So, this is my attempt to blog in realtime on iPhone, in a dining room in the west side of ProvIdence with 4 people in and out of the workforce (bank workers, a doctor from Kenya, a transplant from Chicago) We are listening to the Obama video, in which he really focuses on the three principles of his reform-controlling cost, picking your own doctor and getting everyone covered. They are planning a 27 June 'community' event. And he is aiming for the grassroots.In the end, our group decided to meet again next week, to work on using the website to call people and focus their thinking on health care and to work toward some sort of "volunteer" event in conjunction with one of the Farmer's Market's that seem so ubiquitous these days in Providence and Pawtucket.
Ideas included a health fair, maybe along with a farmer's market. People really want to do something. It is hard to type on this thing
People really didn't like the mandate (the Massachusetts plan), and many have had experiences with gaps in coverage, and people spoke of the need to make insurance universally available and accessible the folks on the margins. People liked the idea of Medicare for everyone. There was much concern about how much this was all going to cost and the notion of health care related bankrupcies was a bit scary. People are not sure what they want, but they want it to be easy.
But my epiphany came with the realization that our whole system of payment is based on the notion that there are people out there willing to take a sucker bet. See, insurance is a bet: One party (call them people) fronts money to the other party (call them insurance companies) and says "I will bet you that the cost of my (and/or my families) health care will be more than this". If "people" are correct, the "insurance company" spends more money on the "people" than the stake that we gave them and we get health care. Why do I call this a "sucker bet"? Because, ultimately, and in non-random ways, we ALL get sick. So why do the insurance companies take the bets? Because they are VERY good at manipulating those odds, through co-pays, prior authorizations, exclusions and the like. ALL of the things that we are proposing to do to the system under the HELP committee's proposal or Baucus' proposal from Finance are attempts to retain that relationship at the core, the bet in which Insurers need us to either be healthy or to be off of their plan to maximize profit. They change the rules of engagement to move toward the goals set by the President, that healthcare control cost, allow patients choice of provider and be as universally accessible as possible. Once we change the rules, however, the insurance companies will work really hard to find ways around the new rules. They are good at it, as they should be. As the core, insurance is a sucker bet that will only be taken by folks who we allow to find ways around the rules. Gambling is certainly one way of spreading risk around. It just doesn't work so well when the risk is a certainty. We have done this with many services in the past, including schools, fire departments and police departments.
Wait, you say, fire departments? Yep, used to be a subscription and competition and all of that. Led to fights over the sweet deals, fights on the streets and less than universal coverage. Sound familiar?
Single payor is a way of reducing a lot of that confusion: it allows you to rationalize the payment scheme, eliminate the fighting on the streets, save money AND control costs, something that the "invisible hand" of the marketplace does poorly for things with inelastic demand. Single payor would allow doctors to be doctors, rather than entrepreneurs. SIngle payor would mean that patients don't have so many arguments with the multiple payers in figuring out what to do. When you look at it that way, it is a no brainer.
The folks in my group liked this argument. If only I knew how to make it politically feasible.
Getting back to the larger question, why is the Obama campaign, now the soul of the Democratic Party, doing this grassroots thing? Nice article discussing that in yesterday's Times- check it out here.