The blogosphere is buzzing with discussions about the promise of health care reform. For a weekly poster like me, it is impossible to keep up. As 2009 approaches, and more importantly, as 1.20.09 approaches, I thought I would offer my insights into the topic from the perspective of the administrator of an employer and union sponsored health benefit plan
If there is one thing that unites the comments it is their oppositional posture. Insurance companies are the most common enemy, but hardly anyone escapes.
So I would like to go on the offensive and tick off a few positives that I would like to see in health care reform. Please indulge my autocratic use of the term “will”.
1. Every individual will be required to have health insurance.
2.There will be a defined set of benefit plans.
3. There will be a uniform drug formulary.
4. There will be payment reform.
5. Medical education reform will include major financial support by the federal government. 6. There will be a system for a fair redress of medical errors.
7. Cost to the individual will be based on ability to pay.8. There will be delivery system reform
9. There will be room for experimentation.
10. Above all, there will be recognition that the health of the nation is not dependent solely on its health care system. It depends on good nutrition, opportunities for exercise and outdoor recreation, on the education of its citizenry, on safe working environments, on safe drinking water and sanitation systems, and on clean air.
Over time I will take the opportunity to expand on these topics. Some may notice that I offer no silver bullets: fix this one thing and all will be right. It took this country a long time to get into this mess. Fixing it will take time, leadership, and concerted effort.
Health Care Reform in Germany
This past spring, Health Affairs, the premier health policy journal, had an interview with the German Minister of Health, Ulla Schmidt. The interview focused on reforms to Germany’s health system instituted principally in 2007. Minister Schmitt was asked what were the goals of the reforms. Her answer – she wanted to preserve the principles of social solidarity and affordability that had always been a part the German health system.
In comparison to health care in the United States, the Germans system could hardly be called a system in crises. The per capita costs were about half of what they were in this country $3,200 per person in Germany compared to $6,400 here. But they did have too many uninsured – about 0.2% of the population. The United States, by comparison has 15% uninsured.
So the question is, What do Germans understand by social solidarity? Minister Schmitt explained that everyone in Germany has guaranteed access to health care and everyone contributes to the financing based on their ability to pay. Well, if that is social solidarity, where does affordability fit in? For Minister Schmitt, if the entire system is not affordable, the social solidarity begins to break down.
Too much of the health care debate in this country is muddled by ideology on both sides. For many in this country, European health care sytems smack of “socialism.” Yet, two of the defining characteristics of the German system are not real popular among progressives in this country. The Germans have an individual mandate and they rely on insurance companies, although in Germany they give them a more accurate name, Krankenkassen, or Sickness Funds.
A column in Tuesday’s New York Times raises an issue not raised by many who opine on the bailout of the auto industry – the relationship between health care financing and the bailout. David Leonhardt examines the much discussed wage disparity between the unionized autoworkers and their non-union counterparts employed by foreign manufactures in the US like Toyota and Nissan.
Ezra Klein in his blog picks up the same theme. Apparently the Republicans in the US Senate missed their helpful analysis – as did most of the talking heads on the news shows.
They make two relevant points. Most of the disparity between the wages is in legacy cost, and secondly, wages are not the significant cost driver in the cost of an automobile. They both agree that Detroit’s troubles are not related to costs, but to their inability to design and build cars that the American public wants.
Personally, I do not think the car makers deserve all of the criticism they received; a lot, just not all of it. Until a couple of months ago, our family had two American made vehicles in our driveway. Their combined mileage was almost 350,000. Our high priced foreign car cost more per year to repair than the other two combined.
In my last post, I wrote that health care reform proposals need to focus on the patient side of the health care delivery system by designing systems that eliminate the cumbersome, even tortuous routes that patients must travel to enter that increasingly privileged space – a person with health insurance.
An illustrative example is the Qualified Medical Child Support Order (QMCSO). QMCSOs apply to those children who live with one parent but the court orders the other parent to provide the health insurance. The parent who has custody of the child is called, logically, the custodial parent. The other parent is called, can you guess, the non-custodial parent.
Every child support agency in every county and state in the country has a bureaucracy for the purpose of enforcing and administering QMCSOs. It does not matter why the parents are not together. Some are divorces, but some were never married. For a group of 25,000 Participants, my staff probably spends one to three days per month on issues related to QMCSOs.
Very little of that time is spent processing the paperwork. Most of it is dealing with custodial parents, non-custodial parents, child support agencies (issuing agencies in bureaucratese), carriers, attorneys and other stakeholders. In other words, our staff’s time is matched by someone else’s staff time. I did an extrapolation to the US population. It assumes our population is a representative sample of the general population. By my estimate, it is costing the United States economy $100,000,000.
The room was packed, and the message came through loud and clear at the informational briefing this morning on the state of Hawaii’s agriculture industry. It was a joint meeting of the Committees on Agriculture and Water, Land & Ocean Resources.
The industry faces its more critical period ever, and without significant changes, agriculture as we know it, may cease to exist in Hawaii in the near future. Here are some of the highlights from the briefing:
Dean Okimoto – President of Hawaii Farm Bureau, Owner of Nalo Farms
Nalo Farms is at great risk. Okimoto has been working on an expansion project for a few years which he hopes to open on Monday. He has poured much of his savings into the project as he has had to pay off a loan with no incoming project revenue for the past 15 months. He says that it feels like he is losing business, not gaining business, and even the farm itself is not doing well.
The danger for the industry is that once we lose a farm, it never comes back. Nalo Farms is not alone. Several farms have closed in recent months. Part of the problem is that agriculture is like "the Rodney Dangerfield of the economy" – it gets no respect. In particular, Hawaii’s tourism industry is highly dependent on agriculture, but Okimoto believes that there is little recognition from the tourism industry, nor collaboration between the two industries.
Buddy Nobriga – President of Nobriga Ranch
Nobriga contends that the Hawaii Department of Agriculture is one of the smallest Ag Departments in the nation. The state needs a larger, stronger department that can help the farmers and ranchers. There are not enough inspectors to monitor the quality of imported milk. We don’t have strong relationships with the USDA. We don’t have the land to establish dairies.
We need agriculture in order to be sustainable. In a way, agriculture and farmers are like the "security" of the state.
Meredith Ching – Alexander and Baldwin (large landowner)
Large landowners face the same problems as small farms. The lack of rainfall in the past decade has had a cumulative effect on island crops. 2008 was the driest year over the past 85 years. In addition, the state has been in a prolonged drought for the past decade, with the past two years being exceptionally dry.
Yvonne Izu – Hawaii Farm Bureau, former state water commissioner
The legislature needs to amend the state water code law. The East Maui decision is a perfect example of how the water code does not support agriculture. This is one way the legislature can help farmers without spending money. Farmers do not have hope that agriculture can survive in this state.
Richard Ha – President, Hamakua Springs
The world has changed. He has had to lay off 20 workers recently. He says you can tell that farming is bad when fertilizer sales go down. Fertilizer sales have been going down since last spring. There is, however, an opportunity to use agricultural lands for energy crops. A bill passed last year allows farmers to finance loans for energy projects, although this may not be quite enough incentive to bring more people into farming.
He has a blog now. "These days, you gotta blog if you’re a farmer."
Eric Tanouye – Greenpoint Nursery
Tanouye’s 20-year-old son is in college and has said that he wants to work in the family business. This excites Tanouye because it would mean three generations working in the business. Tanouye is also the President of the Florists and Shippers Association and he has visited members across the state on all the islands. All of them face very difficult times. It is unprecedented.
Kylie Matsuda – Matsuda and Fukuyama Farms in Kahuku
She represents the 4th generation of farmers in Kahuku. She has a degree in Tourism Industry Management, but wanted to go back and be part of the family farm business. Her parents did not want her to do it, but she wanted to use her tourism expertise and expand the business into agri-tourism. She had to fight to get her job at the farm. She feels that farming can become viable again if you consider value-added products which will bring additional dollars.
For example, tourists can’t take home fresh fruits and vegetables, but they take back dried fruit, jams and jellies, and other products. There are also farm-related activities to market.
What can be done? Some suggestions:
*Clarify the state policy on water. The East Maui decision seemed to put farmers at a lower level of beneficiary than others. The water commission needs to understand the importance and value of the agriculture industry to the state.
*Provide tax credits for new farmers. Incent farmers to start farming.
*Support more farmers’ markets. It provides more revenue and forces farmers to interface with their market and the public, and through dialog, they can improve their product and have fun talking to people.
*Dean Okimoto summarized: He wanted to make it clear that the farmers are not looking to the legislature to solve all their problems. However, the legislature can be helpful in making other industries and the general public more aware that farming is critical to our state. Right now, tourism does not appreciate or support agriculture. Someone needs to hold their (tourism’s) feet to the fire in helping agriculture.
Chair Clift Tsuji and Chair Ken Ito expressed their appreciation to the farmers for coming today; they understood the gravity of the situation. They will be using the information from the briefing to propose legislation for the 2009 session.
Since November 4th, interest in health reform proposals has understandably intensified. I like to flatter myself that this blog might make a small contribution. But I do have a day job and so the horn I blow here only has one note; if we simplify the system we can find the money we need to cover the people without health insurance and increase product satisfaction among all stakeholders.
I am not a policy wonk who views the health care system wonderfully distilled through the glorious abstraction of statistics; nor am I encumbered by practical politics. I view the system from the bottom looking up. I have a stake in the present system, but that stake is poorly represented in these musings. I am a gatekeeper to the health care maze. In my ideal world there would be far less need for the work I am doing.
I know from daily encounters just how daunting that maze is for people needing care. I tend to demonize piece rate physicians who are too quick to deny care rather than trust the maze.
So when I read others who write about health care reform I look for my theme. On Sunday, November 23, 2008, the Washington Post published an opinion piece by Shannon Brownlee and Ezekiel Emanuel, 5 Myths About Our Ailing Health-Care System. The authors are right on target with four of the five myths that they debunk. They drive home the point that we are paying a lot of money for our health care, that we are paying a lot of money for not particularly good health care, that we really are paying the price through premiums, taxes, and lost wages, and that Americans are ready for a change.