Det er, når livet viser sig så usikkert og tilfældigt, at vi må foretage et valg. Enten løfter vi os ud over hævngerrigheden og holder fast i vores medmenneskelighed, eller vi daler ned hvor der er angst og frygt. For mig er det ikke et svært valg.
Læs mere i min kronik om Vilkårlighed og dødens alt for menneskelige ansigt i Kristeligt Dagblad.
Læs mit debatindlæg i Dagbladet Information om “Positiv særbehandling kan fuldende ligestillingen.” Et citat om USA: “Mens vores mødre kæmpede for retten til at være mere end nogens sekretær, fik min generation retten til at arbejde så meget, at der aldrig blev tid til at stifte familie…Her kan Danmark stå som rollemodel.”
An Opinion by Andreas Lauritzen
It is no secret that Americans are spending more money on health care than they can afford. According to the OECD, Americans are less healthy than people in countries spending half their gross domestic product on health care. Yet only a single measure of President Barack Obama’s signature program, the Patient Protection and Affordable Care Act, is dedicated to curbing the increase in health care costs on a national scale: the establishment of Accountable Care Organizations (ACOs).
The Affordable Care Act contains many mechanisms aimed at lowering insurance costs, such as offering health insurance through state exchanges and widening the insurance pool through the individual mandate. But these provisions do not decrease the rate at which health care costs are rising in relation to gross domestic product. They only make it more affordable to buy health care insurance. Thus, it is more appropriate to call President Obama’s new law insurance reform rather than health care reform.
The purpose of an Accountable Care Organization is to provide better care for patients without augmenting costs. Studies have shown that improving the transparency of communication and increasing cooperation among different health care actors can significantly drive down costs and increase health care quality. Often doctors’ offices cannot communicate with hospitals. The standardization of electronic health records by ACOs helps to solve this problem.
The Mayo Clinic in Minnesota is an example of an ACO which has driven down costs to unparalleled levels while simultaneously providing some of the best care for patients in the world. It has achieved this by, among other things, promoting better communication and cooperation between health care agents.
Currently, there are about 1,400 independent ACOs across America. The Center for Medicare and Medicaid Services is the federal entity allocating and overseeing funds to create and develop ACOs. Many of those already existing are small practices at decidedly different stages in their ability to change incentives that drive down costs. Thus, the Center is charged with grouping and transforming these smaller practices into larger units in order to more effectively manage care.
The success of Accountable Care Organizations rests on three highly critical points:
First, the current political reality creates pressure on the government to create ACOs at a fast pace.The danger is that these organizations will not significantly effect rising health care costs in the near future. If there is a lack of progress in curbing costs, then not only will it mean cuts in health care, but it will also hand the Republicans vital political capital to overturn the health care law.
Second, Congress has the power to perform draconian cuts in 2017 through the Independent Payment Advisory Board. If there is a lack of progress or if the political climate changes to oppose the Accountable Care Act in national elections, then these cuts are likely to occur. Removing funds will be a serious blow to the facilitation of affordable care.
Third, there is a danger that ACOs become Health Maintenance Organizations (HMOs) in disguise. In the 1990’s, managed care stood for everything that is bad about the American health care system. Helen Hunt expressed America’s frustration in her 1997 Oscar winning performance in: “As Good as it Gets,” when she exclaimed: “Those [bleep] HMOs pieces of [bleep]!”
Managed care is not a public favorite. In 1981, the Reagan Administration removed the requirement that HMOs be non-profit organizations. The idea was that if someone could make a profit and save money, it should be allowed.
Today, all HMOs are for-profit, except for Kaiser Permanente in California. The result is devastating. These organizations went from caring about their patients to caring more for their shareholders by, among other things, ensuring that patients not overuse the system.
In most HMOs, every dollar spent on actual care is deemed a loss because it does not go to shareholders. Much is lost, such as the freedom to see any doctor one wants and the ability to visit any specialist without prior authorization. Even if a patient is in desperate need of a specialist, he or she will not receive further treatment if the insurance company decides not to pay.
While HMOs restrict patient choice, ACOs are designed to preserve them. A significant difference is that patients are not forced to choose a network of doctors. Instead, they can choose any provider they wish.
But if accountable care begins to resemble the failed model of HMOs, it will prove devastating for President Obama’s signature legislation and for the Democratic Party. While it is unlikely that health care providers will want to relive the 90’s, it is a fact that accountable care shares some of the same cost-effective measures of managed care; namely, capitated payment.
Capitated payment allocates a fixed budget per patient. In capitation, the doctor’s incentive is to provide the care needed until the patient is cured. But because of the fixed budget, any unnecessary care is eliminated and costs are kept down to a minimum. This is in contrast to traditional fee-for-service in which the physician is paid for every single service and procedure performed, and costs are high because there is no incentive to refuse to provide unnecessary treatment.
ACOs have to work fast and show significant results in reducing health care costs. Any failure can place significant political capital in the hands of Republicans in the next presidential campaign. Surely, Hilary Clinton, for one, will not stand a chance if the 2016 election is all about the failure of health care reform.
A dilemma for viewers in Denmark waiting for daredevil Felix Baumgartner to break the sound barrier was whether to switch to the international TV hit, The Killing (Forbrydelsen). Ten minutes before the show, sportscaster Ulla Essendrop voiced Denmark’s frustration by tweeting: “JUUUUUUUUUUUUMP.”
Two days later, Washington Post journalist Erza Klein tweeted “My sources say Obama will enter tonight’s town hall by space jumping from approximately 130,000 feet…” The President’s successful comeback that evening was dissected by 7.2 million tweets.
Of course, many still view Twitter as a fleeting pastime. But there are 140 million active users monthly and the company is valued at billions of dollars. To prove once again that tweeting is more than an official couch sport, here are four reasons why Twitter is important.
First, it provides up-to-the-second snapshots of events. Live blogging can only stream information through one channel. But with Twitter, users can tap into endless channels for instant fact checking, expert commentary and belly-aching humor. The result is a deeper, more sophisticated understanding.
This is illustrated by the Twitter reaction during the second presidential face-off. One debate question concerned the doubling of gas prices since Obama took office. Resembling two fighting bighorn sheep, the candidates clashed horns repeatedly, but generally avoided answering the question. The confusion was settled when experts tweeted that prices plummeted because of the global financial crisis and that gas prices are largely controlled internationally, with little help from the President.
Second, while breaking news used to be captured through photos or quotes, now it is tweeted. Similar to interpreting intelligence data, the trick is to find the gem. Last summer, many were convinced that America’s near-universal health care program, ObamaCare, was stillborn. This was because it was assumed that the U.S. Supreme Court’s conservative majority would overturn it. But according to legal journalist Jeffrey Toobin, conservative Chief Justice Roberts’ switch to save the program was leaked via Twitter two months before the Court upheld it.
Third, Twitter further breaks down the barriers between average Janes and the famous. Michael Moore, the director of the film Bowling for Columbine, dedicated his day to getting Americans to vote on November 6. He provided his cell phone number, tweeting: “If u know someone who isn’t going to vote but might if I called or texted them, text me their cell # …” Five hours later, he tweeted his 1.2 million followers, “Thx for sending numbers of your loved ones who weren’t gonna vote. Have been on the phone or texting with scads of them for the past 4 hrs!”
Moore’s example provides direct evidence of a final advantage: Twitter’s potential to spur democratic participation. Admittedly, it can be difficult to measure just how effective Twitter is. But Lady Gaga tweeted and retweeted her 31 million followers 13 times on Election Day. One tweet read, “If you’re old enough to vote for the first time, exercise your right today! It matters & can change the world.” If anyone could convince a young American to vote, it is she.
Danish Football Fans, EURO2012
photo by Kathrin Pelgröm
Painting the flag on the faces of football fans on the way to the game against Portugal made me nervous. Was I getting the proportions right? After all, I am American. Luckily, I was sitting on a train with over 400 Danes covered in a celebration of red and white, including flags. By the end of the tour in Lviv, Ukraine, I could draw this cherished symbol and had become a convert of Danish national pride.
Call it arrogance, but Americans are used to relaxing and waiting for success. Of course this perception is unrealistic. The U.S. never made it past stage two of the 2010 World Cup, losing 1-2 to Ghana. Still, the feeling of being unbeatable persists because we say that football doesn’t really count.
In contrast, I found cheering for Denmark stressful, yet rewarding. The train nearly danced on the rails on the way to the Fan Zone and the game against Portugal. Having already won the Netherlands 1-0, we were euphorically jumping up and down, continuing at the stadium: “Dem som ikke hopper, de elsker Portugal,” (Those who aren’t jumping, they love Portugal).
Our high spirits burst like a punctured balloon when the Portuguese scored in the 24th and 36th minutes. We were flying again before the first half ended, when Michael Krohn-Dehli headed the ball in for a goal. “Ole, vi er Danskerne, vi er Danskerne!” (Ole’, we are the Danes, we are the Danes!). Hope peaked to new levels when Nicklas Bendtner headed the ball in to make it 2-2. With only 10 minutes left of the game, we waited out the tense atmosphere, but were again disappointed when the Portuguese scored with 3 minutes to go.
There was no party that night. Yet hope sprung eternal because Denmark won the European Championships in 1992. Marching into the Fan Zone before the game against Germany, there was a feeling that it could happen again. “Deutschland, Deutschland alles ist vorbei!” (It’s all over Germany!).
When our red and white force of over 400 was met by Ukrainians smiling from the sidewalks and waving from the balconies, I was surprised to find that I felt like crying. Although we lost the game to Germany 1-2, I had become a convert to Danish national pride. Here success doesn’t come by default and we run into walls most of the time. Instead, success requires an unwavering collective belief and a stubborn tenacity to hold on for the ride. Because we know, one day, it will be like 1992 again.
Dansk Roligans, EM 2012
foto af Kathrin Pelgröm
Det gjorde mig nervøs at male flag i ansigtet på fodboldfans på vej til kampen mod Portugal. Var proportionerne rigtige? Jeg er trods alt amerikaner. Heldigvis sad jeg i et tog med over 400 danskere, der var dækket af de rød-hvide farver, deriblandt flag. Imod slutningen af turen til Lviv, Ukraine kunne jeg male det elskede symbol og var konverteret til dansk, national stolthed. Continue reading
Following oral arguments at the Supreme Court, a consensus has emerged that the individual mandate is in jeopardy. Before this rush to judgment becomes a tsunami, let us consider the legal consequences. After all, the justices are not rock stars, but public servants.
If politics win, the results will be more troubling than the unrealistic parade of horribles that dominate today. Though not as colorful a soundbite as being forced to buy broccoli, a decision against the mandate could foment a revolution.
56-årige Mary Brown fra Florida mener ikke, at den amerikanske forbundsregering har ret til at tvinge hende til at tegne en sundhedsforsikring for sig selv og sine tre medarbejdere. Brown har tidligere haft en sundhedsforsikring, men hun opsagde den på grund af omkostningerne. Hun valgte i stedet at bruge pengene til driften af det bilværksted hun ejer. Nu har hun besluttet at indgå i et gruppesøgsmål sammen med andre modstandere samt 26 delstater. De kæmper imod Obama- regeringens sundhedsreformlov, den såkaldte Obamacare.
Som hovedsagsøger symboliserer Brown en vanskelig situation for små og mellemstore virksomheder, der frygter økonomiske problemer. De påstår, at den tvungne sundhedsforsikring, det såkaldte “individual mandate”, er forfatningsstridig. I sidste måned blev sagen fremlagt i USAs højesteret. Der vil foreligge en endelig afgørelse inden for tre måneder.
Den amerikanske presse spår, at Mary Brown vil sejre, men de juridiske problemstillinger peger i den modsatte retning. Sagen sætter Brown og de øvrige parter, der er forkæmpere for den personlige frihed, op imod regeringens bud på den økonomisk mest fornuftige løsning til sikring af almen sundhedspleje. Det er et sammenstød mellem værdier, der nu er havnet i retten. Modstridende holdninger reduceres til en diskussion om, hvordan den tvungne sundhedsforsikring skal defineres, og hvordan de juridiske vurderinger skal foretages.
Sagen handler om, hvorvidt den tvungne sundhedsforsikring kan rummes inden for den bemyndigelse i forfatningen der regulerer handel mellem delstater. Det kan den, hvis retten vurderer, at den har en væsentlig betydning for handel på tværs af statsgrænser. Det er der to argumenter for. Det ene er, at den tvungne sundhedsforsikring er en væsentlig del af en større regulering. Det andet er, at den omhandler økonomisk aktivitet, som påvirker handel mellem delstater. Andre nationale ordninger i den kategori inkluderer blandt andet forbud mod pengeafpresning, racediskrimination i restauranter og hoteller og dyrkning af marihuana.
Alle parterne er enige om, at regeringen kan regulere sundhedspleje generelt, fordi den påvirker handlen mellem delstater. Men den tvungne sundhedsforsikring er ikke en væsentlig del af en større regulering, siger Brown og hendes medsagsøgere. Den skaber derimod problemer, fordi raske mennesker uden behov for pleje kommer til at betale for de sygdomsramte.
Sagsøgerne fremføre endvidere, at beslutningen om at undgå en sundhedsforsikring ikke er en økonomisk aktivitet. Derfor ville en regulering være grundlovsstridig, fordi den tidligere nævnte bemyndigelse i forfatningen kun omfatter økonomiske aktiviteter.
Under sagens forløb fik Browns bilværksted problemer. Selvom virksomheden havde et godt omdømme, måtte hun kæmpe hårdt for dens overlevelse. Samtidig blev Florida ramt af BPs olieulykke, og flere af hendes kunder led økonomiske tab. Til sidst blev hun nødt til at indgive konkursbegæring, og hun er nu arbejdsløs. Hendes situation er dermed forandret, og der argumenteres i amerikanske medier for, at hun nu i højere grad er et symbol for sin modparts synspunkt.
Som forsvar hævder regeringen, at den tvungne sundhedsforsikring er en væsentlig del af en større regulering, fordi den gør det muligt at stille krav om almen sundhedspleje. Det er erfaringen fra syv delstater, som uden at have indført den tvungne sundhedsforsikring, har gennemført et krav til forsikringsselskaberne om, at de ikke må afvise folk på grund af deres helbredstilstand. Resultatet var stigende forsikringspriser, et fald i antallet af forsikringsdækkede og færre forsikringsudbydere. I stærk kontrast hertil står Massachusetts, som har implementeret den tvungne sundhedsforsikring og dermed er en succeshistorie.
Ifølge regeringen handler sagen ikke om raske mennesker, som betaler for de syge. Faktisk er de fleste ikke forsikrede, fordi de simpelthen ikke har råd til det. Modstanderne mener, at det der skal reguleres, ikke er en økonomisk aktivitet. Men set fra regeringens synspunkt er det en økonomisk aktivitet og derfor er det grundlovssikret. Det handler om tidspunktet og måden at betale for sundhedspleje.
Den tvungne sundhedsforsikring er en klassisk løsning på et helt almindeligt økonomisk problem. I USA har alle ret til at tage på skadestuen, uanset om de kan betale eller ej. Ifølge regeringen kommer familier, som er forsikrede til at betale over 5.500 kroner i stigende forsikringspræmier for at dække dem, som ikke er det. Problemet er løst ved den tvungne sundhedsforsikring, fordi alle nu har mulighed for at betale.
Fra et juridisk perspektiv virker regeringens argumenter mere velfunderede, og dens analyser følger i højere grad retspraksis. Retten har en tendens til at bøje sig for Kongressens vurdering af, hvad der kan reguleres under bemyndigelsen i forfatningen. Men den tvungne sundhedsforsikring er ikke en almindelig sag. Derfor kommer de personlige rettigheder ind i billedet.
I USAs føderale system har delstaterne ret til at lovgive om den tvungne sundhedsforsikring, mens det ikke kan lade sig gøre hos forbundsregeringen. Det skyldes, at Kongressens magt er begrænset til bestemte bevillinger specifikt nævnt i forfatningen.
Mary Brown og hendes meningsfæller påstår, at hvis den tvungne sundhedsforsikring bliver grundlovssikret, vil regeringen have ret til at kontrollere alt andet i folks liv. For eksempel at staten kunne kræve, at folk køber biler for at løse bilindustriens problemer. De advarer om, at hvis forbundsregeringen udvider magten på denne måde, mister folk deres rettigheder. Derfor ønsker sagsøgerne, at regeringens magt skal begrænses, ellers vil individets frihed være i overhængende fare.
Men retspraksis på området handler om de omstændigheder under hvilke, forbundsregeringen kan beordre delstaterne til at gennemføre noget. Målet er at gøre det klart, hvem der kan holdes ansvarlig for politiske beslutninger – forbundsregeringen eller delstaterne. I forbindelse med den tvungne sundhedsforsikring argumenterer forsvareren i sagen for, at den personlige frihed ikke er sat på spil, fordi loven involverer folk direkte og ikke delstaterne. I dette tilfælde er forbundsregeringen politisk ansvarlig for, hvad den har gjort, og utilfredse vælgere kan stemme den ud ved næste valg.
Problemet, som Højesteret skal løse, er, hvordan afgørelsen kan begrænses. Regeringen siger, at sundhedssektoren er unik. En afgørelse kan blive truffet, så den kun gælder på forsikringsområder, hvor det er næsten 100 procent sikkert, at folk faktisk vil benytte forsikringen, men ikke sikkert hvornår de skal bruge den eller hvor meget det vil koste.
Hvis regeringen har overbevist retten om, at sundhedsplejemarkedet er unikt og kan begrænses, vil Obama-regeringens vigtigste mærkesag blive grundlovssikret. Det vil selvfølgelig være nemmere at forsvare sundhedsreformen ved at tale om retten til sundhedspleje uanset folks økonomiske muligheder, som tilfældet er i Europa. Hvis Obamas sundhedsreform overlever vil begrebet om, at alle har ret til pleje, blive udbredt i USA. Måske vil Brown efterhånden også ændre mening.
Robin Elizabeth Herr 