Gingrich & Goodman Idea #10: "Make Medical Breakthroughs Accessible to Patients"

The final "GOP idea" shared by Newt Gingrich and John C. Goodman is to "Make medical breakthroughs accessible to patients".

Breakthrough drugs, innovative devices and new therapies to treat rare, complex diseases as well as chronic conditions should be sped to the market. We can do this by cutting red tape before and during review by the Food and Drug Administration and by deploying information technology to monitor the quality of drugs and devices once they reach the marketplace.

The FDA doesn't get much love from anybody. When it doesn't approve medications or medical devices quickly, it is a behemoth that must be streamlined. But when it makes a mistake, approving a dangerous drug or device, even if the error was caused in part by streamlining the same critics previously demanded. At the far extreme, some call for eliminating the FDA and simply letting the market do its magic - I guess if enough patients die, people will figure out that they don't want a particular medication, treatment or medical device.

With some of the FDA's sluggishness it does appear that a new device or treatment could be a genuine boon to patients, and could potentially decrease medical costs. Consider, for example, the artificial pancreas. The FDA describes itself as having taken a "proactive role" in the development of the technology, but diabetes patients still wait. The FDA cites concerns about safety and the accuracy of sensors - after all, an error in the administration of insulin could be lethal - and that at best an artificial pancreas won't function as well as the real thing. But no question, there are diabetes patients who would accept that risk and find the FDA's caution to be both excessive and frustrating.

But let's take a step back for a moment. Let's assume that the FDA's approval process could be streamlined, such that new devices and drugs could be approved much more quickly without jeopardizing patient health. Although there are exceptions, and the artificial pancreas may prove to be one, how often have new medications and new technologies reduced the cost of health care? Usually they have the opposite effect - investment in new technologies and the high cost of patented drugs and devices push overall healthcare costs up. With due respect for Gingrich's love of science fiction, how does he expect that a proliferation of drugs and devices, not fully tested, will decrease health care costs as opposed to increasing them - not only to pay for the patented technologies themselves, but to treat patients who experience bad outcomes due to errors resulting from an accelerated approval process?

If Gingrich and Goodman have answers then, once again, I expect that this is a proposal that would get broad bipartisan support. Without answers, given their insistence that the reform bill be revenue-neutral, I expect that the GOP will be quick to reject it.

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Gingrich & Goodman Idea #9: "Stop Health-Care Fraud"

I guess it's hard to come up with a list of "10 GOP ideas", which I suppose John C. Goodman and Newt Gingrich include non-GOP ideas, ideas at odds with actual GOP ideas, and even Democratic Party ideas in their list. As with "making health insurance affordable", it's rather silly for either party to try to lay claim to fighting fraud.

Every year up to $120 billion is stolen by criminals who defraud public programs like Medicare and Medicaid, according to the National Health Care Anti-Fraud Association. We can help prevent this by using responsible approaches such as enhanced coordination of benefits, third-party liability verification, and electronic payment.

Were the GOP to propose legislation with a serious likelihood of combating fraud, I think it would pass by overwhelming support from both parties. But... this isn't actually a GOP priority and they have proposed no such bill.

Who is making a crack-down on fraud a priority? Well, it's not Newt Gingrich:

"The Obama administration is committed to turning up the heat on Medicare fraud and employing all the weapons in the federal government's arsenal to target those who are defrauding the American taxpayer," HHS Secretary Kathleen Sebelius said during a news conference at the Justice Department with Attorney General Eric Holder.

"But our joint efforts don't just stop at the jailhouse door," she said. "Every dollar we can save by stopping fraud can be used to strengthen the long-term fiscal health of Medicare, bring down costs and deliver better service to Medicare beneficiaries."

The government's job will be anything but easy.

During the past five years, thousands of Medicare fraud offenders have shown that they can outsmart the vulnerable healthcare system for the elderly and disabled. Their weapons: cash kickbacks to Medicare patients, manipulation of medical records to justify bogus charges, and use of different billing codes to get around Medicare's technology to block false claims.

Maybe Gingrich missed the speech?

The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud, as well as unwarranted subsidies in Medicare that go to insurance companies -- subsidies that do everything to pad their profits but don't improve the care of seniors. And we will also create an independent commission of doctors and medical experts charged with identifying more waste in the years ahead.

Without wanting to diminish the importance of empowering patients, it should be noted that if you restructure Medicare's payment system such that each doctor can "renegotiate and reprice their services" with each individual patient, as Gingrich and Goodman propose, you're significantly increasing the opportunity for fraud.

I'll give Gingrich and Goodman credit for having the President's back on this issue, but I'm surprised they don't know that President Obama is a Democrat.

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Gingrich & Goodman Idea #8: "Eliminate Junk Lawsuits"

One of the interesting aspects of healthcare reform has been how quiet the insurance industry has been. When you hear people like Newt Gingrich talk, you would think that "tort reform" was perhaps the most pressing issue that must be addressed as part of a reform package. But instead the insurance companies appear happy with the status quo.

If you think about it, the insurance industry has good cause to be happy with the status quo. Despite their squawking about evil "trial lawyers," they have achieved their "tort reform" goals in pretty much every state. They have consistently focused on four goals: limit damages awards, so that the most severely injured individuals recover get little compensation for their pain and suffering; abolish "joint and several damages" and implement the "empty chair defense" to force plaintiff's lawyers to sue every conceivable defendant and drive up the costs of litigation; require notice periods and "certificates of merit" before a lawsuit can be commenced so as to prolong and again drive up the cost of litigation; and shorten statutes of limitations and implement statutes of repose, such that patients have a narrow window of time to make their claims before they're permanently barred from doing so, regardless of a claim's merit.

I read an article recently by a doctor who was sued as part of a malpractice case and who was ultimately dropped from the suit. She asked her defense lawyer "Why was I sued" and the defense lawyer lied, "I don't know." The defense lawyer does know. If you have a system of "joint and several liability", you can sue those you believe are most responsible. If a defendant believes others are in fact responsible, or are more responsible, the defendant can bring those others into the case. Insurance companies have worked very hard to abolish joint and several liability and to create the "empty chair defense" - so that a defendant can point to the "empty chair" where that defendant "should be sitting" and argue at trial that the plaintiff didn't sue the actual culprit, and that the actual culprit is responsible for most or all of the damages. That defense may amount to lies and innuendo, but courtroom arguments won't support a defamation case and the goal is to win, right? So to avoid that outcome the plaintiff now brings every conceivable defendant at the start of the litigation. This pro-insurance industry reform increases the cost and burden of litigation, and measurably harms the health professionals (and others - this isn't limited to malpractice) who are brought into claims to avoid the "empty chair defense". Plaintiff's lawyers would be happy to go back to joint and several liability with the onus on the defendant to bring in a supposedly culpable third party, and that should work out quite well for doctors, but the insurance industry is not going to give up this "reform".

Of the four leading "reforms", arguably the "certificate of merit" should help avoid "junk lawsuits" but in reality malpractice lawyers work hard not to file meritorious claims. Even without that requirement, due to the high cost of litigation, malpractice lawyers pay medical professionals to help them screen their cases - they don't want to waste their time and money on cases they cannot win. The dubious claims get filed because lawyers lack the information necessary to fully assess the merits of the claim without discovery - without forcing that information out of the defendants and their insurance companies. The certificate of merit prepared for such a case is prepared by a doctor who is similarly forced to make assumptions about what happened. So in practice it's a great way to generate revenue for doctors who prepare certificates of merit, drive up the cost of litigation and drag out the settlement process, but does little to ensure that a case is meritorious.

Some realities of medical malpractice litigation:

• Most malpractice cases are correctly decided.


• Those in which are arguably wrongly decided in favor of the plaintiff have smaller-than-average recoveries, and claims without merit are "generally resolved appropriately".


• About one in six malpractice cases are wrongly decided in favor of the doctor.

Further,

the malpractice system performs reasonably well in its function of separating claims without merit from those with merit and compensating the latter. In a sense, our findings lend support to this view: three quarters of the litigation outcomes were concordant with the merits of the claim.

And, when "non-error claims" were made, it was not for a lack of diligence by the plaintiff's lawyers:

The profile of non-error claims we observed does not square with the notion of opportunistic trial lawyers pursuing questionable lawsuits in circumstances in which their chances of winning are reasonable and prospective returns in the event of a win are high. Rather, our findings underscore how difficult it may be for plaintiffs and their attorneys to discern what has happened before the initiation of a claim and the acquisition of knowledge that comes from the investigations, consultation with experts, and sharing of information that litigation triggers.

The most serious problem identified?

Although the number of claims without merit that resulted in compensation was fairly small, the converse form of inaccuracy — claims associated with error and injury that did not result in compensation — was substantially more common. One in six claims involved errors and received no payment. The plaintiffs behind such unrequited claims must shoulder the substantial economic and noneconomic burdens that flow from preventable injury. Moreover, failure to pay claims involving error adds to a larger phenomenon of underpayment generated by the vast number of negligent injuries that never surface as claims.

That's right - not enough people injured by malpractice receive fair compensation for their injuries. All of that information coming from the New England Journal of Medicine.

One of the criticisms of the malpractice system is that too much of the money that goes into the system goes to the cost of litigation, with too little ending up in the pockets of an injured plaintiff. It's a fair criticism. It's also fair to recognize that delay and increased cost are a defense lawyer's friend, and the plaintiff's lawyer's enemy. A dream case for the plaintiff's lawyer would involve calling the defendant's insurance adjuster, negotiating a fair settlement, executing the settlement agreement, and getting a check at the earliest possible date. It almost never happens. Instead, even when liability is blindingly obvious, insurance companies want to make plaintiff's lawyers work for the money, and benefit from prolonging litigation during which time a severely injured plaintiff may decide that they would rather take a small settlement now than have to wait additional months or years to be more fully compensated. Returning to the New England Journal of Medicine:

Frivolous litigation is in the bull's-eye of the current tort-reform efforts of state and federal legislators. The need to constrain the number and costs of frivolous lawsuits is touted as one of the primary justifications for such popular reforms as limits on attorneys' fees, caps on damages, panels for screening claims, and expert precertification requirements. Our findings suggest that moves to curb frivolous litigation, if successful, will have a relatively limited effect on the caseload and costs of litigation. The vast majority of resources go toward resolving and paying claims that involve errors. A higher-value target for reform than discouraging claims that do not belong in the system would be streamlining the processing of claims that do belong.

Plaintiff's lawyers would get on board with that. Why won't Newt Gingrich's clients in the insurance industry?

Frankly, "tort reform" is a subject that a few poeple find interesting, but makes most people's eyes glaze over. That's why the insurance industry and its shills use misleading sound bites "junk lawsuits", "lawsuit lottery", etc., to mischaracterize the facts. (Why don't "tort reform" advocates ever show us the paraplegic in a wheelchair, or the severely brain injured child, who "won" this "lawsuit lottery"?) When there's real scholarship available from credible sources, such as the NEJM article quoted above, it's disgraceful that the mainstream media gives unquestioning coverage to the insurance company spin than they do to the facts, but... that's pretty typical of mainstream media coverage of contentious or scientific issues.

Speaking of shills....

The Newt Gingrich, John C. Goodman editorial is subtitled, "We don't need to study lawsuit reform for one minute longer", so I guess they've read the NEJM article and... yeah, right. They don't want to study lawsuit reform for one minute longer lest some facts enter the debate. It's enough to declare that "The current system is broken" then demand "reforms" that will ensure that even fewer victims of medical malpractice receive any compensation, and fewer of the rest receive fair compensation. And of all states to hold up as an example, Texas - a state that went farther than any other to kowtow to the insurance industry to the significant detriment of victims of malpractice. Tort reform was sold on lines like this: "52 counties in Texas now have no obstetrician. Wide swaths of Texas have no neurosurgeon or orthopedic surgeon". Four years after "tort reform", the number of counties without obstetricians is unchanged--152 counties still have none, according to the Observer's examination of county-by-county data at the state Medical Board... Nearly half of Texas counties--124, or 49 percent--have no obstetrician, neurosurgeon, or orthopedic surgeon. Those specialists aside, 21 Texas counties have no physician of any kind." Let's not forget the New Yorker article, in which a doctor turns a spotlight on high medical costs in Texas:

Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.

“Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said.

Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said.

“It’s malpractice,” a family physician who had practiced here for thirty-three years said.

“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?

“Practically to zero,” the cardiologist admitted.

“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.

So Texas-sized "tort reform" left it with one of the highest cost, most wasteful healthcare markets in the nation. And when confronted with that fact doctors still try to blame "malpractice litigation" even though virtually no malpractice suits are filed.

In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.

It must make Newt Gingrich very proud.

All of that said, let me briefly touch on the reasons why I don't think that the insurance companies are eager for the federal government to impose Texas-style "tort reform" upon the nation, and are instead appear largely content with the softer reform measures that exist in both the House and Senate bills. It's not that they're trying to silence their shills, but even Gingrich put "malpractice reform" eighth on his list of "ideas". If you impose a national cap on damages, it's likely to be higher than many state caps - many such caps were imposed decades ago and have not since been raised - and to be indexed to inflation.

Further, it's easier to target Congress with a litany of cases in which a cap brought about an unjust result, both because you're targeting one legislative body instead of fifty and because you're better able to get media attention, potentially having the cap raised in subsequent years. It's hard to make a "conservative" case for a federally imposed statute of limitations for malpractice cases, and you suffer the same consequence - it is easy to find examples of people, particularly people injured as minors, whose claims were cut off by a statute of limitations before they realized the severity or cause of their injury, or before they were legally competent to pursue the claim. A national statute of limitations could significantly expand the number of people able to bring claims currently time-barred under state law. Imposing an abolition of joint and several liability would be hard to disguise as anything but an intrusion on states rights. Further, all of these restrictions would be subject to appeal to the U.S. Supreme Court which, although largely pro-industry, might nonetheless have a difficult time finding a constitutional basis for supporting the federalization of a single type of tort, or reading the 7th Amendment out of the Constitution.

You would also think that a "conservative" like Newt Gingrich would want to empower states - any of which can, right now, emulate Texas - to enjoy the right to fashion their own remedies consistent with their own views of public policy. Surely he's heard of this thing called "federalism"? Instead, as with insurance regulation, he'll apparently support anything his industry sponsors want even if it undermines federalism. Of course, that's no surprise if you look at his track record.

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Gingrich & Goodman Idea #7: "Inform Consumers"

As a healthcare consumer, you already have a lot of information available to you. In what they purport to be a GOP reform idea, Newt Gingrich and John C. Goodman want to give you more. It's reasonable enough to make information available, but here's the thing: this is complicated stuff. If you're going to try to reduce terabytes of data into a form that a typical layperson can understand, to put it mildly the result will be oversimplified. If you try to add the context necessary to understand the data, the result will be complex. Does a hospital's survival rate for a particular procedure directly correlate to the skill of its surgeons, or is it that the hospital with the better survival rate turns away the difficult patients? Also, at times data will inspire a conclusion that is premature or incorrect, due to a lack of sufficient data to support a statistically significant finding, differences in procedure not reflected in the data, data entry errors, and many other potentially confounding factors.

Further, these are the type of issues where patients should be able to rely upon the advice of their own doctor. The doctor should be able to advise them about choices of procedure, surgeon, clinic or hospital, and ensuring that the doctor has good data available could assist her in making a recommendation. But to dump that information and responsibility upon a typical patient is not helpful, and will often be overwhelming.

Gingrich and Goodman specifically propose using government data, "like Medicare claims data (stripped of patient information)", to "help consumers answer important questions about their care." Do they mean that the data should be stripped of patient information before it is analyzed? Because without that context you're inevitably going to skew the result of the analysis. I don't believe that Medicare is presently willing to release any such data for analysis without stripping individual patient information, so if Gingrich and Goodman want that to happen they will have some serious privacy concerns and regulatory hurdles to overcome. (Even if a patient is identified by a random number, if you put enough pieces together you can often associate the record with an actual person. But without that data, you don't necessarily know if the person who died during a heart bypass operation had a health history that put them at high risk of death, skewing a hospital's statistics.)

But you know what? More information is rarely a bad thing, and a lot of those concerns can be overcome. Even if the data is used primarily by doctors advising their patients, it could be very helpful. And there are politicians actively working toward this type of solution. So let's look at this "GOP idea" in the real world.

Equipping patients and the entire health community with the most accurate medical research available will enable them to make the best possible clinical decisions, improve care quality, and avoid ineffective and harmful health outcomes.

What’s more, a better understanding of which medical treatments work and which don’t could save money. It’s estimated that one-third of procedures and treatments administered in the United States have no proven benefit and account for up to $700 billion annually in current spending. Moreover, some of these treatments can have harmful side effects, produce worse health outcomes, and then, as a result, add to the soaring costs of medical care.

Congress and the Obama administration have recognized the importance of this research by investing $1.1 billion in comparative effectiveness research as part of the $787 billion American Recovery and Reinvestment Act. Despite broad support for this kind of research among the American people, health care providers, and much of the health care industry, there has been vocal opposition to comparative effectiveness research based on fears that the government will intrude on the patient-provider relationship and coverage policies.

The GOP response to that? Largely the accusation that the Obama Administration was trying to put a bureaucrat between patients and their doctors and ration their care. An actual GOP proposal attempted to cancel funding for comparative effectiveness research. Gingrich and Goodman have their political parties confused.

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Gingrich & Goodman Idea #6: "Protect Early Retirees"

In their "Ten GOP ideas" piece, Newt Gingrinch and John C. Goodman observe,

More than 80% of the 78 million baby boomers will likely retire before they become eligible for Medicare. This is often the most difficult time for individuals and families to find affordable insurance.

That, of course, is why 60 Democratic Senators supported a Medicare buy-in for those workers, right up to the point somebody yanked Joe Lieberman's chain and caused him to flip-flop. Moreover, the Democratic Party was apparently more attuned to the actual needs of people who need health insurance but have not yet reached retirement age, because they did not require that a worker retire young before qualifying for the buy-in. If Gingrich and Goodman truly see this as a serious issue, as the Democrats do, why aren't they endorsing that solution?

Instead, they propose that "employers to obtain individually owned insurance for their retirees at group rates". Individual policies at group rates... they truly don't see a tension between those two concepts? Given that some of these individuals will be retiring early due to health problems, what do you think is going to happen to those rates? Insurance companies are already notorious for jacking small employer group rates through the roof when even one employee comes down with a costly illness, such as cancer. Do Gingrich and Goodman picture that the "group rate" concept will be preserved because the insurer will dump that individual, or do they simply not care that the "group rate" would quickly become unaffordable?

Gingrich and Goodman propose that employers help employees save for retirement by using health savings accounts; great, but in case they haven't noticed, most people don't have a lot of extra cash lying around these days. And what happened to the idea that we should break the tie between health insurance and employment? They also propose that "some or all of the premium amount for post-retirement insurance" go into a retiree's health savings account. "Some" meaning that the retiree has to pay an amount above and beyond the cost of insurance - because so many retirees have extra cash lying around to add to their savings accounts. "All" meaning that there is in fact no insurance, just a health savings account. Seriously....

Really, if Goodman, Gingrich and the GOP cared about early retirees, or people nearing the age of retirement who have difficulty obtaining or affording private insurance, but did not want to directly subsidize private insurance at a rate that would make it affordable to that high-cost group, they would be on board with the Medicare buy-in. Instead, they make noises and blow smoke, hoping that you don't notice that their "idea" isn't viable. Not one Republican vote for a Medicare buy-in? Tell me again, just how much the GOP cares about early retirees....

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Gingrich & Goodman Idea #5: "Don't Cut Medicare"

Ah, memories. Remember back in the Clinton era, when Newt Gingrich engineered a shut down the government in no small part over the Republican Party's demand for a $270 billion cut in Medicare spending? Remember back in... right now... when the only "serious" Republican budget proposal involves privatizing Medicare and slashing its funding? Don't believe your lyin' eyes - Newt Gingrich and the GOP love themselves that Medicare program. It's untouchable.

There is no question that Medicare is on an unsustainable course; the government has promised far more than it can deliver. But this problem will not be solved by cutting Medicare in order to create new unfunded liabilities for young people.

Well, let's see... If Medicare is unsustainable due to its expenditures, it's a given that Newt Gingrich opposes tax increases, and he's claiming that he opposes cuts to Medicare spending, what's left?

Cutting Medicare's coverage.

There's no fourth alternative. If Gingrich truly has flip-flopped on his call for massive cuts in Medicare, and believes despite the current budget proposal from Paul Ryan that this is a "GOP" idea, he can only have one thing in mind: reduced benefits for Medicare recipients. Whether that's cuts in services, increased copays and deductibles, a mandate that recipients pay premiums for their coverage, or some combination thereof, Gingrich is proposing offloading costs from Medicare onto its recipients. While pretending that he's trying to preserve funding. (A newt in sheep's clothing.)

Update: Paul Krugman summarizes the actual GOP idea on Medicare cuts: "So, cutting Medicare by $500 billion is wrong — support Republicans, who want to cut it by $650 billion!"

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Gingrich & Goodman Idea #3: "Meet the Needs of the Chronically Ill"

A third "idea" that Newt Gingrich and John C. Goodman claim belongs to the GOP is the idea that health insurance should "Meet the needs of the chronically ill". You know, sometimes it's better to admit you only have nine ideas than to claim that the Republican Party is more concerned than the Democrats about people suffering from chronic illness. What does Gingrich propose?

Most individuals with chronic diseases want to be in charge of their own care. The mother of an asthmatic child, for example, should have a device at home that measures the child's peak airflow and should be taught when to change his medication, rather than going to the doctor each time.

If the GOP were to write up a simple bill encapsulating this proposal, overlooking the fact that it would likely increase healthcare expenditures, I expect that the Senate would pass the bill by a very wide margin, with most of the "nays" likely to come from the Republican side.

What does Newt have in mind? If you recall, one of his goals is to deny coverage for routine medical care, such that you would have to pay for that care out-of-pocket. This proposal is apparently meant to soften the impact of the fact that many chronically ill people will not be able to afford the care they need if Gingrich's dream comes true. So instead he imagines them being given medical devices and trained to "be in charge of their own care", while pretending that his goal is to empower them.

That's not to say this is a bad idea, or shouldn't (to the extent possible) be implemented without gutting health insurance coverage. But there's another side to this: if there were substantial cost savings to be achieved, health insurance companies should be more than happy to implement this idea without any prodding from Congress. And in fact, when it is economically viable, the chronically ill are given the tools they need to administer insulin, breathing treatments, and other treatments that they can reasonably perform at home. It also follows that, to the extent that it is not done, it's because their actuaries don't project a cost savings.

The question thus becomes, are Gingrich and Goodman making this proposal because they seriously want to empower patients even though it will increase healthcare costs, are they making this proposal because they want patients to be empowered to the maximum extent once the device and home-based care are no more costly than the status quo, or are they making this proposal because they want to put a friendlier spin on what prior editorials suggest to be Gingrich's goal - making patients responsible to buy the machine from health savings accounts (if they actually have health savings) with the consequence of their failing to do so (or inability to do so?) meaning that they either forego the care or pay out-of-pocket? Because, as I suggested before, it's only for that third option that they should not be able to easily construct and pass a bipartisan bill.

Consistent with that inference, Gingrich and Goodman propose that those with chronic illnesses can be allowed to self-manage their care through "Health Savings Accounts". They hold up as an example a program operated by Medicaid. So are they advocating "Medicaid for all", at least for basic care and for the disabled? Of course not.

Their contempt for community rating is made plain in their last "reform" proposal, having insurance companies "specialize in managing chronic diseases" so that healthier people can obtain cheaper insurance from non-specialist carriers. They argue, "This is the alternative to forcing insurers to take high-cost patients for cut-rate premiums, which guarantees that these patients will be unwanted" - but no, what it will do is guarantee that you don't have insurance for your chronic illness if and when you develop such an illness. After all, everybody gets sick at some point, and everybody dies. The Gingrich/Goodman plan seems intent on making sure that you bear that cost out-of-pocket (if you can afford it) rather than spreading the risk through insurance - despite the fact that the purpose of insurance is to spread risk.

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Gingrich & Goodman Idea #2: "Make Health Insurance Portable"

Why is it that group health insurance plans cost less - usually far less - per enrollee than individual plans with comparable benefits? There are two obvious reasons. First, the larger the group, the more health care costs can be spread across the group, making the insurer's costs far more predictable even while insuring people with pre-existing conditions. Second, people who are healthy enough to work jobs that carry health insurance benefits are, on the whole, going to be healthier than a population of people willing to pay out-of-pocket for comparable coverage but who do not hold jobs.

Newt Gingrich is acutely aware of the fact that people who want health insurance, and perhaps particularly those who want comprehensive health insurance coverage but cannot afford it, are concerned about the cost of medical care for themselves and their families. He has thus made it a cornerstone of his own "reform" proposals to shift risk from the insurer to the individual - that is, to make the individual "responsible" for more of the cost such that the individual will "choose" to consume fewer healthcare services. I don't know how much Gingrich believes that this approach would "save" in the broader market - relatively healthy individuals who take a fevered infant to the emergency room rather than waiting to see if a high fever breaks, or who seek treatment for a lung infection before it either clears up on its own... or turns into pneumonia). But I suspect that his actual goal is to target people with chronic health conditions so that, for example, diabetics will pay more out-of-pocket for their continuing care, medicine and supplies. It would be nice if Gingrich were more specific on the subject but, if my hunch is correct, it's easy to understand why he's not.

The second idea proposed by Gingrich and Goodman as a "GOP health idea" is to "Make health insurance portable". They propose portability as a "way of solving the problems of pre-existing conditions", and advocates for employment-based insurance to "travel" with employees between jobs and "in and out of the labor market". It's really difficult for me to be charitable to Gingrich here - to find a way to interpret this proposal as consistent with his words. Because the net effect of the proposal would be to eliminate the insurer's ability to define a predictable group for its group rates. If, three years into the plan, the "group" now includes a significant number of people who have quit to take dangerous jobs, who have become too sick to work, who are self-employed doing who-knows-what, who are scattered across dozens of employers... the dynamics of the group are no longer the same. The "group" rate can be expected to skyrocket, amounting to an averaging of individual rates as opposed to the formerly discounted group rate.

Gingrich and Goodman are similarly dishonest in suggesting, "individuals should have the ability to purchase health insurance across state lines". At present, if I want to offer insurance in a state with strong consumer protection laws, I have to abide by the laws and regulations of that state. Gingrich and Goodman want me to be able to skip across state lines into whatever state offers the fewest protections and mandates the least amount of coverage, yet still be allowed to offer insurance in the more protective state without following its laws.

This proposal is unlikely to draw additional insurers into a state due to high costs of entry: there is a huge cost in developing a provider network within a state, signing up enough customers to make a plan profitable, and maintaining that level of subscribers. But you can bet your money that insurers will scramble into the state with the fewest regulations to fatten their bottom lines.

Gingrich and Goodman state, without connecting the thought to their specific proposals, that "When insurers compete for consumers, prices will fall and quality will improve." That goal can be achieved within the current system, such as when an employer offers a cafeteria plan allowing employees to choose between participating insurers and multiple insurance plans. That goal could be advanced by adding a serious national player to the scene - such as a "public option". But it's at best disingenuous to pretend that undermining group-based insurance rates or allowing insurers to regulate across state lines to avoid consumer protection laws and state regulations will increase "competition" in any way that is beneficial to consumers. On the other hand it is consistent with Gingrich's long-stated goal of weakening the scope of insurance coverage while forcing consumers to pay for more of their care out-of-pocket. What a surprise.

Finally, given that the current Senate bill includes some language allowing for the type of portability Gingrich and Goodman favor, why isn't the GOP working with the Senate over the details of that idea rather than stonewalling the Democratic bill and pretending that this is exclusively a GOP idea?

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Gingrich & Goodman Idea #1: "Make Insurance Affordable"

The first idea proposed by Gingrich and Goodman as a "GOP health idea" is to "Make insurance affordable". I mean, wow. It's so simple. So elegant. So... platitudinous. It's fair to respond that the Democratic bill shares that goal.

Gingrich and Goodman complain that the current approach to taxing health insurance is "arbitrary and unfair", whining about "Cadillac plans" (the type of plan that they, themselves, likely enjoy through their own employment) getting a big subsidy while people buying their own plans get almost no tax break. They claim that "More equitable tax treatment would lower costs for individuals and families" - true. You could give everybody the same tax break, and suddenly insurance would be more affordable for those buying their own plans. Which, of course, is why Gingrich and Goodman immediately drop that ball - that's certainly not the type of tax equality that they want.

They then engage in an appeal to authority - not a specific authority, but an unnamed authority. "Many health economists conclude that tax relief for health insurance should be a fixed-dollar amount, independent of the amount of insurance purchased." That sounds a lot like the tax credit idea floated by John McCain during his presidential run. But here's the thing - the goal of that proposal is not to make health care more affordable. It's about limiting the benefits available through health insurance policies, by discouraging employers (save, of course, at the executive level) from offering comprehensive insurance plans. By failing to identify the economists behind their appeal to authority, Gingrich and Goodman avoid the other side of those proposals - that vocal proponents of that particular reform (like Gingrich himself) propose this idea with the goal of reducing the number of people who enjoy comprehensive health insurance.

By putting the words into the mouths of "many health economists", Gingrich and Goodman cleverly avoid endorsing the idea themselves. Why not "We agree with those health economists who argue..."? For that matter, how about explaining how representative those views are among health economists (does "many" mean 3%, 30%, 60%), and why as can be reasonably inferred do "many" health economists reach other conclusions.

Moreover, if this is truly a GOP goal, where are the GOP voices in favor of the current Senate bill, that includes a surcharge on high cost plans. That could be treated as a starting point for phasing out the subsidy for employer-based coverage. Gingrich knows enough about Congress to understand that the tax subsidy is not going to be wiped out overnight, or even over a few years, so it's dishonest of him to suggest that the GOP would somehow be able to do something dramatically different than what the Senate Democrats have proposed.

Finally, if we truly are talking about "fairness" here, we could decide as a nation, "Here's the minimum amount of insurance coverage a person should enjoy in our society," then attach a dollar figure to that coverage. Note that although Gingrich likes to pretend that the amount should be equal across the nation, if you know anything about health insurance you know that the cost of similar coverage will vary depending upon your geographic location. Once that amount is determined, people could be issued a tax credit in that amount to cover the cost of their basic policy. Or we could develop a national insurance plan that covers those basics and not have to worry about tax credits. That would provide everybody with equal, reasonably priced insurance, and anybody who wanted more could turn to the private market.

Fair, affordable, and... well, let's be honest. Although it's entirely consistent with what he writes in his editorial, were such a policy implemented Gingrich's head would probably explode.

A cogent case can be made for why the present system of tax subsidies for health insurance is unfair, why equal tax benefits should be extended to the self-employed, why phasing out the subsidy may be good tax policy and how doing so may help untether people who need continuity in their healthcare coverage from a particular employer. But those issues don't appear to be of great interest to Goodman and Gingrich. Even if you have missed Gingrich's prior commentary on the subject, it is patent from the balance of their editorial that the goal here is to "make insurance affordable" by giving people less insurance coverage. It's likely under Gingrich's various plans that this is "less is more" turned upside-down - you get less coverage for more money than an equivalent plan would currently cost. But it's "affordable" because you get a lot less coverage and thus still costs less than your current comprehensive health insurance plan.

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Newt Gingrich's "Health Idea" Deceptions

Although they say "Never attribute to malice that which can be adequately explained by stupidity", Newt Gingrich is not a stupid man. So there's no reason to cut him, or his writing partner Jon C. Goodman, any slack over their Wall Street Journal piece on "GOP Health Ideas". The first distortion comes right in the headline - despite his past role, Gingrich is not a spokesperson for the Republican Party. Instead he profits by advocating on behalf of the health industry. John Goodman likes to brag that he helped take down healthcare reform under the Clinton Administration, and if his mini-bios are indicative prefers to be called libertarian as opposed to "Republican". In other words, these aren't GOP ideas - they're the private ideas of the authors.

It isn't difficult to find the actual GOP ideas on healthcare reform. All you have to do is go to GOP.com and click, er, look under, er... search... Hm. Not so much a GOP priority? Well then, let's try GOP.gov... and whoah - they summarize their plan as reflecting four ideas:

Number one: let families and businesses buy health insurance across state lines.

Number two: allow individuals, small businesses, and trade associations to pool together and acquire health insurance at lower prices, the same way large corporations and labor unions do.

Number three: give states the tools to create their own innovative reforms that lower health care costs.

Number four: end junk lawsuits that contribute to higher health care costs by increasing the number of tests and procedures that physicians sometimes order not because they think it's good medicine, but because they are afraid of being sued.

And four ideas that neither offer any meaningful reform beyond weakening state protections to health insurance consumers and victims of malpractice - while simultaneously giving lip service to federalism. The CBO's scoring of the last "serious" GOP proposal boiled down to "It's just short of a joke". The proposal provided about 40% of the cost savings projected from the Democratic bill, while insuring 33 million fewer people (3 million more people insured by 2019, as opposed to 36 million under the Democratic bill).

Now I don't want to read too much into a CBO rating, as their methodology is not always great - and neither is their track record. Being nonpartisan does not, of itself, make your economic projections more accurate. But as CBO ratings are often held up as a gold standard by both major parties, it seems reasonable to compare actual GOP proposals to the Democratic bill on that basis.

No wonder Gingrich and Goodman prefer to embellish. Follow the links for more information on each idea:

1. Make insurance affordable


2. Make health insurance portable


3. Meet the needs of the chronically ill


4. Allow doctors and patients to control costs


5. Don't cut Medicare


6. Protect early retirees


7. Inform consumers


8. Eliminate junk lawsuits


9. Stop health-care fraud


10. Make medical breakthroughs accessible to patients