Tuesday, August 18, 2009

Public Enemy

In order to better understand the occasionally dreaded Public Option, I’d first like to recall a story I heard from the founders of Ben & Jerry, who spoke at my undergraduate institution when I was a freshman. They talked about the beginnings of their company, starting small in Vermont and quickly observing that they were successful because their product was good. It was so good, in fact, that they were noticed by the big companies in the ice cream market, specifically Pillsbury (owners of Haagen Dazs), which felt threatened by this tiny outfit in the snowy abyss of Vermont. Ben and Jerry found it funny that a giant multinational company so dominant in the field would worry about a small upstart and try to strong-arm distributors into not selling the upstart’s product, that they hired a plane to fly a banner at a Boston College football game stating “What’s the Doughboy Afraid Of?”, leading to a legendary advertising campaign that turned them into major players in their field. (Of course, the answer to that question is that the Doughboy was probably afraid of the awesomeness that is Coffee Heath Bar Crunch, Strawberry Cheesecake, or Dublin Mudslide.) In healthcare, one could easily imagine that for-profit private insurance companies are the doughboys…but who plays Ben & Jerry?

File that anecdote away for a moment. Now, I want you to close your eyes and imagine something rather fanciful. Wait. Open your eyes again. OK, forget the part about how closing your eyes means you can’t read what I'm writing. Just imagine something along with me. Imagine a healthcare system in a society that is entirely government run. Patients report to government-sanctioned hospitals, see physicians only within the government-approved network, and pay fees mandated entirely by the government. There’s more: the government sets what drugs within each class can be prescribed in this system (and makes it more difficult to obtain so-called “non-formulary” drugs, those that are basically not as cheap as the ones the government gets after negotiating with drug companies), it utilizes its own electronic medical record, and it inserts an oddly musky smell into the hallways of the hospitals it runs.

Is this a nightmare? A dream? A reason to transform into a screaming lunatic, unable to articulate even the most remotely intelligible thought while narrowly avoiding the rupture of every bulging vein in his increasingly sweaty forehead? Well, I got some news for you – what I just described isn’t some sissy Scandinavian healthcare program or a totalitarian Soviet-era monstrosity, it’s the Veteran’s Administration healthcare system that I’ve worked in as a medical student and a resident, and it has been around for a while. And let me tell you something even more earth-shattering, another government-run program that includes parts of what was described above is something called…Medicare. The point of this exercise is to dispel the myth that government has no place in healthcare, or that it is not already heavily involved in our healthcare. I thought people already knew this, but all those “keep the government out of my Medicare” quotes reaffirm how dense many of us are.

With that background, let’s take a look at the next semi-interesting part of the health care bill, Section 221 – Establishment and Administration of a Public Health Insurance Option as an Exchange-Qualified Health Benefits Plan. In this plan, the Secretary of Health and Human Services “shall provide for the offering of an Exchange-participating health benefits plan (in this division referred to as the `public health insurance option') that ensures choice, competition, and stability of affordable, high quality coverage throughout the United States in accordance with this subtitle. In designing the option, the Secretary's primary responsibility is to create a low-cost plan without compromising quality or access to care.” In other words, this plan is intended to serve as a check on the world of for-profit private insurance - our modern day Doughboy - that currently rules the health-o-sphere. On the surface, at least, this sounds like a good thing…unless you are in the health insurance company loving camp, which I suspect is less popular than a Brett Favre jersey at Packers camp. Let’s dig further at what this offers:

  • “Ensuring a Level Playing Field” – In other words, requiring that the public option be held to the same rules that all of the other insurance options. Reasonable.
  • “Provisions of Benefit Levels” – Here it is described that you can choose between “basic, enhanced, and premium plans”, as well as a potential “premium-plus” plan. Wait, I thought the point was that everyone should have access to the same affordable healthcare? This implies that there will be differences in the type of coverage one gets…or does the “enhanced” plan simply refer to the free Enzyte that comes with a subscription (in which case, sign me up!) . Admittedly, this smells fishy, but would not be a significant departure from the way the VA works in terms of service-connection, so I can handle it.

There are various other smaller details in this plan that are not all that interesting (unless you find “data collection” interesting, in which case I have a used life-size Britney Spears blow-up doll for you). I’d like to go back to the imagery put forward earlier in this piece, because it represents not only a government-run system, but also the health care plan we give to our troops we entrust to defend our freedom. I know first-hand that it is not a perfect system, and that there are many ways it could be improved (nurses who give a shit would be a good start). That said, it is at worst comparable to the private insurance plans out there and often much better. Better in terms of access to basic care and specialist services, to evidence-based therapies, and to integrated systems that move with the patient. Since private insurance companies (who have no access to this small market of veterans seeking health care) currently have no competitive interest to provide these services to the much larger population that they supposedly serve, perhaps a bit of competition might actually be a good thing - it appears that in the realm of healthcare, the government is the only party willing to and big enough to play the role of Ben & Jerry. We already have many public universities competing with successful private ones and public mail systems competing with private mail services, all leading to better options for you, the consumer.

After all, what is the doughboy afraid of?


  1. This isn't directly related to the new policy but talks about why it won't fix the inherent problems in the system.
    I thought it was well analyzed and well written

  2. I'm so glad you're back, Fake Doctor. I'm gonna be a doctor too!

  3. you make this damn bill almost worth reading
    or i could let you do it for me
    heck yes, lazy sundays - saturdays

  4. Usually my eyes glaze over a quarter of the way through s health care policy discussion. Not this time. We share a similar perspective on this, but I'd be coming back for more even if this wasn't the case. However, you make on almost unforgivable mistake. You neglected to mention B and J's "Phish Food" (or something like that).

  5. Greetings,

    My name is Barbara O’ Brien and my blogging at The Mahablog, Crooks and Liars, AlterNet, and elsewhere on the progressive political and health blogophere has earned me the notoriety of being a panelist at the Yearly Kos Convention and a featured guest blogger at the Take Back America Conference in Washington, DC.

    I’m contacting you because I found your site in a health reform blog search and want to tell you about my newest blogging platform —the public concern of health care and its reform. Our shared concerns include health reform, tort reform, public health, safe workplaces, and asbestos contamination.

    To increase awareness on these important issues, my goal is to get a resource link on your site or even allow me to provide a guest posting. Please contact me back, I hope to hear from you soon. Drop by our site www.maacenter.org in the meantime.


    Barbara O’ Brien

  6. I'm all for increasing access to health care, no denial for pre-existing conditions and helping people out. But I will be eternally upset with any system that takes more of my tax dollars to treat people with conditions they bring on themselves. Does the 400 lb woman need another hospitalization for DKA? HONK? she can pay for it out of her own pocket. Oh, you can't breathe Mr. 200 pack/year smoker? well, you don't come in the hospital till you can pay cash up front!
    Our tax dollars should not go toward enabling these type of people. anyone with that kind of history should be forced to pay more into the pot they steal from with each admission than someone who needs hospitalization for a trauma or longstanding health problems not related directly to user stupidity.

  7. Hi,

    I am interested to visit your blogs Plz help me.

  8. The most reasonable healthcare commentary I've yet heard. Glad you're back in business, FD.

    Also, it looks like some Hot (chic?) wants to visit =)

  9. The analogy is insightful, Public Health Care would be awesome - I wasn't even aware that there was different types of coverage under the Reform. Would this be based on income levels?

    However, I do not agree with the Mister Mr. that posted before that are tax dollars should not go to enabling behaviors. Who's to say what is good or bad in any circumstance.

    Why would you deny the 400+lb man/woman care ...what if the underlying reason they let themselves go or did not take better care of themselves was because they were molested/raped as children and psychologically the fat is a form of protection. OR, they had a stroke which affected the area of their brain that controlled "the feeling of fullness/satisfaction when eating" would you deny this individual HELP

    We should not place but(s) to the situation... We need to come together and help one another.

    I' am not a tree hugger or anything of the like but discriminating services is not the way to help communities.

    Just my three cents - love the blog though

  10. can you write a blog post about how you're doing now? the whole natalie portman engagement/pregnancy thing must be hitting hard. I felt for you the minute i heard. no really, that was my first thought. sad but true.
    love your blog

  11. Nooo. Where did you go to? I was reading your blogs from beginning to end, I just stumbled upon them in the past couple of days. I love your writing style and thoughts!

    I feel as though I'm missing the second half of my favorite author's career achievement work of literature. Are you still there? Please respond! I love reading your posts! Do you ever plan on blogging again? my email: messenger727@hotmail.com

  12. First of all, thanks for posting this because it saves me reading a 4,0000000 page bill.

    The bill may seem complicated but its all economics. Its goddamn a million pages but it says one thing. PEOPLE NEED HEALTHCARE. Now that we have that out of the way lets look at the root of the problem. People can't afford health care so either the Doctor/Hospital eats the cost, or the insurance companies do. Seems that insurance companies lobbied well enough so the doctor/hospital eats most of the cost while insurance gets a way with paying lower rates. Sucks!

    Well if Hospital eats the cost it has to raise its revenue by raising the cost of say a bag of saline to like 600 bucks. Really 600. For some shit i could make at home with a beaker. Those paying out of pocket get screwed while those paying with medicare or medicaid get bye fine paying a small percentage of what hospital charge. The hospital has to make money somewhere otherwise it would make less money than the cost it accrues. Thus we get rising cost in health care.

    They also do this with pharmaceuticals (lower the cost at which they can sell their products) and thus they ship jobs oversees to cut costs. It is the government that makes things costly.

    So what do you do...Well I kind of have an idea that is probably unfeasible but theoretically would help. Make insurance non-profit. Cut out the middle man. The theory behind insurance is that a lot of people pays for the little that actually does get hurt. Insurance makes money by siphoning money from the doctor via the doctors decreased wages and the patient via monthly insurance bills. Then what do they do? They record record profits. Who the fuck needs insurance companies? I like the system they set up but I don't like how they make money off of people's lives. Make it non profit (possibly payable in taxes) and its win for patient and doctor and loss for insurance companies. Alas they lobby like fiends so that would nevvver happen.

  13. As a fellow medstudent and of course a follower i just wanted to know how are you doing.
    Come back. Write.

    And if by any reason you are happy doing other stuff, keep doing them. I wish you the best.

  14. Hi! I’m a writer for the blog nydoctorsugerntcare.blogspot.com. I wanted to do a little interview on you, your blog, and your issues/views on urgent care.
    If you’d like to do an interview please contact me here om this email. sm@newyorkdoctorsurgentcare.com

  15. Excellent topics...
    You were doing well...but no ne post!!

  16. thanks such a lovely blog.Fake doctor

  17. I admire your blog . Mr. Fake doctor
    I will advice all my friends on twitter

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