Politico has a version which can be copied (paragraph breaks lost when pasted). Thanks to Dawn for posting the link to TPM.
The letter opens with the usual rhetoric, the usual list of existing problems which can only be answered by single payer savings through reduction of overhead and marketing costs, removal of excessive profits and high compensation packages for executives. Toward the end of the first page, Obama writes:
At this historic juncture, we share the goal of quality, affordable health care for all Americans. But I want to stress that reform cannot mean focusing on expanded coverage alone. Indeed, without a serious, sustained effort to reduce the growth rate of health care costs, affordable health care coverage will remain out of reach. So we must attack the root causes of the inflation in health care. That means promoting the best practices not simply the most expensive. We should ask why places like the Mayo Clinic in Minnesota, the Cleveland Clinic in Ohio, and other institutions can offer the highest quality care at costs well below the national norm. We need to learn from their successes and replicate those best practices across our country. That's how we can achieve reform that preserves and strengthens what's best about our health care system, while fixing what is broken.
The plans you are discussing embody my core belief that Americans should have better choices for health insurance, building on the principle that if they like the coverage they have now, they can keep it, while seeing their costs lowered as our reforms take hold. But for those who don't have such options, I agree that we should create a health insurance exchange -- a
market where Americans can one-stop shop for a health care plan, compare benefits and prices, and choose the plan that's best for them, in the same way that Members of Congress and their families can. None of these plans should deny coverage on the basis of a preexisting condition, and all of these plans should include an affordable basic benefit package that includes prevention, and protection against catastrophic costs. I strongly believe that Americans should have the choice of a public health insurance option operating alongside private plans. This will give them a better range of choices, make the health care market more competitive, and keep insurance companies honest.
That "affordable basic benefit package...includes prevention, and protection against catastrophic costs," which sure sounds like a high deductible plan, perhaps with "wellness check ups" and vaccines covered, but not much else...until the insured is underwater with costs from a "catastrophic" illness.
However, since right now we're reading between the lines and examing tea leaves, who really knows. Obama's not telling the public anything concrete which can be evaluated and judged.
I understand the Committees are moving towards a principle of shared responsibility -- making every American responsible for having health insurance coverage, and asking that employers share in the cost. I share the goal of ending lapses and gaps in coverage that make us less healthy and drive up everyone's costs, and I am open to your ideas on shared responsibility. But I believe if we are going to make people responsible for owning health insurance, we must make health care affordable. If we do end up with a system where people are responsible for their own insurance, we need to provide a hardship waiver to exempt Americans who cannot afford it. In addition, while I believe that employers have a responsibility to support health insurance for their employees, small businesses face a number of special challenges in affording health benefits and should be exempted.
Health care reform must not add to our deficits over the next 10 years -- it must be at least deficit neutral and put America on a path to reducing its deficit over time. To fulfill this promise, I have set aside $635 billion in a health reserve fund as a down payment on reform. This reserve fund includes a number of proposals to cut spending by $309 billion over 10 years --reducing overpayments to Medicare Advantage private insurers; strengthening Medicare and Medicaid payment accuracy by cutting waste, fraud and abuse; improving care for Medicare patients after hospitalizations; and encouraging physicians to form "accountable care organizations" to improve the quality of care for Medicare patients. The reserve fund also includes a proposal to limit the tax rate at which high-income taxpayers can take itemized deductions to 28 percent, which, together with other steps to close loopholes, would raise $326 billion over 10 years.
I am committed to working with the Congress to fully offset the cost of health care reform by reducing Medicare and Medicaid spending by another $200 to $300 billion over the next 10 years, and by enacting appropriate proposals to generate additional revenues. These savings will come not only by adopting new technologies and addressing the vastly different costs of care, but from going after the key drivers of skyrocketing health care costs, including unmanaged chronic diseases, duplicated tests, and unnecessary hospital readmissions.
So, Medicare/Medicaid cuts come over 10 years, that's pretty clear. Seems he thinks that will come from cutting" waste, fraud and abuse" (WFA) and improving care...somehow. And that interesting phrase in quotes, "accountable care organizations." Any guesses as to what that means?
And those "key drivers" of every increasing costs? See no mention of the overhead, high profits, bureaucracy needed to deny care, etc., caused by the Big Insurers' profit model of doing business. Dear Mr. Presdient, we can't afford to not have single payer. Really. Get a grip!
I look forward to our Corrente healthcare and insurance mavens tearing this apart. Thanks in advance.
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Here's my favorite line:
If we do end up with a system where people are responsible for their own insurance, we need to provide a hardship waiver to exempt Americans who cannot afford it.
So the really poor people will still go naked.
But they won't be punished for it. Yay!
We will push and push and push until some larger force makes us stop.
What utter crap.
Well, he's no LBJ. Hell, he's not even WJC. I hope this plan fails.
The liberty of democracy is not safe if people tolerate growth of private power to a point where it becomes stronger than their democratic state itself. That, in its essence, is fascism.---FDR
He's no TR, no FDR, no Truman, no Jimmy Carter. Nixon? I'm
not sure what Obama's objective really is or what his plan will be like, but it could possilby be somewhat like Nixon's. If the Big Insurers felt it would let them keep on making big profits.
obama = nixon
that's an unsettling thought.
at least we got the epa while nixon was in office, so maybe there's hope for obama.
Another good line--seems to indicate those savings will take
a good while to affect what people pay for that insurance they "want to keep."
accountable care organizations
it's yet another proposed model for 'payment reform' basically, and they want to experiment on the old folks first, because gawd knows they're sucking all the
oxygen out of the roommoney out of the system.it's kind of a defacto large group practice, where all the physicians associated with a hospital, whether as employees or not, are lumped into one group and are collectively responsible for the 'outcomes' of all the medicare patients that utilize that hospital. medpac seems to like the idea and is apparently mulling over whether this should be voluntary or compulsory. if all [or perhaps a significant number] the patients in a group do well, all the physicians get a bonus. if the patients do poorly, all the physicians are penalized monetarily.
sounds like a wiener to me.
Uh, sounds like a paperwork (or DRM) nightmare to gather and
evaluate all the outcomes, with the necessary inputs and follow ups to determine how and why such outcomes came about.
But I don't know the system all that well, so perhaps much of the info is currently gathered...?
yes and no
some of the information is already being gathered and reported [and has probably been useful]. i've been reading about quality reporting, it's time consuming [the reporting, not the reading], electronic records will [possibly] make it less time-consuming.
doctors who have been participating in medicare's new pay-for-performance project seem to be divided in their opinions. generally, large group practices have the money and the manpower and already have the computing power to make the reporting easy, and their volume is large enough that the 1%-2% extra pay is worth going for. small practices have decided it's just not worth the time and expense. plus, not all the doctors got the full amount they were expecting to get, making it even less worth the effort, for them.
i'm very much in favor of putting a lot of effort into patient safety. anesthesiologists made a concerted effort to study what they were doing that was killing patients some years ago, and instituted meaningful reforms that cut way down on patient deaths in surgery. and more recently there's been this checklist. these are excellent measures, and well worth the efforts that went into them.
i feel like such a luddite otherwise. i want my doctors to spend their office time talking to me, not their computers, not the insurance companies, not even a medicare bureaucrat. if they need a measly 2% more $$ from me to do that, I'LL pay them, and gladly.
The doctor who actually asked if I had any questions she could
help me with was the anesthesiologist, apropos of nothing. But she called me a few days before the surgery, on a Saturday, answered questions and gave me her number to call if she could answer any more! She really was helpful and just having someone to ask, without feeling I was being a pest, was a great relief.
That she was a woman might have been one factor in her approach to patients--wonder if the study and guidelines had any effect.
that's wonderful
when a friend was dying of cancer awhile back, several of us [friends, family, neighbors] got together to look after him -- including talking to the doctors and taking notes [since he was in a chemical fog much of the time from all the meds]. the oncologist assigned to his case was very good, but initially, before that came about, the anesthesiologist [male] was the one who answered all our questions.
dunno if that's two cases where the anesthesiologists were just exceptionally patient-oriented, or if perhaps this has become a standard cultural feature of this specialty. i hope it's the latter.
medicare/medicaid cuts
this could be ok, actually.
obama has repeatedly referenced cutting out [or at least cutting back] the extra subsidies given to private insurers for their participation in medicare advantage plans, which is about 20% of medicare now, and for which we the taxpayers pay [depending on whose data you look at] 12%-17% more than it would cost to have those people in traditional medicare.
the other savings point frequently mentioned in both medicare and medicaid is the waste, fraud, and abuse, of which there really is a noticeable amount, some of it by the large hospital chains [for-profit, of course], some of it by fake medical equipment suppliers, just to name a few sources.
catastrophic
this one is a little more difficult to tealeaf read, in part because i've decided that obama just is not a wonk at all on health care, and mostly parrots what he's being told by his coterie of advisers.
the latest proposal to come out of baucus' finance committee describes [beginning about pg 8] a health insurance exchange that requires insurers to offer plans at 4 levels of actuarial value: 76%, 82%, 87%, and 93%. i thought 76% sounded low, but those numbers appear to come from this analysis, where medicare parts a, b, d are rated at 76%, so maybe [and maybe not] your worries here [and mine too] about the 'affordable' plan being high-deductible are [sorta] unfounded. of course, medicare has a couple of problems, with no limit on out-of-pocket expenses, and that dratted doughnut hole in part d, so it's not perfect. beats what i have right now.
then again, the baucus proposal calls for insurers to offer actuarially equivalent plans in each of the four levels. actuarial equivalence looks good on paper, but in actual fact often proves to be a total farce. i've lost the link i had, and can't find it, but someone did a nice real-life kind of comparison of two actuarially equivalent plans for breast cancer treatment, which included 87 weeks of chemotherapy. in one of the plans, if you started treatment in the middle of the year, it was structured such that meeting the various deductibles and out-of-pocket expenses cost a great deal more [in both plans if you started treatment at the beginning of the year, your out-of-pocket costs were about the same, but the lesser plan, since 87 weeks stretches across 3 calendar years if you start in may or june, hit you with 3 big fat deductibles].
mayo clinic, cleveland clinic, et al
this talking point comes directly from the dartmouth atlas project which documents how much medicare spending per patient varies by what part of the country you live in. the takeaway lesson that all the conservatives and conservadems took away from it is that we're spending too much on all those greedy old people who live in the high-cost areas and we could save beaucoup billions if we get them to stop using so many services.
the real takeaway from the dap should be more along the lines of: [1] are we under-spending in some areas of the country? [very possibly] and [2] how much of that variation is legitimate [eg, more spending in locales where the population is generally unhealthier probably can't be changed].
as for what the mayo and cleveland clinics are doing to make them so much more cost-effective, some of the factors...
Mayo clinic in FL DID replicate MI
Gotta run, but that New Yorker article that's been floating around has that. Check it out.
Excellent point on salaries. The FKDs #1 priority is not controlling costs, but keeping the insurance companies in business. If they really cared about controlling costs, they'd remove the incentive for over-testing that fee-for-servive gives, and push for one, two, many Mayo Clinics.
First they ignore you, then they ridicule you, then they fight you, then you win. -- Mahatma Gandhi
yep, read it, hope to post on it someday
they'd remove the incentive for over-testing that fee-for-service gives
eh, you might want to remember that canada, germany, japan, france, many others, are all largely fee-for-service.
they control costs not by bundling payments, or pay-for-performance, etc, but with price controls: setting limits on how much the doctors, hospitals, and insurance companies [in multi-payer countries] can charge, not to mention that in canada [and some others?] the hospitals are non-profits, and in the multi-payer countries the insurance companies are non-profits too.
those hospitals in mcallen [and harlingen, i forget did he talk about harlingen too?] are for-profit hospital chains.
as for the mayo clinic here in florida, i'll have to go back and reread the article, but somewhere, either on the dartmouth atlas website itself, or on another website talking about the dartmouth atlas, the florida mayo clinic is [or perhaps was] not as cost-efficient as the rochester clinic, though still very good. mostly this wasn't stated as a criticism of the model, just as an observation that regional variations happen to even the best of them, and probably for real-life reasons.
one of the problems with replicating the mayo clinic model is how do you do that in rural areas where there aren't lots and lots and lots of patients in a small geographic area who can get to your hospital easily? you can have smaller satellite hospitals and clinics that are part of your overall organization and arrange for your patients who need the big hospital to somehow get there. it's doable, some large hmo groups [which is what the mayo clinic is] are doing it successfully.
and ackshully the fkd [or more accurately, their health wonks] is pushing for many mayo clinics. accountable care organizations are basically a clone of that model, with some tweaks.
Indeed, Cortese says that the
Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.
in some respects. ok, i'll look into that further.
Hipparch-Have I told you lately how much I value your input here
Thanks so much for your explanations and links.
And, how was that evening(s?) of reading Hillary's 90's healthcare plan?
Also, should this post and thread go under the Today in Health Care Reform? and how?
thank you
for your cogent questions. i find it easier to answer what other people are asking than to figure out on my own what to say.
if you want your post to show up in the today in health care reform feed, you can type single payer or [i think] health care in the tags box.
i’m just making my way through the hillarycare items bit by bit, since it’s old news and there are SO MANY PEOPLE ON THE INTERNET WHO ARE WRONG! ABOUT HEALTHCARE!!!
if you want to repackage any of my comments [here or elsewhere] into another post of your own, at any time, feel free.
Today in Health Care Reform
Posts tagged with "single payer", "HR 676", or "health care reform" automatically show up in Today...
First they ignore you, then they ridicule you, then they fight you, then you win. -- Mahatma Gandhi
"health care reform" doesn't work
but "health care" does. i tried my latest post with both tags.
And those "key drivers" of
And those "key drivers" of every increasing costs? See no mention of the overhead, high profits, bureaucracy needed to deny care, etc., caused by the Big Insurers' profit model of doing business. Dear Mr. Presdient, we can't afford to not have single payer. Really. Get a grip!
bingo! couldn't have said it better myself.
the working poor...
actually, the really poor will be covered. Its the middle class and the working poor -- who will be screwed. The lower working classes won't be able to afford health insurance regardless, and the "middle" classes will (as per usual) mortgage themselves to the hilt, making it impossible for them to pay for increases in health care costs or if/when they experience an economic reversal.
File that under "B" for "Bingo" n/t
.
Are Obama's words just words or "just words?"
I think its great to critically evaluate what the guy says, but what he does seems more important. If Obama were a model of honesty and integrity I'd be more willing to take what he says seriously. I do think its important to look for clues to what he'd do and verify what he says--whether he does it or not--but I think at best we'll only get an all-things-for-all-people speech as per usual. I'd rather the majority of time be spent looking at his actions behind the scenes, not his publicity stunts. His FISA vote and his TARP whipping were two of the biggest clues to his *current* "philosophy". And his campaign was evidence that he's quite comfortable with lying (Somali garb photo) and cheating (the whole damn primary process).
Only tyrants rig elections.
Actions indeed speak louder than words, so agree with you; but
right now we have little from Obama that is firm and committed to regarding healthcare, whether it's parasite pampering reform or real reform for the people. So, what little he commits to writing is important if only to be able to gague what he may actually do.
The parts of his Middle East/Muslim relations speech I listened to today got the same reaction from me as his speeches on healthcare have. What is he leaving unsaid, did I miss the weasel words, and that many good arguments for what would be very good actions instead, coming from Obama, lead to the wrong or inadequate acttions.
Trust but verify? No way: listen, read, compare, evaluate, but most of all continue to try to bring whatever pressure "liberal bleeding hearts" and DFHs
can to important issues.