This amendment would have far less if not no traction, if the "left" and "right" simply came to terms on a dual strategy of providing access and controlling costs. It is difficult in my mind to ask someone else to pledge cash to finance someone else's needs when the underlying costs are without any foreseeable constraint. Meaningfully constrain the costs, and I am confident the "heartless" right would find heart and help the uninsured component. Those who relentlessly push the uninsured issue without credible commitment to the cost issue, simply push their objective further away.

I agree almost completely with your views. As a conservative leaning individual, I have migrated from opposition to "universal coverage" to a more carefully crafted discussion about the "terms and conditions". However, this clearly has the makings of a slippery slope. I consider "catastrophic" insurance to be an entirely reasonable benefit design for many, many people, and we use the "poor" argument to protect what is over insurance for most of us. In the employed environment, the idea of increasing deductibles with income almost always runs into stiff opposition. "Why should I face less benefits as I become more valuable to the company?" Of course this becomes another argument as to why health insurance should be delinked from employers. With the right incentives, people with more means will and should elect higher risk policies. The idea of a "basic" benefit for all, against the continuum of differing personal needs, seems decidedly unsound. If my adult daughter was "poor on the government's assessment", is she foolish in the eyes of public policy to ask me to backstop her with a high deductible policy such that as a healthy individual she can part with less money for an overfed health care industry? Or why should I help her if government is knocking at the door with a hand out? Public policy will never be able to keep up with these nuances.

Dean, if I conveyed malice for Democrats, that is not the intention. You seem to hold some angst for Republicans or the right. I realize "trying" has its good qualities, but repetitious failure is ultimately a disastrous course in the long term, especially when the critical success factors are so obviously absent at the outset. Nobody should accept a highly flawed strategy with the satisfaction that "at least we tried". I would think we just dig a far deeper and intractable hole for future generations.

As for whether we have a more or less active government than others in health care, I don't know that is an easy call. Our government is VERY active in our system. Problem is their activism is misdirected and certainly compromised by a heavy dose of politics. I share your view that we can learn alot by looking at other systems, but unless the hypothetical transfer of a "winning" system involves the acceptance of the industry pay scales of that country, I don't see the logic that we could replicate the economic results of that country. Perhaps you see that we have the political will to control the personal incomes of the industry. I don't think we do in a direct regulatory manner but would be willing to support an "experiment" that demonstrated such.

I am also cautious about the use of "affordability" as it can easily mean to some, simply finding the money from someone else to subsidize my health care premium. That track of increasing the funding is probably in itself inflationary. If "affordability" is meant cutting the underlying costs of the current system, then let's say it more explicitly that way. Solving the uninsured is connected to controlling costs. The "heavy lifting" is the latter in my estimation, as that issue has been a bothersome political debate for about 40 years.

Dean, where do I start is a challenge. I am not "blaming anyone" even though you elect to frame my posture that way. This is a field of interest that is loaded with "shifting the blame". My appeal is to rationality: Define the problem (which is a fundamental failure of most health care debate); weigh the alternatives; test the best solutions (no where on the landscape of any of the proposals); and execute on a larger scale. In my experience it is a first rate struggle to insert the meaningful control of costs into the heads of all sorts of people who chose to define the struggle singularly as the uninsured. For the most part the debate is very intellectually dishonest about the cost component of the problem because it does not pay users or providers to overly mess with this subject. In the State of Oregon, without doing any reform, there is a 3 fold variation in uncomplicated like procedures among hospitals in their asking prices for these services. The State has been bureaucratically collecting and analyzing this data for approximately 30 years with virtually no discernable response. The largest unilateral cost shifter in the market is government sponsored care. I had one hospital administrator tell me a couple of years ago that his hospital had not received an increase in reimbursement rates from the Oregon Health Plan since its first year of inception.

I support the concept of guaranteed issue as a needed insurance reform, but it is a simplistic view to be for this without describing the conditions. I think there are only 3 states in the country that have this provision now and if you do not do it artfully it is a disaster...as was experienced in the State of Washington. The execution there effectively drove all carriers out of the individual market for a number of years and as an individual you literally could not buy individual insurance irrespective of health care condition. Insurers play hardball in selecting favorable risk, but the buyers also have significant games to manipulate as well. This tension between the two is why many feel there is no choice but to "mandate" that all are covered. Unfortunately the downside of mandating in my mind is that the economic interests of the industry clearly wins, and you as the individual will ultimately be "screwed"...unless you think someone else is going to pay your tab. What would be more ideal for the industry's interests than a universal mandate where thoughtful analysis suggests as much as 50% of its services may be ineffective or unnecessary.

While I am not at all comfortable with the absence of Republican activism on this subject, I do believe it would be best to center health care reform in community based settings as opposed to untested national crap shoots that are largely irreversible. If you know comprehensively what should be done, I think your burden should be to prove it in a pilot that is independently evaluated. Someone should look at your game plan very closely, affirm that Dean has a good shot, and let's see him deploy it in Yamhill county with our complete support and enablement. Sort of the "put up or shut up" challenge. In my pursuits the main stream (that being legislature, regulators, payers, providers, unions, etc.) are all absolutely petrified of "outside of the box" experimentation, because they fear the "tipping point" consequences. As one small example, there is worthy national debate about migrating to "defined contribution" from "defined benefits". Laws and regulations effectively stand in the way of even experimenting with these alternatives. Indeed many vested interests vigorously oppose such considerations. We talk passionately about the need for health care reform, while effectively giving Medicare, public employees, self funded employers an exclusion from the reform. How do you consider health care reform and exclude the very people (public employees) who are to lead on this subject? Let's face it, it is essential to many of these vested interests that "reform" remain restricted to the uninsured such that it is not disruptive to "my benefits". If the box is drawn that way, and I believe it is, we will be recyling failure.

The consistent failure of just about all reform plans of the day, is that they do not have a credible strategy to control costs. Wyden believes emphasizing prevention is the leverage point, and yet academic scholars who look at this matter suggest there is "no credible evidence that investments in prevention, reduce health care spending". Not to pick overly on him, all of them express trite, populist and unsubstantiated theories.

My plan which you have reviewed calls for a robust public and private system in competition on a level playing field which you seem to support as well. The key to this is a requirement of a level playing field. If the public segment ends up with indefinite limits to subsidies not shared with the private sector, it will be a highly dysfunctional situation. To get to this level playing field, government sponsored care probably has to come up with about 20% more money on its current lives to bring it into parity with the private sector. That will be a big problem, but if you don't commit to that the competitive market will never function properly.

I remain of the view that I don't think Democratic proposals awarding near security to private insurance market is a good concession....and my roots are in the private sector.

Enough.

I think all of us should stipulate that the costs of U.S. Health Care is a decreasing value proposition. There are studies from credible sources that as much as 45% of the care rendered may be unnecessary. Putting aside the altruism, it is a commercial business loaded with sellers that want to make more money than last year, whether they be for profit or non profit in origin. To control costs...which most agree is essential, regulatory or free market based systems must deploy strategies that constrain how much these interests take home. That is a very unpleasant task, which politicians will be among the last to want to engage....their business being the awarding of benefits, not constraining income. I cannot connect these dots...we know that costs need to be constrained; we know just about all health care costs in the food chain, can be related to someone's take home pay; we know that placed in a political framework, it becomes an almost impossible task; and yet so many speak with such confidence that we should deposit this with government and public employees to resolve...as if they can do something which large interest groups will not support.

David, you may be right. However, it seems to me that the system of another country would be co opted about 100 ways by the politics of U.S. health care before it hit the streets here. Therefore this approach in addition to any "home grown" views on reform can only be seen as speculative. Therefore "proof of concept" should be inserted into the thought process. We would not accept clinical trials in beagles as proof that a drug will work in humans.

Going in, my strong preference is to provide a "single payer like" alternative, in competition with aggressive private sector choices and let us as individuals select what we want. If you truly want a single payer system, you should have that election. If I prefer a very high deductible insurance system with far more self determination, the option should be equally honored. For either side of this advocacy to impose its will on the other, even in the majority, is likely to kill of the potential success of any solution if significant numbers of people don't want it.

I can send you a paper and specific proposal that expands on this view if you are interested.