An intellectual freedom blog with an emphasis on libraries and technology

Friday, July 13, 2007

Are you a good risk or a bad risk?

Most of us start out as good risks, but we all become bad ones eventually. "Good" and "Bad" here do not have pejorative meanings: they refer to concepts that insurance executives understand very well. In health insurance, those of us born without any serious health problems start out as good risks. As we age, we become more vulnerable to illness, the injuries that only slow us down a bit in our youth can prove catastrophic when our bones become more brittle and we take longer to recover. As our life spans have increased, we come down with diseases that our ancestors did not live long enough to contract. These natural and predictable changes to our bodies make us "bad" risks. Not all young people are good risks. Some have congenital conditions or genetic diseases, or even just genetically based "odds" of having a serious health problem in youth or middle age. But no matter what, we all will become bad risks if we live long enough.

For an insurance executive, you make a profit insuring the good risks and you avoid insuring the bad risks. The premiums private insurance companies offer to young healthy people cost so much less than those they offer to older people that the young healthy ones can not resist the bargain. Also, many young people starting out in life do so under a mountain of student load debt. For most of them the jobs they have usually do not pay very much either. But even when an older person has climbed the ladder and has a higher income (and not everyone does) the premiums for health insurance become astronomical. This is way out of proportion to the greater income that an older person may have. They are bad risks. They must pay more.

The structure of this system, the "rules of the game," dictate that all health insurance companies must do all they can to attract the good risks, not insure the bad risks, and then boot the good risks out of the system as soon as they become bad risks. A company that does not have enough good risks will quickly go out of business. When their competitors lure away the good risks with lower premiums the company will have mostly bad risks left, which cost more than the premiums an ordinary member of the community can afford. But if you keep the good risks pooled with the bad, it all works out. Some of the good risks die (accident or quick killing disease) early enough in their lives to create a "gain" in the pool of funds to which all contribute. New "good risks" entire the pool all the time and the "bad risks" do not live forever. Someone who lives longer and needs more health care than the person "pays" for, benefits from the funds that the unfortunate unlucky good risks contributed before their untimely deaths. In a system that pools both good and bad risks, It's all about sharing risk.

This is not conspiracy theory. By allowing "free market" rules to reign you create a structural problem. Allowing companies to compete for "good risks" and dump the "bad risks" results in lower premiums for the good risks. But if you allow for this segmentation, sectioning off the two risks into separate pools, one pool of risks generates windfall profits while the other can not pay its own expenses. This also flies in the face of sharing risk. We're all part of the same life-cycle - we all become bad risks eventually, even if we start out as "good" ones. Those who decry this criticism with accusations of "conspiracy theory" miss this point, do not understand the nature of sharing risk, or have some other agenda. The structure of the industry, the "rules of the game" compel them to separate the risks.

But what you must keep in mind is that the good risks so seldom get sick or sustain serious injuries that even with the much lower premiums, the insurance company can amass a truly huge war chest containing hundreds of millions of dollars. They can throw millions of dollars at any candidate running against any elected official who stands up to the insurance industry. The good risks' premiums make the for-profit insurance industry so flush with funds that many of them can run dozens of TV commercials a week telling you what wonderful humanitarians they are. But their humanitarian face they show to people with lots of money or to good risks. Other people see a different face. Oh, and the good risks are so good that the insurance companies even have enough funds to pay 6 and 7 figure salaries to their top executives, give bonuses to the claims examiners who deny the most coverage and pay for 4 lobbyists for each member of Congress. What if we used that money to provide health care?

The news of layoffs of Ford Motors in Business Week mentioned the cost of providing health benefits now constitutes a cost the company can no longer afford. We (the U.S.) is no longer competitive because other post-industrial countries have national health care. Their companies do not have to provide health benefits. They have no link between employment and health care. The U.S. is the only industrialized country without a national health care service.

A successful national health care service must utilize what's called the "single payer" model, or some form of it. In the single payer model, the good risks and the bad risks pay the same premiums. The "surplus" from the good risks who seldom face serious illness and heal from injuries more quickly pays for the care of the "bad" risks that we all we become some day. Everyone is part of the same cycle. Instead of political campaign contributions and TV commercials the good risks' premiums go to providing care. This system also keeps the price affordable. When you remove the incentive to charge "what the market will bear" for medical diagnostics and surgeries, etc. the prices come down. For years I have read articles about how uninsured pay more (when they can afford a hospital stay at all). The explanations from the health care industry is that they charge the same for everyone, but the insurance companies and HMOs, PPOs, etc. can negotiate a bigger discount. Think about it. If you don't realize this is insane stop reading now and please don't bother to comment. The "discount" kind of argument is called "Sophistry" and the dishonesty shines through no matter how you phrase it. Put another way: don't think of it as socialism, think of it as the uninsured negotiating a really big discount.

And all the screaming about government inefficiency does not stand up to the facts. Consumer Reports has published lengthy articles about health insurance in which it compared the "overhead" of HMOs with that of Medicare and Medicaid. The overhead measured as a number of dollars per hundred dollars of re-imbursement breaks out as follows: Medicare and Medicaid: $3 per hundred ; HMOs average around $15 per hundred with the most cost-effective one, Kaiser Permanente, holding at about $12 per hundred. Think of all the money we would have to spend on health care if the marketing executives and the upper management had to go find something useful to do. When you see Michael Moore's movie Sicko! look past the grandstanding and the PR stunts while you consider that even the insured do not receive the health care the Insurance companies promise to deliver. Anecdotal, you say? String enough anecdotes together and you have research. And when we talk about efficiency, the private corporation proves very efficient -- at taking our money then not giving us what they promised in return.

The chief criticism of our present system concerns prevention. If a person receives regular check-ups, proper diagnostic procedures and spends enough time with a physician to learn about nutrition and exercise, we can reduce costs. And the policy of only insuring people with jobs will prove self-defeating as well. Imagine a young person just starting out. The person is unemployed, or under-employed. If that person does not receive medical attention for a problem in its early stages then that person enters the insured pool with a serious chronic condition which requires far more resources and money to deal with than had we allowed the person to see a doctor in the first place. If the system no longer forces uninsured people to neglect their health then they will not have only the ER to turn to and have to wait until the condition becomes serious or life-threatening. The ERs are overloaded now because there are so many people without primary health care. That makes the ERs big money pits, which is why hospitals are getting rid of them. There are now half as many ERs in the San Francisco Bay area as there were during the Loma Preita earthquake in 1989. But the population has increased. Nice to know we're prepared.

An MRI in Japan costs less than half as much as one done in the U.S. Grossly overweight patients need a whole different machine - one that is not only larger but also uses more radiation to make a picture. MacDonald's spends hundreds of millions of dollars advertising its food, not as an occasional treat, but as a staple. I can tell you as an insider in the education business that education costs money. If we want people to live more healthy lives those hundreds of millions that MacD's has to throw at advertisement directed very specifically at children would really come in handy.  No exaggeration: MacDonald's spends more advertising to children than the Federal Government does in aid to public elementary schools. Stopping people from eating crappy food costs money. But not as much money as the medical costs obesity incurs. Preventative care saves money.

But a National system can not work if it has to "cooperate" with private insurance. If we let private insurance poach the good risks and then dump them in the government-run part of the system as soon as they start to cost too much, the government-run system will rapidly turn into a money pit and the private companies will continue to stuff hundreds of millions of dollars into their campaign war-chests, ready to crush any politicians who try to implement a single-payer system. If we enter into a system in which each person can only have as much healthcare as they have "paid" for (health spending accounts) then we have no sharing of risk, and that system breaks down eventually too.

Which is why the democrats can not save us. Obama did not even have a health care plan until after a person embarrassed him with a question about one and all the other democrats present had an answer. Now that he has had his staff come up with something, he promises not to do away with private insurance (of course not). Edwards' rhetoric sounds good until you listen carefully. He stresses that no one "with a job" should be without health care. This panders to the element in the U.S. population that goes into apoplexy over the possibility that some lazy someone somewhere is receiving something paid for with the apoplectic's tax money. Edward's "plan" according to a June 14 Associate Press article, includes requiring health insurance companies to spend 85% of the premiums they collect on patient care. Sounds great until you remember that's the average amount that private insurance companies pay already. Phrased the same way, Medicare and Medicaid pay the equivalent of 97%. His plan ignores the reality that the profit private insurance companies gain from poaching the good risks. He promises to "tax millionaires" to pay for his plan. This may prove difficult as millionaires have resources and power they can use to squash a health plan that relies on taxing them. But all this misses the point: if you stop letting private insurance poach the good risks and then dump them into the government paid part of the system later on we will have the money to pay for a universal health care system. Private, for-profit insurance company CEOs may have to sell a summer home or two to get by after their layoffs and the people who actually do the work can join the publicly run system as auditors, fraud investigators and claims examiners. We will still need people to combat fraud and abuse of the system. And if democrats and republicans do not place adequate safeguards in the system then white collar criminals will take advantage of it (and the pundits will all cry about how that proves that government can't run a health care system).

Speaking of critics of national health care who claim that government run programs remain intrinsically inefficient, Michelle Malkin tried to argue that the scandal resulting from the revelations of how badly the Bush Administration's VA hospitals, and Walter Reed in particular, treat Iraq War veterans means that government run health care does not work. I'd like to say that only Malkin could torture logic that badly, but sadly we can expect others to take up this canard. Some interesting facts: Dr. David S.C. Chu, undersecretary of defense for personnel and readiness, and Dr. William Winkenwerder Jr., the assistant secretary of defense for health affairs ran the VA's health care into the ground. According to

... Chu and Winkenwerder had the wrong priorities, focusing on cutting costs while greater numbers of returning soldiers struggled against an increasingly strained military health care system. Both men know how to manage costs: Chu is an economist and mathematician who once worked in an Army comptroller office. And Winkenwerder is a former health insurance industry executive. But their résumés also point to the problem, according to their detractors. "The military tried to run military health care on the cheap -- like an HMO," said Paul Sullivan, who until March 2006 was a project manager at the Department of Veterans Affairs in charge of data on returning veterans. "And the consequences are the medical catastrophe and the bureaucratic nightmare that we see right now."

Anyone can create an inefficient system. That part is always easy. The United States could create a viable, single–payer universal health care system that reduces costs and improves health. This requires oversight and public involvement. If we let a handful of people tell us what can have, we will continue to have a mess. Universal health care does not make a 100% solution. We will always have frauds, bureaucrats and hypochondriacs making the system less than 100% perfect. Instead of focusing on the lack of a perfect solution, consider an improved one. Every other industrialized country has some kind of universal health-care system. We don't we?

Wednesday, July 11, 2007

Big Blue's Secret memo about Sicko!

I have discovered the a VP for BlueCross wrote a memo about the movie Sicko! which someone leaked to Micheal Moore. Although Moore's web site lambasts many elements in this memo, I found a few additional points worth mentioning.

Barclay Fitzpatrick, VP for Corporate Communications for Blue Cross saw Sicko! and reported his experience in the (no longer) secret memo. The single most interesting part of his 4 page description and commentary comes from the fact that he did not take issue with any of the factual information presented in the film. He decries its "divisiveness," and "divisive tone" but does not deny the accuracy of the cases or data it presents. For example:

You would have to be dead to be unaffected by Moore's movie, he is an effective storyteller. In Sicko Moore presents a collage of injustices by selecting stories, no matter how exceptional to the norm, that present the health insurance industry as a set of organizations and people dedicated to denying claims in the name of profit. Denial for treatments that are considered "experimental" is a common story, along with denial for previous conditions, and denial for application errors or omissions. Individual employees from Humana and other insurers are interviewed who claim to have actively pursued claim denial as an institutionalized goal in the name of profit.

Let's take this apart one piece at a time. First, "selecting stories, no matter how exceptional to the norm..." How does one establish a norm? Is a norm true in 90% of the cases? 51% of the cases? He does not say. "Denial for treatments that are considered "experimental" is a common story." But he does not say that this "common story" is false. He also ignores (and in so doing, confirms as undisputed) that Moore shows these "exceptional to the norm" stories simply do not happen in countries with universal health care. Most importantly, the sentence: "Individual employees from Humana and other insurers ... who claim to have actively pursued claim denial as an institutionalized goal" does not in itself dispute the claim. The wording deftly implies falsehood without actually stating such outright. Think about it. If the "claims" were false and such never happened in the industry, would not the writer state such in a memo designed to give guidance for "damage control?" He also fails to mention Laura Pimo's testimony, which Moore makes the centerpiece of the film's section on the inner workings of the Health Insurance industry. She testified under oath before a Congressional committee bluntly admitting that she wrongly denied coverage to a person who died for lack of medical care. When evaluating damage control memos you should look at what the writer does not say as much as what he does. Barclay Fitzpatrick crafted an astonishing evasion of the blindingly obvious.

Second, in a list of "key areas of misperception cultivated by the movie" he mentions

"Perhaps most damaging of all, Moore completely fails to address the most significant driver of health care costs - our own lifestyle choices - and seeks to focus attention and efforts on the alluring 'quick-fix' of universal health care. It has taken a generation of poor nutrition and exercise to get obesity and related health issues - and subsequent costs - to their current levels, and Moore's movie fails to acknowledge the causal relationship or need to change (he briefly touches the subject in a non-memorable way)."

I remember the part of the movie Fitzpatrick refers to as touching on "the subject in a non-memorable way." Moore interviews a doctor in England, discovering that the doctors there receive bonuses for reducing the number of smokers in their practice, or lowering the blood pressure or cholesterol levels of their patients. Gee, I found it memorable. (Or maybe he refers to Moore's passing mention that our mortality rate is just above that of Slovakia, making us 43rd in the world. If so the fact that he failed to note the difference in physicians incentives between the U.S. and Britain speaks volumes in itself). Fitzpatrick continues:

"Contrast this to the recent Health Care Symposium held in Harrisburg - where a panel of representatives from Government, Insurance, Hospitals, Business, Physicians, and even Lawyers agreed on one thing - that there was no quick fix and that Health and Wellness was the critical area of focus."

If "health and wellness" is truly the critical factor, then why doesn't the U.S. health insurance industry reward doctors the way the British one does? And why do they expect that doctors can educate their patients about healthier living if they are forced to see so many a day that they can only spend 5 to 10 minutes with each one? Also, this Panel at the "Health Care Symposium" did not include patients (but it did include "even lawyers!"). This omission tells us how much health insurance executives cares about patients. Along the same lines, the attempt to blame costs on our poor habits fails to explain how obesity influences the cost of MRIs? The 18-month old who died while traveling from one ER to an "in-network" one did not look obese, nor did the young woman denied chemotherapy for cancer. But I understand when cancer goes untreated a person can really slim down a lot.

More guilt by omission occurs in another part of the memo:

" The Impact
Moore's movies are intentionally intense and his objective in Sicko seems to be to revive the earlier Clinton efforts - not to achieve universal coverage with this movie, but to push the topic to the top of the agenda. He will be just as successful whether proponents mount momentum or discussion entails key stakeholders defending why it won't work.
[emphasis mine]

I find the last 5 words fascinating, especially the word "defending." Not "explaining," not "proving," not "demonstrating." Also who are the "key stakeholders" anyway? My guess would be the "representatives from Government, Insurance, Hospitals, Business, Physicians, and even Lawyers" mentioned above (not patients). And the memo does not state why "it [universal healthcare] won't work" nor do the "talking points" at the end give so much as a sketchy reason why "it won't work." That "it" works in other countries Fitzpatrick does not dispute, another telling omission. If it works in France and Britain, why will it not work in the U.S.? Any concrete reasons? All the memo gives are condescending descriptions of Universal health care as an "alluring 'quick-fix'" and that in other countries "Everybody gets along and takes care of each other and life is beautiful because there is universal health care," as well as the references to Moore's "diviseness" mentioned above. My favorite quote along these lines is "Positive change to our healthcare system can be best achieved through shared responsibility, not recrimination." OK, so who's sharing responsibility for the dead people? You know, the ones that prompt medical attention (or any medical attention at all) could have saved? Who is "sharing responsibility" for the September 11th volunteers who do not have insurance? Who is sharing responsibility for Edith Rodriguez, who bled to death in an ER last may, vomiting blood while the nurses ignored her? The government managed to take responsibility for the health care of the prisoners at Guantanamo (and other prisoners in our penal system). I would never suggest denying medical care for prisoners. I only wonder why rest of us can't have the same treatment as a prisoner. For the uninsured (and uninsurable) the medical care a prisoner receives constitutes a vast improvement over his present situation.

Health insurance companies have the money and the power to dictate policy. Fitzpatrick laments that in Sicko! "Legislators are presented as bought stooges for the political agendas of insurers and big Pharma." If you didn't want us to see them as your stooges you shouldn't have shoveled millions of dollars (paid for with members' premiums) into their re-election campaigns. Universal health care works in other industrialized countries and the main reason we do not have it in the U.S. is that people like Barclay Fitzpatrick, people who occupy positions of power and influence but do not hold elective office nor find themselves subject to any accountability except to their boards or stockholders, who lie by omission or misdirection, who write secret memos, will not allow it to work.

Friday, July 06, 2007

Court of the Queen of Hearts

Updated below
In another example of the legal system imitating Alice in Wonderland the 6th U.S. Circuit Court of Appeals shot down a lawsuit which challenged the warrant-less surveillance of all of us. Because the plaintiffs, a group of lawyers and journalists led by the ACLU, "had no standing to sue" (meaning that they could not prove damage). In legalese, the decision vacates an order of a lower court and sent the case back to that court for dismissal.

Remember the Queen of Hearts in Lewis Caroll's story? How else do you wrap you mind around a case in which the secrecy protects the government from challenge because the people objecting to the loss of their rights can not pierce the veil of secrecy enough to find evidence they need to proceed with any legal remedy? Any lawyers care to comment?

Glenn Greenwald posted a lengthy and excelent analysis of this decision and its implications on his blog at It's well worth the read.