Minnesota's March for Healthcare - in conjuction with the nationwide movement of marches on Sunday, September 13 to demand real healthcare reform.
In cooperation with TakeActionMN
Sunday, September 13, 2009 at 12 noon
Phillips Park
1530 E. Franklin Ave.
Minneapolis, MN
Speakers:
Congressman Keith Ellison
John Marty, State Senator and Candidate for Governor
Reverend Grant Stevenson
Erin Murphy, State Representative
For more information visit www.march4healthcare.com
email: mnhealthcarereform@gmail.com
[This event is not sponsored or affiliated with Organizing for America. It is a truly grassroots action at its most powerful! and finest!]
State and federal lawmakers are focusing increasingly on health care reform, and a growing number are expressing serious interest in "patient-focused" or "consumer-centered" approaches. This is certainly a positive development. Lawmakers of both parties are now more inclined to advocate making the patient the focus of America's health care system.
However, the vocabulary of health care policy is often elastic, and different people use the same terms to express significantly different concepts. This elasticity adds to the general confusion among the public and policymakers that seems to plague this area of public policy and often results in legislators and taxpayers talking at cross-purposes or past one another.
Consequently, clarifying the rationale, objectives, and principles of consumer-centered health care reform is important so that participants in the discussions, particularly the taxpayers, accurately comprehend the concepts and implications of this approach and are better equipped to evaluate the various proposed reforms at the federal and state levels.
Key Principles
The fundamental objective of a patient-centered health care system is to maximize value for individuals and families so that they receive more benefit and better results for their health care dollars, both as patients and as consumers buying health insurance. Only when individuals choose and own their own health insurance will the other actors in the system—health plans and providers—have the right incentives to deliver better value in the form of improved results at lower prices.
If policymakers are serious about real patient-centered, consumer-driven health care reform, they should ensure that their legislative proposals embody six key principles:
The Key Tests of Reform
Notall health care reform legislation that is labeled consumer-oriented is equally effective or significant. The key test is whether or not it puts in place structural changes that maximize the ability of a large number of individuals to make basic choices about their own health insurance coverage and medical care.
Individuals are both consumers and patients. In a consumer-centered health system, individuals directly control the flow of dollars, buy and own their own health plans, pick the kinds of coverage that they want, and determine which plans offer them the best value.
In such a system, consumers expect transparent prices, and consumer choice stimulates competition among plans and providers to offer better value for money. That competition, in turn, drives innovation in both clinical practice and plan design. For individuals as patients and consumers, value for money is judged in terms of results: better medical outcomes, improvements in their health condition or status, cost-effective treatments, and health plans that save them money by helping them stay well and, when they do need care, by identifying the providers that offer the best results at the best price for their particular condition.
Thus, true consumer-centered health reform is system-focused reform, not product-focused reform. Its objective is to improve performance and results by changing the basic structure and incentives of health care markets so as to maximize value for money in health insurance and medical care. It is not simply an exercise in legislating new product designs or trying to plug gaps in coverage by crafting new programs for targeted subpopulations. Instead, true consumer-centered health reform focuses on making fundamental structural changes in the system, as opposed to merely expanding the existing system or micromanaging insurance plan designs or provider reimbursement methodologies.
Policymakers need to step out of the conventional mindset that accepts the basic structure of the present system as a given and attempts only to modify it around the edges. For example, legislative proposals to promote certain product types— e.g., health maintenance organizations (HMOs) and health savings accounts (HSAs)—may well have beneficial effects, but they do not fundamentally change how the system functions as long as someone else picks the health plan for the individual. Similarly, no amount of regulatory tinkering with provider reimbursement rates or payment methodologies can create more than marginal improvements in value as long as the system vests control over key decisions with employer and government "payers" who are not the ones receiving the medical care or using the health insurance policy.
Rather, consumer-centered health reform challenges policymakers to redesign the basic rules of the health care market to create new incentives for all of the actors in the system to put the interests of consumers and patients first.
Properly designed structural reforms will also produce a better framework and new incentives for addressing the current system's failings in cost, access, and quality more effectively. If responding to consumer needs and preferences is made the organizing principle of the system, then insurers and providers will have the right incentives to develop innovative ways to deliver better value to consumers and patients in the form of lower costs and improved outcomes.
In a reformed market, competition will produce new and better plan designs, clinical practices, and provider payment arrangements without lawmakers needing to micromanage the process. At the same time, it will generate new opportunities for lawmakers to focus public assistance more effectively to ensure that all Americans have access to the benefits of a system that offers better value.
The fundamental problem with the current system is that it encourages all participants (payers, insurers, providers, and patients) to engage in a giant game of cost-shifting, with each party trying to stick one or more of the others with a bigger share of the bill. Thus, while there may be plenty of competition in the present system, much of it is a zero-sum competition in which there is a loser for every winner. What America's health care system desperately needs are structural changes that create positive-sum competition in which all participants can "win" by working, often collaboratively, to improve the health care value proposition.[1]
The Consumer As Key Decision Maker
The place to start examining any economic or social system is with its basic organizing principle, which is identified by asking "Who is the key decision maker in the system?" In any economic or social system, the key decision maker is the one who sets the parameters for the other participants in the system. The other participants must act in response to the needs or preferences of the key decision makers.
Political science clarifies this process. For example, in a democratic system of representative government, the organizing principle is popular sovereignty, identified by the fact that voters are the key decision makers. Other participants (e.g., office holders, public employees, lobbyists, and interest groups) operate within the framework of the preferences periodically expressed by voters in elections. To advance his or her interests successfully, another participant must ultimately persuade voters either that they already want what the participant is proposing or that they should want it.
This creates a cascading chain of incentives throughout the system. For example, the most successful way for a lobbyist to persuade a politician to vote for what the lobbyist wants is to show the politician how such a vote would be popular with voters.
Other political systems (e.g., monarchies, aristocracies, and dictatorships) have different organizing principles, each of which can be determined by identifying the key decision makers in these systems.
The same holds true in economics. Most market economic systems are "consumer-driven" because the individual customer is the key decision maker. The other participants (e.g., producers, shippers, wholesalers, and retailers) must operate within the framework of the consumers' preferences as expressed through their purchases. To advance their own interests successfully, the other players must find ways to persuade customers either that they are offering what the customers already want or that the customers should want what they are offering.
Again, the result is a cascading chain of incentives. Thus, the surest way for a shipper to get a producer's business is to demonstrate that it can deliver goods to retailers or consumers more quickly and at less cost.
As in politics, alternative economic system designs can be recognized by identifying the key decision makers and, thus, the systems' organizing principles.
For example, the organizing principle of a monopoly is that the economic sector is "producer-driven." A monopoly exists (whether by accident or by design) when only one producer provides a particular product, thus making that producer the key decision maker. With no alternative producers available, other participants in the sector (e.g., consumers and retailers) are constrained by what the sole producer decides to produce and its quantity, timing, and price.
Likewise, when suppliers collude, such as through a guild or cartel, the resulting market can be described as "supplier-driven," reflecting the fact that suppliers hold the key decision-making power in that particular sector.
The Health Care Sector Anomaly
In health care, on the supply side of the supply and demand equation are physicians, hospitals, and other health care professionals and institutions. Collectively, they are commonly referred to as health care providers. On the demand side are the patients who are seeking or receiving medical treatment. The broader term "consumer" encompasses not only patients, but also individuals who, while not actively seeking or receiving medical care, purchase related products and services, most notably health insurance.
In the U.S. and many other countries, health care differs from most other economic sectors because government policies have sponsored, promoted, and maintained an anomaly in the sector—an additional set of participants known as third-party payers. While individuals always ultimately pay the costs of any health system, governments have instituted policies that effectively divert a portion of their incomes into the hands of others (the payers), who then make the basic or key decisions on how to spend the money on behalf of patients.
The simplest variant of this arrangement is the single-payer system, in which the government taxes its citizens and then pays medical providers for treating them. The U.S. and some other countries have developed multipayer variants of the same basic model.
In multipayer health systems, the government is almost always one of the payers, but its role is more limited than in single-payer systems, typically operating tax-funded medical care payment programs only for certain subgroups of the population. For example, in the U.S., the federal government runs a tax-funded single-payer system for the elderly called Medicare, while the state governments run a similar system for the poor called Medicaid.
However, for the majority of individuals in countries operating multipayer health systems, the relevant third-party payers are private entities such as employers, unions, or associations. These private payers divert a portion of their workers' or members' income either to buy health insurance or to pay medical bills directly on behalf of their employees or members. These arrangements can be either mandatory, as in Germany, or voluntary, as in the U.S.[2]
Yet, in a voluntary third-party payment system, individuals are unlikely to hand over large chunks of their income and the authority to spend it without something that makes the arrangement significantly more advantageous to them than buying the services directly. That is particularly true for something as personal and important as health insurance and medical care.
In the U.S., these arrangements exist largely because employee compensation that is diverted through employers to buy the employees' health insurance is exempt from federal income and payroll taxes. In contrast, if workers wanted their employers to divert part of their compensation for other purposes—such as buying groceries, paying for their housing, or leasing cars for their personal use—they would find that tax law treats such arrangements as income and taxes the workers accordingly. While the law does not prevent employers and workers from entering into third-party payment arrangements for food, housing, transportation, or anything else, such arrangements are uncommon because they offer no clear advantage (tax or otherwise) to workers over receiving their compensation in cash and then paying directly for the goods or services of their choice.
The Evolution of the Health Care System
Current health care systems are a relatively recent phenomenon. They evolved in response to advances in biology, chemistry, and physics since the end of the 19th century that transformed medicine into a scientific discipline and an expanding economic sector. Even though the purpose of medicine is to better the lives and health of patients, the health care financing arrangements that evolved over the past century have never been truly consumer-centered.
Through at least the first half of the 20th century, health systems were essentially provider-centered. Patients were expected to defer to the judgment of medical professionals and to pay what was charged. It was considered highly unprofessional for physicians to engage in explicit price competition. Hospitals granted admitting privileges to physicians, and physicians referred patients to the hospitals where they had such privileges. Thus, a hospital's real customers were the doctors who controlled the flow of paying patients, not the patients themselves.
This basic structure persisted even as third-party payers, whether governments or employers, were introduced into the equation. Third-party payers were expected to pay the usual and customary charges billed by physicians and hospitals for their services, but not to question the benefits, quality, or value of these services. This provider-centered focus can be seen in early health insurance arrangements. For example, in the 1930s, hospitals organized Blue Cross and doctors organized Blue Shield to guarantee providers steady, predictable income streams by having patients—and later, their employers—effectively prepay for medical care on a subscription basis.
However, the resulting growth in the cost of medical care eventually spurred payers to start questioning the bills, beginning in the 1970s. At first, the focus was on the prices charged by providers. Payers, both government programs and private insurers working for the employers who were their customers, imposed payment limits on provider charges. Over time, those initial limits evolved into complex and comprehensive payer-imposed provider fee schedules.
However, as the payers soon discovered, prices constituted only half of the cost equation. Costs were still climbing thanks to steady increases in the volume and intensity of the medical care being provided. In recent decades, payers have tried to tackle this other half of the cost equation with a variety of restrictions on patient access to specific treatments or technologies.
The result is that today's health care financing systems, whether at home or abroad, are functionally payer-centered, with third-party payers having displaced providers as the key decision makers in the system.
In this specific sense, there is no qualitative difference between a single-payer system and a multipayer system. Both systems are payer-centered. Consequently, both systems generate the same incentives for other participants to respond to payers' demands and preferences rather than those of providers or patients. In a single-payer or a multipayer system, the payers decide whether or not to contract out to private insurers all or part of their role in managing the system, and they determine the terms and extent of such contracts. Private insurers therefore first serve the interests of the third-party payers who are their customers.
Thus, the relevant question is "For whom do the private insurers work?" not "Are private insurers part of the system?"
The Alternative: A Patient-Centered, Consumer-Based System
The obvious shortcoming of a provider-centered system is that it distorts the system in the direction of providing more, regardless of cost. The natural tendency of providers is to assume that increasing the volume and intensity of medical services will generate more benefit. Of course, this assumption is not consistently true. Depending on the circumstances, a particular test or therapy can be unnecessary or ineffective. Indeed, many medical interventions entail significant risks to the patient and can cause more harm than good. At other times, the modest benefits are not worth the costs.
In contrast, the shortcoming of a payer-centered system is that it distorts the system in the opposite direction by focusing on the cost side of the equation to the detriment of the benefit side. The most obvious, most effective, and simplest way to limit costs is by not spending money, but simply paying less or refusing to pay at all does not inherently produce more benefit or better value for the patient.
Furthermore, both a provider-centered system and a payer-centered system have an inherent bias to favor short-term considerations over long-term considerations. In a provider-centered system, the incentive is to do more now without adequately considering the possibility that such a course of action could produce a worse result later. In a payer-centered system, the incentive is to save money today without adequately considering the possibility that this could increase future costs.
Neither a provider-centered system nor a payer-centered system has the requisite incentives to maximize value systematically and consistently. Only consumers have a natural interest in a system that reduces costs while simultaneously improving results over the long term.
For any economic system to be value-maximizing, it must consistently and broadly reward consumers with lower cost and greater benefits if they seek the best value and must reward producers and suppliers with more business and higher incomes if they offer a better value than their competitors.
Thus, the foundational insight behind consumer-centered health care reform is that the only way to achieve better value in health care is to make the consumer the key decision maker in the system. Only when users and payers are the same will the incentives in the health care system properly align to seek and generate better value. Since third-party payers are never the users of the system—after all, doctors and hospitals treat people, they don't treat governments or companies—the only way to align the incentives to produce better value is to give those who use the system (patients and consumers) control over the funding and the associated spending decision. No other alternative arrangement can systematically and consistently produce more for less and secure value for the patient.
The Objectives of Patient-Centered, Consumer-Based Reform
The overarching objective of consumer-centered health care reform is to transform the health care market into one that maximizes value, meaning that the system's operational dynamic is competition among participants to produce better results at lower cost for patients and consumers. Once delivering better value to consumers becomes what enables other participants (e.g., doctors, hospitals, insurers, drug makers, and insurance agents) to "win" within the system, many of the current problems start to solve themselves. A consumer-centered system begins to control costs because it creates increased pressure to justify costs better in terms of demonstrated benefit. At the same time, a consumer-centered system generates pressure to improve results by demanding data showing that anticipated benefits are commensurate with expected costs.
Consumer choice also creates stronger incentives for measuring and reporting quality and performance because consumers need that information to make better decisions, thus producing improvements in those areas as well. Even a portion of the access problem begins to solve itself. When health insurance attaches to the person instead of to the job, fewer people encounter circumstances in which they lose their health insurance coverage, and the size of the uninsured population is commensurately reduced.
A secondary objective is to provide lawmakers with a better foundation on which to build complementary public policies that more effectively address those access issues that competitive markets alone cannot solve. For example, the existence of a consumer-centered market for food makes it easier for policymakers to assist those who need help beyond what the market can provide through such means as subsidies in the form of food stamps or targeted incentives for grocery stores to operate in economically or geographically marginal, underserved areas. In a similar fashion, the presence of a consumer-centered, value-maximizing health system would allow lawmakers to focus tax dollars on helping those individuals who are financially or geographically disadvantaged to "buy into" a well-functioning system.
Another secondary objective is to encourage greater innovation. In this regard, health system innovation encompasses not only medical innovation to produce new and better treatments and therapies, but also innovation in organization and financing such as developing better clinical practices for treating patients, better provider payment arrangements, and better insurance plan designs.
This last point is particularly important. By putting the interests of patients and consumers first, a consumer-centered system forces other participants, particularly insurers and providers, to rethink their relationships and interactions. The current confrontational dynamic, in which providers try to force payers to spend more and payers try to force providers to charge less and do less, becomes an unproductive strategy for both sides because it does not produce the better value that consumers want. Instead, in a consumer-centered market, providers and insurers would find that they can both win (gain market share and increase income) if they collaborate to deliver better value (more benefits for less costs) to patients and consumers. This forces them to think more creatively and urgently about how providers can improve their quality, results, and efficiency and how insurers can restructure provider payment and contracting arrangements to capture newly created value and pass the savings and benefits on to their customers.[3]
The Key Principles of Real Reform
Lawmakers looking to design the right policy framework for enabling a consumer-centered, value-maximizing health system need to start with six key principles.
PRINCIPLE #1: Individual consumers are the key decision makers in the system.
In a consumer-centered health care system, individuals are the key decision makers with respect to medical treatments and health insurance. The current payers in the system (governments and employers) will still play an important role, but in a different fashion. They will no longer manage the details of the system, but will instead play supporting roles in assisting consumers, who become the system's primary decision makers. The role of employer will center on providing their employees as consumers with financial engineering and decision-support services.
The financial engineering aspect encompasses various employer strategies to help workers participate in the system more efficiently. For example, the workplace is a convenient location for distributing information and handling administrative tasks, such as workers choosing coverage from a menu of options during an annual open season. Similarly, employer participation in an automatic payroll deduction system for insurance premiums is an administrative efficiency that benefits workers at very little cost to employers.
Most important, as long as federal tax policy treats worker compensation for health care as tax-free to the worker if it is passed through the employer's hands, employers can leverage the tax code to ensure that their employees' spending on health insurance and medical care takes advantage of that favorable tax treatment. Doing so effectively lowers the cost of health insurance and medical care to workers by 15 percent to 50 percent because workers do not pay taxes on this compensation.[4]
Employers can also play a decision-support role by assisting their employees with information and guidance in making health care choices. Most often, this will take the form of the employer or an insurance broker under contract with the employer helping individual workers pick the insurance plans that best suit their personal circumstances and preferences. Employers can also offer their employees a range of related services, such as workplace clinics; health promotion programs; information on the costs, risks, and benefits of common treatments; and comparative data on the quality and results of health care providers. Employers inclined in this direction will find that numerous vendors already exist who are willing and able to bring these and similar programs into the workplace.
For governments, their role in a consumer-centered system shifts to financial assistance. Ultimately, the goal should be for the government to stop trying to design and operate public health insurance plans and instead focus on providing disadvantaged individuals with the necessary funds to buy into the same consumer-centered system that everyone else uses.
This will primarily take the form of steps to shift public assistance from a defined-benefit model to a premium-support model. In the current defined-benefit model, the government operates separate public health insurance plans for specified subsets of the population—something that government is poorly equipped to do competently. In a premium-support model, the government would operate programs to supplement the incomes of those who do not have sufficient funds to buy adequate health insurance and medical care in the market, just as the government now does with food stamps to help the poor buy groceries.
In some places, such as rural areas or economically distressed locations, governments might also provide assistance in the form of targeted subsidies or incentives to ensure that essential health services are available—for example, by funding clinics or offering inducements to health professionals to practice in those areas.
PRINCIPLE #2: Individuals buy and own their own health insurance coverage.
For a health system to be consumer-driven, health insurance coverage must be purchased and owned by individual consumers. In other words, the coverage contract must be an agreement between the insurer and the individual consumer. If the contract is between the insurer and some other party, such as an employer or a government, then the other party, not the individual consumer, is the insurer's real customer.
While at one level a coverage contract is a legal arrangement, it is primarily an economic arrangement. The legal aspects of the contract simply define the specifics of the underlying economic arrangement between the insurer as the supplier and the counterparty as the customer. As a supplier, the insurer is legally obligated and economically motivated to work in the interest of its customers. However, when the counterparty is an employer or government, that entity becomes the insurer's customer, and the counterparty's interests may differ from or be contrary to the individual's interests, even if the coverage is ostensibly purchased for the individual.
A simple analogy illustrates this key point. When a parent purchases breakfast cereal for a child, the customer is the parent, not the child. The parent and the child may have different opinions as to the best cereal to purchase. Indeed, these different opinions likely result from differences between the interests and preferences of the parent and the child. For example, the child likely prefers flavor over nutrition, while the parent will likely view nutrition as more important than flavor. Of course, the child's preferences likely influence, at least partially, the parent's decision, and cereal makers may even try to exploit this by pitching advertising to the child in the hope that he will influence his parents.
Ultimately, the buying decision rests with the parent, who is therefore the cereal maker's true customer. For the child to be the customer, the child must make the purchasing decision, using either his own money or money given him by a parent. Absent such a shift in decision-making authority, to sell more cereal, the cereal maker must first make its products attractive to the parents who will buy them, regardless of how attractive it makes the cereals to the children who will eat them. This means that the cereal maker must focus on the aspects that matter most to parents, such as nutritional content or pricing that gives them good value for their money.
While parents letting their children choose which breakfast cereal to buy is probably not a good idea, having individual consumers—not their employers or the government—choose their own health insurance plans is a good idea.
PRINCIPLE #3: Individual consumers choose their own health insurance coverage.
Individual ownership of coverage is an essential criterion for a consumer-driven market, but it is not the only criterion. A market characterized by individuals purchasing the product is still not a consumer-driven market if only one product is available, if there is only one supplier, or if the suppliers are organized in a cartel.
In such monopolistic circumstances, the lack of meaningful choice for consumers means that the key decision-making power still resides on the supply side of the economic equation. For the market-shaping power of the key decision maker to shift from the supply side to the demand side, consumers must have a choice of competing products and suppliers. Only then must suppliers respond to consumers instead of the other way around.
The linchpin of a consumer-centered health care market is the opportunity for individuals to choose the health insurance coverage that best suits their own preferences. While choice of health care providers is certainly essential to a well-functioning, consumer-centered market, the ability to choose among a diverse array of competing health insurance plans is the most important feature. This is true for two reasons.
First,health insurance is the principal mechanism for financing medical care. Indeed, this is true even when consumers opt for high-deductible plans and purchase much of their routine medical care directly from providers. For a health system to be truly consumer-centered, individual consumers must ultimately decide how the money in the system is spent. Thus, the first and most basic decision that consumers must be allowed to make is which health insurance plan to purchase.
Second,the choice of a health insurance plan of necessity incorporates a whole set of other implicit choices, such as what the plan will pay for versus what the consumer will purchase directly from providers, how and from whom the consumer will receive care, and how the plan will assist consumers in deciding among competing providers and treatment options. This last consideration is particularly important. Even the most sophisticated consumer may not have all of the relevant information available or have sufficient time to gather and analyze it when deciding among providers and treatments. However, health plans have—or should have—the information and expertise to assist consumers in making these decisions.
What consumers want is good value—meaning the best medical care at the best price. In a competitive market in which consumers choose their own health insurance, insurers succeed and prosper by offering consumers a better value proposition than their competitors offer. In other words, they apply their data and expertise to finding their customers the best medical care at the best price or, better yet, to finding ways to help their customers minimize their medical spending by staying or becoming healthy.
Thus, when individual consumers decide which insurance plan to purchase, insurers become the consumers' expert agents, helping them to navigate the health care system and obtain the best results at the lowest cost.
PRINCIPLE #4: Individuals have a wide range of coverage choices.
In any truly consumer-centered market, multiple suppliers compete to offer consumers better products at better prices. Yet for market competition to produce better value consistently—that is, by simultaneously increasing benefits while decreasing costs—consumers must be free to choose from a range of different options, and suppliers must have wide latitude to innovate in meeting consumer demands and preferences with new and better products. Thus, a precondition to any well-functioning, consumer-centered market is that lawmakers avoid unduly restricting either the options available to consumers or the scope for supplier innovation.
Government does need to set some basic rules for any well-functioning market. Much like establishing product safety standards or a uniform system of weights and measures, government can establish rules that facilitate well-functioning markets without unduly restricting supplier innovation or consumer choice. However, for a competitive market to function optimally, the basic rules need to permit wide scope for suppliers to innovate in developing new and better products and features to meet consumer needs and preferences.
Furthermore, lawmakers need to recognize that not all consumers have the same needs, preferences, or priorities. Suppliers must be free to innovate in offering different products to different subsets of consumers, targeting their different needs and preferences. This is particularly important in the health care sector where constantly expanding scientific knowledge and the resulting innovations in medical treatment force continual reassessment of what is "best" for individual patients and specific medical conditions.
For example, in health care, it is appropriate for government to limit the practice of medicine to those who demonstrate adequate knowledge and skill, but lawmakers should avoid inappropriately restricting provider competition with rules beyond those necessary to ensure basic provider competence and patient safety. Likewise, lawmakers should also take care to avoid imposing regulations that needlessly micromanage providers, stifle innovation in clinical practices, or favor one set of providers over another.[5]
In the same fashion, lawmakers need to set basic standards and rules for health insurance products and the companies that offer them. Yet they need to resist the temptation to substitute their judgment for the consumers' judgment.
In setting health insurance market rules, lawmakers should focus on establishing the broad market parameters and allow market competition to work out the details. For example, in setting coverage standards, lawmakers should limit themselves to specifying basic coverage categories, such as physician services, hospital services, and prescription drugs. They should avoid micromanaging the market by, among other things, imposing coverage mandates for specific conditions or treatments or by stipulating how plans must contract with providers.
Similarly, lawmakers should not enact measures that favor one particular plan design over others. Government policy should treat all plan designs (e.g., HMO, preferred provider organization (PPO), indemnity insurance, and HSA with high-deductible insurance) equally. Such an approach not only permits beneficial competition and innovation, but just as importantly respects and accommodates differing personal preferences among consumers.
PRINCIPLE #5: Prices are transparent to consumers.
The same holds true in establishing rules for the price side of the price/benefit equation. In all cases, lawmakers should avoid direct "price setting" because such interventions inevitably distort the market in ways that end up harming both suppliers and consumers.
Yet government does play a legitimate role in ensuring that a market functions fairly and smoothly by establishing basic pricing rules, which enable consumers to comparison shop effectively by clearly informing them up front about the price of each option. For example, government requires grocers to include the unit price on the label of products sold by weight or volume and requires lenders to disclose the effective annual percentage rate (APR) of a loan when offering financing to prospective borrowers.
In a similar fashion, lawmakers will need to reach agreement with stakeholders on the appropriate standards for calculating and communicating prices to consumers in the health system. While enhanced price transparency at the provider level will certainly improve the functioning of the health system, the bigger issue will be the rules for how insurers price their health plan offerings.
Because insurance premiums can be calculated in a number of different ways, lawmakers need to establish rules for reporting those prices so that consumers can comparison shop among the different offerings. In other words, which factors and parameters will be used in reporting prices? Will prices (premiums) be reported on an age-adjusted basis? If so, will the competing plans produce rate tables priced in one-year age increments, or will five-year age increments be sufficient for insurers and simpler for consumers? Lawmakers will need to address similar questions about other possible rating factors, such as geography and family status.
Regardless of the specifics, lawmakers need to establish some set of basic rules on reporting premiums. Otherwise, if competing insurers priced their plans in different ways, or if insurers customized the premium charged to each individual customer, it would be difficult or even impossible for consumers to comparison shop among plans. Without some agreed convention on reporting prices, the balance of power in the market shifts back to the supplier because the answer to the consumer's question "What is the price?" becomes "It depends." This makes it difficult for consumers to weigh the relative costs and benefits of competing options accurately and makes the market supplier-driven instead of consumer-driven.
The specifics of the pricing convention are less important than making certain that some standard pricing convention is used. For example, for many years the standard convention on the New York Stock Exchange was to price stocks in eighths of a U.S. dollar, while the London Stock Exchange used hundredths of a British pound. Although they used different pricing conventions, both markets worked equally smoothly. Indeed, when U.S. stock markets switched to using hundredths of a U.S. dollar, some market participants fared marginally better or worse than they had fared under the previous convention, but the markets continued to function smoothly. In contrast, a stock market would become less transparent and less efficient if each company was listed using its own choice of currency and fractional system.
In setting these and other market parameters, lawmakers should focus on ensuring that the resulting rules are transparent and equitable to consumers and that they provide insurers with a level playing field while accommodating their legitimate business concerns.
PRINCIPLE #6: Consumers have regular opportunities to make coverage choices on predictable terms.
For a market to be truly consumer-centered, individuals must be able, at least periodically, to reconsider past purchasing decisions and make different ones. A market that restricts consumer choice by unreasonably locking consumers into past decisions also has the effect of shifting the balance of power in the market back to suppliers.
For example, if a market rule locked consumers into buying new cars only from the manufacturers of their first cars, this would clearly shift market power from consumers back to suppliers and reduce producer competition and its resulting benefits. With much of its customer base locked into its product line, each producer would have significantly less incentive to respond to consumer demands for better products, more innovative features, and lower prices.
For the health insurance market to be truly consumer-driven, a clear set of rules must establish when and under what terms consumers can choose among competing options. Otherwise, adverse selection or constant churning could undermine the stability and viability of these markets. Nonetheless, these rules need to ensure that the market puts the interests of consumers firmly ahead of the interests of suppliers (the insurers) while still accommodating the legitimate business concerns of the suppliers.
This feature of consumer-centered health reform will likely be the most unsettling to many insurers because it will require them to adjust their business practices to accommodate a new market dynamic in which the customer picks the supplier. In the current dynamic, the supplier picks its customers through various strategies that focus on selling to some potential customers but not to others.
In setting this portion of the market rules for a consumer-centered system, lawmakers need to start from a clear understanding of both the product in question and the needs and behavior of consumers.
A significant portion of any health insurance plan is not insurance in the classic sense of financial protection against unpredictable risks or costs. All health insurance plans still retain some element of this protection, but it is no longer their primary feature. Rather, a large share of health insurance today consists of prepayment for medical care of varying cost and predictability. While the concept of using health insurance to pay for a full range of possible medical care was originally developed decades ago to serve the providers' interest in having more predictable income, that concept has since superseded its original intent.
Today, health insurance plans are a way for consumers to manage their need to finance medical care of varying predictability. In recent decades, advances in medical science have steadily made more medical services more predictable for more patients. Furthermore, the current trends in scientific discoveries and their practical applications in the clinical setting will make even more medical care more predictable for more patients in the future. This is an irreversible dynamic that is driven by steadily expanding knowledge in the basic sciences of biology, chemistry, and physics, closely followed by constant practical innovation in applying that knowledge to the development of new tests and therapies.
This ongoing scientific evolution has several practical implications for health insurance and health insurance markets.
First,it is no longer practical or desirable for policymakers to attempt to fight the rising tide of scientific knowledge by trying to restrict health insurance plans to paying only for the limited and ever-shrinking share of medical care that is genuinely unpredictable. Even the more consumer-directed plan designs that limit coverage by requiring subscribers to pay directly for more of their routine care will need to evolve to accommodate this new reality—for example, through mechanisms to ensure that incentives are properly aligned between the care that subscribers purchase directly and the care paid for by the plan—so that the totality of treatment is integrated and produces optimal results. While such plans will continue to attract a share of consumers, they will need to demonstrate in a competitive market that the total proposition offered—the combination of services paid directly by the consumer and services reimbursed by the plan—is a good value compared to other plan designs and produces a combined outcome for the consumer that is as good as or better than that offered by alternative, competing arrangements.
Second,plans will need to become more of the consumer's "expert agent" who works to identify for customers the best providers and treatment options available at the best prices. Some current business practices, such as negotiating provider contracts based mainly on price and then steering patients to those providers, will not compete adequately in a value-maximizing market.[6] Instead, plans will need to develop new strategies. For example, they might cover all providers in a given market but vary patient co-pays according to an analysis, which the plan makes available to its subscribers, of which providers offer the best results at the best prices. Pharmacy benefit managers have already pioneered such a business strategy in the form of tiered co-pays for different competing drugs.
Third,a consumer-centered system will need to curtail some current insurer underwriting practices that exclude, limit, or charge above-standard rates for coverage for certain individuals or certain medical conditions. While these traditional practices will need to be retained in a limited form as penalties against those who wait until they are sick to buy coverage, they cannot be applied when individuals with coverage choose a different plan if the new market is truly consumer-centered. One of the important incentives for purchasing health insurance when an individual is healthy must be the assurance that future changes in health status will not disadvantage the individual when retaining existing coverage or choosing new coverage.[7]
Fourth,as science increasingly makes more medical care more predictable, health plans must recognize that they are increasingly less in the business of cross-subsidizing unpredictable risks and more in the business of cross-subsidizing health status. In this regard, cross-subsidizing health status is not only a horizontal exercise—commonly understood as the healthy paying for the sick—but also a longitudinal one in which a healthy person today will probably be in poorer health at some point in the future or even vice versa.
A competitive, consumer-centered system will force insurers to rethink some of their business practices in this area as well. For example, insurers might experiment with offering features such as multi-year contracting, premium discounts for participation in wellness or disease management programs, or cash rebates to subscribers who successfully meet agreed-upon health improvement goals. These and other novel plan designs can create powerful new incentives for consumers, providers, and insurers to work together to achieve better value by keeping or making consumers healthier at a lower cost.
Fifth,lawmakers must ensure that the market rules in this regard are fair to consumers, while also accommodating the legitimate business concerns of insurers. For example, if consumers are to be able to choose coverage at standard rates regardless of health status, it will be necessary to limit when consumers can make these choices to avoid confusion in the market. For instance, consumers could be limited to choosing or changing coverage only during an annual open season, or for some other fixed period of time, with exceptions for special circumstances such as loss of employment or loss of coverage under a spouse's plan.
Similarly, lawmakers will need to work closely and cooperatively with insurers to devise risk-adjustment mechanisms to give insurers incentives not to avoid subscribers with health problems, but rather to help them get better outcomes at better prices or even to specialize in identifying and organizing cost-effective treatments for patients with specific conditions, such as diabetes, cancer, and heart disease. The market will need risk-adjustment mechanisms that allow each insurer to accept all customers regardless of their individual health status and that permit all insurers to aggregate a portion of their large claims and equitably redistribute these costs across all consumers in the market.[8]
Conclusion
The current debate over health care reform is usually framed in terms of addressing cost and access problems, accompanied by occasional discussions about the need to improve quality and outcomes in the system. Yet those issues are all manifestations of a more fundamental dissatisfaction with the status quo. Implicitly, both policymakers and the public are motivated by a sense that health care today is not living up to their expectations for value at either the individual level or the societal level.
While America's current health system has clear strengths, it also has significant weaknesses. For all the benefits that it provides in helping people to live longer and healthier lives, America's health care system seems too costly, confusing, inefficient, and uneven in its results, and it leaves too many people without adequate access to its benefits. Fundamentally, Americans as individuals and as a society intuitively recognize that the present health system could do a much better job of delivering value.
Put simply, Americans rightly sense that either they are paying too much for their present health system or the system should be delivering better results given what they are already paying.
The solution and the challenge for policymakers is to undertake the reforms needed to transform the present system into one that does a much better job of rewarding the seeking and creation of better value. As the experience of other economic sectors shows, health care need not be a zero-sum game in which costs can be controlled only by limiting benefits and benefits can be expanded only by increasing costs. Rather, a value-maximizing system will simultaneously demand and reward continuous improvements in benefits while continuously reducing costs.
Such a value-maximizing result can be achieved in health care only if the system is restructured to make the consumer the key decision maker. When individual consumers decide how the money is spent, either directly for medical care or indirectly through their health insurance choices, the incentives will be aligned throughout the system to generate better value—in other words, to produce more for less.
All Americans should be able to agree with the goal of creating a value-maximizing health care system. Consumer-centered health care marketreforms are the only effective means for achieving that goal.
Edmund F. Haislmaier is Senior Research Fellow in the Center for Health Policy Studies at The Heritage Foundation.
[1] For a concise discussion of why structural change is needed and how to refocus competition on value maximization, see Michael E. Porter and Elizabeth Olmsted Teisberg, "Redefining Competition in Health Care," Harvard Business Review, June 2004. For a longer discussion, see Michael E. Porter and Elizabeth Olmsted Teisberg, Redefining Health Care: Creating Value-Based Competition on Results (Boston, Mass.: Harvard Business School Press, 2006). See also Regina E. Herzlinger, Who Killed Health Care? America's $2 Trillion Medical Problem—and the Consumer-Driven Cure (New York, N.Y.: McGraw-Hill, 2007).
[2] For a concise overview of the German health system, see David G. Green, Ben Irvine, and Ben Cackett, "Health Care in Germany," Civitas, 2005, at www.civitas.org.uk/nhs/germany.php (April 15, 2008).
[3] See Porter and Teisberg, "Redefining Competition in Health Care" and Redefining Health Care: Creating Value-Based Competition on Results.
[4] The value to a worker of the tax exclusion for employer-sponsored health insurance is equal to the combined marginal income and payroll tax rates that would be imposed if the compensation were instead paid to the worker as taxable cash income. For a low-wage worker with no federal income tax liability, the tax exclusion is worth 15.3 cents per dollar of health benefits, reflecting the combined employee and employer payroll (FICA) tax rate. Thus, the value of the tax exclusion for that worker is effectively a 15 percent discount on the cost of buying health insurance. For a worker in the 28 percent income tax bracket, the value of the tax exclusion is 43 percent (15 percent payroll tax plus 28 percent federal income tax) and, depending on the applicable state income tax rate, can approach 50 percent when avoidance of state taxes is included.
[5] Examples of such counterproductive regulations include certificate-of-need laws that restrict the availability of medical facilities, technologies, or services; insurance benefit laws that dictate how plans are to pay certain favored health care providers; and laws that unreasonably restrict competition among providers, such as ones that bar the creation of specialty hospitals. For further discussions of these various regulations, see Michael J. New, "The Effect of State Regulations on Health Insurance Premiums: A Revised Analysis," Heritage Foundation Center for Data Analysis Report No. CDA06–04, July 25, 2006, at www.heritage.org/Research/HealthCare/cda06-04.cfm; Ashok Roy, "How Congress Is Killing Competition: The Future of Specialty Hospitals," Heritage Foundation WebMemo No. 1740, December 13, 2007, at www.heritage.org/Research/HealthCare/wm1740.cfm; U.S. Federal Trade Commission and U.S. Department of Justice, Improving Health Care: A Dose of Competition, July 2004, at www.justice.gov/atr/public/health_care/204694.htm (April 15, 2008); and Patrick A. Rivers, Myron D. Fottler, and Mustafa Zeedan Younis, "Does Certificate of Need Really Contain Hospital Costs in the United States?" Health Education Journal, Vol. 66, No. 3 (September 2007), pp. 229–244.
[6] See Porter and Teisberg, "Redefining Competition in Health Care" and Redefining Health Care: Creating Value-Based Competition on Results.
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Your Excellency President Barrack Obama,
I am very grateful for your speech delivered in the Ghana’s parliament on July 11, 2009 addressing not only the population of Ghana but also all the people of the African continent in general.
As an American of Rwandan origin, I would particularly like to bring to your attention my opinion on the current governance in Rwanda.
In Rwanda there is a vague law outlawing "genocide ideology". This law is written so broadly that it can encompass even the most innocuous comments. As many Rwandans have discovered, disagreeing with the government or making unpopular statements could easily be portrayed as genocide ideology, punishable by sentences of 10 to 25 years. That leaves little political space for dissent.
In Rwanda, there is no meaningful opposition in Rwanda. The press is cowed. Nongovernmental organizations are under attack. When parliamentary elections held last September produced a whopping 92% victory for Kagame's ruling party, evidence collected by the European Union and Rwandan monitors suggested that the government actually inflated the percentage of opposition votes so as to avoid the appearance of an embarrassing Soviet-style acclamation.
Kagame and his western supporters claim that Tutsis and Hutus have been united as “Rwandans” by Kagame which absolutely is not true. Although the Rwandan people are terrorized and severely oppressed they cannot speak up because soldiers and local defense militia are everywhere, on each hill, with a specific mission to silence and/or physically eliminate any potential opponent.
In Rwanda, the monopoly system has made it possibble that most of the wealth be concentrated into a small group of individuals that rule the country, to the expenses of the mass.
In Rwanda, one instrument of repression in Rwanda is the gacaca courts -- informal tribunals run without trained lawyers or judges -- which the government established at the community level to try alleged perpetrators of the genocide. The original impetus was understandable: Rwandan prisons were overpopulated with tens of thousands of alleged genocidaires and no prospect of the country's regular courts trying them within any reasonable time. The gacaca courts provided a quick, if informal, way to resolve these cases. In theory, members of the community would know who had or had not been involved in the genocide, but in reality the lack of involvement by legal professionals has left the proceedings open to manipulation.
Another powerful tool of repression is free and forced labor (modern slavery) that has been institutionalized under the umbrella of TIG works (from a French acronym TIG: Travaux d’Intérêts Généraux or Works of General Interests) which began in 2005 along with the Gacaca courts system. Both Gacaca courts and TIG works together constitute a powerful tool of public repression that went unnoticed by the International Community mostly due to a powerful network composed of some renowned western ideologues that advise Kagame in the commercialization of the Rwandan genocide.
Kagame is often given credit for apparent economic growth in Rwanda. People who blindly give such false statements in order to maintain Kagame on Power should do their homework before making such misleading statements that do neither serve the American interests in region nor genocide survivor’s interests in Rwanda. Poverty is wide spread nationwide and Rwanda’s economic growth per capita has not reached its 1994 level before the Rwandan genocide.
Here is an excerpt from the UNDP, 2008 report on Rwanda: “Although the Rwandan economy depends mainly on agriculture, which supports 80% of the workforce and produces 42% of the GDP, the agricultural sector receives a mere 3% of the national budget, a far cry from the 10% threshold recommended by the United Nations Food and Agriculture Organization (FAO). Government spending in Rwanda is clearly oriented away from the majority and toward those who will help the government maintain its power”.
Thank you for your understanding and cooperation.Sincerely,
So I finally have my website up and running...its been a long road, but I am finally done with the hard part. I am most proud of the Women in politics page. This page is dedicated to the women in politics...past and present. Right now there are some posts about both. Starting next week, there will be one interview per week that highlights a different woman that is involved in politics right now, and highlights there achievements, and struggles. If you would like to see a particular woman highlighted, feel free to go to the site and email me, or respond to me here.
There is also information about current political events, video blogs, and the 2010 races...as they are right now...more content will be coming as the days go on. Looking to make this a fun and interactive website...so stop by and tell me what you think...and make sure to check back often for the new content
Here are some of the things we will be discussing at the Health Care Forum on May 12th. I hope you can make it!
Did you know:
Consider the following facts:
· 50 million people are uninsured and many more are underinsured;
· 37% of Americans report rationing care due to a lack of healthcare coverage;
· The uninsured are more likely to go to the emergency room for care and 20% more likely to be admitted to intensive care;
· 20% more likely to die when receiving intensive care within Intensive Care Units (ICU);
· Many of us go without psychiatric care;
· 18,000 people die each year because of a lack of medical insurance;
· Health care costs are rising at two times the rate of inflation (a major contributor to foreclosures)
· Administrative costs account for 31% of healthcare expenditures (by comparison, that is double the proportion in Canada).
SOURCE: Did You Know, MN Universal Health Care Coalition
We're going to be discussing the Minnesota Universal Health Care Initiative at this meeting. Then we're going to talk about ways to support it or alternatives. All are welcome.
It's possible you haven't heard from me since the election. I've not been idle. I had a house party in December. I hosted a service event on Martin Luther King Day which was wildly successful, collecting over two tons of food for Neighborhood House Food Shelf and 25 plus units of blood for Memorial Blood. I recently participated in a recap/potluck regarding that event hosted by fellow volunteer Linda Zwicky. During that party, I discovered what I'm doing next. Ever since the election, I haven't been settled or sure of what the next step for me personally would be with respect to our new administration. I am keenly interested in community gardening and have taken steps to educate myself in this area in hopes of fostering community gardens all over the Twin Cities. My thought was to throw myself wholly into the urban gardening movement and consider that to be my contribution to the new administration. After all, food democracy was a worthy and concrete endeavor and with the economic crisis looming, it seemed like a justice issue as much as a health and environmental issue. So when I attended the recap of our service event last weekend, I wasn't prepared for the epiphany I experienced. We were talking about what to do going forward. Lots of smart people in the room, as usual. We talked about how we were all waiting for the Obama Administration's organizing arm, Organizing for America, to lead us. An astute observer nixed this concept. No, the administration was waiting for us to lead them. Huh?
Much as I wanted to forget about door-knocking and phone banking, I had to admit this was still a powerful calling. I had to reconcile myself--can I pursue urban gardening and continue to organize for Obama? Yes, simple as it sounds and it was oft repeated during the campaign, change happens from the bottom up. Reminded of this at the meeting I attended recently, we agreed we wanted to continue to meet to try and bring change to our communities and to our country with the help of OFA and the Obama administration. We agreed that we wanted to continue to meet face-to-face on a monthly basis. We agreed that our activities could include a broad range of activities, from the community gardening projects I am interested in to lobbying legislators for health care or door-knocking and phone calling as we did during the campaign.
AndI realized that my urban gardening project, once I really understood it fully, would fit neatly into the new organizing paradigm. Service projects for kids in the garden, help in the garden on planting day, invitations to the community on harvest days all would fit into Organizing for America.
The one thing that we all seemed to agree is that this group needed to meet face to face. It wasn't enough to communicate via email or online blog postings. We gained sustenance from EACH OTHER and so once a month meetings were imperative.
Thus, Face to Face for Change - Twin Cities was created. Its goal seemed simple--to meet on a monthly basis to exchange ideas and plan for change in its many shapes and forms. We will be there to support OFA and this fledgling administration's agenda, in much the same way we supported its agenda during the campaign.
I'll invite you to join as soon as the site has approved our group. We hope to organize for the next phase of this Movement--the part where the lion's share of the work will be involved--creating permanent change we can believe in. I hope to see you there. Katie McGee
I am a psychiatric RN who is becoming more and more frustrated with the amount of time I spend on the telephone attempting to get medications approved for patients. This is a decision made by their insurance company EACH of which has totally different rules about which medications can and and cannot be paid for--not always taking into account what is best for the patient. Something must be done so that we ALL are able to receive the best medical care.
I attended a meeting in MN where a group has been working on Health Care Reform for some time. They have researched different ways to find the most effective and efficient manner to have EVERYONE insured. I did not think I would agree that the form they advocated was the best. BUT after this informative session I was totally in agreement that the Single Payer System would be the best.
This is their web site. http://www.muhcc.org/home.html check it out. Rebecca
Hello MN Change Agents!As Communications Director of the MN CAN (Community Action Network) I’ve been asked to help get the word out.
By way of introduction, as a tail end baby boomer, I have lived and worked in Minnesota my entire life. More specifically, that currently means living in White Bear Lake but I grew up in Coon Rapids and Anoka school districts, and have lived in Burnsville, Bloomington, Maplewood, Woodbury, Mankato, Golden Valley, and NE Mpls, as well. (For what it’s worth, I also have immediate family in Ham Lake, Andover, Blaine, Lakeville, Minneapolis, St. Paul, St. Cloud, St. Joseph, and Hastings:) Some of you may remember me as we biked—quite literally pedaling thousands of miles—together in the late ‘70s/early ‘80s throughout greater Minnesota with the Jaunt w/Jim (Klobuchar) Ride sponsored by the Minneapolis STRIB.
Others of you may be familiar w/my online efforts during the 2008 campaign, but I also travelled to Indiana and South Dakota to knock on doors during the primary and spent the summer working as a grassroots organizer for the Obama campaign in St. Cloud—where we gathered together to watch then Senator Obama accept the DNC nomination for POTUS at the largest Watch Party in the state of Minnesota. Like many of you I’ve also been hosting and/or attending smaller scale house parties in support of Change for the last two years and feel invested, not to mention heard, in the political process for the first time ever.
My right hand in CAN is Tom Hayes, a tireless self described “non-partisan synergist” for Change who spent hours blogging during the campaign. Tom was an Obama precinct captain in Northfield, worked closely with the metro campaign volunteers and ObamaWorks. In addition, he helped moderate and maintain the Rapid Response group on BarackObama.com. You can learn more about Tom’s leadership/philosophical approach in one of his latest online articles: If You're Not Part of the Solution.
By now you may know a little something about the CAN groups. To be clear we are not OFA 2.0 but a grassroots Community Action Network born of a strong desire to show support for our new President; helping in any way we can to DO SOMETHING about the state of the union inherited from the Bush legacy. So we requested, and graciously received, permission to build out within MyBO throughout the U.S. If you have any specific questions, please feel free to write one of the original founders, LisaLindo@aol.com, for clarification.Someone said it’s impossible to give Barack Obama too much feedback: But we’re going to try anywayJ I believe the phenomenon of this movement for Change evolved as a result of many factors coming together in this time; none of which would have been possible w/out the type of leader we find in President Obama—who has fought hard to provide everyone of us w/access to the information/tools we need to connect the dots. Now, as Tavis Smiley observed on Larry King this evening, their accountability is our responsibility. Thus, we need your help to organize and to put together action events throughout Minnesota to support our President and your communities statewide. (If you are presently located in a different state and want to stay in the loop for local activities, just let us know so we can get you connected.)
In any case we hope you’ll join us on http://My.BarackObama.com/page/group/MinnesotaCAN
We are building out this infrastructure to organize America in support of our new Leader. Please “come out” and join our (virtual) national Barn Building Party for President Obama. Our grassroots teams, in an effort to support Barack, are rolling out Grassroots Government 2.0. before the snow melts!
Our first and foremost immediate objective is to form ranks. To get involved, these are the instructions:1. Join these two groups:o http://my.barackobama.com/page/group/MinnesotaCANo http://my.barackobama.com/page/group/USACAN
2. Update your Personal Profile on MyBO with real contact information so we can interact accordingly.3. Do your part to help us develop this robust nationwide project: All MyBO members who want to participate in Grassroots Government 2.0 need to join their respective State CAN group.
To give you a heads up, a call has been put out for each county across the country to have their second CAN meeting Saturday, March 7th. (In your county, it may be the first meeting as we gear up.) At these face to face meetings in each county across MN we will elect officers, assign issue teams by individual interests, and connect people who share local concerns to work across CAN; joining forces and implementing solutions. This is the plan we make in support of President Barack Obama's upcoming legislation and programs; which are detailed in the President’s Blue Print for Change and posted at www.whitehouse.gov. Please pass this on to your friends, fellow Obama Supporters, list serves et al: The more voices people hear about how important it is to meet up in each county, in each community, the better chance we have of getting bodies in those seats, votes in those polls, and voices in the National Conversation.“We are the ones we've been waiting for. We are the change that we seek..” --Barack Obama
This is not a drill: Now is the time!
Text of President Barack Obama's inaugural address on Tuesday, as prepared for delivery and released by the Presidential Inaugural Committee.
OBAMA: My fellow citizens:
I stand here today humbled by the task before us, grateful for the trust you have bestowed, mindful of the sacrifices borne by our ancestors. I thank President Bush for his service to our nation, as well as the generosity and cooperation he has shown throughout this transition.
Forty-four Americans have now taken the presidential oath. The words have been spoken during rising tides of prosperity and the still waters of peace. Yet, every so often the oath is taken amidst gathering clouds and raging storms. At these moments, America has carried on not simply because of the skill or vision of those in high office, but because we the people have remained faithful to the ideals of our forebears, and true to our founding documents.
So it has been. So it must be with this generation of Americans.
That we are in the midst of crisis is now well understood. Our nation is at war, against a far-reaching network of violence and hatred. Our economy is badly weakened, a consequence of greed and irresponsibility on the part of some, but also our collective failure to make hard choices and prepare the nation for a new age. Homes have been lost; jobs shed; businesses shuttered. Our health care is too costly; our schools fail too many; and each day brings further evidence that the ways we use energy strengthen our adversaries and threaten our planet.
These are the indicators of crisis, subject to data and statistics. Less measurable but no less profound is a sapping of confidence across our land — a nagging fear that America's decline is inevitable, and that the next generation must lower its sights.
Today I say to you that the challenges we face are real. They are serious and they are many. They will not be met easily or in a short span of time. But know this, America — they will be met.
On this day, we gather because we have chosen hope over fear, unity of purpose over conflict and discord.
On this day, we come to proclaim an end to the petty grievances and false promises, the recriminations and worn out dogmas, that for far too long have strangled our politics.
We remain a young nation, but in the words of scripture, the time has come to set aside childish things. The time has come to reaffirm our enduring spirit; to choose our better history; to carry forward that precious gift, that noble idea, passed on from generation to generation: the God-given promise that all are equal, all are free and all deserve a chance to pursue their full measure of happiness.
In reaffirming the greatness of our nation, we understand that greatness is never a given. It must be earned. Our journey has never been one of shortcuts or settling for less. It has not been the path for the faint-hearted — for those who prefer leisure over work, or seek only the pleasures of riches and fame. Rather, it has been the risk-takers, the doers, the makers of things — some celebrated but more often men and women obscure in their labor, who have carried us up the long, rugged path towards prosperity and freedom.
For us, they packed up their few worldly possessions and traveled across oceans in search of a new life.
For us, they toiled in sweatshops and settled the West; endured the lash of the whip and plowed the hard earth.
For us, they fought and died, in places like Concord and Gettysburg; Normandy and Khe Sahn.
Time and again these men and women struggled and sacrificed and worked till their hands were raw so that we might live a better life. They saw America as bigger than the sum of our individual ambitions; greater than all the differences of birth or wealth or faction.
This is the journey we continue today. We remain the most prosperous, powerful nation on Earth. Our workers are no less productive than when this crisis began. Our minds are no less inventive, our goods and services no less needed than they were last week or last month or last year. Our capacity remains undiminished. But our time of standing pat, of protecting narrow interests and putting off unpleasant decisions — that time has surely passed. Starting today, we must pick ourselves up, dust ourselves off, and begin again the work of remaking America.
For everywhere we look, there is work to be done. The state of the economy calls for action, bold and swift, and we will act — not only to create new jobs, but to lay a new foundation for growth. We will build the roads and bridges, the electric grids and digital lines that feed our commerce and bind us together. We will restore science to its rightful place, and wield technology's wonders to raise health care's quality and lower its cost. We will harness the sun and the winds and the soil to fuel our cars and run our factories. And we will transform our schools and colleges and universities to meet the demands of a new age. All this we can do. And all this we will do.
Now, there are some who question the scale of our ambitions — who suggest that our system cannot tolerate too many big plans. Their memories are short. For they have forgotten what this country has already done; what free men and women can achieve when imagination is joined to common purpose, and necessity to courage.
What the cynics fail to understand is that the ground has shifted beneath them — that the stale political arguments that have consumed us for so long no longer apply. The question we ask today is not whether our government is too big or too small, but whether it works — whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified. Where the answer is yes, we intend to move forward. Where the answer is no, programs will end. And those of us who manage the public's dollars will be held to account — to spend wisely, reform bad habits, and do our business in the light of day — because only then can we restore the vital trust between a people and their government.
Nor is the question before us whether the market is a force for good or ill. Its power to generate wealth and expand freedom is unmatched, but this crisis has reminded us that without a watchful eye, the market can spin out of control — and that a nation cannot prosper long when it favors only the prosperous. The success of our economy has always depended not just on the size of our gross domestic product, but on the reach of our prosperity; on our ability to extend opportunity to every willing heart — not out of charity, but because it is the surest route to our common good.
As for our common defense, we reject as false the choice between our safety and our ideals. Our founding fathers, faced with perils we can scarcely imagine, drafted a charter to assure the rule of law and the rights of man, a charter expanded by the blood of generations. Those ideals still light the world, and we will not give them up for expedience's sake. And so to all other peoples and governments who are watching today, from the grandest capitals to the small village where my father was born: know that America is a friend of each nation and every man, woman, and child who seeks a future of peace and dignity, and that we are ready to lead once more.
Recall that earlier generations faced down fascism and communism not just with missiles and tanks, but with sturdy alliances and enduring convictions. They understood that our power alone cannot protect us, nor does it entitle us to do as we please. Instead, they knew that our power grows through its prudent use; our security emanates from the justness of our cause, the force of our example, the tempering qualities of humility and restraint.
We are the keepers of this legacy. Guided by these principles once more, we can meet those new threats that demand even greater effort — even greater cooperation and understanding between nations. We will begin to responsibly leave Iraq to its people, and forge a hard-earned peace in Afghanistan. With old friends and former foes, we will work tirelessly to lessen the nuclear threat, and roll back the specter of a warming planet. We will not apologize for our way of life, nor will we waver in its defense, and for those who seek to advance their aims by inducing terror and slaughtering innocents, we say to you now that our spirit is stronger and cannot be broken; you cannot outlast us, and we will defeat you.
For we know that our patchwork heritage is a strength, not a weakness. We are a nation of Christians and Muslims, Jews and Hindus — and non-believers. We are shaped by every language and culture, drawn from every end of this Earth; and because we have tasted the bitter swill of civil war and segregation, and emerged from that dark chapter stronger and more united, we cannot help but believe that the old hatreds shall someday pass; that the lines of tribe shall soon dissolve; that as the world grows smaller, our common humanity shall reveal itself; and that America must play its role in ushering in a new era of peace.
To the Muslim world, we seek a new way forward, based on mutual interest and mutual respect. To those leaders around the globe who seek to sow conflict, or blame their society's ills on the West — know that your people will judge you on what you can build, not what you destroy. To those who cling to power through corruption and deceit and the silencing of dissent, know that you are on the wrong side of history; but that we will extend a hand if you are willing to unclench your fist.
To the people of poor nations, we pledge to work alongside you to make your farms flourish and let clean waters flow; to nourish starved bodies and feed hungry minds. And to those nations like ours that enjoy relative plenty, we say we can no longer afford indifference to suffering outside our borders; nor can we consume the world's resources without regard to effect. For the world has changed, and we must change with it.
As we consider the road that unfolds before us, we remember with humble gratitude those brave Americans who, at this very hour, patrol far-off deserts and distant mountains. They have something to tell us today, just as the fallen heroes who lie in Arlington whisper through the ages. We honor them not only because they are guardians of our liberty, but because they embody the spirit of service; a willingness to find meaning in something greater than themselves. And yet, at this moment — a moment that will define a generation — it is precisely this spirit that must inhabit us all.
For as much as government can do and must do, it is ultimately the faith and determination of the American people upon which this nation relies. It is the kindness to take in a stranger when the levees break, the selflessness of workers who would rather cut their hours than see a friend lose their job which sees us through our darkest hours. It is the firefighter's courage to storm a stairway filled with smoke, but also a parent's willingness to nurture a child, that finally decides our fate.
Our challenges may be new. The instruments with which we meet them may be new. But those values upon which our success depends — hard work and honesty, courage and fair play, tolerance and curiosity, loyalty and patriotism — these things are old. These things are true. They have been the quiet force of progress throughout our history. What is demanded then is a return to these truths. What is required of us now is a new era of responsibility — a recognition, on the part of every American, that we have duties to ourselves, our nation, and the world, duties that we do not grudgingly accept but rather seize gladly, firm in the knowledge that there is nothing so satisfying to the spirit, so defining of our character, than giving our all to a difficult task.
This is the price and the promise of citizenship.
This is the source of our confidence — the knowledge that God calls on us to shape an uncertain destiny.
This is the meaning of our liberty and our creed — why men and women and children of every race and every faith can join in celebration across this magnificent mall, and why a man whose father less than sixty years ago might not have been served at a local restaurant can now stand before you to take a most sacred oath.
So let us mark this day with remembrance, of who we are and how far we have traveled. In the year of America's birth, in the coldest of months, a small band of patriots huddled by dying campfires on the shores of an icy river. The capital was abandoned. The enemy was advancing. The snow was stained with blood. At a moment when the outcome of our revolution was most in doubt, the father of our nation ordered these words be read to the people:
"Let it be told to the future world ... that in the depth of winter, when nothing but hope and virtue could survive...that the city and the country, alarmed at one common danger, came forth to meet (it)."
America, in the face of our common dangers, in this winter of our hardship, let us remember these timeless words. With hope and virtue, let us brave once more the icy currents, and endure what storms may come. Let it be said by our children's children that when we were tested we refused to let this journey end, that we did not turn back nor did we falter; and with eyes fixed on the horizon and God's grace upon us, we carried forth that great gift of freedom and delivered it safely to future generations.
Hello Everyone,
I cannot wait until next week, January 20, 2009! It seems like liberation day for the country. I propose a toast, by everyone the moment after the chief justice says those magic words, "Congratulations Mr. President." I am goingto start a atalog ofcomments by people on, "Where they were" and "What they were doing" when Barack Hussein Obama became our nation's 44th president.
I have been reading through so many questions on Change.gov, and I have noticed so many questions that I look at and wonder...what was this person thinking.
So here are some thoughts I would like to express...
One...so many have asked the question "why do I have to pay for individuals who did things wrong, when I did everything right?" My question is why, because someone is caught up in this economic downturn, do you automatically assume that the person has done something wrong? What about the people who did everything right, but because of others greed, they are in trouble...why do you assume the people asking for help do not fall into that category?
My second thought...Maybe we should all take a step back and understand what a President can truely do. I understand, and partake in the excitement of a President who promises change from the same old politics, but all of the questions requesting things completely out of the control of a President does nothing to advance the cooperation that will be needed between the Government and the communities they serve. I understand that everyone has the right to ask what they choose, but questions that request the President to do things beyond his control are not productive.
Common questions I have come across...and my thoughts on them...Please give me your input...these are meant to get ideas going, so that we can be more proactive in our Government...
I have come across several questions that have had to do with legalizing Marijauna and taxing it the same way we tax cigarettes and alcohol. The common argument is that this would give an instant boost to the economy, both by the tax revenue this would raise and also by the billions of tax dollars saved in law enforcement costs each year. I personally see the argument, whether or not I believe in the cause, as a plausible way to stimulate the economy. What are your thoughts on this?
The next question that I have seen over and over is in regards to U.S. stimulus...Why not give a stimulus check to each American adult...the amount varries based on the questioner, but range from $30,000 each to 1 million each...included in the stimulus package to be voted on later this month. The arguement...That giving that much would allow those who have been hit hard to pay their mortgage payments and get bills caught up, and will then continue to stimulate the economy by spending, saving, or investing the rest. What are your thoughts on this?
The last question I am going to address here is whether or not we should abolish the current tax system and go to a sales tax instead of income tax system? I would like to hear all your ideas on this subjects as I am still trying to weigh the pros and cons of each. What are your thoughts on this?
The great part about this is that you can vote on which questions you want the Obama team to answer...with the questions that get the most votes being the ones they answer...if you have time you should stop by change.gov and answer a few...
November 12, 2008 – Wednesday
Written on the morning of November 5, 2008 The sound of hope rang. The darkness seemed to be getting darker.Weariness lay heavy upon my shoulders.The future was hanging in the balance. But then a sound arose; at first it was just a whisper.The sound got louder and louder upon request.Then the sound broke through. The sound of hope sounded, it rang through the world.Like a light breaking the darkness.Like a friend who came to help carry the load; hope rang loud and clear. And others accompany hope as well.Where hope is; faith and love come along side it.They help guide hope on its mission. And as faith and love are requested, they too will get louder and louder.Until we hear the sound of them clearly as well. Then the sound that breaks all barriers will move through woman and men.Bringing peace within their hands.To heal and bring together their wounded and broken land. These men and women will see the evidence of their belief.For once they sound together they will drown out un-belief. Once they sound together; love and unity they will bring.
The sound of hope rang.
The darkness seemed to be getting darker.
Weariness lay heavy upon my shoulders.
The future was hanging in the balance.
But then a sound arose; at first it was just a whisper.
The sound got louder and louder upon request.
Then the sound broke through.
The sound of hope sounded, it rang through the world.
Like a light breaking the darkness.
Like a friend who came to help carry the load; hope rang loud and clear.
And others accompany hope as well.Where hope is; faith and love come along side it.
They help guide hope on its mission.
And as faith and love are requested, they too will get louder and louder.
Until we hear the sound of them clearly as well.
Then the sound that breaks all barriers will move through woman and men.
Bringing peace within their hands.
To heal and bring together their wounded and broken land.
These men and women will see the evidence of their belief.
For once they sound together they will drown out un-belief.
Once they sound together; love and unity they will bring.
Congratulations, a thousand times! The hardest thing ahead, in the face of adulation and vilification, will probably be to remember who you are: honest, fair and deliberative.The biggest hazard of power is the fallacy that one no longer has to be polite, or consider all sides, or be faithful to one's family.
I hope you also remember those that brung you to the dance; don't believe those who say this country is center-right. The left brought you here, and it's to the left that you owe the biggest debt.
Most candidates would have been happy with a few thousand volunteers, you reaped the bounty of thousands of people who have been working for 8 years, organizing their communities for fairness in health care, war/peace spending, and economic justice.
Sure, a lot of regular "Joes" saw the need to volunteer a couple of times in the closing weeks, but we were the ones who volunteered early and often, going full-time in the last weeks, sacrificing health and wealth, because we really know what it takes to win.
We are still here, not looking for a handout, but for rational systems to green and educate the planet and to make life sustainable, not just for Dick Cheney's (or Nancy Pelosi's) buddies, but for every last child on earth. Peace, Shalom, Salaam.
Did anyone save a copy of the 30 minute infomercial last week on the 3 networks? I copied it but managed to mess it up. If someone has it, I would LOVE a DVD copy of it and would certainly pay for the DVD and postage costs, and something for your time and trouble too. I know we cannot buy and sell--I am just looking for a personal copy for me.
If you could possibly do this, please email me at rgesf415@comcast.net and we can set something up. THANKS!!!
For whatever struggles I have had through this campaign, such as pro life issues and the like, I have never wavered on my personal affection and hope that Barack Obama, if elected, would bring us the change we need. NOW HE CAN!
My faith, ultimately, is in God, not President-Elect Obama, but...I am proud to have had some association with his campaign for change. I remember, as a child of 12, when Martin Luther King was assasinated, as well as Robert Kennedy.
Whatever your faith tradition, or even if you don't have one, PLEASE just say a prayer for the safety and well being of our new First Family tonight.
YES WE CAN--YES WE DID--AND YES WE WILL. God bless!
