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December 20, 2011


Brian, your 12/20/11 feedback to Politifact regarding their Medicare confusion was an excellent post at the time. To make their ruling they obviously had confused understanding of traditional Medicare, the original Ryan plan, and the latest Ryan-Wyden plan. And your old post is even more salient today as people continue to mistakenly or intentionally misinterpret the latest Ryan plan.

Kudos to you for understanding that plan perfectly from day one and immediately setting out to make sure others did as well. Here’s my favorite excerpt from your comments:

“Do you know anything about the recently released Wyden-Ryan plan? Apparently not, because Ryan's revised plan is considerably closer to the current Medicare, though as an option it now preserves traditional Medicare. Did you hear that last phrase: ‘preserves traditional Medicare.’ In Ryan's new iteration of Medicare reform, he has agreed to preserve traditional Medicare along with a voucher system that provides premium support for private insurance.”

Big Oil

DJ, I guess you didn't read the reason I didn't publish a previous comment of yours. See my "Blogger Brian" comment on:

When I heard about the Wyden-Plan Medicare plan, I assumed that "preserving traditional Medicare" meant just that. Actually, Ryan wants to turn Medicare into a voucher program. Seniors would have to buy into a private insurance plan or pay for a "public option" insurance plan. See:

"When they qualify for Medicare, the government would provide a set amount of money annually to them to purchase either a private health plan, or the traditional government-administered program."

"The Republican-controlled House, along party lines, twice approved his [Ryan's] proposals to overhaul the popular social insurance program for the elderly and disabled by giving beneficiaries a set amount of money every year to buy coverage from competing health plans. That is a fundamental shift from today’s program, where the federal government must help pay for every doctor visit and medical service that an individual uses."

So this is a big change to Medicare. I'm not in favor of forcing Medicare recipients into a voucher program. We'll see in November if American voters are. I bet they will feel like I do, and re-elect Obama.

Brian’s stated goal: “preserve traditional Medicare.”

Brian, even Wyden is warning that the current course under Obamacare will not “preserve traditional Medicare” beyond 2022 (some say 2024).

You’re a retired health planner and policy analyst, a soon-to-be Medicare beneficiary, a Wyden voter, and a political junkie – how could you not know that? How for eight months did you not conclude that Wyden-Ryan was a bad idea until Romney picked Ryan as his running mate?? Coincidence?

Wyden has said repeatedly that his plan is not a voucher plan, but a premium support plan. And despite his double talk Wyden’s website describes the mechanics of premium support (yes, it applies to both his private and traditional Medicare plans) exactly as Ryan’s website does. Which is the same as the mechanics of premium support described in Ryan’s budget bill, and the same as Romney’s website describes his.

Sorry, Senator Wyden, but if the Ryan and Romney plans are “voucher” plans – then so is yours.

The reality is – as Wyden’s website points out – “Medicare as we know it” is already on its way out “if nothing is done to change its current course.” Which will require “premium support” or a “voucher” plan, call it whatever you want. And that, of course, means a vote for Obama is the real vote to end “Medicare as we know it.”

Big Oil

DJ, you're right about one thing: having worked at a medical school (Oregon Health Sciences University), health planning agency (State Health Planning and Development), and a private non-profit bioethics enterprise (Oregon Health Decisions), I know quite a bit more about the health care system than most people.

Part of what I know, and other health policy experts also have known for a long time, is how inefficient health care in this country is. I'll write a blog post about this soon, probably, so will keep this comment fairly brief.

Physician Atul Gawande has a fascinating piece about this in a recent New Yorker. Read it and understand health care better:

I think your eyes will be opened. The choice isn't between free market competition and government regulation. What Obama is trying to do is a mixture, as Gawande's article talks about. The Affordable Care Act is putting this country on a path where "best medical practices" are adopted much more quickly than the many years it takes now.

Health care providers have to get past their cottage industry phase, where every doctor, nurse, or whoever does their own thing, as they see fit. (I have some good stories about this from my medical school days.) Obama's plan for Medicare makes more sense than Romney's for many reasons, one of which is that Obama understands what is happening in the health care industry.

Again, read Gawande's article. There's lots of room for cost savings that don't decrease (and likely will increase) quality of care. This helps explain why $716 billion in cost saving can be found in Medicare without affecting benefits. Romney isn't living the real modern medical care world, which shows why he can't be trusted to be president.

Oregon is a leader in coordination of care, assessing "best practices," and such. I'm proud to have been part of efforts to start to make that happen many years ago.

Good article by Gawande, Brian, but we must be getting different messages from it. Where does Gawande reference the Affordable Care Act, or Obamacare melding the free market with regulation?

There is probably more collective intelligence and brain power in the field of medicine than in any other US industry. But from the perspective of a competitive capitalist, the Cheesecake Factory/healthcare industry contrast underscores what we already know to be true: Competition and consumer choice – not brain power, price controls, or regulation – drives innovation and efficiency. Absence thereof promotes the status quo. This is why Gawande says, “Scaling good ideas has been one of our deepest problems in medicine.”

The dysfunctionality of the healthcare enterprise (compared to the efficiency of competition-based enterprise) is a decades old legacy borne out of uncompetitive insured care and, far worse, single payer government care. Both have been largely structured to ensure the patient makes choices with minimal regard for or visibility to cost. Here’s how Milton Friedman described the effect:

“There are four ways in which you can spend money.”

1) “You can spend your own money on yourself. When you do that, why then you really watch out what you’re doing, and you try to get the most for your money.”

2) “Then you can spend your own money on somebody else. For example, I buy a birthday present for someone. Well, then I’m not so careful about the content of the present, but I’m very careful about the cost.”

3) “Then, I can spend somebody else’s money on myself. And if I spend somebody else’s money on myself, then I’m sure going to have a good lunch!”

4) “Finally, I can spend somebody else’s money on somebody else. And if I spend somebody else’s money on somebody else, I’m not concerned about how much it is, and I’m not concerned about what I get. And that’s government.”

Friedman’s #4 is the single-payer model. Doctor reimbursement cuts and 2024 insolvency prove that spending ‘somebody else’s money on somebody else’ doesn’t drive innovation or efficiency – yet this is the Obamacare model for the future of Medicare. Until the consumer is voting with their dollars and has skin in the game when making product/service value choices I fail to see the free market incentive necessary to drive the efficiency required to keep Medicare afloat (or the nation for that matter).

Big Oil

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