Continuing on the politics of healthcare reform, it should be noted that there are Republicans who can talk, knowledgeably, about healthcare; it's very easy for progressives to lull themselves into assuming that no one can, or will, cogently complain about provisions in the reform bill. That's a big mistake, because while the "conservative talking points" of screaming "Socialized Medicine!" may be absurd, behind that are some conservaoves who can make doing nothing (or doing something else) sound eminently reasonable.
One who could, arguably, is Bobby Jindal. I have my issues with Jindal, and I disagree with his conservative approach... but Jindal's got experience and some understanding of the issues involved. And as much as anyone, he can lay out a cogent, if disputable, case against the reform bill. Which he has, today, in the Wall Street Journal.
The depressing reality is that JIndal doesn't offer much; he's got your basic right wing "massive government takeover" rhetoric which adds little substantive to the discussion, and while he's right about the high price tag with no clear way to pay for it, he's a little faux-naive in suggesting that somehow real reform can be done for less; he knows better, if only because he's faced some hard choices, at a number of points in his own career, about trying to rein in health care costs.
What I'd like to do, though, is focus on the "seven principles" he suggests as conservative ideals in health reform, because I think he both offers a blueprint for an alternative right-side approach to healthcare issues... which, ultimately, is as problematic, or more so, than what's on the table.
•Consumer choice guided by transparency. We need a system where individuals choose an integrated plan that adopts the best disease-management practices, as opposed to fragmented care. Pricing and outcomes data for all tests, treatments and procedures should be posted on the Internet. Portable electronic health-care records can reduce paperwork, duplication and errors, while also empowering consumers to seek the provider that best meets their needs.
Jindal starts with a conservative talking point - consumer choice. Never mind that most "consumers" have no idea how to choose among health insurers or providers (indeed "freedom to choose" is a phrase I wish we could erase from the healthcare debates, because it reinforces notions that we can have anything, regardless of cost). The "pricing and outcomes data" he's calling for... doesn't exist. It will cost millions to create it. Likewise, Electronic Medical Records - which, by the way, everyone wants, except doctors - will cost billions to implement, millions more in data transfer, and faces enormous technical and real time hurdles (like, those reluctant doctors). And does any of that really "empower" patients? No study really suggests that it does.
•Aligned consumer interests. Consumers should be financially invested in better health decisions through health-savings accounts, lower premiums and reduced cost sharing. If they seek care in cost-effective settings, comply with medical regimens, preventative care, and lifestyles that reduce the likelihood of chronic disease, they should share in the savings.
Jindal's second point continues on the conservative line - this is the notion that a "free market" based solution to health care can lower costs and improve care. Again... nothing has shown that anything of the sort is true. Even if it did, the people who need to feel the "free market" pressures are providers, not patients. Jindal has nothing to suggest that hospitals or doctors are actively trying to lower costs due to a "competitive" environment; indeed, hospitals and doctors have a price setting starting point that almost no one can touch - Medicare's reimbursement rates, which tend to drive pricing across the healthcare industry. Jindal's subsidiary point, about incentives for healthy living, already exist in most insurers. The "savings" they provide is essentialy meaningless.
•Medical lawsuit reform. The practice of defensive medicine costs an estimated $100 billion-plus each year, according to the American Academy of Orthopaedic Surgeons, which used a study by economists Daniel P. Kessler and Mark B. McClellan. No health reform is serious about reducing costs unless it reduces the costs of frivolous lawsuits.
"Tort reform" is a conservative bugaboo that has never really sold well; that's especially true in malpractice, because Republican calls for limitations on malpractice suits tend to deny or ignore the very real bad cases of injury or death which are out there. Also, almost every study of "defensive medicine" suggests that attempts to rein in tests and duplicative services for this express purpose would result in small (maybe 5% - which gives some idea of how that $100 billion figure Jindal cites realtes to all of our healthcare spending) savings in total health costs. Excessive testing is rarely about "defense" - it's mostly about "profit motive"... which Jindal's embrace of "free market" incentives can't really combat.
•Insurance reform. Congress should establish simple guidelines to make policies more portable, with more coverage for pre-existing conditions. Reinsurance, high-risk pools, and other mechanisms can reduce the dangers of adverse risk selection and the incentive to avoid covering the sick. Individuals should also be able to keep insurance as they change jobs or states.
This is a lovely idea... which Jindal makes no attempt to try and suggest how it would work in practice. "Portability" sounds great (and would be)... but in a system that runs on your employer's selection of a health insurer... when you change jobs, you probably chage insurers. How do you avoid that? Well, you could set up a single insurer... oh wait. Republicans, by the way, have opposed most attempts to add portability... because insurers and companies don't generally like it. Jindal's other point - about increasing the size of risk pools and eliminating incentives to cherry pick... are already in the reform bill.
•Pooling for small businesses, the self-employed, and others. All consumers should have equal opportunity to buy the lowest-cost, highest-quality insurance available. Individuals should benefit from the economies of scale currently available to those working for large employers. They should be free to purchase their health coverage without tax penalty through their employer, church, union, etc.
... All of which is in the current reform proposals.
•Pay for performance, not activity. Roughly 75% of health-care spending is for the care of chronic conditions such as heart disease, cancer and diabetes—and there is little coordination of this care. We can save money and improve outcomes by using integrated networks of care with rigorous, transparent outcome measures emphasizing prevention and disease management.
This is called capitation... and it's opposed, mainly, by providers. Massachusetts is already moving towards this model, and Obama has signalled he wants his reform plan to include it as well. And the "outcomes based best practices" are already in the bill.
•Refundable tax credits. Low-income working Americans without health insurance should get help in buying private coverage through a refundable tax credit. This is preferable to building a separate, government-run health-care plan.
Preferable, maybe. Less expensive? Hardly. Which you think Jindal would know.
The net effect is that roughly half of Jindal's "conservative principles" are already addressed; another portion could be. His most ambitious proposals - around capitation and creating better practice incentives, are goals shared with the left... and will be damned difficult to implement. If Jindal's serious about them, you'd think he'd reach out to people who share his ideals. Indeed, Jindal, for all his healthcare expertise, did little as a member of Congress to seen any of what he's proposing here actually come to fruition; that's also true of his time as Governor of Louisiana (though he has made some ambitious moves to change Medicaid in Louisiana, which is desperately needed, even if some of his proposals there are dubious). Where Jindal has had the power and opportunity to impact some of the ideas he's presenting... he's done little. Why, then, should he get credit for suggesting them now?
Even granting that his ideas, generally, are interesting... they basically differ little from where many left-leaning health advocates come down on similar issues... except in some of his "free market" type proposals, and those, really, deserve more debate than they've gotten, too. And just as pointedly, basically everything he's proposing, all in, would cost hundreds of billions of dollars, too... which makes his objections to the Democratic proposals based on cost, as I said, kind of faux-naive. If money were the issue, you'd think he'd try to do less with less. But mainly, Jindal's suggesting things that even conservatives have not agreed to; and that's really the point: if Republicans could get organized enough to use Jindal's proposals as a starying point... we really could get some significant healthcare reform done. And that problem... is not about Democrats. We already live in Bobby's World of Healthcare Ideas... unlike some people.
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