[Alumni-chat] Re: Alumni-chat Digest, Vol 7, Issue 1

[Sistersara at aol.com]

In a message dated 9/1/2007 3:52:55 P.M. Central Daylight Time,  
theodora at imbris.com writes:

David,  As for HIllary care,  of course, we don't know what  would have been
if she had been able to do what she wanted to do, instead  of finally caving
in to insurance companies and creating "managed  care".




Hillary made two huge mistakes in 1993-94 had she wanted to actually move  
the mountain down the road a bit on Health care -- both are political  mistakes. 
 
 
The first was her commission structure.  She had virtually no elected  
officials on it, she totally ignored congress, and what she attempted was the  
compromises that usually fall to Legislators in the process of actually drafting  a 
bill.  She had every lobby and interest group she could think of  involved, 
except the ones that actually count -- Politicians.  Why she did  it this way, 
I don't know.  Was it because she wanted to be in charge of  what generally 
goes on in Mark-Up? (where Power counts), I don't know.  But  this pretty much 
guaranteed failure.  
 
Second problem.  Her dealings with Senators and Representatives were  total 
flops.  Hillary was new to Health Care -- virtually all Senators and  
Representatives have both case managers who deal with individual problems, and  if they 
are on the right committees -- staff experts who have been at this for  
decades.  When she went around to visit the members, they would bring in  their 
staffers, and they ran circles around her.  
 
Over the years I had some very interesting discussions with Paul Wellstone  
about how the debate went in those years, and subsequently how his view of how  
to go about successfully building a National Health System should actually  
proceed.  Just for the hell of it, I will lay out her the evolution as I  
understand it of one Progressive Senator's thinking.  
 
Paul was elected on the generic Single Payer -- something like the Canadian  
Model platform.  It was a centerpiece of his position in 1990, and he kept  at 
it till he died.  But his view of how it should be organized did  change.  
 
Paul came to believe that the role of the Federal Government should be  
somewhat limited.  It should, collect the tax to support much of the  program.  It 
should lay out the menu of covered services every citizen  would be able to 
access.  It should fund and oversee most medical research  using the National 
Institutes of Health, the National Academy of Medicine and  the CDC.  (Paul 
favored eliminating the Surgeon General, and combining the  Public Health Service 
with CDC, vastly expanding its role.)  Paul also  believed the grand 
compromise (or at least one of them) would involve the Feds  paying for all medical 
education plus living stipends for student Doctors,  Nurses, and most medical 
technology fields.  Because any real reform will  be about eliminating fee for 
service, and going to a salary/appointment to a job  structure, taking over the 
full cost of education and in-service education would  have to be a Federal 
Expense, and would be part of the grand compromise with the  professions.  He 
also believed we had to expand medical ed -- currently we  depend on third world 
countries to send us perhaps 20% of our young medical  personnel for 
"training" and then if they are any good, we recruit them for  jobs.  Paul thought we 
should home grow what we require, and the Federal  Government would need to 
work with national and state Medical and Nursing  associations to expand 
schools.  
 
But where he evolved was with regard to design of service delivery.   He 
thought each state should be required to design a quality, but economical  d
elivery system that fit its needs and circumstances.  He thought something  like a 
Board of Regents, appointed by the Governor and Legislator of each state  -- 
one point of distance between actual elected officials, and appointments to  
fairly long term Regents boards would provide the right degree of political  
sensitivity to consumer needs -- but would also allow Professionals to  
participate in management of the delivery system.  He would have required  that over a 
period of years, all health facilities would be held in trust by the  states, 
and these boards of regents would have planning staff, and be able to  design 
the most economical yet highest quality means of delivering services  specific 
to the conditions of each state.  In political terms, Paul thought  that many 
states would define areas of service so that small group practices  would bid 
on them -- or existing managed care or Insurance groups could reform  their 
business model, and see a way to contract to participate.  But the  whole thing 
would be organized at the state level, .allowing states to design  ways to 
meet the Federal Menu in different ways reflecting their own  circumstances.  
Paul believed, for instance, that using MA Nurse  Practioners in low population 
rural areas tied directly to 24/7 speciality  clinics via telecommunications 
nets, and also backed up by air ambulance  services -- would be economical in 
"Greater Minnesota"  ... but in Suburban  and Urban areas different 
distributions of skill sets would be  appropriate.  States would be better able to 
organize such service  distribution systems -- and making the state legislature 
politically sensitive  made more sense than making service delivery a federal 
matter.  
 
Finance -- Paul would have devised something like a value added tax for  both 
production and services to support the whole system.  He would have  also 
taxed imports of goods and services on the same rational, believing this  might 
make it just as economical to keep jobs on-shore rather than off-shoring  to 
low wage, low service sites.  The Federal Government would divide up  this 
revenue on a per-capita basis and block grant it to meet the Federal menu  to the 
states.  States would bear the cost of bricks and mortar -- building  new 
hospitals, clinics, renovating old ones.  Much of that funding would  probably come 
from state level taxes, or bonding decided on in the normal  appropriations 
process by the state legislature.  Paul would have also  added a progressive 
surcharge to ordinary income tax at the Federal Level.   But he would also have 
eliminated all "Health Insurance" as it now stands.   He would have gradually 
integrated medicare/medicade, Tribal Health Care under  treaties, the VA 
medical system and all other special entitlements.   Everyone would be treated 
equally within the system, but obviously a state with  many Vets would have to 
consider the needs to provide specialized services as  authorized under the menu 
-- and vet benefits would be on the menu.  A  state would have to decide 
whether it wanted to offer a speciality clinic for  face lifts.  As to drugs and 
other out-patient prescriptions, these would  be purchased by state regent 
boards, and distributed through private pharmacies  at cost plus service fees.  
 
I contributed two narratives to Paul's thinking.  The first was a  story 
about putting a member of an Elderhostel group I led in Denmark into the  hospital 
because of a heart condition.  As the group leader I had the  insurance 
packet that had to be filled out in order for the coverage Elderhostel  carried on 
international programs to pay out.  I have never had such a  laugh on 
something serious.  I had to collect the names of all the  medications that were part 
of the treatment, and get the cost -- essentially per  pill or injection.  
Well Denmark purchases all of its medications  nationally on a bid system, and no 
one knows what they cost per pill.  They  just figure out on a national basis 
what they will need, they factor in a little  inflation in need, and then 
they put out a bid, and negotiate down.  They  have a central distribution center 
that stocks all hospitals, clinics and  pharmacies.  Even in the 1980's it 
was all electronic.  But no one  knew what it cost.  I had the absolute joy of 
introducing a Danish Doctor  to the Joys of Fee for Service Medicine, (and 
thank you AEA,) I did it all in  Danish.  
 
The second thing I passed on to Paul was my translation of a debate in the  
Danish Folketing about increasing the budget for the national school lunch  
program.  The fact that bad nutrition in youth had been determined to be a  
contributing factor to heart disease perhaps 40 years later had been pretty well  
proven up caused the Folketing (the national Legislature) to debate the cost of 
 replacing all the bad stuff with good stuff in the 7-16 year old school 
lunch  programs.  The issue at question was how much money would be saved perhaps  
40 or 50 years down the pike by vastly improving the nutritional standard of  
school lunches.  Fewer expensive heart attacks was actually a legislative  
priority -- not now, 50 years in the future.  Obviously having a national  
health system with long term budget impacts is a pre-condition to having such a  
debate, and our Senate has never really had such.  They get distracted with  
debates about corporate coke machines in school lunch rooms.  Paul got it  
written up, put it in the congressional record, and circulated it to members of  
Health, Education and Labor Committee on which he served.  Of course if you  
reduce the number of persons with heart disease, you also provide a good to your  
citizens other than just being responsible with the budget.  He told me  
afterwards that committee members could not imagine a debate about policy that  
looked that far out, both Republicans and Democrats.  We don't even have  our 
Heart Societies collaborating with out school lunch program advocates.   But the 
Danes took the research, ran the numbers for 40-50 years out, and had a  
debate about it, and changed the nutrition guidelines for that program in  
concordance with the known data.  
 
Anyhow this is where he was when the plane crashed, and we got a total  
neo-con occupying that seat.  We have to change the terms of the debate,  and 
unless we do that we will get nowhere.    
 
 



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