"One Cannot Measure What One Does Not Manage": Public Option v. Private Gain? (Part XIII-m)

June 19, 2009
Jeff Kaplan

"The reform includes a broad range of measures to extend and improve care and help curb rising costs, but the epicenter of the debate is over what is called the 'public option.'"

I like the cogent commentary of Robert Borosage ("Private Muscle And The Public Option In Health Care." June 17, 2009), speaking about the 'end game' in health care reform: "The reform includes a broad range of measures to extend and improve care and help curb rising costs, but the epicenter of the debate is over what is called the 'public option,' " which is mandating businesses to either provide insurance or pay a comparable amount into a general fund. Then, the onus of responsibility devolves to the individual to get coverage (there will be subsidies for those who can't afford 'adequate' coverage). "We'll be able to retain the insurance we have, or have the choice of a range of plans, including a public option, modeled after Medicare. A strong public option, competing with private insurance, is key to helping to get costs under control."

But wait a minute or a decade..... the politicking, notwithstanding, what concerns some healthcare professionals (especially those in mental health care and support services) is a bit of 'bait and switch': If single payer is off the table, they'll sneak in with "single payer lite"—ie, they'll leverage a number of earmarks—qualifiers tagged onto the government option and have their cake and eat it too.

Here's the Public Plan in a Nutshell

• Federally administered

• Marketplace competition that I image must include 'report cards'

• The standard for all plans = comprehensive benefits + high quality/costs contained + affordability + accessibility (including free choice of practitioners

• Open enrollment; lasting coverage, assured; the default choice

• Prospect for eventual merger with Medicare

As a colleague, Jack said, recently, "Sounds nice until you break it down. I have no problem with the open enrollment part. But how can one have affordability and totally free choice of practitioners? Besides, some practitioners may be quacks and should not be practicing at all. Some may simply use the most expensive procedure when a less expensive one will do just as well. Where is the oversight? Where are the protections against fraud?

It seems to me that it has more to do with the providers self interest and assurances of their incomes and not so much the patients. Remember that this is a group who thinks every one needs psychoanalysis at G_d knows how much a pop for years."

"Affordable"? I think not!

From: Fredrick H. (MD, PhD, JD):

Subject: Government option vs. single payer

Date: Jun 18, 2009 12:05 PM

Jack, you refer to mental health providers playing a little 'bait and switch'-- and if single payer is off the table, they'll just sneak it in anyway as "single payer lite" in the form of earmarks.

What's wrong with that? Who voted single-payer "off-the-table"? Insurance lobbyists and the senators they own. I see nothing suspect in using political tricks to fight political tricks.

And, how can one have affordability and totally free choice of practitioners?

It's easy! The plan stipulates a maximum it will pay, regardless of practitioner.

And about the fact that some practitioners may be quacks and should not be practicing at all?

I agree; those legally determined to be quacks, should have their licenses pulled, or they should be excluded from being paid by the system at all.

You say that some may simply use the most expensive procedure when a less expensive one will do just as well.

Absolutely! That's where public openly-arrived-at guidelines come into effect, with requirements that the practitioner scientifically justify departures from them.

Re: this is a group who thinks every one needs psychoanalysis at God knows how much a pop for years.

I agree that much of psychoanalysis is a fraud and a cult. We need guidelines that require scientific evidence of its effectiveness before it is paid for. however, that does NOT mean that we must distort the reform of the overall medical system just because of this problem.

Fredrick adds the following after a brief give and take, later the same day

Jack: I agree that ALL expenditures should be subject to scientific analysis, to the extent possible.

But, you have to realize that while many accepted procedures, and even entire fields of practice, like chiropractic and homeopathy, have no scientific basis, their placebo benefit often forestalls the use of more expensive accepted techniques, so they save the payers money.

So, should insurers refuse to pay for placebos, even if the alternative is more costly?

I also agree that other people shouldn't have to pay for Viagra, but I'm not sure exactly what general principle that's based on, or where it should be applied.

Viagra makes old men happy. Anti-depressants make middle-aged women happy.

If you block one, why not the other? Why give people knee transplants instead of crutches? Why prostate operations instead of catheters? Why give fat people pills to lose weight, when if they were strong enough they could just eat less? Why give women birth control pills, when they could just stop having sex?

Does if come down to simple the puritanical belief that "sin" and self-indulgence (as designated by fundamentalist believers) should be punished, or at least not encouraged?

Is that the purpose of medicine? I prefer a medicine that comforts, not one that moralizes.