A Letter to Blue Cross

This is a real letter written by a reader to Blue Cross of California, after they rejected his application for insurance. Because -- I shit you not -- of heartburn. Read the whole thing. It's far more powerful, and illuminating, than anything I write. And if any of you have similar stories, e-mail me.

To Whom It May Concern:

I'm not sure if this letter is going to be read, or even cared about in the
least, but as a taxpaying American I would hope that a responsible
corporation would acknowledge opinions or complaints originating from the
public they aim to serve. Let your corporate conscience be your guide as I
will let my faith in the overall good of people serve me as a motivator to
continue with my opinion.

That being said, I have a serious problem in regards to your eligibility
requirements for individual health care plans. A bit about myself: I am a
very active 28 year old male, who exercises regularly (4-6 days a week),
does not use any tobacco products, eats organic foods whenever possible,
takes vitamins, gets enough sleep, rarely even catches a cold and has
absolutely no history of disease. I recently applied for one of your
"Tonik" health plans because it was finally affordable to me. I have been
without health care for over 5 years and felt that the time had come for me
to make a financial commitment to my health. However, as a young, perfectly
healthy average male, I am appalled that you would deny my claim for health
insurance. After speaking with a representative over the phone, I was told
in a very polite tone and with no hint of sarcasm that I was ineligible due
to the fact that I had had Heartburn in the last 6 months; and furthermore
that I could reapply in 6 months (again with no hint of sarcasm or
acknowledgment of the fact that I clearly wouldn't state I'd ever had
Heartburn if it meant no health care).

Needless to say, I find it insulting and ludicrous that such a benign
symptom as Heartburn can deem me uninsurable by even just one of your plans
Not to mention that I received an email stating that I should apply to the
California Major Risk Program. Major risk of what I ask you? (rhetorically)
Not only are you compelling applicants to lie about seemingly innocuous
symptoms that nearly everyone experiences from time to time (I challenge you
to find any member of society who doesn't experience Heartburn occasionally
from spicy foods or even minor food allergies), but you are standing
hypocritically against the very reason that we are forced have health
insurance in this country. If I can't get health care without insurance
(alas I am not a millionaire), and I can't get insurance to obtain health
care if I need it, then to whom and for what does said insurance serve it's
purpose?

Despite the fact that I am sure this letter is falling on deaf ears, I urge
you to rethink your ethical stance of denying health insurance applicants
the very care that they may need but are financial inept at attaining.

Is your company not in existence for the very nature of helping people
obtain medical care for an affordable cost? If you deny people with a
possible condition the right to affordable health care are you not going
against the mission of your company in the first place? Or is profit all
you care about? And please don't mistake me from the above questions, I
hardly consider Heartburn a costly or even dangerous "condition" in an
average 28 year old male and I'm sure you'd be hard pressed to find a health
care professional who would disagree with me. That aside, had I even a
slightly more serious symptom that would point towards a great need of
health care, than I am certain my claim would have been denied even
faster...if it were humanly possible. Sure, for the right price, any sort
of insurance is possible, but why not try to actually serve the real public?
People who can't afford health care and therefore turn to you as their only
hope.

You have a great responsibility bestowed upon you by our present health care
system. You have the opportunity to bring health to many underprivileged
people (and do not mistake my use of the word 'underprivileged' to adhere to
solely those who are not as fortunate to utilize the market forces for their
personal financial gain…I am only referring to the underprivileged slice of
the societal pie that is without health care regardless of class and such).
And thus, I too am given the golden key of choice. By this you can be sure
I will not be choosing your company's services, and though I am not thrilled
with my other choices, I will seek out a company with a seemingly better
understanding of the massive responsibilities entrusted to it by our
country's present health care system...if it even exists.

Let me close in saying that I don't expect to receive any sort of response
from your corporation. If by some stroke of conscience you are compelled to
respond to my letter, than please refrain from sending me some lawyer jargon
about how you are always right, that it was in the fine print, and that
Heartburn may in fact be a sign of a serious problem. Furthermore do not
respond with statistics or righteous finger pointing, or worse: trying to
sell me a more expensive plan. If you are not writing a heartfelt, sincere
response, then don't bother.

Sincerely,

[Name Deleted]

Your World in Charts: Uninsured Edition

As of late, we've had some commenters hanging around demanding we redefine the word "uninsured," attempting to downplay the problem of lack of coverage, denying all widely accepted measures of the uninsured, and, when that fails, writing the uninsured off as statistical artifacts of momentary lapses in coverage. Soon enough, they suggest, insurance is procured; no harm, no foul. So this struck me as relevant:

When it comes to insurance, the stability of coverage matters. Indeed, what we tend to see is that the effects of having uncertain coverage -- or insufficient coverage -- are very much like the effects of being totally uninsured. The intermittently insured ignore prescriptions, forego specialists, skip treatment, and deny themselves doctor's visits at nearly the rate of the uninsured.

Meanwhile, so far as the total number -- 45.3 million Americans uninsured -- goes, I was struck to see that even the insurance industry uses it. Hell, they even think (or at least say) that "Politicians need to prioritize this issue. Our community has put forth a workable approach to meet the needs of the uninsured - a diverse population that needs targeted solutions which can be implemented in the short term."

The insurance industry isn't prone to overhyping the millions of Americans without insurance, and if they thought themselves capable of calling it 15 million rather than 45 million, they would. They don't. And so, if you're a denier, ask yourself: Are you really comfortable with a world in which the insurance industry is more intellectually honest than you are?

You Don't Know The Shape I'm In

I'm unconvinced by the mortality data in here, at least as it relates to the present day, but there's no doubt that a primary role of programs like Medicare is to simply insulate individuals from financial ruin. Indeed, I've never thought the health benefits are the most important reason to extend coverage to the uninsured -- though there will be health benefits, and they are important. In any large population, particularly one that trends young, as the uninsured do, only a small number in any given year will see real health improvement from easier access to care. But the economic security and freedom offered by medical coverage will aid every member of the community, freeing them to search for better jobs and see doctors without anxiety and treat nagging-but-not-mortal conditions that harmed their quality of life.

That said, for the small number who do need the care and currently forego it, insurance is crucial, and its absence is catastrophic. Indeed, I don't even know what to say about this...

Gotta Give Them Credit

It certainly is a new day in Washington when the wonderful Elizabeth Warren is being called to testify before the Senate Banking Committee. On that note, I've been remiss in not linking to this startling study (pdf) by Demos connecting credit debt to medical care. According to their findings, about 30% of middle- and low-income households with debt say medical costs have been a contributor. Of that group, 40 percent had more than $10,000 in debt, and those without health insurance carried a crushing $14,512 load. Indeed, the households with medically-related debt had more debt than those in hock for other expenses -- $11,623 to $7,964.

Nowadays, hospitals and health care providers often accept credit cards, which means the uninsured and underinsured are not only paying worse absolute prices (good insurance bargains down the total prices of each unit of care), they're also paying interest on those bad deals. Just another way in which it's really quite expensive to be poor. What I'm really excited for, though, is when HSAs and their mega-deductibles enter wide use and individuals who haven't socked away sufficient money begin putting their care on the plastic. Even now, about half of all HSA users haven't put a penny into their accounts. So the next step isn't only to transfer more risk onto these individuals, it's to help plunge them deep into debt.

The Hacker Plan

I'm getting near-overwhelmed with the array of new health care plans, but I'd be remiss not to mention Jacob Hacker's new plan through EPI. And I am never remiss. Hacker's plan isn't Medicare-for-All, at least not quite. As he puts it, it's really Medicare-for-Many. The government will create a new, Medicare-style health plan that's open for enrollment to any and all individuals interested in jumping in, covers mental health and maternal care, and has strict limits on out-of-pocket spending. Simultaneously, all employers will be required to offer insurance as good or better than the new government plan. If they don't want to contract out with the private sector, they'll pay 6% of payroll to enter their workers into the government plan. The unemployed and self-employed will have to buy coverage, and there'll be heavy subsidies tied to income. Done.

You'll notice that, unlike the other plans, Hacker's took four sentences to explain. It's a simple, elegant mechanism for coverage, requiring none of the complex market restructuring and odd coverage schemes of the plans that seek to preserve the private insurance market as a protected whole. Its secondary virtue is that it offers an easy, potential path to effective single-payer, allowing the government insurer to compete with private insurers, and possibly outcompete them as well. And by using the example of Medicare, Hacker promises familiarity with what's being offered -- a crucial advantage given the dangers complexity pose in the public arena. It's worth noting that the plan also has another name: HR 5886, introduced by Pete Stark during the last Congress. The differences between the two are minimal, and Hacker boasts involvement in both.

Elsewhere, Merril Goozner looks at the plan's cost containment and Dr. Steve rounds up some more reactions.

Also at Tapped

Individual Mandates and Universal Health Insurance

I want to spend some more time digging into Schwarzenegger's health care plan before analyzing it in full, but a quick point on the early reactions: I'm hearing a lot of hating on the individual mandate* -- and I don't get it. Some are complaining that the mandate "criminalizes the uninsured," others are saying ""The uninsured shouldn’t have a financial penalty onto top of the health and financial consequences of being uninsured." So let me try and say this clearly: Single-payer health care is an individual mandate. The enforcement mechanism, in that case, is taxation. If you don't pay your taxes, you're breaking the law. If you decide to withhold the portion of your taxes that go towards health care, you're a criminal. In fact, there is absolutely no universal health care system that wouldn't include a mandate of some kind -- that's how you make it universal. Indeed, without a mandate, you can't have a decent health system: If the healthy can opt-out until they get sick, coverage will be unaffordable for everyone. For a risk pool to work, it needs members at low risk.

The question with an individual mandate is subsidization and affordability. If we pass a law levying an individual mandate and subsidizing premiums down to $50 a month, there'll be few complaints. A mandate with no subsidization, however, is an impossible burden on millions of families. When evaluating an individual mandate, that's where liberals need to focus: The generosity of the subsidies. The Wyden Plan, for instance, subsidizes up to 400 percent of the poverty line. The Massachusetts plan subsidizes up to 300 percent. The Schwarzenegger plan subsidizes up to 250 percent. That looks too low, and I'll talk more about it later today. But for now, folks need to keep in mind that you can't simultaneously demand universal health care and reject mandates. Universal health care is a coverage mandate -- whether the enforcement comes through tax receipts or proof of premium payment is not a relavent distinction. Either one can be an overwhelming burden on the poor or the foundation of a progressive, generous system. The focus, always, should be on telling the two apart.

*An individual mandate is a law forcing the purchase of some minimum level of health insurance.

--Also at Tapped

Why Individual Health Insurance is a Cruel Joke

As follow-up to some of my earlier posts, Graham compiles over 84 reasons insurers may drop you.

Unbelievable

From Lisa Girion's story on insurance underwriting (which I say more about at Tapped), here's a list of jobs which will lead major insurers in California to simply refuse to offer you coverage -- at any price:

Air traffic control

Building, moving

Chemical/rubber manufacturing

Circus or carnival work

Concrete or asphalt work

Crop dusting

Firefighting

Furniture and fixtures manufacturing

Lumber work, including wood chopping, timber cutting and working in a sawmill

Migrant labor

Oil well or refinery work

Police work

Roofing

Sandblasting

Sports, semi-pro or professional

Stockyard work, with or without butchering

Stables, all employees

Stunt work

Telecom installation

Transportation and aviation

Tree climbing

Tunnel work

War reporting

Window work at heights exceeding three stories

One wonders if making a living doing telecom installation, or roofing, or window cleaning, or lumber work, or construction is really so sinful that we think it acceptable for our health system to deny such workers health coverage.

It's The Economics (As Always)

Garance asks me to comment on this fascinating New York Times article laying out the strong correlations between health and education. She wonders if our health care debate isn't "too focused on questions of coverage and disease treatment, rather than on actually improving the long-term health of the population through public health initiatives whose are results are not immediately apparent."

That's simultaneously true and untrue, but let's bracket it for the moment. The question of whether we could vastly improve health outcomes in this country by forcing everyone into college is an interesting one, but I'm skeptical. Given that no one thinks the dedicated study of Proust unlocks secret immortality enzymes, the question is what education is correlating with to create these outcomes. Most likely, it's a host of factors. On the individual level, less physically taxing jobs, more occupational control, more social capital, less economic stress, more personal power (feelings of control are heavily correlated with good health), etc.

More globally, higher levels of society-wide education will correlate with higher economic growth, a less menial economy, higher incomes, etc. And the article strongly implies that a primary effect of more education is that it makes people smart enough to not smoke, in which case we should pump research into smoking bans (thank you, DC!). And it should be noted that we could make everyone much healthier if we could make them Hispanic.

Those concerns aired, Garance is absolutely right: Our health care debate focuses too much on insurance. Most everyone in this country can access some sort of care, even if only at the point of crisis. That's not an optimal situation, but the available strides in outcomes are fairly limited. The way we pay for coverage simply isn't the primary determinant of health. That said, I wouldn't pull the throttle back on the reform fight by even an inch.

The health care question is more economic than medical -- indeed, it's likely the most important economic problem facing the country. Everyone gets care, but the ambulance ride or cancer diagnosis bankrupts no small number of Americans. That they also lack access to preventive medicine and early diagnostics is deeply troubling. Meanwhile, health care is going to chew up our national economy if we don't get medical inflation under control, and the vagaries of the employer-based health system substantially reduce the freedom of individuals to pursue their own dreams, business ideas, and general bliss while simultaneously bankrupting employers and incentivizing a race to the bottom in benefits.

Indeed, though there are better ways to improve health outcomes than reforming the way our system delivers coverage (like massively funding the NIH), there's nothing that would do more to ensure the economic security and personal freedom of average Americans, or the financial health of the country, than reforming the system. And in the end, it's not an either/or question. A better system would save money, freeing up funds for other public health and social policy priorities.

Also at Tapped

Reds Everywhere

Ankush points me towards an article in the Business section of The New York Times arguing for single-payer health care.  That's not exactly a common pairing, so seeing such an unexpected marriage of section and socialism does my heart good.  The piece is a perfectly adequate recapitulation of the arguments you already know, though it calls a lot of systems "single-payer" when they aren't.  But then, the importance of such an article isn't its innovativeness, but its audience.  The data comparing our spending and outcomes to those of other developed nations is an irrefutable, irresistible, condemnation of our system.  Indeed, this graphic alone is a more than suitable argument for reform:

The more who know the statistics, the easier the next fight will be.  And so I'm glad to see them being explained to audiences generally insulated against such revelations.  In the end, the case for moving towards public provision of health care is a simple one: It makes damn good business sense.  As the above graph shows, you may pay more through the government, but you pay far less overall.  And any businessman knows that that's the important metric.

Healthy? Just Ask Your Insurer.

The LA Times roars out of the gate this morning with a searing article on insurance industry underwriting and the many insignificant ailments that will lead insurers to simply refuse you any and all coverage.

Jerry Flanagan, an advocate with the Foundation for Consumer and Taxpayer Rights, said it wouldn't take much to be left out of the private-insurance market. "A minor asthma condition or a surgery 10 years ago that requires no further medical care is enough to get you blacklisted forever," he said.

As a result, some people forgo treatment so as not to tarnish their health records. Others withhold information from doctors or ask them to leave details out of their records. For those who are uninsurable, healthcare often is the chief reason they stay in or take a certain job.

Claudine Swartz enjoyed running her own consulting business but had been rejected for individual insurance. After a scare over a benign cyst in her breast, the San Francisco resident closed her business and got a job with the University of California's health system, where she enjoys guaranteed coverage.

The episode made her realize that without insurance, she would have been on the hook for catastrophic expenses if her diagnosis had been more serious.

"I wasn't willing to take that risk," said Swartz, 35. "It's a real problem for people trying to be entrepreneurial and work on their own."[...]

Insurers declined to disclose the underwriting guidelines that lead to rejection or higher premiums. But a review of public records, as well as rejection letters sent to individuals, shows that California carriers turn people away or charge them higher premiums for conditions that range from the catastrophic to the common. Cancer, epilepsy and AIDS make the list, along with breast implants, ear infections, varicose veins and sleep apnea.

Jeffrey Miles, a vice president of the California Assn. of Health Underwriters, a trade group for independent insurance agents, said one of his clients — a 27-year-old woman "in perfect health with absolutely nothing wrong" — was rejected because she had seen a psychologist for three months after breaking up with a boyfriend.

"I call it hangnail underwriting," Miles said. "If a person has taken virtually any medication, they are going to be turned down. If people have had any psychological counseling at any time in recent history, they are going to get turned down."

Swartz, the consultant, said the reason she couldn't get individual coverage was a condition in her records that she may never have actually had. Her physician had diagnosed ulcerative colitis. But after years without additional symptoms, Swartz said, her doctor decided the initial diagnosis was probably wrong.

Consumer advocates say out-of-date, ambiguous and even erroneous medical information can render people uninsurable. Sometimes the reasons can seem absurd. In a letter to an otherwise healthy recent college graduate, for instance, Blue Cross listed among the reasons it denied coverage a past bout of jock itch, "successfully treated with cream."

Community rating -- forcing insurers to insure everyone at the same price, and barring them from rejecting any applicant -- ends this practice. Which is why it's a non-negotiable element of any serious reform plan. But anyway: Happy New Years. My resolution? To keep working towards a better, fairer, more just system.

Luck

There's not a whole ton to say about such stories of woe. I will note that they show how luck works in health care. The mother's stroke and the rare genetic blood disorders in two of the sons aren't conditions higher deductibles or more cost-sharing would help with. Such reforms would just bankrupt a working family already laboring beneath far too much. Meanwhile, you think these folks are ever going to get decent insurance outside of a massive corporation or government pool again? Yeah, me neither.

Elsewhere, my friend Murray Waas's rebuttal to Washington Ciity Paper's shameful attempts to turn his survival of cancer into some hack bit of pop-psychology is powerful and affecting. I'll note that cancer drove Murray, then a Pulitzer-prize finalist journalist, into bankruptcy. with all the stigma that carries. One of the City Paper reporters actually accused him of being "a deadbeat cancer survivor." And the award for Most Extraordinary Display of Prickishness in Pursuit of an Article goes to....

I've spoken to Murray more recently about insurance costs and they are, for him (and all others who've once been sick), not cheap. Is there anything humane about a health care system that strains to price out those who've been unlucky enough to avail themselves of its services? We have a massive, miraculous industry devoted to healing paired with a massive, malicious industry devoted to making such miracles unaffordable to those likeliest to need them.

Kondracke Vs. The Facts

I'm not exactly going to stun anyone by suggesting that Mort Kondracke doesn't know what he's talking about, but this is rather offensive:

The reason that V.A. prices are lower is, it's basically a socialized medical system. You go to a V.A. doctor, you go to a V.A. hospital, you go to a V.A. pharmacy and the V.A. pharmacies only have 25 percent of the drugs that seniors actually use all the time. So, you know, it doesn't work.

There is an implicit contract between pundits and their audiences. The audiences, whose attention pays our salaries, are working off the assumed information that the networks and publications elevate only those who take the time to accurately comprehend the issues they're speaking about. And we, as our part of the deal, are supposed to take ten minutes and figure out what we're talking about.

The VA, just like the Medicare presciription drug plans, uses a formulary of drugs on which they negotiate discounts. That formulary contains drugs for every condition, but mostly eschews the copycats and useless medications that clutter up the market. Your pharmacy, remarkably enough, does the same thing. Now, VA users still have coverage for drugs off the formulary, they just don't get the bargained discounts on them. And here's the kicker: The VA has the best outcomes, for the lowest cost.

Those two points are not unrelated. As part of "knowing what I'm talking about," I called Phil Longman, who's done the best work on the system. As he explained, the VA is almost fetishistically rigorous about testing new drugs for efficacy and safety before adding them to the formulary. Vioxx, for instance, was never added to the list, because the VA thought it neither effective nor safe. They were right, and their patients were protected. That didn't -- and doesn't -- mean VA doctors can't approve off-formulary drugs. They just have to explain why doing so is necessary. In that way, the VA incentivizes the proven, well-priced drugs on their formulary rather than the ones in the news, but doesn't eliminate new and necessary treatments.

And how's that worked out? Well, in 2003, The New England Journal of Medicine found the "socialized" VA better on all 11 metrics of care than fee-for-service Medicare. The Annal of Internal Medicine found they surpass the commercial managed-care systems on all seven metrics of care for diabates patients. The National Committee for Quality Assurance, the gold-standard, found the VA the best health system in the country, beating out such star performers as John Hopkins and the Mayo Clinic. And an astounding 81% of Vets approve of their care, higher than Medicare, Medicaid, or the private sector.

But Kondracke doesn't know any of that. Or if he does, he's not telling. And in doing, he's breaking trust with and misinforming his audience. What conservatives literally cannot get around -- and so must ignore -- is that the single best health system in the country today is the socialized one. But inconvenient as it is for their ideology, what's all the more inconvenient is that the pundits Americans entrust to know about and inform them of these things are failing to do so.

Also at Tapped

Hey Arnold!

This article on Schwarzenegger's halting, halfhearted attempts to bring universal coverage to California neatly encapsulates the central hurdle facing Republican reformers: Taxes. You simply cannot cover a new segment of the population without the addition of some revenues. And since Schwarzenegger's advisors are already ruling out funding streams as minors as cigarette taxes, you've got just about no place to turn.

The example of Massachusetts has, in some ways, been destructive here, as governors have looked to that state and then done some throat-clearing about replication. Problem is, Massachusetts was a rare case that didn't need new revenues. As I explained in this article, a previous wave of progressive health reform had already created a massive fund to care for the uninsured in the Commonwealth -- which meant the Roney plan only had to redirect revenues, not create new ones. Add in a huge hospital-industrial complex, a very low number of uninsured residents, the threat of an expansive, universal care ballot measure, and the government's withholding of a $750 million health waiver, and you've got an easy path to change.

That said, there is something to the federalist strategy on universal health care, wherein various states give it their best shot and create models for the rest of the nation. Problem is, it's hard for states fund such experiments. That's why I've some affection for Russ Feingold's idea (mp3), which would guarantee a handful of states tens of billions to institute such plans. I'd amp up both the money allocated and the number of states included, but it's an interesting compromise proposal that could, in a Democratic Congress, make it through the legislative process with few enemies, and even attract a presidential signature.

Insurance, Schminsurance

Arnold Kling spends a lot of time explaining that what we think of isn't health insurance. "[W]hat we call health insurance covers things like new eyeglasses, which is not a rare, catastrophic event." Alright. So call it health coverage. He argues that what we really need to do is move towards "something that looks like insurance, not like a scheme to insulate individual consumers from all health expenses." But why? Which is to say, if consumers, as they've repeatedly proven, don't want insurance, but instead want insulation, why shouldn't we seek to make that work (as it does in a variety of other countries and systems). Eyeglasses may be predictable, but they're still expensive, and folks seem to like the fact that they don't have to pay the costs all at once, and the genetically lucky have to give a bit to the genetically unlucky. Just because we call it insurance, doesn't mean we want what we buy to protect our house from fire.

Health Care Attitudes

Kaiser, ABC, and USA Today just released a pretty expansive poll documenting the country's opinions on health care. The nickel version is that your countrymen are mostly liberal, deeply confused, and more likely to loathe the status quo than clearly conceptualize potential alternatives. Respondents said it was the third most important issue in the country, behind Iraq and the economy, but before immigration, gas prices, or terrorism. That's probably because opinions towards the system are so overwhelmingly negative: 80 percent are dissatisfied with the cost of health care in the country, and 54 percent are dissatisfied with the quality. So the system starts out with few friends.

From there, things get more complicated. Nearly 90 percent are satisfied with the quality of care they received. Nearly 60 percent are satisfied with their costs. In other words, Americans believe everyone else's health care system costs too much and delivers too little. Their own system rocks. Meanwhile, a full 25 percent reported that they or someone in their household had problems paying for medical bill in the last 12 months, and 28 percent put off medical treatment due to cost. Of that 28 percent, 70 percent admitted that the delayed treatment was "serious." And remember, this is all in the last year.

Individual fears become more acute when asked about the future. 60 percent worry about affording insurance "over the next few years" and 56 percent fear losing their coverage if they lose their job. As for what's driving all these high costs, the reported culprits, in descending order, are excess profits of drug and insurance companies, medical malpractice lawsuits, fraud and waste, overpaid doctors, administrative costs, unnecessary treatments, unhealthy lifestyles, expensive new treatments, the aging population, and better medical care. That's depressing. In order to get an accurate view of what's driving health costs, you'd need to basically invert that list. To say the American people have it backwards is to be unusually precise.

How to fix it? Letting individuals shop around for the best prices they can get garners wide support, with 80 percent judging it some level of effective. Suggest far higher deductibles and low risk insulation, however, and watch that drop. 56 percent would prefer "a universal coverage program...like Medicare that is government run and financed by taxpayers" to the current system, but that number plummets if you ask about higher taxes, limited choice, or rationing. 70 percent support an employer mandate while a mere plurality support tax breaks for low-income workers (despite the fact that high income workers currently enjoy a massive tax break through employer deductions).

So, in sum: The health care system sucks, but nearly every American's health care is great. That would suggest the opportunities for reform are minor, unless directed at the loathed elements (like insurance or Pharma). Folks don't like the high costs and fear they'll soon be overtaken by bills, but they blame all manner of minor and moderate contributors for the problem, not their own health choices, overtreatment, or new technologies. Universal care is heavily desired, but only if it doesn't cost anything or demand any sacrifices. In other words, the appetite for reform outpaces the realism of would-be reformers. The tradeoffs of the current system seem poorly understood, and attitudes towards its desirability are contradictory. Not a whole lot of hope in here for anyone.

In Case You Were Curious

As per usual, if anyone is still confused as to the median voter's stubborn resistance to admitting the economy's overall awesomeness, new data showing that health premiums went up 7.7 percent in 2005 may help illuminate things. 7.7 percent, after all, was more than twice the inflation rate and the growth in worker's wages. In fact, since 2000, health premiums have gone up by 87 percent. Somehow, I doubt the average worker's salary has done the same.

Blame Canada? Mexico? HMOs?

Jane's post arguing (in part) that the growth in the uninsured over the last decade has come mainly in the foreign born population is an important one, and should be taken seriously. However, I think they almost obscure more than they illuminate, and deserve a bit more context. What's fascinating about the data she cites is that the actual percentage of both natives and foreign-born residents lacking health insurance has changed relatively little. Since 1993, the number of native-born Americans with coverage has ranged between 86.3% and 88.1%, with 2005 seeing 86.6%. As for the number of foreign-born Americans, their coverage numbers have remained between 65.5 percent and 67.7 percent, with 2005 ending at 66.4%. Which is to say the percentage covered among both groups has remained relative stable.

What did happen is that the foreign-born population increased from 22 million to 35 million over that period: a far more rapid expansion than the native population saw during the same timespan. Indeed, while in 1993, 32 million native-born Americans were uninsured and 7 million foreign-born Americans lacked coverage, in 2005, 35 million native-born Americans were uninsured while 12 million foreign-born Americans went without protection. While the uninsured of each population remained approximately the same, the foreign-born population exhibited a great absolute increase. None of which really changes the basic narrative: 35 million uninsured natives, 12 million uninsured foreigners, 47 million uninsured total. Nothing to be proud of.