consideration of the underlying quality, effectiveness, or cost. There are “lip service” efforts at the margins to influence this, but most of it is of marginal consequence.

            As far as the effectiveness of other nations, there is data out which alleges the trend line of these nations is almost equal to the U.S. and equally disturbing. If we took a picture of the comparable incomes of U.S. health care professionals as contrasted to the incomes of those in other countries, we probably could account for almost all of the variation and then some. Ironically, much of utilization data shows lower admission rates, length of stay, etc. and yet higher costs. Hospital nurses are now pushing incomes of $100,000 a year, oncologists in Portland are rumored to be making as much as $1M a year. 7/10 top Oregon health care CEOs make over $1M a year. These numbers are far more generous than other countries for a variety of reasons extending to profound cultural differences. Doesn’t require an advanced degree to conclude if we expect to make our costs look the same as other countries, we must have comparable personal incomes. Why should a nurse in Portland, make twice as much as her counterpart in London? Therefore comparisons to other countries is instructive but not entirely useful.

  • Jerry

    We are not left with nations with single payer systems having better health care. They don’t. Their people come here for MANY health care issues all the time. We have been over this before. You should move to one of those countries and then get back to us on how wonderful everything is…please give it a try….you might be surprised.

    Maybe Cuba??

    • Stephen Gregg

      The definitive judgment as to “who has the best system” is an impossible task in a society that is at all individually focused. Certainly we can make “system wide”, “on average” conclusions among systems. But those views are largely irrelevant to the 1-2% of the population at any given time with profoundly sophisticated and life threatening problems, that are not served well by the “on average, pretty good” mentality of a single payer system. Many of us at some point will find ourselves in the 1-2% category potentially confronted with a bureaucracy heavily tilted to the interests of the majority, which at any given time are people who are perfectly healthy. Who is to have greater consistent care about yourself than you?

      • dean

        Jerry…Cuba is a 3rd world nation. My comparisons are with other first world nations. They won’t let me move there, I don’t speak the lingo, and my business is dependent on Nrthwest customers, so sorry, I’m staying for the time being.

        Stephen…if 20% of us are eating 80% of all the costs, and if 1-2% of us are in life threatening conditions, then it is hard to see how a freer choice system helps. One may not be in the best place to “go shopping.”

        I’m digging deeper into the Clinton and Obama plans. I think your analysis on cost control is correct. Other nations with single payer systems ar also having to deal with excessive health care inflation. The 2 big reasons seem to be aging populations (Europe and Japan are ahead of us on the curve) and expensive new technology.

        What strikes me the more I look into this is the desire for each of us to want to remain as healthy as possible for as long as possible, which is consistent with “preventative care.” And the desire for each of us to be made better or for life to be prolonged when the wheels come off, as they must. What I arrive at is the logic of a tiered system, with basic, day to day health care & maintenance equally open to all, a second tier that deals with chronic illnesses, and a third that deals with aging related issues compassionately, but not foolishly. All this seems to add up to a socialized insurance system with a range of choices individuals can make along the way.

        • Stephen Gregg

          I have three friends who at the moment are being challenged with life threatening conditions. 2 of the 3 have elected to go “out of area” to the nation’s “best” for the condition they have. The third has elected to “stay home” by personal election. Life threatening conditions does not mean incapacity in a lot of cases if not most. For me, being a member of a traditional HMO involves a personal trade off and a form of risk I would not take because of the constraints and not knowing the qualifications of the HMO to take care of a yet to be determined personal condition. Generally, “systems thinkers” expect the consumer to conform to prescribed protocols irrespective of immediate merit. I am of the school that this may be fine for pedestrian requirements, but I don’t value insurance for that purpose. When I do value insurance is for the major unanticipated challenge, and in that case I intend to make a determination with advise of others as to where the “best place” is to go, and get there as soon as possible in the development of my condition. Many of these “best places” can be cheaper than the local options, with far fewer complications, and state of the art everything. Clearly “systems” don’t like this kind of unilateral consumer action. Ask yourself why more Oregon “systems” do not promote access to the Mayo Clinic. Not likely to be a cost or quality issue…might it have something to do with the flow of money??

          I am one who takes his pet to Petco and not his Vet to get his immunizations because it is more cost effective. I would be attracted to going to a public clinic for routine stuff, getting my cholesterol checked at Safeway etc. The problem with this behavior is that “systems” do not like this, because of its lack of integration with the systems control and oversight over my actions. It also raises havoc with the logic of building this new age information system that insists on knowing everything about my content. “Systems thinking” will likely watch me get old and feeble and insist that I enter the system’s view of a proper institutional setting, when I will resist that. One of the problems I see with the “tier” proposition as you outlined, is that business deployment of this will without any question seek to organize itself vertically and seek constraints that capture you as a part of that vertical integration, rationalizing the “goodness” of that. Much of this is all about control and money…which is the dark side of many good intentions.

          Thought “socialized” was both a dirty word and relatively meaningless. The push back is on how “systems” construct boundaries that harm people to the self interest of the system. This does not mean at all that I am a fan of being able to demand whatever I want without constraint at someone else’s expense. Quite the opposite, I don’t think any of my nominal health care expenses should be absorbed by anyone else. Think we generally seek to over insure people increasing everyone’s expense.

          Good talking to you.

  • Steve Buckstein

    For those who find the exchange between Dean and Stephen Gregg valuable, as I do, here is the short version of Stephen’s reform proposal:

    Bridging the Ideological Divide in Health Care Reform: An Actionable Plan for Oregon

    • dean

      Not that my endorsement is worth much on this site, but to second Steve B, Stephen G’s proposal is well worth reading. As are the proposals by Obama and Clinton, one of which is likely to be the next president and set the agenda on this issue. As is data from the World Health Organization that compares nations on health expenditures and results, and shows the deep hole we are in.

      If conservatives and Republicans were to embrace Stephen G’s proposal and get behind it, they could change the public debate on health care. Instead, and unfortunately, they usually deny the problem and stonewall any solutions.

      • Stephen Gregg

        If our dialogs are a microcosm of the “challenge of attitude” I think we have demonstrated how entirely reasonable people want very different things, which was a constraint I tried to respect vs. attack, when I constructed my proposal. The point is that we are sufficiently divided that any proposal that tilts to a “winner” will ultimately lose because of a significant and vehement objection from the other view. “Getting it passed” is just the beginning of the cycle. It is equally important that Democrats and Republicans support my solution as anything that comes from either “side” is going to get clobbered by the other side for the same partisan reasons you keep on reminding us about. I consider the Republican position defensive and far less than proactive, and the Democrat position wrong headed and loaded with denial. Which “medicine ” do we want? Dean in my estimation it would be better to migrate from attacking the “other side” to figuring out a solution that has prospects of accommodating the other guy’s view, while moving us ahead in an intelligent way. As my article points out to continue to debate ideological sides to this issue makes us part of the problem, and if we endorse something that is relatively certain to fail, then we are also guilty of enabling failure, even though someone else led us there. OHP was moved ahead with recognizable critical flaws. A few led us there, many people with passion enabled it…so who is accountable? Unfortunately all the tracks are nicely covered.

        I have thought about alternative solutions for a very long time, and the proposal I have offered is the only way out of the debate that I see. Clearly all of us must understand that when we turn this over entirely to Presidential and legislative leadership, whatever is proposed will go through a gauntlet of sabotage eviscerating its critical substance. The higher we push it up the pole, the more compromised the solution will be. You believe the odds of success are improved by the Presidential contest. Unfortunately, I see deferring the solution to that process lessens the prospects for a sustainable solution. We shall see.

        • dean

          I agree with everything you just said, but I am less pessimistic about the prospects for the Dems to prevail in the short term. Longer term, whatever they pass will have to be re-adjusted over time for all the reasons you have raised and more.

          IF what Clinton or Obama proposes passes, 3 major issues are resolved:

          1) universal “access” to health insurance (under Obama, some could choose to not participate, but they will have access)
          2) a wider array of available insurance choices for everyone
          3) health access security. i.e. you don’t lose health care access if you lose your job or your business goes belly up.

          The initial “cost” is a repeal of the Bush tax cuts for upper income tax payers, to subsidize insurance purchase by lower-middle income tax payers.

          The uncertainty is in how much if any money is actually “saved” in terms of overall health care expenditures, and what will happen to health cost inflation in the coming years. I suspect a short term reduction of inflation, but a future ramping up as we baby boomers start checking in for heavy maintenance, repair, and mileage stretching.

          I would say another uncertainty is whether our collective health actually improves. Will we gradually move up from our presnt 37th level internationally? Who knows?

  • Stephen Gregg

    Don’t think the math or politics will work in the short or long term. But being a “proposer” gives you some teflon protection irrespective of results. Similarly many feel that unilateral withdrawal from Iraq is not going to happen irrespective of who is in office and despite what is said to get elected. Will be interesting to see how the “winners” whoever they are evade and rationalize their lack of “deliverables” at the end of the day. Wyden reminded me several years ago when he told me….”Steve, politics is the business of getting what can be done, done”. Perfect!!