Friday, August 28, 2009

Massachusetts Legislature -- Huh?

When Republican Mitt Romney was governor of Massachusetts, and it appeared that John Kerry, our junior senator, might become president, the Legislature didn't want the Mittster naming a temporary replacement. So, it changed the law and prevented him from doing so by forcing an election for the office. I didn't see anything wrong with that: it's called using your power to prevent the opposition from gaining an advantage. There is no doubt that Romney would have chosen a Republican to fill the seat, replacing a Democrat in a state that is heavily Democratic. Thwarting the Republicans this way seems natural as both a matter of expediency and a matter of principle.

Now that Senator Kennedy has died, the issue has cropped up again. This time, there is a Democratic governor, and the state is still heavily Democratic. Furthermore, it is very important that the Democrats have as many votes as possible to back up President Obama's policies, which have the overwhelming support of Massachusetts voters. So why is the legislature having difficulty in restoring the governor's power to appoint a temporary successor? It seems like a no-brainer. However, I suspect that in a state so heavily Democratic, the usual two-party rivalry has been replaced by intraparty jealousies and bitterness. Governor Patrick has not gotten along with important factions within the legislature, who are consequently reluctant to give him any more power or prestige. This is yet another example of Democrats being self-destructive, undisciplined and clueless.

Of course, this is the same supposedly progressive legislature which finds it impossible to forbid text messaging while driving. What could be more of a no-brainer? Would any sane person like to be on the same roadway with a jerk who was trying to read or type a message on a tiny phone while driving? This is totally beyond my comprehension. I could understand the legislature's previous reluctance to pass drunk-driving laws with teeth, and for police and judges to fail to back up the laws already there. After all, lots of legislators in the Bay State, as well as judges and police officers, like their little nip(s) and probably couldn't see what all the fuss was about. When I served on the Middlesex Grand Jury, we had cases of drivers with a dozen DUI and similar convictions who were still on the road -- or at least until they finally killed or maimed someone. But texting? How many of our reps and senators are texters? No one can do it safely while driving, but I doubt that very many of them can do it even in the confines of their living room. So why don't they forbid this crazy practice? Sure beats the hell out of me (as we say in New England). Somebody explain this ... please.

(I have written to some of my reps but haven't gotten a reply yet.)

Here's what Utah has been doing: .

Wednesday, August 26, 2009

RIP Ted Kennedy

I wonder if Ted donated his spine to the Democratic Party: They certainly could use it.

Saturday, August 22, 2009

More about Whole Foods CEO

Here are several additional comments related to my last blog about John Mackey, CEO of Whole Foods.

1. Mr. Mackey agreed several years ago to work for a salary of $1.00/year. Of course, as he himself has said in public interviews, he has plenty of money. Only 1/2 cheer: rah/2.

2. Mr. Mackey's description of the Whole Foods healthcare plan can be found here: I encourage readers' comments on this. To be fair, I've seen worse and, of course, better (at least from an employee's perspective).

One important point that Mr. Mackey leaves unsaid in the above document is what happens when an employee actually has to use the "major medical" component of Whole Food's plan. He claims that after the first $3,500 in employee out of pocket expenses, the plan covers 100% of expenses afterwards. But what about a serious illness that requires, say, a month of treatment? What prevents Whole Foods from simply firing that employee after, say, two weeks? When they do, the insurance lapses and the sick employee loses all further coverage. Fortunately, the worst of this kind of outrageous behavior is forbidden -- at least for a maximum of 12 weeks and only for companies with more than 50 employees -- by the Family Medical Leave Act. This bit of "federal interference" was opposed bitterly by George Bush, the WSJ, and the Republicans. I wonder what Mr. Mackey's position is on it?

Also, what about things like pregnancy coverage and sick days?

3. The average age of a Whole Foods employee is about 33; they are, as Mr. Mackey points out, generally quite healthy because they are young. Consequently, they are willing to bet they won't get sick -- a bet they usually win -- and so they are relatively happy with his plan. But if one of them does get sick they lose their $3500 very quickly. If the illness is debilitating, like MS or cancer, 12 weeks go by and they have no coverage. Too bad.

4. Mr. Mackey and a lot of other people seem to misunderstand what insurance is about. Insurance is a means of sharing risk. The healthy people of necessity must pay enough to make up for the costs of those unfortunate enough to get sick. The whole point is that we don't know the future and so we hedge our bets. If you buy insurance, you have no right to complain that you paid but didn't use it. If you need the insurance you have every right to collect on it. The more insurance companies can charge people for getting sick -- by setting high rates for selected groups and high copayments and deductibles -- the less they are taking a risk and the less profit they are entitled to. High deductibles and copays combined with loss of insurance upon termination of employment is really not selling insurance, it is closer to betting on a sure thing. Because they can get away with this without regulation is why insurance companies make lots of money and why they object to true sharing of risk via national universal coverage.

5. Before leaving Mr. Mackey, I'd like to mention his use of the term "entitlement". This is another example of the right wing setting the terminology. It makes it sound as if someone collecting Social Security or Medicare is a spoiled rich child demanding something that they haven't earned. It goes with phonies like "death tax", "rationing of care" and "death panel." The fact that conservatives really hate to face is that Social Security is a shared compact in which one generation agrees to help members of the previous generation retire with some financial dignity when they get old. They expect that the succeeding generation will do the same for them. It should not be called an "entitlement" but a fair and humane social compact. Medicare is similar: it is paid for by a tax and is a form of insurance. You are entitled to it not because you are petulant and demand it, but because you have paid for it through a fairly heavy tax. Our better instincts (something conservatives are loath to acknowledge except as they apply to entrepreneurs) tell us that older people should be able to obtain medicines they need to make their lives worthwhile. Funny how conservatives worry about phony death taxes and death panels, but don't seem to acknowledge that unaffordable medicines result in real deaths. It's the same lack of introspection that makes them think that we don't have healthcare rationing of the worst kind right now.

Finally, I quoted the cost of healthcare coverage as about $1000/month. According to today's Boston Globe, Massachusetts leads the country with an average annual premium for a family plan offered by a private sector employer of nearly $14,000. Nationwide, the figure is closer to $12,000, which is what I suggested. Individual coverage, of course, would be much lower than family plans. On the other hand, these figures are for memberships in employer plans. If you try to buy insurance on your own, without belonging to such a "plan", the cost would be more.

Yesterdays blog comments on Mr. Mackey's WSJ article still stand.

Friday, August 21, 2009

Whole Foods and healthcare

On August 11 John Mackey, CEO of Whole Foods Market Inc. wrote a column in the Wall Street Journal on health care. This piece raised the hackles of a lot of health-conscious people who buy their food at that chain of stores, many of which, in New England, were formerly known as Bread and Circus before they were taken over by Mr. Mackey's Texas-based company.

The piece itself, which I comment on below, is mostly standard knee-jerk conservative business-speak -- you know: let business be business and "if only ordinary folk would make the enlightened decisions about their lives that my kind of people make, there wouldn't be any problem." The fact that Mackey is CEO of Whole Foods makes his remarks particularly galling, since most of his customers see through this claptrap and resent having to buy from a company that pays his salary.

Here are his main recommendations (italics indicate direct quotes).

1. Remove the legal obstacles that slow the creation of high-deductible health insurance plans and health savings accounts (HSAs).

This is particularly disingenuous, since high-deductible policies are fine for wealthy people who have the ready cash to pay, in the case of Whole Foods, the first $2500. No problem for Mr. Mackey, but everyone knows that for most of us further down the salary chain, the effect is to put off seeing a doctor until our condition is pretty bad: high fever and bad pain etc. What could be a better example of the "Let them eat cake" attitude: Why can't they just pay the doctor's fee if they are so ill -- after all, we're trying to save money here aren't we?

My wife observes that this is particularly significant for a company like Whole Foods. Employees will put off the expense of a doctor's visit until they are feeling really bad. Thus, they will go to work while sick, at a store where they handle food and interact with customers all day long. Would you trust your health to such a store?

But, no matter for Mr. Mackey.

2. Equalize the tax laws so that employer-provided health insurance and individually owned health insurance have the same tax benefits.

In a vacuum, this principle is reasonable enough. The problem is that most of us who have health insurance have it through our employer. This is not the way it has to be, but is a relic of the unplanned, random nature of the way insurance has evolved in our market place. You'd have to have a pretty high income to provide your own insurance, which for even moderate coverage would run upwards of $1000 per month -- if you could find a group plan. Thus, in effect, Mr. Mackey is recommending yet another tax break for the wealthy, or a tax increase for the already stretched thin middle class. I'm sure that this fact is not lost on his WSJ audience...

3. Repeal all state laws which prevent insurance companies from competing across state lines.

Ah these Texans. In case you didn't know it, Texas has the laxest consumer protection of nearly any state. Many insurance companies there are chafing at the bit to sell their snake-oil policies out of state as well. These are the policies that don't cover pre-existing conditions, have high copayments on nearly everything, restrict you to a tiny list of doctors and disallow payments for nearly every procedure they can get away with under ... gulp ... Texas law. And, of course, it's all hidden in tiny print and incomprehensible language. Would you buy a used car by mail knowing Texas law? If you would, then you'll love their insurance policies.

4. Repeal government mandates regarding what insurance companies must cover.

Here we cut to the quick. The conservatives love to yell "government mandates." But, government mandates include Child Labor laws, Truth in Advertising, the Pure Food and Drug Act and the Americans with Disabilities Act. Darn those Feds for putting in wheel chair ramps and preventing the sale of dangerous drugs and chemicals across state lines.

One government mandate proposed is that pre-existing conditions be covered in health insurance. Apparently Mr. Mackey thinks that if you have heart disease or your kid has cancer or diabetes, the Feds should have no right to prevent your new insurer from refusing to pay for continued treatment. Nice guy, but hey, we're trying to save money here, right?

5. Enact tort reform to end the ruinous lawsuits that force doctors to pay insurance costs of hundreds of thousands of dollars per year.

Tort reform, like government mandates, means lots of things. No one wants huge lawsuits over trivialities, but neither do they want victims of true malpractice and negligence to get screwed. In Texas, tort-reform has meant the latter, while examples of the former are fairly rare. If a hospital is lax in hygiene -- and many are as study after study has shown -- and this leads to a staph infection causing severe disfigurement, what does tort reform have to say? What about the removal of the wrong kidney, or a sponge left in the abdominal cavity? Depends on who wrote the tort reform law; I'd hate it to be the Texas legislature.

6. Make costs transparent so that consumers understand what health-care treatments cost.

No problem here. Same should hold true for the true costs of industrial pollution, excessive truck weight and risky behavior by banks.

7. Enact Medicare reform.

Yup, that's what Obama wants to do too. So?

8. Finally, revise tax forms to make it easier for individuals to make a voluntary, tax-deductible donation to help the millions of people who have no insurance and aren't covered by Medicare, Medicaid or the State Children's Health Insurance Program.

Aw shucks, we'll all chip in voluntarily to help those poor folks. Like we did for kids who worked in sweatshops for 60 hours a week; like we did for coal miners who got black lung disease or who were killed in unsafe mines; like we did for seniors who faced an old age of poverty and disease; like we did for the millions who had no electricity or plumbing in rural areas.

Puleeze. If it weren't for the New Deal and the labor movement, we'd be living in pretty bad conditions indeed. No amount of nickel and dime (dime as in what Mr. Rockefeller Sr. used to give to folks who inspired his charity) giving has ever, in America, gone far in fixing up the things that really needed fixing.

Mr. Mackey is either ignorant or a phony. I'd go with the latter. We're giving up on Whole Foods.

Wednesday, August 19, 2009

Democrats should "go it alone"

After back-pedalling on "the public option", the Democrats tried veering away toward "health co-ops", supposedly to see if Republicans were really interested in compromise.

As I've said many times before: no, they aren't.

The Republicans are trying to damage Obama and his party, not trying to solve America's healthcare issues. The fact that they were willing to tell overt lies about proposed healthcare reform, such as cynically calling end-of-life counselling "death panels," shows that there is no depth to which they will not sink in order to achieve in the media what they could not achieve in the ballot box.

The current incarnation of the Republican party is hopeless. Sen. Charles Grassley recently announced that he would vote against healthcare provisions which he himself thought worthwhile in order to foster party unity. Here, party unity means kow-towing to the conservative wing represented by the religious right, the gun lobby, and big-business groups like The Club for Growth. (Don't think the Republicans are for "the little businessman": they favor large and powerful corporations at every opportunity in everything from anti-trust legislation to copyright and patent policies.) The reason for making obeisance to these fringies is that they represent about all that is dependably "Republican" these days. The party that opposed Social Security, child labor laws and Medicare, and pushed deregulation of everything, is now completely out of touch with the vast majority of Americans. All it can do is tell lies, lies, and more lies.

As I've said, Obama and the Democrats must unite and totally marginalize the bankrupt G.O.P. I suggest that they go on the attack and use the media to itemize every single untruth the Party of Big Business has been hawking. They should make it clear that the citizens of every other advanced country have better and cheaper healthcare, and that they are happy about it. They should use some of the film clip resources of The Daily Show, which so amply demonstrate the two-faced nature of their opponents. If they blow this because of their usual cowardice and/or naivete, then we might as well invite Sarah Palin to take over.

Friday, August 14, 2009

Krauthammer on preventive healthcare

In a recent column "The inconvenient truth about preventive care" (8/14/09), Charles Krauthammer claims that evidence shows that preventive medicine will not save money in overall healthcare costs. He gives an example of a test which costs $500 and can save $10,000 in later expenses when it gives a positive reading. He argues that when 1 in 10 people have the disease, the overall savings are real, but when only 1 in 100 will test positive, the overall expenses of giving the test to the 99 out of 100 people who don't have the disease result in a large net loss. This reasoning is not, in general, correct; here are several reasons why.

1. Not everyone gets any particular test. Patients are generally screened before being given expensive ones that detect rare diseases. Children and young adults are rarely given colonoscopies; generally healthy people are not routinely given chest X-rays, CAT-scans or MRIs. Mammograms are recommended on the basis of age and estimated risk.

2. Some tests can detect several diseases very early. For example, a single routine blood or urine analysis can detect many different incipient diseases such as anemia, bladder infection or diabetes. Without a healthcare program providing such a test for an appropriate group of the population, these easily-detectable diseases would go unrecognized until they became serious and expensive to treat.

3. The ratio of $500 of prevention to $10,000 of cure is extremely simplistic. I'm sure that Krauthammer knows this, but as a single example it is very misleading. Take the case of diabetes, where the detection by a routine blood test (and follow-ups in the case of a positive result) is fairly inexpensive. The cost of untreated diabetes is far greater than $10,000. Severe diabetes often leads to blindness and amputation; does anyone think that a pricetag for such an outcome is merely $10,000? Furthermore, in that segment of the population where the risk of diabetes might suggest a non-routine screening, the expected proportion of positive diagnoses is far higher than 1 %.

More generally, how do we assess the true cost of a disease? Is it simply the treatment? When we ask about the finances of a late detection of breast cancer, do we talk simply about the costly radiation and chemotherapy, or do we also add in the lost wages during treatment and the expenses, such as daycare, resulting from unsuccessful treatment?

4. In the context of non-universal health-care -- which is what we have now -- the costs of uncovered disease is much greater than Krauthammer acknowledges. A person suffering, for example, from severe chest or stomach pain but who doesn't have medical coverage, will typically go to a hospital emergency room. Such a visit typically costs hundreds if not thousands of dollars, irrespective of what is detected or what treatment is indicated. On the other hand, a person with a health care plan would typically visit a primary-care physician who would know that person's history and direct that person's care to the appropriate specialists if needed. Expensive emergency-room care would be reserved for cases of critical trauma -- which is what they were designed for.

In any case, Mr. Krauthammer misses the point of the healthcare issue. Healthcare will not "pay for itself": no one ever suggested such a thing. However, it is well-established -- beyond debate -- that it is possible to provide universal healthcare that is far better in outcome than anything we have here in the U.S., and at a cost far less than what we currently pay. How do we know that? From statistics, projections, medical or economic theory? No. We KNOW this because most of the developed countries of the world already do it. Furthermore, they do it with LESS "rationing" than we have currently within our for-profit system. A large fraction (maybe 1/6 and increasing) of our population is already rationed out because they simply have no coverage. Of the remaining, nearly everyone already experiences rationing. Almost no one can choose any doctor and any procedure at any time. The insurance companies simply don't allow it. Furthermore, many millions of people with coverage have their care rationed by the large deductibles and co-payments. Sure, Canadians may have to wait months for a hip replacement; but, you don't get one here if you don't have coverage, and even with coverage you'll probably have to pay some and wait some.

In France, for example, which has a hybrid public/private plan, everyone has basic coverage for preventive care and most illnesses -- similar to the coverage that most Americans with healthcare now have, minus the deductibles and copays. For those who want to chose any doctor for any procedure at any time, they can buy an extended plan through private insurers -- for which they pay extra. France has a higher life-expectancy and lower infant mortality than we do, and people there love their healthcare system.

We know that universal healthcare is achievable since it has been achieved over and over again. Any theory that says it can't be done cheaper and more effectively than the way we do it now is proved simply wrong by the facts "on the ground" as they say in the military.