Consider the following:

• The Washington Post reports that senators wrote loopholes sought by the health-insurance lobby that would allow them to continue operating outside the proposed insurance marketplace (public option and insurance exchanges) intended to protect consumers from inequities in the current system.  One Senate bill would allow insurers to tailor policies to draw healthy individuals out of the new markets, leaving coverage less affordable for those who stay behind.  The same requirements applied to basic reforms, such as requiring insurers to accept people regardless of preexisting medical conditions and banning annual and lifetime limits on coverage, would not apply to host of other requirements intended to help consumers compare health plans on an apples-to-apples basis and force insurers to compete more directly on price.  For example, the bill written by the Senate health committee would not require insurers operating outside the marketplace to provide standardized disclosures about what they cover.  It would not prohibit health plans outside the exchanges from using marketing practices that discourage the seriously ill from enrolling, as the bill requires of insurers inside the exchanges.  Just to conjure up a couple of sleazy tactics that insurance marketing consultants get up in the morning to invent and hone, companies would be free to hold recruitment and enrollment events late at night, when only young, healthy people are awake, or on second floor walk-ups where no one with any difficulty climbing stairs can access.
• The New York Times reports that lobbyists employed by Genentec, a subsidiary of Roche, and two Washington law firms, ghostwrote House floor speeches and entries in the Congressional record for both Democrats and Republicans.  Of course, when busted, congressmen started shoveling it with statements such as “I regret that the language was the same. I did not know it was.”  Likewise, in response to inquiries about the connection between huge campaign contributions to many House members and the privilege of ghostwriting statements,  Evan L. Morris, head of Genentech’s Washington office, joined the bull fest by saying, “There was no connection between the contributions and the statements.”  The few emails obtained by the Times exposing this abrogation on the part of representatives of the responsibility to actually represent voters begs the question, is this just the tip of the iceberg when it comes to corporate influence over the reform bill?
• Even the New York Times editorialists are hoodwinked into believing that the nonsense being tossed around in Washington reflects the best and brightest ideas.  In their Sunday, November 15 lead editorial, they state, “…no one has an easy fix for rising medical costs.  The fundamental fix — reshaping how care is delivered and how doctors are paid in a wasteful, dysfunctional system — is likely to be achieved only through trial and error and incremental gains.”  Among  the important proposals in the House and Senate bills that try to address this problem, the Times lists as fifth Reform of the Delivery System.  Here they state that, “Most agree that the solution is to push doctors to accept fixed payments to care for a particular illness or for a patient’s needs over a year. No one knows how to make that happen quickly.”

Really?  HealthAccessRI has known for several years how to make this happen immediately.

What all this means is that the eventual bill will emerge as a hodge podge of secondary and tertiary level reforms masquerading as primary which might over time provide minor alleviation of a thoroughly broken non-system.  Maybe.  But more likely insurance companies will find ways to undermine any public option or exchange and eventually drive it into the ground.  Republicans will then call reform a cataclysmic failure.  They will be right.   They will then amplify by orders of magnitude their mantra that government is the problem, not the solution.  Republicans will regain a legislative majority and probably the presidency and hold it for decades.

What’s at stake in the health care debate has almost nothing to do with health care in rural America. It has to do with profit.

On Monday night, America’s Health Insurance Plans [3], an industry trade group, called out the U.S. Congress, and drew a bead on health care reform. AHIP told us[4]that health insurance would become very expensive under reform — apparently expecting the nation to dance as the group shot at our feet.

It’s a gunfight, all right. With all the shooting, however, nobody is addressing the health care issues that affect rural Americans. Let me explain.

Any health policy expert, and anyone else who is paying attention to the rumble that is passing for a health care debate, has known for months that health insurance is going to get more expensive as a result of reform.  Why?  The keystone for reform is community rating — a.k.a., “guaranteed issue” — rules that would require health insurance companies to insure anyone who wants insurance and charge them about the same rate, regardless of age, health, or gender.

That’s what health insurance was originally supposed to do – take a little money from a lot of well people, and use it to pay for the care of a few sick people. But that’s not what insurance companies do now.

In the early 1980s, insurance companies figured out that if they insured only well people, they’d get to collect money but wouldn’t have to pay it out. Getting to keep all that money would make them more profitable. Meanwhile, people who get sick become poor, and qualify for government insurance – for Medicare and Medicaid. The insurance companies get to keep the money from well people, and then taxpayers pay for those who get sick. It was a pretty good racket.

But reform threatened to change all that, and make insurance companies take care of everyone.  As soon as you make insurance companies take care of the sick, they’ll pass those costs on to the people who pay the premiums — and so the costs of premiums will go up.   The Senate Finance Committee passed out a health care reform bill Tuesday. The Senate faced the insurance industry, and blinked.

We knew that all along, and so did they. But it felt unfair to most Americans that some people paid way more than others for health insurance. Meanwhile, those who might actually get sick often couldn’t find health insurance that was anywhere near affordable.

So Congress began to work on changing the system, thinking that fairness was worth the extra cost.  Insurance companies were willing to play along because Congress was going to combine insurance reform with an insurance mandate, the requirement that everyone had to buy insurance or pay a big financial penalty.  Insurers stood to gain 50 million new customers from that deal, and they calculated that having to cover everyone, which might cost them some more money, was worth doing if they got 50 million new customers, and lots of potential new profit, in the bargain.

The deal looked good…until someone in Congress who could add figured out the following: We were about to require uninsured truck drivers and librarians, hair dressers and cement finishers, fishermen and family farmers, people otherwise known as voters, to spend $15,000 per family per year on health insurance they would rarely use, or face a $4000 tax penalty.  Congress tried to control the cost increases with ideas about insurance cooperatives and a “public plan,” but neither had ever been used successfully to control costs. The “public plan” is very likely a political non-starter (although backlash against the insurance companies hired guns might actually give the “public plan” new life).

Doesn’t matter.  Neither insurance cooperatives nor the public plan are likely to make much difference to rural Americans. People living in rural places need good doctors and good hospitals, good dentists and good physical therapists, good drug stores and good home nurses close enough to home so they are all of some use. What we don’t need is expensive health insurance that can’t deliver the services rural Americans need and use.

There was talk about giving some people incentives to help cushion the financial blow, but it didn’t take a rocket scientist to figure out any Senator or Congressperson who voted for such a scheme would probably never get elected to anything ever again. Think added costs and higher taxes.

Congress looked this deal, which was great for the health insurance companies but not so good for anyone else, right in the eye, and Congress blinked.  The Senate Finance Committee changed the deal.  Now there is a $750 penalty (instead of $4,000) for families of four earning $160,000 a year who don’t buy health insurance.  That is to say, the Senate Finance Committee made the mandate go away.

But they left the new rules for health insurance companies in place. Insurance companies don’t get 50 million new customers, but they do have to think about paying the health care costs of people who are actually sick. (To be fair to the poor health insurance companies, Congress weakened the community rating standards, and let insurance companies keep charging some people 5 times as much as other people. As any 3-year-old knows, having a temper tantrum is a perfectly reasonable response to someone taking away your cookie.)

See why the insurance companies (through America’s Health Insurance Plans) are stamping their feet and stirring up dust?

It’s too early to know the outcome of this fight.  If we are lucky, Congress will hold firm and not give in to the health plans.  But the health plans have a lot of money, and lots of lobbyists. Stranger things have happened.

There is a saying in Africa: When elephants fight, the grass gets trampled. Neither an insurance mandate nor community rating will fix health care in the US.  Insurance is the problem, not the solution.

The country needs a health care system, not just health insurance reform.  We need to provide primary care to all Americans, because primary care costs next to nothing ($300-500 per person per year, compared to health insurance, which is $5,000 to $6,000 per person per year) and if we provide primary care to all Americans, we’ll have a system that is fair, a system that is affordable, and a system that is about health for everyone, not profit for corporations.

It’s time to end this gunfight before anybody else gets hurt or killed.

Michael Fine [5], M.D., the top ranked family physician in Rhode Island (ten years running, in Rhode Island Monthly’s Best Doctors in RI), is an author, community organizer and health policy expert. Dr. Fine is also the managing director of Health Access Rhode Island [6], a network of family practices that provides affordable primary care to people without insurance.