Pearlstein Interview transcript 2

[Guest guest]

Pearlstein

Washington Post Columnist

Wednesday, January 18, 2006; 11:00 AM

Washington Post business columnist Pearlstein was online to

discuss the Bush administration's latest economic policy initiative

on health care.

In today's column , he writes that by framing the debate as an

ideological choice between individual control and more government,

Bush is setting himself up for another Social Security-like failure.

A transcript follows.

About Pearlstein: Pearlstein writes about business and the

economy for The Washington Post. His journalism career includes

editing roles at The Post and Inc. magazine. He was founding

publisher and editor of The Boston Observer, a monthly journal of

liberal opinion. He got his start in journalism reporting for two New

Hampshire newspapers -- the Concord Monitor and the 's Daily

Democrat. Pearlstein has also worked as a television news reporter

and a congressional staffer.

His column archive is online here .

____________________

Need to ask my doctor what Nexium can do for me: When does it get

recognized as so broken that a universal health insurance program

becomes acceptable?

Your Wednesday column is pretty good on the facts. It does leave

something to be desired when making suggestions, and it throws in an

ad hominem attack on the Democrats.

Health costs are now up to 16% of GDP and growing faster than wages.

Employer sponsored health insurance continues to drop. Co-pays are

ubiquitous and are at a sufficient level to force the consumer to

weigh the co-pay vs. the health benefit of seeing a doctor. The free

market does not work in health care to provide best services at

lowest cost, instead insurance companies work to cherry pick good

health risks and shun riskier individuals and groups.

Some facts that were left off

Medicare drug plan is a disaster for Medicaid participants. People

are not getting the drugs they need to stay alive. This is the

another poster child for Bush government competence.

Poor people not on Medicaid cannot see a doctor (except via emergency

room or with very large payment in advance which they could provide

except that, oops, they don't have any money because THEY'RE POOR).

The GOP tossed out all the Democrat's suggestions on how to make an

affordable Medicare drug plan and substituted a payoff to their big-

Pharma.

Bush will probably tout Health Savings Accounts, a pitiful response

since HSA's are makes the consumer 'self-insure' and further reduces

the large pool/social insurance aspects which are where some cost

savings might be achieved, especially if view over time and if the

rate of increase in health expenditures can be slowed from the

current 'doubling in 5 years' pace.

So, when will you come out for universal health insurance?

Pearlstein: Look, you can rant and rave and do your liberal

rain dance all you want, but its not going to change the political

reality in the United States: we're not going to adopt a government-

run national health insurance plan. Its too much of a change for our

system to handle, its not consistent with our political culture and

its hardly the way to go at a time when the national programs in

other countries are also hitting the wall. In hindsight, it would

have been a good way to go. But we made a different choice, and there

is lots we can do, and need to do, to build on the current system.

Your own partisan stripes are showing. The Dems have plenty to

account for on this issue, and your inability to accept even my mild

jab at them reveals where you are coming from. To begin this

conversation by immediately blaming everything on big bad Pharma or

declaring the Medicare drug benefit program a disaster based on first-

month administrative screwups doesn't speak well to your

understanding of public policy issues. You sound more like a partisan

hack than the serious discussant you pretend to be.

_______________________

San Capistrano, CA: It seems that the terms of engagement on

health care reform should include universality (including everyone),

ensuring financial security (comprehensive benefits and limiting cost

sharing), slowing health care inflation (global budgeting), equitable

funding (progressive taxation), preventing both over- and under-

utilization of health services (appropriate capacity adjustments and

queue-management), and reduction of the profound administrative waste

(uniform payer management). How would it be possible to achieve this

without either a single payer system or a private insurance system

that is so tightly regulated that it functions as a single payer

system?

Don McCanne, M.D.

Senior Health Policy Fellow

Physicians for a National health Program

don-mccanne.org

Pearlstein: One of the interesting things I've noticed in

recent years is the number of physicians who are now willing to talk

about national health insurance. That's a good thing, because it

really helps leavans the conversation. I've just given you my reasons

for not putting much hope in going in that direction. But there is no

question that this system of managed competition which have will have

to become more managed, and more regulated. I think that can be done

in ways that don't involve putting docs on salaries, having the

government set prices, having the government determine how many MRI

machines there are out there, passing laws preventing people from

obtaining medical services from private sources, etc.

Let me suggest where we need more government involvement.

The feds need to do more to get/help the big pharma companies to get

other industrialized countries to pay their fair share of R & D costs.

Some limits on consumer advertising would be useful.

The feds need to take the lead and put big money in health care IT,

including setting the standards and templates that will allow

everyone to communicate with each other.

The feds needs to take the lead and make big investment in outcomes

research, science-based medicine and disease management, and come up

with reinbursement schemes that push the system toward these ends.

The feds need to subsidize private health care for low-wage workers

and the unemployed.

If we do those things, plus require health insurance for all workers,

plus some of the things Bush wants to do, the system won't be

perfect, but it will be much better. And we won't have to get into

bruising issues about a state-run system that, in the end, your side

(which may be my side) will lose.

_______________________

Brooklyn, NY: Thanks for pointing out the problem with the ideology

around this issue.

I'm in the process of doing what I'm supposed to do--upgrading my

skills to change to a more lucrative field. As a consequence, I'm a

part-time worker and part-time student: I don't take enough classes

to get health insurance from the school and I work freelance and

short-term contract. I have one part-time job providing a significant

portion of my income, but because the hours I work are variable (some

weeks I work 40 hours, some weeks I don't work at all), I can't take

advantage of their high-deductible health insurance plan. If I don't

bill, how do they deduct my payment? It can't be done. Some kind of

universal coverage would help.

The discussion around health care doesn't recognize people like me

who are not unemployed, but who have unorthodox arrangements. I don't

expect a nanny company or a nanny state to take care of me, but I

resent this Catch-22 in which, in order to play by the current rules

of the game, I have to play Russian roulette with my health.

I know I have a health issue that is real and should be treated, but

I can't figure out how to get a doctor to see me, much less pay for

it. I'm not free-clinic material; I work. Every day, I worry. And

every day, I resent more deeply the cavalier attitude of the

ideologues running this country who would rather self-indulgently

rant on television and try to score political points than do the hard

work of governing that might make it possible for me to see a doctor

more than once every few years.

Pearlstein: Your situation is not uncommon, but its really

very manageable within the context of a better managed private

system. Allow companies to provide a basic health insurance package

nationwide should generate a plan that you can afford to buy. And

getting the tax code right should allow you both to deduct the

expense of buying it, as a self-employed person, along with some

amount of out-of-pocket expenses for deductibles and co-payments and

uncovered services. This isn't the hard part of the exercise. Having

said that, and made that available, we also need to require you to

take up that insurance. That also needs to be part of the deal.

_______________________

Charlotte, NC: One more way how the government can improve the health

care: to create an independent research institute (half of the

funding coming from taxpayers and the other half from the drug

companies and hospitals) that would assess the efficiency of new

drugs/treatments compared to existing drugs/treatments. That would be

a large improvement over the current procedure, where drugs, for

example, are not compared with existing drugs/procedures, but with

placebo.

Pearlstein: We have one already in government, and you're

right -- it should be expanded and given more power and visibility.

_______________________

Vienna, VA: " Nonsense " seems to be a bit strong a term for describing

market potential for fixing health care. There seem to be several

market-based possibilities that have real potential for improving the

situation, including:

- Opening the pharmaceutical import market to companies from all

countries with reasonable drug safety regulation standards.

- Publicly subsidizing medical professional education (another sector

where costs are out of control) so that shortages of qualified

professionals is not a factor contributing to costs.

- Funding teaching hospitals, patterned after the relatively

successful VA model, in every major metropolitan area. Besides

providing the capacity to train professionals, these could take the

high cost and high risk patients out of the actuarial pool.

- Having all health providers publish price and quality schedules,

reporting " total cost of ownership " numbers (ie, ob/gyn costs for the

entire pregnancy, including $200 tylenol), so that consumers can make

informed choices.

Unfortunately, without common sense political leadership, it is

highly unlikely that the situation will ever improve. In today's

market, that 16% of GDP buys an awful lot of congressmen.

Pearlstein: You're right on every point but one: opening the

U.S. market to drug imports. I can tell by your comments you know

that's really silly. The problem is that this " market " isn't really a

market since drug prices overseas are dictated on a take-it-or-leave-

it basis by foreign governments and their national health plans. What

we need is for drugs to be priced in every country according to that

country's ability to pay, which would be the cost of materials an

dproduction in the case of poor African countries and the highest in

the US -- but still below where they are today. The folks who are

getting a free ride on drugs these days are the Japanese, the

Europeans and some mid-income countries. Big Pharma has to be highly

incented to strike tougher pricing deals with those countries that

can afford to pay a greater share of R & amp;D costs.

_______________________

Albany, NY: I appreciated your column about health care and politics.

I especially appreciated your words about the universality of

coverage.

I have a problem with your comments on HSA's, though, that they " show

some real promise. " Call me cynical, but the only promise that these

things show is for employers and government to foist their costs off

on to employees and taxpayers.

Establishing and promoting HSA's can't be a part of any kind of

universal coverage. As Krugman recently said, HSA's may work for the

upper class, but they would not be a benefit to the lower classes.

Pearlstein: Krugman is not right, if you'll pardon my saying

so. If you want to trust anyone's research, trust the Rand Corp.

health care division, which has been doing the best work on this sort

of thing for decades. They say its still too early to tell, but that

there are probably some modest one-time savings to be gained from

such structures, with maybe some continuing downward pressure on

prices of some things as consumers become more cost conscious. Also,

the nay-sayers here are essentially arguing that people, over time,

can't and won't learn about what services are worth foresaking and

which ones aren't. That silly. People do learn, and to suggest that

low income people can't learn is, well, rather condescending, don't

you think? For as long as I can remember, in fact, liberals have

implicitly taken this view that poor people are incapable of managing

their lives in this cruel, capalistic system of ours -- that was the

essential message in their opposing welfare reform. And you know

what? They were wrong about that and they are probably wrong about

poor people being able to manage a bit more of their own health care,

particularly in the context of being members of managed care health

plans that are well-run. Will they get perfect health care, or all

the health care they think they want? No. But it will be a hell of a

lot better than the system most of them have now. And my guess is

that they would learn how to use the system to their own best

advantage, in good ways as well as some bad ways, pretty darn

quickly. They may be low income, and they may not have great formal

education, but they ain't stupid.

_______________________

Anonymous: Health insurance and health care is a huge issue with my

family. The year my father died, his former employer went bankrupt

and my mother was left without health insurance. My sister goes to a

physician who is described in your article . . . " the doctor who

benefits financially by providing more medical treatment than

patients need. " Her husband's employer provides great health

insurance, and I believe my sister's many diagnosed diseases are a

result of this superior coverage. And, while my husband's employer

provides 100% paid health insurance, I continue to pay $3600/year for

my FEHB (Federal Employee) health insurance because I fear being like

my mother - a retiree without health insurance. Health insurance

should not be this complicated and should control people's lives to

this extent.

We need basic coverage for all Americans with a healthy dose of

reality. If we don't take responsibility for bad habits - overeating,

smoking, not exercising - we'll suffer the consequencing. Doctors no

longer have the liberty of being kind to obese, smoking, couch-

potatoes. Health care affects the GNP and is a cause for out-sourcing

of manufacturing to foreign countries.

Hey, none of us are perfect. But, don't you think a lot of us need to

wake up to the reality surrounding health care that we are hiding

from?

Pearlstein: Yes, I do. Which is another reason for moving

toward a system where more of the cost of the system is born directly

(as opposed to indirectly) by patients themselves. There is too much

moral hazard in first dollar coverage. At the margin, there are some

people who don't do enough to control their weight because they know

there will be no financial penalty in having their health insurance

pay for the consequences of that bad living. And in an insurance

system, the rest of us who do take care of ourselves have to

subsidize their bad habits. With more cost-sharing, that perverse

subsidy is reduced.

_______________________

Chevy Chase, Md.: The premise of the " economic " approaches to health

care is that we as a Nation consume too much, and given the devotion

of approximately 16% of GNP to healthcare maybe we do. But too much

of what kinds of healthcare? Do we consume too much routine and

preventive care? Health savings accounts coupled with catastrophic

insurance might restrain our use of routine and preventive

healthcare, but it is not at all clear to me that this would be a

good thing, or that it would save any societal resources in the long

run. -The recent series on diabetes in that other national paper (NY

Times) showed that doctors and hospitals lose money providing

preventive and routine diabetes care, and make money providing

treatment of the serious complications that arise more often in the

absence of such routine and preventive care.] Based on my limited

experience, we as a Nation spend huge sums at the end stages of life,

and fighting the kind of catastrophic illnesses where expenditures

are not the equivalent of deciding to spend $400 on a suit, or $150

on a less-good but still serviceable suit. To save money, we have to

spend money to keep ourselves in better health, to minimize the

incidence of type II diabetes and other chronic conditions that can

be minimized by routine healthcare and public health measures. In

addition, we have to grapple seriously with end-of-life care; this is

an intensely personal issue that implicates the most profound

questions of religion, what it means to be alive, and consideration

and respect for others. There certainly are no easy answers, but we

can't ignore the very substantial portion of our healthcare

expenditures that go to the provision of care to the terminally ill.

Those who sloganeer about the " culture of life " should not at the

same time be able to complain that too much is spent on healthcare,

without being called upon to address the contradiction. We need a

broader " culture of respect " that encompasses both those who desire

to fight for every last second of life and equally those who choose

to let their lives come to a close with as much dignity as possible.

Pearlstein: You raise very important points, which I didn't

have room for in a short column, but need to be part of the debate.

Health savings accounts and so-called catastrophic policies should

not be designed to discourage preventive care that is shown to have

good payoff -- that obvious, and NOBODY disagrees with that. NOBODY.

On the other hand, if patients have some financial skin in the game,

it does make them a bit more conscious about the cost of those

services, and can help put some downward price pressure there where

right now there are none. I mean, does a routine set of tests for

your annual physical really have to cost $450, as it did for me

recently. I doubt it. But until people start complaining, you won't

get reductions.

You are completely right that the big banana here is controlling

costs for the 20 percent of the population who, in any given year,

consume 80 or 90 percent of all health care, much of it at end of

life. And that is where evidence-based managed care and disease

management come in. These are the really crucial things we have to

master, and they involve not only doing the cost-benefit analysis

necessary, but getting the information in a non-threatening way to

patients and doctors and then giving them, and their insurers, the

right incentives to embrace them. That's easier said than done, I

realize. But rationing care -- that is, using a fixed amount of money

each year to the best medical advantage for each patient and for the

society as a whole -- is something we all need to acknowledge needs

to begin happening more. We can't afford, as a society, to give

everyone all the medical care they might want, without any reference

to the benefits relative to the cost.

_______________________

andria: I fear that the reality of aging boomers, overweight

adults plus overweight children being diagnosed with adult onset

diabetes, the US is in denial of its nation's health crisis.

Yesterday's article on Arkansas' governor and his health redemption

was worth reading.

I rarely believe that doctors are hosing their patients. Figure that

the average patient is overweight with or developing chronic health

problems(hypertension & diabetes).

The discussion should also include major prevention efforts. I liked

the governor's approach to grant state employee's 30 minutes to

exercise. If people are allowed to take a break to smoke, shouldn't

we give them a break to stay healthy.

Regarding the health care accounts, I don't think it will help people

with no insurance. My child had a MINOR accident, no blood, no

sutures, no emergency room visit. Excluding x-rays, primary care

doctor visit, follow-up visits, and co-pays, the initial bill WITHOUT

INSURANCE was $800!!!

washingtonpost.com: Fire in the Belly

Pearlstein: That $800 is a good example. Now you're mad. Maybe

there are doctors that would be willing to do it for $500. If we had

a way of finding them, and making prices more transparent, maybe

you'd chose such doctors for such routine procedures. And maybe the

threat of lost business would cause your $800 doctor to lower her

prices. That's how a competitive system works. But right now, nobody

asks, nobody tells what their prices are or will be, and the system

has no price competition to it at your level.

_______________________

Waynesboro, VA: Go, Steve! You understand the facts and the political

reality we're facing. Yes, a government run single-payer system makes

a lot of sense, but it just isn't going to happen, at least not in

our lifetime. We need to build on existing structures like Medicare

and employer-based insurance while working toward universality and

aligning incentives.

Pearlstein: Thanks, Waynesboro. It was getting a bit lonely

here.

_______________________

Arizona Bay, Az: Dude you don't need to be mean and accuse people of

doing a " liberal rain dance. " The person took the time to ask you a

question and you could at least respect them instead of doing

a " conservative rain dance. " Geez grow up!

Pearlstein: No,the person didn't just do that. He/she got a

bit pissy and started questioning motives....

_______________________

Anonymous: " And yes, preempt those crazy state laws mandating

coverage of chiropractors, podiatrists and massage therapists. "

Why are you lumping podiatrists with chiros and massage therapists?

Podiatrists are MDs that specialize in disorders/problems with feet.

Pearlstein: Yes, and they get paid to cut toe nails, as well.

Insurers are actually pretty good at identifying what services are

the ones patients demand be covered, and those that aren't. And if

they get it wrong, people go to other insurance plans. Why not leave

it to that competitive process to determine what services are

covered, rather than bribing legislators with political contributions

to dictate those choices, which is how the current system works.

_______________________

Bethesda, MD: Do you think we should get profit out of the Healthcare

system? And how else can you do it without having National Healthcare?

Pearlstein: There's nothing wrong with profit in a health care

system, as long as it is reasonable. Why have profit for food, when

there are people starving? Why have profit for fuel oil when some

people are shivering? Is there a difference between the owner of a

drug company earning a reasonable profit and a doctor earning

$500,000 a year in salary or fee income?

_______________________

Arizona Bay, Az: What's wrong with importing CHEAPER drugs? Oh yeah

thats right the Pharmaceutical Industry has a huge stranglehold on

this country. Duh, what was I thinking?

Pearlstein: The reason is that they aren't really cheaper.

They are the same drugs from the same factories (US factories, by the

waY0 that supply the US. This is a question of pricing, not

importation. And if you allow importation, all you will really do is

raise the prices in other countries (which may be a good idea) and

spend a lot of time and money (and risk) sending drugs in a big

circle. Let's address this problem directly and everyone in every

country will be better off.

_______________________

burg, Pa.: Let me state the obvious. The health care system is

too complicated even experts do not understand it. I recall an audit

of health insurance forms in burg that found an extremely high

error rate (I believe there was at least one mistake on just about

every form.) If the experts either don't know the system or at least

can't handle the paper work properly, how can we expect the public to

understand it? Most reforms tinker at the edges, and maybe many

reforms will improve things, but isn't there a bottom line here: how

does it help a complicated system by making it even more complicated?

Is there any way we can just make health care understandable,

services knowable and guaranteed, and affordable?

Pearlstein: The administrative paperwork is obviously more

complicated than it has to be. But I'm not sure you can avoid some

level of complication in health care, because the answers aren't

always easy and obvious, there's lots of judgment and emotion and

risk involved, and the sums of money being shelled out by people

other than patients themselves are very large, so there is a need for

accountability. It is true that we spend as much as 20 percent in our

private-sector system on administrative paperwork, and that is way,

way, way too high. Making better use of simpler reinbursement

mechanisms and information technology should be able to cut that in

half.

_______________________

Waynesboro, VA: I suppose you're referring to the AHRQ, which was

gutted because it presumed to suggest, based on medical evidence,

that most spine surgeries were non-beneficial. The spine surgeons and

their hospital allies almost got its budget zeroed; instead, it

changed its name and announced it would no longer issue clinical

quality guidelines in order to be spared.

Pearlstein: I didn't know that little bit of history. Thanks.

I'd like to follow up on that.

_______________________

Waynesboro, VA: Wait a minute. We already have too many doctors

performing too many tests and procedures on too many patients.

Medicine has a unique ability to induce demand for it's services,

driving up costs instead of limiting them through competition. The

Dartmouth Atlas of Healthcare geographic variation data show that

poor quality and higher cost care is directly associated with higher

numbers of hospital beds and medical specialists per capita.

Pearlstein: You again. As you probably know, I've written

several columns about the Dartmouth work. Obviously, competition as

currently arrayed doesn't solve that problem. So we have to attack it

from several angles, including evidence-based managed care offered by

competing health plans.

_______________________

Burke, VA: Get and handle on drug costs. Make it simple. No insurance

for drugs. Gov't sets prices and pays wholeprice for most all drugs.

Customers only pay distribution cost and pharmacy cost. No paperwork

cost. No lawsuits for any approved by FDA drug (assuming honest

data). As a nation we are paying for drugs anyway with lots of

middlemen taking their cut etc. Net cost would be significantly

lower. Drug companies would be paid for R & amp;D and fair profit. No

ads on TV.

Pearlstein: Some intriguing ideas there. You're right about

one thing: the cost of R & amp;D plus actual production accounts for an

appallingly low percentage of the total price. And government needs

to become a tough purchaser of drugs on behalf of its " patients " to

begin to wring out those non-productive costs.

_______________________

washingtonpost.com: Pearlstein's column archive is online

here .

_______________________

Washington, DC: There is an illogic to HSAs that has troubled me and

I've seen the issue addressed: Studies show that 5% of the people

receive 50% of the medical care (by cost) and 20% of the people

receive 80% of the care. If this is the case, how can high deductible

plans control costs because it is clear that the small (sick)

minority will reach both their deductible and catastrophic out of

pocket limit? In the end, won't HSAs simply require individuals to

pay more out of pocket (de-socializing some of the risk) so that

large institutional payers (government and businesses who provide

health insurance to workers) pay less?

Pearlstein: It won't, as we discussed here before. That is

going to require better case management and evidence-based medicine.

But when you are dealing with $1 trillion a year, even the 20 percent

that is left over is still a lot of money, so helping to hold down

the cost increases is worth doing.

_______________________

Woodbridge Va: I complement you last week and then you go and make a

really snarky (and inaccurate) comment about the White House wanting

to get government out of everything including healthcare. Try reading

Fred article on Bush in the current issue of Weekly Standard.

There is a serious divide among conservatives between the always anti-

government crowd and those who would use federal spending to promote

choice, accountability and personal responsibility. The White House

is firmly in the latter camp and has the deficits to prove it.

Unless and until the Democrats retake Congress or the White House,

the real debate on health care (and most other issues) will be

between these two groups. The Democrats have taken themselves out of

most policy debates by their knee jerk rejection of any and all

Republican proposals. If we suddenly lost our senses and proposed a

cradle to grave welfare state financed by a 95 percent income tax,

they would immediately attack us for pandering to the rich because a

person making $1 million a year would have an after tax income larger

than the national median.

BTW, one of the proposals quietly gaining ground among many

conservatives is to match a government requirement for health

insurance (similar to state requirements for auto) with a refundable

tax credit. There appears to be a market to provide the coverage and

it would maintain choice and accountability.

Pearlstein: The whole pitch the White House and its academic

supporters are presenting is that their health care reform will

reduce the role of big bad government in health care and give us all

more choice and control over our own lives. That's what THEY are

saying.

_______________________

Washington, DC: Not trying to be flip here, but sometimes the fiction

in " West Wing " actually makes for a better discussion of reality than

reality. At one point in the " debate, " Santos makes the point that

the administrative cost of Medicare is a fraction of what private

plans are. Was that fiction or fact?

Pearlstein: That's fact. But then again, the basic Medicare

program doesn't try to manage care, which also means their is more

utilization than necessary in many cases, and less utilization in

other cases, where it could be useful. But managing care requires

administrative cost. What that means is that it may be worthy

spending some money to better manage care, both in terms of lower

cost and better outcomes. And we need to figure out a process to do

that. Medicare is now offering some managed care options, although

the results are only mixed there. The insurers are making money, but

its not clear that the outcomes are better or the overall cost is

lower. But its worth continuing to experiement with it until we get

it right.

_______________________

Waynesboro, VA: Overutilization of healthcare, which you mention in

your article, is as big a problem as underutilization but seldom

discussed because addressing will hit lots of politically welled

connected folks in the wallet. Approximately one third of the

services provided by Medicare are either harmful or non-beneficial to

the patients that receive them. How can we address this when the

people with the money make the rules?

Pearlstein: By giving them the incentive, financial and

otherwise, to give the best and most effective health care, not the

most health care. You do that by paying provideers on the basis of

outcomes and sticking within proven protocols, not for the quantity

of service they provide. That's where the real revolution will come.

_______________________

Dunn Loring, Va.: According to a 2003 U.N. study, 25 countries have

life expectancies that are longer than the U.S. They all have

universal/national health care systems that cost less than what we

spend. If you're not ashamed of that, go to the CIA World Fact Book

and you'll see that a male child born today in Cuba, of all places,

has a higher life expectancy than a male child born here. These are

facts and not a liberal rant--our government should be ashamed.

Pearlstein: Our society should be ashamed, including our

government. I couldn't agree more. But there are different solutions

to that problem. National health insurance could be one. But its not

the only one -- nor is it within the realm of political possibility.

_______________________

Arizona Bay, Az: Maybe we as a country need to elect leaders who are

willing to stand up against the pharmaceutical industry, etc and get

this country health care for everyone. The U.S. is the only

industrialized country in the world without health care provided for

all citizens. THAT IS PATHETIC!!!!!!!!! Even you have to admit that.

(Sorry if this comes off as another " liberal rain dance " )

Pearlstein: I don't have to admit it. I wrote it this morning.

_______________________

Atlanta, Ga: Many issue regarding healthcare are unrealistic

expectations competing against limited resources. Both physicians and

patients have driven healthcare expenditures towards the most

expensive but least effective policies today. More money is spent for

after a disease happens then to prevent the disease to begin with.

For example, we are willing to cover gastric bypass surgery but

unwilling to provide diet education and counseling at a fraction of

the cost to prevent the need for the surgery and the associated

complications.

This is exacerbated by a profit-motive by those in the middle -

pharma, the insurers and corporations. I do believe in a universal

health plan - to an extent. I feel that preventive health care and

long-term disease " effective " management should be provided to all.

However, beyond that, healthcare should be balanced between market

forces and population needs. Mammograms, yes it has proven value, so

a system should be created to cover the costs for those who need it.

MRI " s for everyone, no but if you want it then pay for it. Though I

take issue with employer- provided coverage, even I found the

land Walmart bill a poor way to handle the situation. It would be

better to help corporations develop health plans (akin to minimum

wage) that all should be expected to cover - again preventive health,

etc but additional coverage should be at their discretion and the

employee contributing to the cost.

And if we (as patients) are truly concerned about our health, then we

should be willing to contribute. If I can pay $5 for a cup of coffee

daily then why shouldn't I pay $5-10 for a checkup. If I am willing

to pay an extra $30 a month for HBO, then why can't I pay $30 a month

for my medication.

Finally, though there are some extremes, doctor's should not bear the

burden of all this. I have yet to hear of a lawyer, politician, or

executive state " our costs are to high, let's cut our salaries " .

Unfortunately, the same doesn't hold for physicians.

I would say more but will stop here.

Pearlstein: Good points, all. Thanks.

_______________________

Somerset, NJ: The health care situation is falling apart as we write.

The prescription drug program is not working, and its problems are

going to become ever more prominent.

This president will simply not act differently than he has acted. And

unless the Congress changes hands, nothing but tinkering will take

place. What we need to plan for is a system that is pretty completely

shattered at the end of his term. It may well be that the states need

to take the lead for the next two years.

Pearlstein: Ah, the old " the world will continue to spiral out

of control until the Democrats regain power and make things right "

argument. Let me remind you that Democrats were about as successful

in controlling health care costs and improving quality as the

Republicans. That doesn't strike me as a useful place to begin this

national conversation. Sorry.(Are you related to Gene Sperling?)

_______________________

Valparaiso Indiana: That $800 charge exists as part of " game the

system " by providers and insurance companies. You can tout

transparency all you want, it won't change things. So long as the tax-

write off or " adjustment " continues, hospitals, doctors and all

providers will over charge to expense the adjustment.

There is an industry out there that gives providers all manner of

software that maximizes income for providers.

Insurers create fee schedules for the doctors on their lists...call

it price fixing. So uninsured face the full whammy.

You are right. There is not a market solution, only more problems.

Pearlstein: Not sure you are right about that.But I can't say

I fully understand what adjustment or tax write off you are referring

to.

_______________________

Pittsburgh, PA: When my father was terminally ill, I followed his

predetermined wishes (advanced directive) - no IV fluids. Well-

meaning family members thought this cruel, thinking he was suffering.

The next year, I watched another family member truly suffer in a

personal care home (paid for by the State), terminally ill, hooked up

to an IV, given morphine every few hours for a month until he died.

This is exactly what you are describing. My father's last days cost,

in terms of health care, a small fraction of the other family

member's cost. The other family, because they are very low income and

did not have to pay for the care, did not worry about the cost of the

care. They wanted their family member with them as long as possible.

We need education. About the limits of healthcare. About necessary

treatments. About ethics. We need doctors who are willing to stand up

and be strong during this time of transition. People will be

resistant initially, but we can't continue making emotionally-based

decisions that will cause the downfall of the American healthcare

system, and perhaps the American way of life.

Pearlstein: These end of life questions of huge, ethically and

financially, and you are so right about the need to begin to face

them. I actually think many doctors have been taking this on in a

good way, and reducing some of the more egregious end of life

treatments when possible. This is an area where the AMA can really

play a leading, positive role.

_______________________

Arlington, Virginia: Your response to the suffering of those without

health care is best reflected by the views of another famous

conservative... " Let the poor die and reduce the surplus population. "

How nice. Here's hoping that you get a midnight visit from some

attitude-correcting ghosts of your twisted past.

Pearlstein: What are you TALKING about? I just wrote a column

calling for every person in the US to have health care, paid for in

part by either employer or the government. What exactly

about " universality " don't you understand?

_______________________

Boston, MA: I haven't heard much discussion of actual health -

outcomes-, where the US lags most of the developed world -- e.g. on

life expectancy and infant mortality.

Your suggestions are focused on fixing some of the financial aspects

of the current system, but the experience of Japan, Canada, Britain,

and Europe is that national coverage produces much better outcomes at

lower cost.

Pearlstein: Yes, it has. But if you read the literature

further, you'll find that some of that has do with factors other than

whether the health system is nationalized or not. And there is some

unhappiness most of those countries you mention, along with Canada,

with the system right now, which is bumping up against some of the

same problems ours is. As I say, if you were devising a system from

scratch today, you'd probably do some version of a national health

plan. But that's not where we are, and we can waste a whole lot of

energy and political capital trying to get there, only to discover

that this country just won't do it. So why not deal with the world as

it is, not as we'd like it to be.

_______________________

Baltimore, MD: Health Care Savings Accounts sound great in principle.

However, I just can't figure out where it would fit in my budget. As

a single person, I make roughly $40K pre-tax each year, and I'm

probably not going to make more in my chosen profession. I don't have

any more $ than I currently pay for great coverage. I sincerely doubt

I'd be considered poor enough for some kind of subsidy, so I see no

advantage to me of a HSA account. I don't think I'm alone in this.

Yes, my benefits cost rises each year, but it's not more than by 5-8%

most years. I don't think that $10-15 more biweekly will buy me an

HSA that's sufficient to take care of my healthcare needs under the

HSA proposals.

I want a single payer government sponsored, transparent healthcare

system. I want a more level playing field. Let those at the top

income levels pay for private care - but lets tax the s--- out of

that privilege. If health care is a privilege for those at the lower

end of the income stream today, let it be more of a privilege for

those at the top.

Pearlstein: If you are young and single and healthy, the HSA's

will probably save you money. How? Because your premium goes down.

And if you don't pay much of the premium directly, the missing piece

of information here is that the portion your employer pays

is,according to nearly all economist, coming directly out of your

pay. In time, lower premiums paid by your employer will translate

into higher pay. I know that you probably don't believe this. But

that IS the way labor markets work.

_______________________

On profit: Since it was brought up, I just wanted to add another

annoying canard in this. Conservatives love to declare " the market "

as always the solution. Then they compare Govt. spending vs private

and declare huge efficiency gains.

One problem there. They always exclude profits. Once you include

those back in, suddenly you discover that there aren't really any

efficiency gains. Instead, the private system squeezes out costs and

transfers those dollars to investors and owners. For the consumer

there is little difference either way, at least in the form of

efficiency gains to them.

Pearlstein: If what you say is true in all instances, then

we'd all be better off with a centrally planned, government owned and

managed economy. We know, however, that this is not true in general.

So there is at least some reason to believe that some level of market

competition might be useful in health care over the long run.

_______________________

re: andria ER visit $800: Do you really expect an injured person

who has had an accident, even a minor one, to go shopping around for

health care options ?

Pearlstein: That's not the point. You have an accident, you go

to your doctor. You chose your doctor at a time when you're not sick.

Even better, you're part of a managed care plan that has negotiated

the best possible rates for you, which you pay through co-payments,

deductibles and premiums in some proportion. So there can be plenty

of shopping around done.

_______________________

Washington, DC: Before you diss podiatrists for cutting toenails, you

should realize that people who already have diabetes NEED to have

good-quality foot care, because even a small injury can lead to

amputations. (I've seen it happen to folks with GENETIC

predispositions to diabetes, meaning they didn't bring it on

themselves, and who died back in the 1970s.)

Pearlstein: That's fine. And because it is so essential, any

worthwhile insurance company would include such services in its

coverage. Why do you need the state legislature mandating it?

_______________________

Arlington, Virginia: Steve, One more thought on your lonely

life...you should make sure that you have enough money saved to have

food served at your funeral, otherwise, nobody will bother to show

up. You don't care about others, why should we care about you?

Pearlstein: Here is the classic example of the liberal canard -

- we are the only people who care about other people, and all the

other people are heartless and selfish. Get a life.

_______________________

Charlotte, NC: To expand my earlier question: the majority of the new

medical procedures and drugs are introduced without any comparisons

with existing ones. To make an analogy, it is like comparing the idea

of having a new model for Toyota with the idea of having no car. When

people are buying cars, they have most of the information available

to shop by comparison. In health care (both medical procedures and

drugs) that doesn't happen

Pearlstein: We don't have that information, most of us,

although more and more of it is becoming available on line, including

annual quality reviews of hospitals. But health insurance plans and

the government (Medicare) certainly have the information and can use

it to decide what they will pay for and what services will be covered.

_______________________

andria: Followup on the $800 bill. It was a broken finger hanging

at a 45 degree angle from the other fingers. Her thumb looked more

like her pinkie finger. I did not have the time to look for the best

price after leaving school at 4:00 PM to go to the primary doctor(20

mins), run to the x-ray(20 mins), get the x-ray (10 mins), and BEG a

doctor to see us at 5:55. Other doctors refused to see her since we

did not have an appointment. Thank God the x-ray staff let me use

their phones and looked up ACCEPTABLE doctors in my plan, while in x-

ray.

My insurance said I could not use the emergency room and to wait

until the next day. Fine if it's not YOUR CHILD needing medical care.

Pearlstein: One of the things we need to work on is 24

hour " emergency care " in settings more cost efficient than hospital

emergy rooms that are set up and priced to handle very much more

dramatic situations. You see some models for this developing, but

there's a long way to go on it. This also may be a matter of getting

hospital emergency rooms to price routine procedures more

realistically rather than trying to get everyone requiring a single

stitch to contribute a portion of the cost of MRI machines.

_______________________

Waynesboro, VA: Only the most highly paid docs make $500,000 a year,

and, yes, it is too much when most primary care and academic

physicians make less than $150,000. But even that salary is in the

top 5% nationwide, yet doctors are constantly claiming that any cut

back in payments will hurt their patients. Pay doctors more for

preventing a hear attack than dealing with it once it occurs. And

make sure that the person deciding if a test or procedure

is " necessary " isn't the one who benefits financially from it.

Steve, as a family doc I can tell you that most of those tests you

got were likely unnecessary. Did you ask why each test was absolutely

necessary, how it would significantly lower your risk of a poor

outcome? I doubt it. Yet you expect others less informed and educated

to control their healthcare.

Pearlstein: Well, I asked my doctor about that and she said

they were necessary for someone my age. Whether they were priced

reasonably is another matter. But a good managed care program (I'm

not in one) could have helped to insure both a competitive price and

insure that only those tests with good cost-benefit results are done.

_______________________

If what you say is true in all instances: Didn't say that. This is a

discussion on health care. And there's always one problem with that

as a " market " . If I choose Coke or Pepsi, I don't die. If I go LCD vs

Plasma TV, I'm not scarred for life and shunned by the opposite sex.

The fact is that health care always has the " you die " issue attached,

and therefore will never work as a properly functioning market.

People will always want the best possible care. And those annoying

poor will continue to refuse to take a bigger risk of dying to reduce

their costs.

This is where " market based " fails out. You can't have much of a

market when quality vs. cost ratios mean you increase you health

risks. Not gonna happen.

Pearlstein: Pure market based fails in health care -- that's

what you said, that's what I wrote this morning. But it doesn't mean

that you can't have a hybrid system that uses some market mechanisms,

where appropriate. That's the system, I think, that most Americans

would be comfortable with.

It has been a lively discussion, folks. See you next week.

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