"Back off the beaches . . . It's time to learn to live with the shoreline, not on it."

Orrin Pilkey of Duke University says it well:

Sooner or later our society must back off the beaches as concerns increase about beach quality and as preservation of major coastal cities becomes a higher priority. The first step will be to discourage beachfront urban renewal. That would mean moving or demolishing threatened buildings, prohibiting the rebuilding (and certainly the super-sizing) of destroyed buildings, and ending further subsidy of beachfront development, including tax-supported beach nourishment and federal flood insurance. It's time to learn to live with the shoreline, not on it.

Other things Pilkey doesn't like, US Army Corps of Engeering policies and seawalls.

Twenty-five years ago, when I began speaking and writing about seawalls and how they destroy beaches, I was shocked at the tenor of the response to this idea both from professional engineers and from developers and politicians. The attacks on me were often quite personal, and letters damning me were written to my university president and to the papers. As a scientist, I was unaccustomed to such personal attacks.

Obamacare conundrum: Good, universal, cheap. Pick two.

Andrea McArdle updates the old engineers' dictum after seeing (1) big losses among Massachusetts health insurers, (2) new subscribers gaming the system and (2) a governor who doesn't seem to understand that price controls never work.

President Obama, please take note.

How to put the the insurance back into health "insurance"

Michael Tanner of the Cato Institute makes the case for high-deductible health care insurance:

But both sides seem curiously unwilling to address the most important participant in the health care equation - the consumer.

Democrats appear to see consumers only as a class needing protection. Their focus is almost exclusively on government action.

Republicans at least give lip service to a consumer-focused health care system, but seem reluctant to really endorse proposals that shift more risk and responsibility to those consumers.

Perhaps that is because in the long-run, the only way to spend less on health care is to consume less health care.

Ellen Sauerbrey's formula for health care reform

Here's her list, from an article she wrote for RedMaryland:

1. Tort reform
2. A tax break for those without employer-based health insurance (e.g. waitresses) that equals the tax break given to those with employer-based insurance (e.g. corporate executives).
3. Allow Maryland citizens to buy health insurance policies in other states (including stripped-down ultra-basic policies that (1) don't cover small, foreseeable expenses, and (2) don't force consumers to pay for the many, many extras mandated by the Maryland General Assembly)
4. Fix the problems in Medicare and Medicaid before expanding them rather than after.

It's a good list.

Explaining the obvious to Michelle Goldberg

In a diavlog last month on BloggingHeads.tv, Michelle Goldberg claims--with astonishing arrogance, condescension, and superficiality--that she doesn't understand why so many folks are opposed to the health care reform bills (32-second clip):

Some responses to her questions & assertions.

ITEM #1. "Do [Townhall protesters] think the current system is acceptable?"

RESPONSE: No. The people who say at town halls that they are "satisfied" with their current health care plans are probably either (1) healthy younger folks who don't have to deal much with the current system and/or fear that they will have to shoulder more of the burden by subsidizing older folks, or (2) they are retired or soon-to-be-retired folks who fear losing elements of their existing Medicare coverage. Both of these fears are warranted, and people tend to fear losing something they already have more than they relish getting new benefits that they don't already have.

ITEM #2. "The worst part is the paperwork"

RESPONSE: Duh. Most people who have dealt with the system agree that the paperwork is awful. I'm just not confident that reform bills proposed by Democrats will reduce paperwork. Expanding government programs hasn't been a good formula for that in the past.

ITEM #3 "There's lots of misguided love for insurance companies among reform opponents."

RESPONSE: Matt Welch--he's amazingly polite to her--does a terrific job of dismantling this assertion, which is just not true. (Clip below, length 1:58, is different from one above):

ITEM #4. "Jim Wilson [yada yada] Glenn Beck. You can't argue 'death panels' and you can't argue 'totalitarianism' "

RESPONSE: If you revisit Aristotle's Rhetoric--the part on style in Book 3--you'll see that use of metaphors is one of the most powerful and effective methods of persuasion and argument. Opponents of health care reform use the terms "death panel" and "totalitarianism" as metaphors for rationing and encroaching government. Yes, they are gross exaggerations. But these metaphors (especially the death panel one) have touched sensitive nerves in the public. So yes, you actually CAN argue death panels and totalitarianism. And responses to these arguments (from Pelosi et al.) have been weak and unconvincing.

ITEM #5. "Just give me something like the French health care system."

RESPONSE: I'm no expert on the French health care system, but some quick Googling indicates that the French system does not suffer from problems the U.S. has with malpractice insurance, defensive care, and the tort system. This means that one of the key steps for getting us to something like the French system is tort reform. To my knowledge, the current Senate bill does little or nothing to deal with this issue.

ITEM #6. The reasons for opposition are "more psychological than economic".

RESPONSE: This was the most condescending of all her statements. If Michelle had looked to some of the more thoughtful folks presenting alternatives to the reform bills she would have found plenty of economic reasons to criticize the reform bills. I can think of three examples:

I. Check out David Goldhill's piece in the Atlantic Magazine How American Health Care Killed My Father. His suggestions:

• Move away from comprehensive health care as the single model for finance health care.
• Put the consumer, not the government at the center of the system.
• Give government the primary task of bringing greater transparency and competition to the health care industry and directly subsidizing those who can't afford care.
• Fund routine care out-of-pocket (not covered by insurance) so the people who care most about cost--consumers--are in their proper, primary role of trading off price, quality and value.
• Fund massive, unpredictable expenses with insurance.
  
• Replace our current web of employer- and government-based insurance with a single [mandatory] program of catastrophic insurance open to all Americans. . . with fixed premiums based solely on age. . . a single national pool, without underwriting for specific risk factors [that] would ultimately replace Medicare, Medicaid and private insurance. [With a high threshold for defining "catastrophic" at approximately $50,000 or more.] Limit insurance payouts in any year to the amount of available premiums.
• Over time, shift over to funding all non-catastrophic care from an improved, mandatory version of HSAs.
• Fund intermediate level expenses (e.g. appendectomies) just as we do things like new cars: with credit. But allow people to borrow against future deposits into their HSA.

The bottom line for this approach:

Imagine how things might change if more people were buying their health care the way they buy anything else. I’m certain that all the obfuscation over prices would vanish pretty quickly, and that we’d see an end to unreadable bills. And that physicians, who spend an enormous amount of time on insurance-related paperwork, would have more time for patients. . . .

It will do a better job than our current system of controlling prices, allocating resources, expanding access, and safeguarding quality. And it will do a better job than a more government-driven approach of harnessing medicine’s dynamism to develop and spread the new knowledge, technologies, and techniques that improve the quality of life. We won’t be perfect consumers, but we’re more likely than large bureaucracies to encourage better medicine over time.

II. Dr. Peter Weiss of Medically Incorrect makes many of the same points in this video. Dr. Weiss's prescription for reform includes the following items:

1. Increase competition among insurance companies by allowing them to compete across state lines.
2. Allow people to buy health insurance through affinity groups like AAA or Costco without regard to pre-existing conditions (just as employees get insurance through large employers).
3. For employees who lose their jobs, allow them to buy COBRA insurance at the employer was paying (not the double or triple rate that COBRA charges).
4. Strive for major illness insurance. Insurance is meant for catastrophes, not for everyday expense. Make people pay out of their own pocket for small predictable expense like office visits and PAP smears.
5. Have a system where consumer must take ownership of expenses (because cost is the main culprit, not access or quality).

III. Then, there's Congressman/Doctor Tom Price's alternative bill titled Empower Patients First (H.R. 3400). It suggests:

• Fix the unfairness in the tax treatment of health insurance by extending a tax credit or deduction to those without employer-sponsored insurance;
• Use automatic enrollment, with a right to “opt out” of health insurance coverage, and promote defined-contributions for employer plans, instead of using government coercion and mandates, to expand coverage;
• Establish health plan portals in the states so that patients can own and control their own health insurance;
• Offer low-income Americans the option of a voucher to purchase private coverage; and
• Give states incentives to experiment with how best to cover high cost individuals.

The full clip on health care is here (length 10:52):

Obama on treasury-draining health care entitlements: "We'll make it up on volume"

The Wall Street Journal's reaction to President Obama's health care speech:

Mr. Obama began by depicting a crisis in the entitlement state, noting that "our health-care system is placing an unsustainable burden on taxpayers," especially Medicare. . . .

On this score he's right. Medicare's unfunded liability—the gap between revenues and promised benefits—is currently some $37 trillion over the next 75 years. Yet the President uses this insolvency as an argument to justify the creation of another health-care entitlement, this time for most everyone under age 65. It's like a variation on the old Marx Brothers routine: "The soup is terrible and the portions are too small."

What health insurance reform should give us: a cheap, high-deductible catastrophic policy.

Which is exactly what none of the current bills would let us have, according to John Stossel:

Consumers could not buy a cheap, high-deductible catastrophic policy [under any of the existing bills currently floating around the House and Senate]

Read the whole thing.

Last week I asked a customer service rep at Maryland's dominant health insurer* if they sell such a policy. She said no, making it sound as if selling catastrophic insurance without the "basic" plan would be an impossibly difficult feat.

At the end, Stossel adds:

Profit is the key to competition. Anyone who claims to favor competition but looks down at profit has no idea what he is talking about.

Well said.

*CareFirst Blue Cross/Blue Shield

Maryland has forced more mandates on health care insurers than any other state

Robert Moffit of the Heritage Foundation, citing a 2001 Blue Cross/Blue Shield study:

Maryland leads the nation with at least 52 mandates on private health insurance . . . Only California, which has 43 mandates, comes close to Maryland.

There seem to be three types of mandates relating to (1) conditions/treatments/services (28 mandates), (2) providers (18 mandates) and (3) patient classes (6 mandates). Here are the mandates relating to conditions, treatments & services:

Alcoholism Treatment
Bone Density Screening
Breast Reconstruction
Cleft Palate
Clinical Trials
Colorectal Screening
Contraceptives
Dental Anesthesia
Diabetic Supplies/Edu
Drug Abuse Treatment
Emergency Services
Formula for PKU
Hair Prostheses (Wigs)
Home Health Care
Hospice Care
Invitro Fertilization
Mammography Screening
Maternity
Mental Health (General)
Mental Health (Parity)
Minimum Mastectomy Stay
Minimum Maternity Stay
Off-Label Drug Use
Orthotics/Prosthetics
Prostate Cancer Screening
Rehabilitation Services
Second Med/Surg Opinion
Well-Child Care

A doctor told me last week that these mandates have driven up health insurance premiums in Maryland. And contributed to declining number of insurers competing in the Maryland market.

Thoughts on health insurance reform from a small-business owner in Maryland

I heard Mike Vallerie talk on the Kendel & Bob Ehrlich Show this morning. He came across as thoughtful, fair and practical. His four key ideas:

1. Tort reform modelled on worker's comp.
2. Roll back the definition of health insurance so that it really is insurance: "A means of indemnity against occurrence of an uncertain event."
3. Individuals should be responsibe for taking care of themselves (i.e. paying for expected, forseeable expenses), and
4. Level the playing field so that small businesses get a fair shake compared to big business.

His website is MikesPlan.net.

How much does a colonoscopy cost? Here's one answer

If we want to contain healthcare costs, one of the first obvious steps is to make sure that patients receive real prices before they have a procedure.

So, from time to time as I run across real-world healthcare prices, I'll pass them on here.

A family member recently had a colonoscopy in December 2008. Beforehand, we googled around a little to get a handle on the cost, but didn't find much. At one point just before the procedure, the patient asked one of the nurses at Greenspring Station Endoscopy how much the total cost would be. She gave a mechanic's shrug, "I don't know."

Everything went smoothly. Our patient liked the staff, was pleased with the experience, and thought Greenspring was a well-run place.

But, as with all doctors and healtcare providers, it would be a great improvement if they would publish prices (or ranges of prices) for prospective patients. In particular they should publish both the "sticker" price and the actual price.

For the nurse's benefit, and for anyone else out there who wants to know, the actual total price was $2,068. This amount, of course, becomes known only after the patient receives the bill indicating the "reduction of billed charges" negotiated by the insurance company**.

----------------------- LIST -- ACTUAL
ITEM ----------------- PRICE --- PRICE
--------------------------------------
Initial consultation.. $ 195 -- $ 130
Prep supplies............ 20 ----- 20
Anesthesia nurse........ 760 ---- 294
Endoscopy facility.... 1,500 ---- 726
Colonoscopy doctor.... 2,025 ---- 465
Lab/tissue diagnosis.... 600 ---- 433
======================================
............. TOTALS $ 5,100 $ 2,068*

*In this particular case, the procedure included cutting out a small number of benign polyps.

**In this case, CareFirst Blue Cross/Blue Shield

Will members rise up against AARP over its health care stand?

Mark Tapscott predicts in the Washington Examiner:

There will be hell to pay for AARP with its members when this ugly reality becomes crystal clear, as it most certainly will.

UPDATE: From the looks this video, Mark might be on to something.

Carefirst listened and responded ... I like it

They redesigned their health insurance cards just as I suggested last year. Nice going Carefirst, and if you played a role Chet Burrell, thank you.

What doctors don't know

I went to a birthday party recently where several guests were 50-ish doctors.

Most of what they said I had heard many times before. They grumbled about lawyers and explained that "we went to med school to treat patients, not to spend half our time filling out forms and fighting with insurance adjusters."

But two bits were new to me. First, none of them knew the story of how health insurance came to be tied to employment. Second, none of them seemed to understand how consumers might benefit from knowing prices before walking into a doctor's office.

Amazing.

They really need to learn the basic facts about the system they've been operating in for decades. Especially before opining on how to fix it.

What's wrong with health insurance companies, Part 1

[UPDATE 6-26-09: BaltoNorth gets results! Carefirst came out with a new card in 2009. Just what I ask for below. Thanks for listening Chet.]

The card that I got from my health insurance company looks like this:

Pretend you're using this card for the first time. Quick, what's your "Membership Number"? What's your "Group Number"? Are you confused? I sure was the first time I used the card.

Why can't Carefirst Blue Cross/Blue Shield* tell us what the numbers mean right on the card? There is an explanation in the Member Handbook, but who brings the handbook with them to the doctor's office?

A message for everyone at Carefirst: Every time I take out my member card I grumble silently to myself. Every time. Every time I look at the card I think "why can''t they live up to their name and care about me by making a few simple changes to their member card? Why can't they design a card that makes things a tiny bit simpler for me? It would be soooo easy."

Chet Burrell, are you listening?


*For all of my gripes about Carefirst (I have plenty more) my sense is that they are not much better or worse than most other health insurance companies.

"Googlified health insurance"

Jeff Jarvis makes a rough sketch of the possibilities: finding new ways to align the interests of doctors, patients and insurance companies.

And Jeff thinks doctors don't get it:

At Davos last year, I sat at a table with a bunch of doctors who complained about their patients going to the internet to get what they said was misinformation. They didn’t want the internet to get in the way. They wanted to remain in control. I told them they were looking at this the wrong way. Instead, I said, they should point their patients to what they though were the best resources.