Health Care

Network News

X Profile
View More Activity
Steven Pearlstein
Washington Post Columnist
Wednesday, September 19, 2007; 11:00 AM

Washington Post business columnist Steven Pearlstein was online Wednesday, Sept. 19 at 11 a.m. ET to discuss how politicians' health-care proposals are affecting debate on the issue.

Read today's column: A Healthy Dose of Hillary

A transcript follows.

About Pearlstein: Steven 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 Foster's Daily Democrat. Pearlstein has also worked as a television news reporter and a congressional staffer.

His column archive is online here.

____________________

Charleston, W.V.: A tax supported single payer insurance plan would benefit physicians, hospitals, employers, and of course the only people who really matter in this discussion, the sick and injured. Because none of the leading presidential candidates are proposing this solution, I have to assume that the health insurance industry and its lobbyists are more important to the candidates than patients. What is it going to take to change health care policy that is more concerned with those who contribute to the unnecessary high cost of care than it is with those who are its victims?

Steven Pearlstein: You should assume that this is not a system consisten with the American experience, American political mores and values and American history. The special interests have done a good job at preventing the current private system from being reformed, and for their success they may be about to have to swallow some stuff they won't like. But this is too big of an issue, of too great of importance to too many people, for it to be decided purely by special interests (who, by the way, are also lobbying against each other). I don't think that is a fair picture of how this is working.

_______________________

Silver Spring, Md.: Steve - what do you think about opening up the Federal system for employers or individuals to buy into?

A common problem is that a small business (less than 50) has someone get sick. Then they find their premiums skyrocket. Sometimes this blows back on the person who was sick in an unhappy way.

It seems like getting those groups under a large umbrella would help stabilize premiums for those entities. Are there downsides to it?

Steven Pearlstein: This opens a good area of discussion which I didn't have time or space to get into this morning.

For the last 35 years, Sen. Ted Kennedy has been talking about letting all Americans have the same wonderful health insurance policy as members of Congress. And for the last 20 years, nearly every Democratic politician has parrotted this idea in some fashion, including Sen. Clinton, who embraced the FEHP as the mechanism to negotiate rates and plans on behalf of anyone who wants to join.

This idea sounds very fetching. But there are some problems.

First, it would have to be a separate pool from the federal employee pool, since it would inevitably raise premiums for federal employees and the government.

Second, the FEHP generally negotiates very rich plans, with very broad coverage, low deductibles and copayments, etc. That is not where we need to start this process. We need the FEHP to negotiate low and mid-cost plans for the people in the small group and individual market who are either now paying through the nose, or who can't afford insurance at all. They should be policies with good preventive care, good (very low co-pay) coverage for catastrophic and chronic diseases, and a high degree of cost sharing for everything else. You've got to get individual premium below $4,000, and the family premium below $10,000, with at least 90 percent of the money going toward health care, not administration.

In time, one would hope we could improve that as the cost of health care is contained and wasteful utilization is curtailed, so the same premium can deliver more and better coverage. But that is where we need to aim, not making sure that everyone has first dollar outpatient mental health and dental coverage.

Now it seems to me a fine idea to have the good folks who negotiate rates and plans for federal employees also do it for anyone else. They are good at what they do, they're already doing it, and they can do it in a way that furthers other public policy goals. But that is different than saying that everyone should have as good a health insurance plan as Senator Kennedy. It's a lovely idea. But in the context of a private insurance system that is already the most expensive in the world, we just can't afford that yet. And to hold out for that or nothing -- which has been the Kennedy position for 35 years--hasn't been particularly effective. We need to try something different.

_______________________

Hilton Head Island, S.C.: Insuring the uninsured is a good start. There are a few harder problems. Cost-shifting leads to a system that accepts the collection of 42 percent of billings. Those who are underinsured or paying out of pocket pay 100 percent to offset the discounts by medicare and medicaid (and private insurers). The malpractice insurance costs inflate the system at many levels and the complexity of the cases are beyond the comprehension of most jurors.

Steven Pearlstein: If I had had space, I would have pointed out that Mrs. Clinton acknowledges the negative impact of malpractice fees in her plan, and embraces reforms built around some successful experiments that encourage providers to report errors and provide compensation to patients through a non-court procedures. It seems to work, and is a good step. Some further reform of malpractice law may be necessary as well. But let me stress something: ITS SMALL POTATOES compared to the other problems in this $2 trillion system. Conservatives simply blow this issue out of proportion because they are on a jihad against plaintiff's lawyers and because it allows them not to deal with the really big problems in the system for which they have no solutions.

Second, cost shifting is a big problem which will be somewhat alleviated under a system of mandated universal coverage, but only somewhat. The government has to come up with a better system for hospital charges that does two things. One, stop the cost shifting from the government to private payers. But, even more important, align Medicare DRG rates with actual costs, so you don't have entire departments that "lose" money, like obstetrics and pediatrics or ICUs, and other departments, like heart surgery and hip replacements, that are "profit centers." This kind of craziness has gone on for years, and it is really distorting the amount and quality of care people are getting. It also distorts the number of doctors that want to go into surgery versus pediatrics, by the way, which in turn further distorts utilization patterns, because we know in the health world that supply generates its own demand.

_______________________

Reston, Va.: I always thought the first step in fixing the health insurance problem would simply be to change the limit on retaining insurance after you leave (or retire or are fired) from 18 or 36 months to forever with the family paying the full cost. It would help the business since their "group" would be larger even though they don't pay for those no longer working for them and it would help insurance since the cash influx would be huge. And eventually all the rates would go down. From just a quick read of Hillary's plan, it sounds like her idea would essentially do the same thing just a slightly different way -- more people in would eventually lead to lower rates for families and also for businesses. Is this a correct read of her plan?

Steven Pearlstein: Well, you may be conflating a couple of issues there.

Hillary would retain the employer-based system, rather than moving aggressively to an individual-based system in which someone other than your employer negotiates plans and rates on your behalf, you pick a plan, and you stay with that plan even if you move from job to job. I'm sure Hillary would have some provision so, if you lost your job, you could retain your old plan for some period of time. And if that time came and went and you still didn't have a job, you could switch to one of the plans negotiated by the FEHP, or sign on to some Medicaid-like plan in your state. The cost of those would be the cost, but because of the subsidy structure she provides, it would never be more than a fixed percentage of your household income, with the rest being made up by the federal government through a refundable tax credit.

_______________________

Toronto, Canada: I trust that when you get into your discussion it will not create the situation where systems the average American know nothing about will become fodder for ill informed comment as to their value. It drive me nuts when I see demeaning words describing what is perfectly acceptable and beneficial to the rest of the industrial world. I personally and people I know have never encountered the horrors as outlined by American opponents of our universal health insurance system. Note the word insurance here. If you don't want one, don't get one, but leave others in peace.

Steven Pearlstein: Nice to hear from our neighbors to the North, whose dollar is now just about on par with ours and whose health system is very adequate and very affordable unless you are very sick, in which case, you have extra insurance to allow you to go to Buffalo.

Here's some news: Americans don't want you to change your system, but Americans wouldn't tolerate having the government set universal budgets, approve individual hospital budgets, decide how many of what kinds of doctors can practice everyone, how many MRI machines there will be, which medicines you can buy, etc -- and not be able to pay their own money for service even if it isn't covered under the state system. It just ain't gonna happen here, and it is silly to even talk about it. It's not in our culture, in our political makeup.

So let's make a deal: we won't malign your system, and please don't malign ours, as ridiculously imperfect as it is.

_______________________

Knoxville, Tenn.: What is your sense of the ultimate compromise on Children's Bill that is now before congress?

Steven Pearlstein: The deal has already been struck, it would seem. States will have the ability to use their funds to extend coverage to children in households with incomes up to 200 percent of poverty, with none of the other stuff about Medicare reimbursement rates or cutting back on subsidies to Medicare drug and manageed care plans. Bush will veto. And he'll lose, because Republicans don't want ads being run that show 1,000 children sitting in an emergency room waiting for care under the headline: Republican Plan for Child Health Care.

_______________________

Lefty from Princeton (Not Paul Krugman): Hi Steve, What can I say at this point? You know what I think. I'll just send you my standard screed and you can print it if you want. If you do, we can see what others think.

Let's forget the immorality of the uninsured that lets poor people die. Forget the burden on businesses that make them less competitive. Just consider health care financing as a business decision. Develop statistics for measuring how we are doing. Look at the competitors (other countries). Look at their cost. If you are honest, you will become an advocate of a single payer system. Here are some facts. They can be checked at www.pnhp.org.

If you look at the 13 wealthiest countries and rank them according to the 16 basic public health statistics, the US ranks 12th or 13th in each one. Yet, yet we spend 2.5 TIMES as much per person as the average of these countries. Other countries get much better health care at much lower cost. (As a sanity check, WHO ranked the US 37th in the world in health care, above Bolivia, but below Slovenia.) All of these other countries use some form of single payer system. Of course, they have some problems, but most of these are because they are not spending enough. We would not have those problems. In spite of all these so-called problems, they get better care. Also Medicare is a single payer system, and it is one of the most popular programs in the history of our country. The plan I like simply gives Medicare (without limitations, co-pays or deductions) to everyone. We could do this without spending any more than we are now.

The reason for this is that we waste at least $200 billion a year on excess paperwork by physicians and at least $100 billion a year on high overhead (15 percent vs. 1.3 percent for Canadians) of private insurance. Look here is a simplified example of what we are doing.

Suppose you have 100 dollars to give to 10 people. You could give $10 to each person. Alternatively, you could develop criteria that determine who is deserving, and then investigate each person. You might find that according to your criteria, only 5 people deserve the money. You spent, however $75, on your investigations, so now you can only give $5 to the 5 deserving ones. We spend much too much money denying people health care.

The basic problem is that the rules are made by private insurance companies whose only goal is to make money, not efficiency or good health care. If they can save a buck by having a physician fill out a 40 page form, they will do so.

What about choice? I am 69 years old and retired. During my career I had five HMOs and five indemnity health plans. I have much more freedom of choice under Medicare than I had under any of the private insurance plans. I have no more referrals, no more in plan - out of plan nonsense. As for choice of insurance plan, why would anyone want choice if everyone had a plan that covered everything? In any case, you could still have private insurance for those who can afford it as most European countries still do.

Steve's main opposition to a single payer system is that it is pie-in-the-sky; we will never get it through. Maybe so. That's what they said about Social Security and Medicare. One thing is for sure. We will never get a rational health care system if we do not try.

O.K. I'll just stop here and let the chatters have their say.

Steven Pearlstein: Medicare is going broke. That's a fact. And if everyone were on Medicare, it would be going broke in even a bigger way. The reason it is going broke is (1) People live longer and use more health care and (2) There is no care management in Medicare, which leaves all decisions up to patients and doctors. Now you could have a Medicare system that begins to manage care and rationalizes the use of a fixed (albeit huge) amount of money. But as soon as you do that, you need somebody to manage it. And while that somebody could either be the government, or an insurance company, it is going to add significantly to the administrative component and start to feel a lot like private insurance. Since we have a private insurance scheme, why dont we try to make that work better rather than shifting it all to the government, since, as you know, we Americans don't really like having too much government. Maybe it will come to that. But let's at least give it one more good try, since this system served us well for many years until the mid-1980s, and the transition would be very messy, politically and every other way.

_______________________

Somers Point, N.J.: I read your article today and saw where you reduced your readers into two categories; one being either rich or selfish.

What about a category for Americans who subscribe to a belief that they should be responsible for the health care for their own children/family. I know that it is old-fashioned, but raising a family should be a responsibility that cannot be transferred to strangers - or "the village."

Finally, Sen. Clinton refreshed my memory of Plan No. 1 when she announced that I, and others, would be permitted, under Plan No. 2, to keep the plans we currently pay for.

While I am sure that it could have been stated differently, she managed to sound regal and arrogant and she reminded me of the regal and arrogant manner in which Sen. Emmanuel, I. Magaziner and she went about stirring-up Plan No. 1.

I went home and thanked God that (sic) Pres. H. Clinton was going to permit me to keep what I already have. Have you considered how she comes off to those of us who know the Constitution?

Steven Pearlstein: You know, that's rather silly. If she came out and said she was going to make you buy your insurance from a regional insurance cooperative, you'd decry her meddling with your life. And if she says she has a plan that allows you to keep doing what you're doing, or take advantage of some new mechanisms, whichever you chose, you now accuse her of being regal. By your criteria, the only thing she should have said is leave everything as it is, which isn't very acceptable in moral (47 million uninsured) or financial terms ($2 trillion, about a third of which is wasted).

This isn't a constitutional issue. It is a policy debate. And government policies, by definition, set the context in which individual choices are made. In that respect, we are not back in the state of nature where you have absolute right to do whatever you want. There are things that require collective action, and health care may be one of them.

_______________________

Egg Harbor Township, N.J.: Isn't it true that the potential savings in health-care reform are mainly embedded in the elimination of insurance company administrative costs and profits? If that is true, then only the Kucinich bill -- HR 676 -- appears to realize that potential? Is prohibition of private health-care insurance Constitutional?

Steven Pearlstein: No, not true.

_______________________

Alexandria, Va.: To me, the unknown question in Hillary's plan is to what extent an individual mandate will be effective in forcing people to get coverage. If you're going to "reform" insurance policies to include guaranteed issue and community rating, you had better make darned sure that EVERYONE is included in the pool, or otherwise the potential for moral hazard is quite significant. Massachusetts' mandate is just coming into effect, and it remains to be seen whether the financial penalties for going bare will be significant enough -- and the financial incentives to buy coverage generous enough -- that there won't be much leakage out of the system. But given the high rates of uninsured drivers (about 15 percent nationally, even with a mandate in virtually every state), I'm skeptical it will work.

Steven Pearlstein: You're right about that -- the only way guaranteed issue and community rating work is for everyone to be included in the various risk pools, and the pools be large enough so that people pay basically the same rates and you don't have insurers spending all their time trying to cherry pick. If the pools aren't large enough, then you need some sort of self-financing reinsurance program so the "healthy" pools are forced to subsidize the "unhealthy" pools.

_______________________

Danvers, Mass.: Will there always be a fat layer of administrative expense on both the insurance and doc sides, and a layer of profit in our health system?

Steven Pearlstein: There is nothing wrong with profit or with administrative expense, as long as they are reasonable. They are not dirty words. In the case of profit, they are the downsides (from a consumer perspective) to a system that, in the long run, generates greater efficiency and innovation and choice through competition, when it works. And in the case of administrative expense, it is necessary to bring some management into the system so that providers use best practices and consumers have good information to make choices and everyone gets the most out of the limited number of dollars we have to spend on health care. As I said before, a good system going forward probably allows for 10 to 15 percent for administration and profit. If you spend 12 percent to get higher quality and eliminate 20 percent of the spending that is wasteful, that looks to me like a good tradeoff.

_______________________

Fairfax, Va.: If participation in Clinton's health-care scheme is going to be mandatory, then what will be the punitive effects of declination? Permanent unemployability, being banned from public education, etc.?

Steven Pearlstein: Being sent to Guantanamo and forced to watch speeches by Bush administration officials for 18 hours a day.

_______________________

Kensington, Md.: Mr. Pearlstein: Do you happen to know if Ms. Clinton's plan had a baseline estimate of uninsured? The reason I ask is that I used to work on a prominent survey of household financial issues, and the number of uninsured was universally misinterpreted (yes, even by your paper--I would appreciate if you would take your colleagues to task for this).

Many surveys get at specifically the number of individuals without "third-party" health coverage. But that group includes many individuals that would qualify for publicly-assisted health care, but are either too lazy or uninformed to pursue it, or simply do not trust doctors and de facto have no demand for health care. Similarly, the uninsured included many, many people who could afford their own health care--the upper middle class or wealthy--but do not do so for similar reasons. And last, some people prefer to be de facto self-insured, to pay out-of-pocket for everything.

The scope of the health-care debate is certainly broader than the uninsured. For example, even those with some basic coverage often find themselves without access to more sophisticated procedures. I am not sure anything can remedy that. But I think that the public and policy makers need to more careful about first focusing on the group that both demands basic health care but cannot afford it. My sense that this is actually quite a manageable group that could be served relatively easily without reinventing health care in this country.

Regarding small businesses: As an economist, I tend to think a bit severely. It is true that health care has positive externalities, but an employer's not providing health care is not neutral: It has negative effects, such as that, coupled with a lack of sick leave, employees are more likely to come to work with contagious illnesses and make other employees ill and lower the quality of life for all. A radical but common sense tactic would be to approach it as an occupational hazard, and penalize employers for not providing a healthy and safe work environment. Unfortunately, we do too much to coddle small businesses, and exempt them from a host of safety and environmental regulations already. In my view, the Small Business Administration and the rules it enforces has been extremely detrimental to the American public and the American worker. The impact small businesses have on job creation is another myth that will not die, no matter how many times economists debunk it. I don't want small businesses to die, but if you don't to follow the same rules as everyone else, don't go into business!

Thanks for taking the time to read such a long comment.

Steven Pearlstein: Interesting.

You make a good point about the uninsured -- there are many millions who are so voluntarily because they chose not to take up insurance offered by their employer or by the government, even though they could afford to. There are some estimates of how many simply have no realistic access to insurance, and it is still a large number, however.

I couldn't agree more with you about the small business razmataz. I love it when people misuse the statistics and say that small businesses create all the new jobs, so you should exempt them from all taxes and regulations and shower them with subsidies. Its not true, of course. But even if you were to accept it as true, then why are you surprised they create all the new jobs. Why should General Motors hire their own cafeteria workers and security guards and computer room operators, when they can outsource the work to small businesses that don't offer benefits and are exempt from all sorts of regulations, and therefore can claim to do the same work for less money. What a surprise!

Here's the truth about job creation: New jobs are created by fast-growing firms, some of which are large but most of which start small and get big rather quickly. The point is that size is not really the key issue -- job growth is occuring at companies of all sizes. And the best way to foster job growth is to let the markets sort out where the work is done most efficiently, rather than tilt the playing field toward large companies or small companies.

_______________________

Washington, D.C.: Hi, Steven - one thing that bothers me about the discussion surrounding the various candidates' health care proposals is how everyone equates "individual mandate" with "universal coverage." No matter the mandate, a significant percentage will still not buy insurance either because they still won't be able to afford it or they simply refuse to do so. States with mandatory car insurance requirements are a good example. Plus, no one is more happy with the "individual mandate" than the insurance industry. If more people are required to purchase coverage, it's more profit for them.

As for Hillary's plan, specifically, I'm not impressed. The gaps she is leaving (like the public health option, federal oversight, etc.) for Congress are pretty important ones that, left unfilled, would make the plan no help to consumers. It says that insurers cannot "discriminate" against those with pre-existing conditions, but that doesn't equate (and this is where a number of pundits have gotten it wrong) to not being able to charge those with pre-existing conditions more for coverage. There are also aspects to her plan that would give employers the incentive to drop their employee plans, which just means more people would have to buy their own plans. It's been estimated that, under her plan, a family of four making $40,000 would have to pay $1200 a month for coverage. Wow.

Steven Pearlstein: A couple of points.

One, her program has lots of wholes and lousy provisions. It is still the best stab at a comprehensive plan, and any plan will get worked over plenty during the congressional process.

Two, no mandate is perfect but you can get a lot closer than having 47 million without insurance.

Three, in addition to rules requiring insurers to provide insurance to anyone who wants to buy a policy, it provides for community rating with only limited ability to vary premiums on the basis of age and health condition.

Fourth, there is always going to be a tension in any reform plan between employer coverage and individual coverage. If you make the individual market as attractive as the group market, which is a good thing, then employers will say, Why should I be involved here? Here's a check, everyone go out and buy your own insurance. And you know what, the government should be indifferent which way employers chose to go, as long as the employer contribution in each case in the same. That creates a nice competitive dynamic. In some cases, employers may want to make themselves more attractive to key employees by having a better run, or more generous, or more effective health program. In others, employers may decide this isn't something they do well and let employees find a better deal on the outside.

Liberal policy wonks worry a lot about "dumping." The way you avoid the bad part of dumping is to require a minimal level of employer financing against a basic insurance package. But in the long run, we need to be indifferent as to whether people get their insurance at work or on the individual market, as long as the choices are good either way.

_______________________

Steven Pearlstein: This has been fun, but we're out of time. I'm going to just print some other comments that are in the queue, without substantive reply from me.

_______________________

Riva, Md.: How can a national heath-care plan improve the USA competition in the global market?

Steven Pearlstein: By lowering employer health care costs.

_______________________

Alexandria, Va.: Who's going to pay for a tax-supported one-payer plan? We don't have enough money in the entire federal budget for that? Also, socialized medicine (or whatever you want to call it) is bad for the patients. I liked Dave Barry's comment when Hillary Clinton tried to "reform" health care in the Clinton years: "America has the best medical care in the world. We have to do something about that."

Steven Pearlstein: Thanks.

_______________________

Princeton, N.J.:"You should assume that this is not a system consistent with the American experience, American political mores and values and American history."

Why? You could have said the same about Social Security, Medicare and indeed, the income tax and slavery. Other countries also had health system like ours and managed to achieve an sensible efficient health-care system. Why can't we do it too?

Steven Pearlstein: Thanks.

_______________________

"innovation and choice through competition": Unh. Again, please explain how a system who's end product is the "consumer" not being dead will function under the automajickal wonder of the market?

The "consumer" is not going to willingly die to cut costs. So our system inevitably ends up where we are now, rationing by income and circumstances of birth. We ration health care _more_ than other comparable countries...we just let third world levels of infant mortality exist among the poor, as one example.

Can we please at least be honest about our system? We choose to let a lot of people die for being poor. We choose to let a lot of kids die by making the bad choice of being born to poor parents. We ration by socio-economic class.

Steven Pearlstein: Thanks.

_______________________

Atlanta, Ga.: And how big of Hillary to allow me to keep what I have. Wow, I'm so impressed. The reality is slowly companies will take away the health-care benefits, and everyone will be using the govt plan.

Steven Pearlstein: Thanks.

_______________________

Alexandria: I hope Somer's Point has no intention of ever using Medicare, and is fighting to have it repealed, since s/he "subscribe to a belief that they should be responsible for the health care for their own children/family".

There is simply no moral justification for having Medicare and not having universal health care. The justification for Medicare is provide health care for people who are retired and, therefore, by definition, do not have employer-provided/subsidized health insurance. That reasoning should lead to an obligation to provide care for the millions of non-retired people who are either unemployed or whose employers do not provide/subsidize their health care.

Whether we should get rid of Medicare or extend it to everyone, I don't know, but there is no moral justification for the status-quo.

Steven Pearlstein: Thanks.

_______________________

re: declination: I'd take a vacation to the Caribbean and a chance to watch a few Paulson speeches. Sign me up for that, rather than the Hillarycare.

Steven Pearlstein: Thanks.

_______________________

Atlanta, Ga.: Hopefully, not too late. One thing that gets lost is that just because people don't have health -insurance- doesn't mean they don't get health -care-.

Another thing is that people come HERE to get their health care, all the time, rather than stay wherever they are. So something here is working. I do believe we need to have more markets at work (i.e, most patients say: oh, let the insurance pay for it - just like in Seinfeld: Do you even know what insurance is (to Kramer)) - i.e., YOU pay for it, eventually, and when everyone says: oh, let the govt handle it - reality is that every time they run a program, costs are way higher, and people aren't typically better off in a global sense. People just don't want to take responsibility for their own health care - they want someone else to pay for it (as for many things).

Helping the market place work, getting govt OUT OF THERE, raising the eligibility age for medicare (really, I believe that - as well as for social security) - so that people are covered when they can't get other insurance - at the end of their lives, when they are most expensive to treat - but reality is, people really don't understand the expense of it all. It's expensive. And always, the wealthiest of us have choices, and the rest of us make do.

Steven Pearlstein: Thanks.

_______________________

Silver Spring, Md.: I am a health economist who has been doing this kind of stuff for quite a while. As you suggested, I would eliminate the entire tax exclusion for employment-based health insurance and replace it with an income related, refundable tax credit--regardless of whether insurance were employment-based or some other system. There just ain't a lot of yield tackling only families with incomes in excess of $250,000. First, there aren't all that many of them. But second, there really aren't all that many gold-plated insurance policies. IRS regs prohibit wild plans for officers of closely held companies. I suspect ERISA or other labor laws (and IRS) limit how much more expensive "officer" plans may exceed those for folks on the factory floor. And insurance itself generates better rates when everyone is in the same pool. Department of Labor stats suggest that the "employer share" is now approaching $3 per hour for worker health benefits, or somewhere around $6000 per year. My guess is the bulk of the range of annual premiums goes from $6000 to $15,000 for families. Bill Gates's tax savings may be $5000 or a little more. This is not the agriculture system where individual subsidies are in the millions. There will be howls regardless, but those subsidies should be shifted away from the wealthiest families to toward lower income, currently uninsured families.

Steven Pearlstein: Thanks.

_______________________

Arlington, Va.: Are any of the candidates (including Hillary) addressing the fact that medicare is going to bankrupt this country in a couple decades? I know that the Comptroller of the U.S. is trying to spread the message and get people to "wake up" to this sobering fact, but we need to have trillions of dollars invested TODAY in order to just be able to pay the programs we have enacted now. But we have zero dollars invested today.

And back to Hillary's plan--did she talk about options for self-employed people? There is a large number of people in this country who have jobs, but don't have "employers." How will her plan help them?

Steven Pearlstein: thanks.

_______________________

Bethesda, Md.: As a doctor, I experience almost daily the problem of HMO style solutions that allow distant bureaucrats and their hired doctor-advisers to dictate treatment decisions that sometimes conflict with my decisions made one-on-one with the patient in front of me (with all info available). You indicate that Hillary's plan will only make the situation worse - more "managed care and rationing." Is that just how it's gonna be? If so, it will help drive even more conscientious doctors out of the system.

Steven Pearlstein: thanks.

_______________________

"malign ours, as ridiculously imperfect as it is": But they should. Idiots are idiots, and our self-centered pathetic excuse for health policy deserves maligning. Sometimes truth is truth, and right is right. It always amuses me when people who are so hardcore about there being good and bad ways to do things go post-modern deconstructionist when reality goes against what they like. By all objective measures, our system is one of the worst in the advanced industrialized countries.

Steven Pearlstein: thanks.

_______________________

Washington, D.C.: Michale Moore's movie "Sicko" gave the impression that a country can establish a system where in people can just go to the doctor or dentist and get treated for what ails them without worrying about cost... It seems to me that we want to create a system that is, first and foremost, in the best interests of the citizens, and that the insurers and providers should fit into that system, rather than a system which caters first to the insurers and the providers. If we do it in the later manner we end up with a system in which the insurers dictate what care the providers can give.

Socialized medicine bad? Can't the economy function with a healthy mix of both socialism and capitalism?

Steven Pearlstein: Thanks.

_______________________

Annapolis, Md.: Has anybody ever talked about making the market more transparent? I have an HSA so in theory I should be able to choose the most cost-efficient doctors. In reality, it's virtually impossible to find out how much something will cost beforehand. I get quoted one price and when I say that's too much they will call 2 days later and say they can do it for 50 percent or less of the initially quoted price.

A free market can only work properly when there is price transparency but in health care there is none.

Steven Pearlstein: Thanks.

_______________________

Rolla, Mo.: Everyone with insurance is paying a hidden tax on the uninsured right now, whether they realize it or not. By law hospitals with emergency rooms have to treat patients who come through their ER's, whether they can pay or not. As the number of uninsured increases, hospitals have to raise charges on those who can pay to make up for the lost revenue on those who don't. This gets passed on to insureds through higher premiums.

Steven Pearlstein: Thanks.

_______________________

Woodbridge, Va.: Steve -- As a conservative Republican, I was VERY impressed with how far her health care plan moves in our direction. As recently as the 108th Congress, CATO was advocating using tax credits to allow low income families to buy health insurance. Heritage has also been supportive of this approach. Now Hillary comes out with a single payer but MULTI PROVIDER plan that leverages market mechanisms rather than imposes government bureaucracy and the knee jerk reaction is to oppose it. What nonsense. Her plan is far from perfect but if she can convince enough people on her side of the aisle to accept the idea that single payer does not necessarily preclude multi provider and market mechanisms beat government mandates; well maybe we really can do a deal on health care.

Steven Pearlstein: Thanks.

_______________________

Washington, D.C.: As a current federal employee, I'm not sure I recognize the image of the gold-plated health care coverage we're supposed to be enjoying. In the plan in which I participate, I pay some $3500 per year for family (myself and spouse) coverage, which doesn't include dental (except for some very modest twice a year check-up costs), doesn't include eyes, and from whose preferred provider list more and more doctors are withdrawing. Compared with the uninsured, we do very well, but I know plenty of people in other jobs who have much better coverage and pay nothing.

Steven Pearlstein: Thanks.

_______________________

Why not: We should adopt the government plan and thus cut out the middle man (ala Anthem, United Healthcare). Thus we would save billions just to start. The wheel is so broken why not try something. It can't get any worse can it?

Steven Pearlstein: Thanks.

_______________________

Politicians/health care comment: I think health care does not get the attention it needs because politicians and the hundreds of thousands of federal workers have great low cost health insurance. So they say "what is the big problem"?

Also they are able to retire early and still keep this low cost health insurance. The majority of us would have to pay the high COBRA rates or a cost individual plan for trying to retire early.

Steven Pearlstein: Thanks.

_______________________

Toronto: How damaging is the current system to business and productivity? I'm thinking not only of the health insurance costs to large firms like GM, but in terms of people staying in jobs they hate or not retiring early because of their employers' health plans, or even unhealthy children growing up to be less productive adult workers?

Steven Pearlstein: Thanks.

_______________________

Morrison, Colo.: From what you say in your column it appears that Hillary's plan tries to bring into the mix some of the sacrifices that will be necessary to provide health care without it coming to dominate (decimate) the economy. Do you really think anyone will be able to get the American people to support a program that will have the rationing required to make it affordable over the long run?

Steven Pearlstein: Thanks.

_______________________

Alexandria, Va.: The family medical practice that I have been going to for 19 years is switching to a program called MDVIP, "Concierge Healthcare." Each of the three physicians is only accepting 600 patients. In order to be "a member" of my doctor's new practice, each family member is required to pay a fee of $1500/year. What you get with that fee is the "doctors cell phone and/or beeper number and is welcome to call when they feel its needed. Same day or next day appointment availability. Patient appointments start on time and are unhurried. Referrals and specialty care are coordinated by the MDVIP practice. Test results are shared with patients in a way that is personal and understandable."

Along with this fee, the patient is still required to meet all deductibles. Is this something new that evidently all physicians will be moving too? Is this just a way for the physicians to compensate for medicare/medicaid patients?

I've never heard of this type of plan until now and am very confused as what to do.

Can you offer any suggestions or comments?

Many thanks.

Steven Pearlstein: Thanks.

_______________________

Clifton, Va.: I worked hard to get a good job and put up with a bunch of real quality supervisors, director and coworkers as a DOD employee to make sure I had decent health insurance and many of my coworkers feel the same way. We don't want anyone messing with our health care especially Congress and the Dems. I don't care that 47 million Americans don't have health care insurance. They don't care about me why should I worry about them. They are better off dead anyway! Do not mess with my health insurance! You hear me. I like be able to choose my doc especially when I need a sports medicine specialist. If you don't stay away from my health care it maybe time for another Revolution/Civil War that was more bloody than the last one. The poor and others who don't have health insurance need to get off their lazy butts and work harder and get an education and a better job. I did so any fool can do it! Are you listening Hillary!

Steven Pearlstein: Thanks, I guess.

_______________________

Editor's Note: washingtonpost.com moderators retain editorial control over Discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions. washingtonpost.com is not responsible for any content posted by third parties.


© 2007 The Washington Post Company

Discussion Archive

Viewpoint is a paid discussion. The Washington Post editorial staff was not involved in the moderation.

Network News

X My Profile
View More Activity