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National Health Care Policy

Original post made by Paul Losch on Jul 29, 2009

This clearly is a complex, contentious, and at times confusing subject facing the country right now.

One thing I have not heard or read a great deal about is whether there are some incremental improvements that most lawmakers can agree to this year.

Most of the press seems to be painting this to be an all or nothing imbrolgio, with certain Republicans claiming it will be President Obama's Waterloo, and the partisan Democrats trying to raise money for ads to support the bills that the majority party is working on.

A great deal of what I hear and read on what are respected broadcast and print media seems to lose sight of what is in the interest of the American public. The focus is on the political "battle."

And given how intractable this matter is, is there another way that gets some big things done in the short term, but allows some gaps and unknowns that can be re-visited after a bill that is passed can be evaluated after a period of time?

Comments (75)

Posted by Sharon, a resident of Midtown
on Jul 29, 2009 at 5:35 pm

[Portion removed by Palo Alto Online staff.]

There are many ways that we can lower the costs associated with our health care system; two that immediately come to mind are to get the Trial Lawyers out of the Doctor's office and to get the Federal Government out of the Doctor's office.

The Government first must show that they can deliver the mail efficiently before we the people could even consider rationally to allow the unconstitutional grab of control for our health care.
Take a look at what we face from a UK MD Web Link

"After 60 years of universal health care, free at the point of usage and funded by taxation, inequalities between the richest and poorest sections of the population have not been reduced.
But Britain does have the dirtiest, most broken-down hospitals in Europe."


Posted by Paul, a resident of Downtown North
on Jul 29, 2009 at 5:53 pm

"Do you want to make your medical decisions or do you want the government to decide and ration."

I wonder why certain people will trust the government with thousands of nuclear bombs, but not with a tongue depressor. I also wonder why they put decisions about their health care in the hands of industry bureaucrats with strong profit-based incentives to deny service, and who get no points for saving lives or enhancing quality of life.


Posted by Sharon, a resident of Midtown
on Jul 29, 2009 at 6:24 pm

[Post removed by Palo Alto Online staff.]


Posted by R Wray, a resident of Midtown
on Jul 29, 2009 at 7:06 pm

If one doesn't think in principles or thinks with the wrong principles, then issues are complex. For instance, if one believes that health care is a right, then it is a complex question of whom to rob to pay for it and whom to enslave to supply it. But if one has a correct principle that there can be no right to things that others must provide, then the solution is simple: don't use force and let people trade among themselves for health care.


Posted by Perspective, a resident of Midtown
on Jul 30, 2009 at 7:34 am

The first hurdle to jump is to stop associating "national health care policy" or "national health care reform" with only one solution: tax-funded and government controlled health care.

There are many great solutions that will lower costs, encourage individuals to buy the newly less expensive options, and still not squash innovation and allow the highest rated health care system in the world to continue to be just that ( we are rated first in speed of access and quality available)..

Just don't want to kill off all the good that is unique to the USA's system to get what I am pretty sure all of us want, which is all of us insured to some minimal standard without losing any of our liberty in the process.

Gotta remember, Michael Moore held up Cuba's health care as exemplary because "everyone had equal access", but I doubt too many of us want "equal access" to those results! Even our poorest and illegal immigrants have better care than that!


Posted by New ideas, a resident of Barron Park
on Jul 30, 2009 at 8:13 am

"we are rated first in speed of access and quality available"

I don't doubt that, but both of those factors contribute significantly to the cost. If you can afford it, great. But what if you can't? Do you just forego treatment?

Another interesting idea that I saw today is that because of the peculiarities of health care economics, market driven care actually increases the overall cost as providers go after profits.

Web Link

That's not to say that nationalized medicine is any better, but you can't just assume that free market medicine will always be cheaper.


Posted by R Wray, a resident of Midtown
on Jul 30, 2009 at 9:40 am

New Ideas, if cheapness is all you're looking for, try your barber. I understand they used to provide medical treatment.


Posted by Paul, a resident of Downtown North
on Jul 30, 2009 at 9:50 am

"But if one has a correct principle that there can be no right to things that others must provide, then the solution is simple: don't use force ... ."

By this "logic" we have no right to have freeways, state parks, sidewalks, city streets, or national defense, because all exist due to what others provide.

" and let people trade among themselves for health care"

An essential role of government is to provide the financial and organizational framework to help people trade among themselves. I do grant that recent Republican administrations have failed this miserably, but we can and must rebuild.


Posted by R Wray, a resident of Midtown
on Jul 30, 2009 at 10:43 am

Paul, the principle is "must" supply, i.e., supply just by virtue of need. In a free society this does not rule out group efforts or division of labor. A "right" in the correct sense can only be a right to action. For example the right to the pursuit of happiness, not the right to happiness.
One role of government is to provide the courts to adjudicate disputes. Other than that it does not interfere with free trade.


Posted by Paul, a resident of Downtown North
on Jul 30, 2009 at 1:31 pm

Hoo, hoo, this one's fun.

"Paul, the principle is "must" supply, i.e., supply just by virtue of need."

As in "... to each according to his needs"?

"For example the right to the pursuit of happiness, not the right to happiness."

But without a right to happiness, what's the point in pursuing happiness? Jefferson's thinking was clear. Read it sometime.

"One role of government is to provide the courts to adjudicate disputes. Other than that it does not interfere with free trade."

Why do you think the FDIC should be abolished so Indy, Wachovia, and WaMu consumers could have lost their savings under free trade, like happened in the Depression? Surely you know that confidence in the economic system is vital to a free market. Nothing builds confidence in the free market system like losing your life's savings to it, right?

Some things are easy to advocate from the comfort of the Barcalounger, safely shielded from consequences by a bit of socialism.


Posted by R Wray, a resident of Midtown
on Jul 30, 2009 at 3:07 pm

Yes, the principles I advocate are the opposite of Marxism.
You have it backwards, why would anyone make an effort to pursue happiness if he has a moral right to it? He would just show up on your doorstep and demand that you make him happy. Jefferson was clear in including "pursuit".
The FDIC insulates consumers from the due diligence they would otherwise perform before investing. It encourages risky activities by the financial institutions. The FDIC should be abolished; it was a factor in causing the recent financial crisis.
Consumers have "confidence" that the government is going to tax away 50 to 60 % of their income.


Posted by Paul Losch, a resident of Palo Alto
on Jul 30, 2009 at 4:23 pm

Paul Losch is a registered user.

I am gong to weigh in here. I generally try to tee up issues relevant to the Palo Alto Community, and let things go from there, without my needing to be part of the discussion after it gets started. But I do have some thoughts about this one.

At a policy and national level, we have I believe around 45 million people, which is 15% of the US popluation, without health care insurance or health care they can afford. That is a huge problem. The ways to go about solving such a problem can vary, but there is no getting around it that something is not working right when that many people live in the US and do not have some sort of health care program that they can be a part of.

As a small business owner, I am overwhelmed by the cost of health insurance for me and employees. I am doing what I think is the right thing by covering people who are critical to the company, but it is very costly.

As the brother of someone who has had health problems his entire life (asthma) I know all to well how many ER's he has had to visit due to his condition and difficulty keeping a physically demanding job as a result of his condition. The ER is not a cheap date.

As a father, I worry about my recently graduated from college son who will not be covered by his parents' health insurance as he moves into what is a very unfriendly job market at the present time.

I am perfectly capable of parsing intellectually interesting and ideologically different points of view around this matter. But I also have 3 very real examples of things that affect my personal life. I will assert that the country will be better off if people like I have in my immediate circumstances have coverage.

How that is specifically designed needs more work, but the objective and the circumstances of people at risk of not having coverage should be at the heart of that design.

Some of the ideological, theoretical rubber in this thread is not on the road.


Posted by GS, a resident of Barron Park
on Jul 30, 2009 at 4:49 pm

"One thing I have not heard or read a great deal about is whether there are some incremental improvements that most lawmakers can agree to this year."

That's where all this is heading: more incremental fixes that fail to address the biggest problems, leaving many millions uninsured, many millions paying through the teeth for the bare minimum coverage, and others who have lucked into good plans for a variety of reasons.

Our system is broken down and expensive. Access to care is rock bottom. The system is so broken that the only real solution is socializing the entire medical system. There are many systems in Europe that work far better than ours.


Posted by stephen levy, a resident of University South
on Jul 30, 2009 at 5:12 pm

stephen levy is a registered user.

My take on the national health care debate is that there are three interrelated issues--1) affordable coverage for people who do not have coverage today, 2) the escalating costs of the current public and private sector components of our health care system and 3) the cost of extending affordable coverage.

Paul Losch's stories lay out the case for coverage from the perspective of a family and small business owner who are not poor--so affordable coverage is not just a being nice to poor residents issue.

I am worried that the plans being discussed in Washington will not effectively control health care costs.

I think that is partly related to fee for service payment structures rather than systems where the providers get capitated payments and are on salary and partly related to lack of coordination and duplication of services--perhaps somewhat casued by fear of lawsuits.

I like the idea of a public insurance option and broad health exchanges to encourage competition. But the public option won't address costs much unless it changes the financial incentives for excessive care. Medicare, which is a public plan, could be a place to start reforming financial incentives as the President is now advocating but all plans will probably involve some hard choices about expensive tests and end of life care.

Getting control (slowing the cost growth) of health care costs is also the only way to finance the expansion of coverage AND address the small business cost problem that Paul mentions and I share.


Posted by Sharon, a resident of Midtown
on Jul 30, 2009 at 5:44 pm



WSJ this week points out that 30% of health care $s are wasted on inappropriate tests and procedures.
Add to that the billions wasted on "alternative medicine" and non evidence based psychotherapy.

Evidence based medical decision making could cut 40% of the costs.
Get the trial lawyers out of the doctors office and off shore non emergency/ elective procedures and we will cut way beyond 50%.

Obama care is like a passenger airline pilot taking off when he does not know if he has enough fuel to reach his destination, would you get on board?

Look at the evidence--

Socialized medicine is a disaster, look at the Massachusetts health care system

1/ The program has so far cost 30 percent more than anticipated.

2/ It already has a $9 billion shortfall projected over the next two years.

3/ Costs have risen 41 percent since the program's inception, well outpacing the rise in health care costs nationwide, which stands at 18 percent.


Posted by Keith, a resident of Midtown
on Jul 30, 2009 at 6:29 pm

"I like the idea of a public insurance option and broad health exchanges to encourage competition"

The public option is just a stealth path to single payer. Barney Frank says it directly. www.youtube.com/watch?v=f3BS4C9el98

The public option eliminates competition, because it subsidizes the governemnt insurance through the endless resources of the federal treasury. Any sane small or large business would immediately switch over to the government system, because they can transfer costs to the taxpayers. Fogetta 'bout employee choice. This is just economics and logic 101.

The translation of single payer is rationing of health care, just like they do in Canada. The final translation is euthanasia of the defectives and the elderly...that is a real bending of the cost curve. Just imagine how much we could save by prohibiting health care to the obese. John Holdren might be happy about this, but most people are probably not.


Posted by GS, a resident of Barron Park
on Jul 30, 2009 at 7:15 pm

Right now the U.S. system blows between 30-50% on bureaucracy, so it shouldn't be hard to get more bang for our buck with a socialized system. Single payer system is the best solution.

Apart from nationalizing health care, it's not possible to slow the growth of health care costs without reducing care. We spend more and more on increasingly expensive treatments.

As to rationing health care, it's naive to think we don't already do that.


Posted by Keith, a resident of Midtown
on Jul 30, 2009 at 8:10 pm

"As to rationing health care, it's naive to think we don't already do that."

My health insurance is pretty standard fare, for a corporate employee (15% deductible up to $10K, then 100% coverage) and I have not been rationed. I don't use it very often, but I did have a need to use it once for a $60K procedure. I was pleasantly surprised how helpful they were, even encouraging me to take more physical therapy than I was interested in.

I have no interest, whatsoever, in putting my health care package at risk of a public option. Why? Because my employer, not being a fool, would dump all of us into the federal system. No thank you!


Posted by GS, a resident of Barron Park
on Jul 30, 2009 at 9:30 pm

"My health insurance is pretty standard fare, for a corporate employee" Exactly. It is being rationed to you. You are getting benefits at the cost of others.


Posted by Keith, a resident of Midtown
on Jul 30, 2009 at 9:50 pm

"Exactly. It is being rationed to you. You are getting benefits at the cost of others."

How do you figure? It is being extracted from my potential salary, not yours or anybody else. Have you ever heard of 'FTE' If so, please explain it back to me, then you will begin to understand.


Posted by GS, a resident of Barron Park
on Jul 30, 2009 at 9:59 pm

First, it's a tax scam--you don't have to pay taxes on it.

Second, the deals one can get from some corporations are very good terms compared to what one can get from smaller groups and much better than what one can get on one's own. That is, you pay less than others for the same services.

So, there is a net transfer to some of a benefit.

And of course this leaves out those who cannot pay at all. You are also diverting resources from them.

You're living on the backs of others.

Now perhaps you begin to understand.


Posted by Very Confusing, a resident of Crescent Park
on Jul 30, 2009 at 10:23 pm

"That is, you pay less than others for the same services."

In practice, I don't know if this is true. Most insured corporate employees of large corporations do not receive the value of health related service they and their employer pay for. That is, they typically pay more per month in insurance than the cost of the health care they receive.

And, the insurance is typically underwritten by the corporations themselves, and simply administered by the health insurance industry player chosen for the job. It's not all robbing Peter to pay Paul.

There is also a general confusion between health care and health insurance, which complicates the situation.

A separate point. In addition to Levy's three interrelated issues, there is at least a fourth. That is, it is now very difficult to get good health care period. The current system seems to promote behavior more like drive-by specialists, insurance company policy monitors, and pharmaceutical company agents than that of GPs who actually try to see their patients as a whole and help them solve their problems.

My guess is the economic forces, especially interests of the insurance companies, have at least in part driven this, but there might be more subtle influences involved.

Government programs tend not to solve this kind of problem. The ability to fall through cracks of government programs is legendary and well-deserved.

As I understand it, medicare doesn't exacerbate this problem, possibly because it allows recipients to choose their own private health care service plans.


Posted by Keith, a resident of Midtown
on Jul 30, 2009 at 10:36 pm

You don't have to pay taxes on many things. Ever heard of the mortgage interest deduction? Non-profit enterprises? Food? Internet purchases? Churches? The list goes on.

I work for a small corporation, so the deal is not as good as you suggest. However, group purchasing power, aka economy of scale, is a reality. The real question is how to get individuals and small groups into pools, and then to share the risk of pre-existing conditions. That is a rational problem that can be solved, without obliterating the current system that works very well for the majority.


Posted by GS, a resident of Barron Park
on Jul 30, 2009 at 11:13 pm

Very,

"Most insured corporate employees of large corporations do not receive the value of health related service they and their employer pay for." That's irrelevant. They pay less than other, smaller groups and individuals.

Keith,

"You don't have to pay taxes on many things." What's your point? You claimed you were paying; I pointed out that in fact you get a subsidy from the federal government. It's part of the way that medical services are rationed in this company. I do get what you're saying. You're fine with it because you're not getting the short end of the stick.

"However, group purchasing power, aka economy of scale, is a reality." Right, this is rationing of health care, in this case in favor of those who work for large corporations.

Your notion that the present system works well for the majority is out of touch. If you're working for a small corporation, your subsidies will be disappearing in the next decade, given the way things are going. Then, you'll catch up to what's going on.


Posted by R Wray, a resident of Midtown
on Jul 31, 2009 at 9:44 am

Mr. Losch, I see your points.
1) As an employer you want off the hook to provide for your employees because it's too expensive. I suggest to you that you may be one of the ones most heavily taxed for the government plan. Don't be so sure that you will come out ahead.
2) You want off the hook to help support your brother. What's your moral right to force me to support him?
3) By the same token, you want others to support your son. I suggest to you that he will do better in a free economy--unless he can go on the dole with a government job.
Many of the concrete-bound arguments on this thread do not address the fundamental issues.


Posted by Paul Losch, a resident of Palo Alto
on Jul 31, 2009 at 3:22 pm

Paul Losch is a registered user.

R Wray,

[Portion removed by Palo Alto Online staff.]

Health insurances is a huge expense for any business, but for small businesses like mine, it is disproportionately expensive, since we cannot "pool" the per employee profile that larger employers are able to do. I welcome leveling the playing field, former President W Bush extolled small businesses, and there is an opportunity to help such places as mine to have a GOP President and our current President deliver on that notion.

You have no right to make contentions about my brother and my relationship with him. You insinuate things that are factually incorrect, and make an attempt to invoke some lack of morality on my part that if you had any facts would make your assertion a laugh.

Am I a bad parent for not worrying about what happens to my wonderful son as he goes out into the world and things that his mother and I have provided for him no longer can be offered to him? I don't think so.

[Portion removed by Palo Alto Online staff.]


Posted by Keith, a resident of Midtown
on Jul 31, 2009 at 4:01 pm

Paul,

The problem with health care issues is that they are personal. I have worked my entire life in the private sector, ups and downs, inlcuding several layoffs. I am now in a position to, finally, have a decent pension and health care benefits. Not nearly so good as an employees of CPA, but still decent. Now I hear people, like Levy, suggesting that a public sector health plan will not become socialized (single payer) medicine. That is patent nonsense. I have to call it like it is, Paul. It is VERY personal to me and my family.

The focus should be on the formation of small business pools, and indididual pools, and assigned risk pools for pre-existing conditions.


Posted by Very Confusing, a resident of Crescent Park
on Jul 31, 2009 at 5:19 pm

""'Most insured corporate employees of large corporations do not receive the value of health related service they and their employer pay for.' That's irrelevant. They pay less than other, smaller groups and individuals."

It's relevant to the point that they are taking money away from others by forcing them to pay more. They are, to the extent they participate at all in money flow of health insurance companies, subsidizing others by paying more than they take back in reimbursements. Yes, smaller companies and individuals pay more, but not because larger employers provide profit to the health insurance companies.


Posted by stephen levy, a resident of University South
on Jul 31, 2009 at 5:41 pm

stephen levy is a registered user.

This is the beginning of Paul Krugman's op-ed today. Whether or not you like Krugman the passage is true.

"At a recent town hall meeting, a man stood up and told Representative Bob Inglis to "keep your government hands off my Medicare." The congressman, a Republican from South Carolina, tried to explain that Medicare is already a government program — but the voter, Mr. Inglis said, "wasn't having any of it."

It's a funny story — but it illustrates the extent to which health reform must climb a wall of misinformation."

Krugman goes on to indicate the large role that government plays into today's private and public payer systems.

Web Link

We are debating changes in govenrment's role but not enormous changes compared to the current system AND most people find the current system poor and/or unsustainable.

So something has to be done to avoid health care costs eating up businesses and residents alike and we are debating more the what rather than whether to.

If any of you have read the limitations on eligibility for the public option and the constraints that will be placed on current private plans or their tax status in any event and would like to try and convince me that the proposed public plan will unfairly impact private plans, have a go at it.

The Congress seems to agree on expanding eligibility, eliminating insurance turn downs for pre-existing conditions, introducing expanded competition through broad health exchanges and/or a public option and probably requiring most or all residents to buy health insurance--lots of major changes.

While other posters worry about the survival of private plans, which I think are pretty secure if they provide good service, I worry that this whole deal can get passed with no serious control of health care costs.


Posted by Keith, a resident of Midtown
on Jul 31, 2009 at 6:13 pm

Mr Levy,

Krugman has long supported single payer. He does not think he can get there directly, thus his stealth strategy to do it one piece at a time. Barney Frank admitted it directly ( Web Link ).

[Portion removed by Palo Alto Online staff.]

Cutting health care costs should involve putting things on the table that are now prohibited from being on the table. For example, tort reform and the trial lawyers, in order to eliminate defensive medicine. Health savings accounts should be promoted, because they would act as an incentive to lessen demands by patients for unnecessary tests, as well as frivilous demands to meet with doctors. Above all, the notion that preventitive medicine will contain costs is sophistry. It may extend life span, at great cost, but it will increase, not decrease costs. Christian Sientists and heavy smokers decrease the health bill; keeping obese diabetics alive for a few more years increases costs.

[Portion removed by Palo Alto Online staff.]


Posted by GS, a resident of Barron Park
on Jul 31, 2009 at 6:50 pm

Keith,

"It's relevant to the point that they are taking money away from others by forcing them to pay more. "

"They are, to the extent they participate at all in money flow of health insurance companies, subsidizing others by paying more than they take back in reimbursements."

No chance. To the extent that they pay more than they take back, they are paying for bureaucracy and profits for the health care machine. In fact the larger companies are being subsidized by everyone else.




Posted by R Wray, a resident of Midtown
on Jul 31, 2009 at 7:03 pm

Mr. Losch,
I could respond more fully to your post, but since you have said that you will not respond, it would be unfair of me to do so.
If you are not a liberal/progressive advocating that the government take away my rights, perhaps I should reconsider my attack on your personal situations that you posted on a public forum.
Regards--in the name of cool reason.


Posted by stephen levy, a resident of University South
on Aug 1, 2009 at 8:36 am

stephen levy is a registered user.

I am still interested in Paul's question of whether there are parts of health care reform with broad agreement that could serve as a starting point.

So I am interested in hearing from long-time and new posters whether they support the requirement in the bills before Congress that insurance companies not be able to deny coverage for pre-existing conditions.


Posted by R Wray, a resident of Midtown
on Aug 1, 2009 at 9:39 am

"requirement in the bills before Congress that insurance companies not be able to deny coverage for pre-existing conditions."
This is one of the most ludicrous edicts being considered. It should be obvious what would happen. No one would pay insurance premiums until they were sick. They might as well outlaw insurance--that's what they are really after.


Posted by Keith, a resident of Midtown
on Aug 1, 2009 at 12:59 pm

I think indvidual health saving accounts (HSA), with tax free funds, company matching, portability, no exclusions for pre-existing conditions make sense. These accounts could be voluntarily put into purchasing pools, then used to purchase health insurance from insurance companies who want to bid on the pool. A certain percentage of the HSA should be redeemable for cash (tax free) each year, if it is not exhausted, as an incentive to not go to the doctor, unless it is a serious thing, as well as to cut down on the number of tests ordered. There should also be a provision that holds harmless the doctor for liability. If the HSA holder agrees to sign that provision, he/she would get a lower rate from the insurance company, and thus more cash at the end of the year.

I think this is something that we should all be able to come toegether on. It might also help to solve some of Paul Losch's issues.


Posted by R Wray, a resident of Midtown
on Aug 1, 2009 at 4:56 pm

There's no political problem with *voluntary* plans. The whole point of the discussion, however, is government(i.e., forced) regulations.
The problems with health care are government caused--through the 50% portion paid by the government and the arbitrary regulations of the medical and insurance industries. The solution is for less government intervention. But everything on the table is for more intervention, and therefore, there is no part of what is being considered which has any merit. Scrap it all and go in the direction of deregulation.


Posted by Perspective, a resident of Midtown
on Aug 1, 2009 at 5:15 pm

Re: krugman's typical use of someone who doesn't already understand that medicare is govt health care to "prove the point" that govt is better.

This is silly. Of course you can find ignorant people on both sides of this issue. It is just as ignorant to believe that any increase in govt health care won't decrease private health insurance choices. Does anyone not remember that seniors used to be able to buy private health insurance?

There is your answer right there to what happens when a "public option" competes with private. The tax-funded one takes over..pushes out private options, ..grows, ..gets abused..then starts rationing.

Simple.

BTW, anyone remember how many citizens jumped on the chance to supplement their Medicare with private insurance plans in the 90s? Handed over their Medicare packages to PRIVATE insurances, who then made money off managing the care more effectively and at less expense to the seniors..think about it folks.


Posted by Perspective, a resident of Midtown
on Aug 1, 2009 at 5:21 pm

[Post removed by Palo Alto Online staff.]


Posted by Keith, a resident of Midtown
on Aug 3, 2009 at 12:14 pm

The Obama plan is clearly an attempt to impose socialized (single payer) medicine. He says so in his own words: Web Link

Why do so many Canadians buy private insurance in the United States, if they are happy with their own single payer system? I would note that it is illegal to buy private health insurance in Canada. The Canadians who buy such insurance understand that it is much better to get treated for a serious health problem in the United States, compared to staying at home and hoping that they win the lottery for treatment. I have a cousin who lives in Canada, and he tells me that they are genrally happy with single payer, as long as it about routine health visits, but that they all try to have a backdoor strategy in the U.S., in case things get serious. He also admits that taxes are higher, in order to pay for single payer. That means that he pays higher taxes and pays for private insurance in the U.S.

I don't understand why people are enamored of the single payer system. Pehaps Mr. Levy could explain it to me.


Posted by GS, a resident of Barron Park
on Aug 3, 2009 at 3:44 pm

The negative claims about the Canadian system are false. Canadians have better access to health care and they waste less money on it. There are many examples of excellent single payer systems around the world.

What we need in this country is a single payer system. It would reduce waste and increase access.


Posted by Keith, a resident of Midtown
on Aug 3, 2009 at 5:22 pm

The Canadians do have good access, but it is a question of what one is getting. My cousin, as an example, only pays about $300 per quarter for care, for his family of four, and he is generally happy with the single payer, even though they need to make appointments weeks ahead of time. However, his father, who has had serious health issues, has had to use his U.S. supplemntal insurance, becasue the wait was so long in Canada. Also, his father can obtain drugs in the U.S. that are not available via the single payer system in Canada. His father came to the lower 48 to get his care, and is happy that he did.

At least we seem to be on the same page of discussion, now. It is single payer vs. free market. From this point, we can all start a realistic discussion of health care systems, and how to pay for them.

I hope Mr. Levy and Paul Losch will join us.


Posted by Paul Losch, a resident of Community Center
on Aug 3, 2009 at 6:53 pm

Keith,

I don't view this as single payer -vs- free market. And my impression is those extremes are not on the table right now.

I am glad your Canadian cousin's dad is able to take advantage of what I would view as "extended, elected coverage." My experience with my now deceased parents is that their choosing to take such coverage made the difficult time toward the end of their lives easier for them and for me as the child with principal responsibility for the late part of their lives.

The majority of the 45 million people in this country lacking health care coverage are not in their senior years. We are talking about routine things like vaccinations, preventative prescriptions, stuff that is preventative, not curative.

I had dinner with a friend over the weekend, and we both were lamenting how costly it is as small business onwers to cover health insurance for employees. We both do it, but many don't because it simply is unaffordable. Somehow, that does not seem right to me.

I really do not know what the best design of our health care system should be, but I do know that there are some very broken components to it, I do think we can do better, and I find this notion that it is "free market" or "single payer" to not be a helpful way to frame the discussion.


Posted by R Wray, a resident of Midtown
on Aug 4, 2009 at 9:53 am

"Single payer" is a euphemism to hide the fact that the single payer is the government. It's socialism.
The present brouhaha is not about the the 15% (45 million), it's about the 85%. It's about taking our individual responsibility and forcing us into a collective where we are under the control of the bureaucrats.
Certainly, employers should not normally be the middle men between the employee and his insurance company. This was instigated by the government in the 1940's and has been perpetuated by various regulations and tax laws. These should be eliminated.
The present ploy of Obama and the power lusters is to vilify the private insurance companies--this is their August campaign. They will hide the fact that the insurance companies are among the most regulated businesses--which is the cause of most of their alleged "evil" practices.
Extremism in the defense of liberty is no vice. This is a black and white case. A wishy-washy approach doesn't cut it.


Posted by Paul Losch, a resident of Palo Alto
on Aug 4, 2009 at 10:08 am

Paul Losch is a registered user.

GOP Senate Whip John Kyle was interviewed on the morning NPR news program. He said that the two big problems that he thinks need to be addressed are people who do not get coverage under the present system and finding a way to make health care insurance more affordable for small businesses and individuals.

He said he favors an incremental approach.


Posted by Keith, a resident of Midtown
on Aug 4, 2009 at 12:50 pm

Paul L,

The public option is a direct route to single payer. I have already explained why, in a previous post, but let me put it in terms that apply to your business, Paul. If a public option existed, you could just withdraw from the entire health coverage issue, and still feel good about yourself. After all, your employess would now have a vehicle to get their own heatlh care coverage. Your employees may not be happy about it, but their complaints would, rationally, fall on deaf ears. You would save $$, becasue you would not have to pay insurance premiums, and you would not, completely, make up for those savings in increased wages. All rational small businesses would dump their employees into the public option.

The public option is backed by the US Treasury, thus it does not, in reality, need to pay it own way. It can just demand more taxpayer funds, just like Medicare and Social Security and Medicaid. Worse, it will cause the doctors and hospitals to charge the private insurance companies even more, in order to subsidize the underpayment of true costs by the public pool. The private insurance companies will be forced out of business, and the public option will become the only option, otherwise known as single payer.

Lost in all the discussion about how to pay, is how to innovate. The favorite boogymen of the single payer crowd are the drug companies. Modern drugs have provided an enormous bang for the buck, preventing many hospital-days. Yet there are huge complaints about the costs of the drugs. A single payer system will buy the lower cost generic drugs, but it will not support the R&D for the next genertion of drugs. This ammounts to rationing without having to call it rationing.

If possible, I would like to direct this discussion to the bending of the cost curve. I think this is best achieved through free market mechanisms, while the socialist approach is supported by others. I am willing to actually discuss this issue, but there seems to be little inclination to do so on this thread. I have already teed up individual health savings accounts (HSA) as a viable approach. What is your approach, Paul (and Mr. Levy)?


Posted by R Wray, a resident of Midtown
on Aug 4, 2009 at 1:11 pm

Here's the 3rd paragraph of an NPR report on the Kyl interview.
"Sen. Jon Kyl (R-Ariz.) tells NPR's Linda Wertheimer in an interview set to air on Morning Edition Tuesday that he'd rather see no health overhaul than adoption of the approaches on the table right now."


Posted by Paul Losch, a resident of Community Center
on Aug 4, 2009 at 1:16 pm

Keith,

I appreciate your walking through your point of view that public option is ultimately a slippery slope to single payer. Your contention is difficult to prove or disprove, but it is a legitimate opinion for someone to have.

Health care policy is not my area of expertise, so I only can comment based on what I hear and read, and my own first hand experiences. And since I am not an expert I tend to look at what are the gaps in the current situation, what are the risks going forward, and what are reasonable objectives that could possibly be met more than one way?

For the sake of discussion, let's take public option off the table. What would the health care look like for it to solve these key objectives (these seem to be the ones that are most prominent the national discussion, and all were mentioned by Senator Kyle in that interview I heard on the radio this morning:

1. Get costs under control
2. Make sure to "do no harm" to those who have existing coverage with which they are satisfied
3. Make it more affordable for small businesses to provide coverage
4. Have a plan or plans that will provide coverage to those who presently do without

At the end of the day, I am indifferent to what the alternative strategies are to achieve those objectives than I am in wanting to see those objectives met.

And, as I suggested in the opening commentary, it may be as a practical matter achieving the changes we need may require a series of steps and a period of time, as opposed to the system morphing in the next few months to entirely meet those and other legitimate objecitves the policy makers identify. I really have not heard or read very much about that notion.

What I would hate to see happen is this becomes a political battle as opposed to a policy battle. It appears that most of the leadership is attempting to do that, but there remains a risk that this whole thing will devolve to that, and that is a disservice to the country, IMHO.


Posted by Keith, a resident of Midtown
on Aug 4, 2009 at 2:16 pm

Paull L.,

I believe the HSA approach accomplishes much of what you want.

1. HSA's incentivize people to NOT go to the doctor, unless it is something serious. They also incentivize to AVOID repetitive tests. Why? Becasue they will get cash back, tax free, at the end of the year, if they do not spend it on unnecessary health care. Public health drives, like immunizations could be automatically charged against the individual HSA, thus there would be no incentive to avoid doing the public good.

2. If HSA applicants sign a "hold harmless" clause, their doctors would no longer need to practice defensive medicine, and HSA holders would get more cash back.

3. HSA holders would need to make a rational choice between generic and brand drugs. There is a trade off, but those indivuals and their doctors would need to make that decision.

4. HSAs would be available to all individuals who want to buy into them. Company matching is an option, to be determined by the compnay and its employees. Non-employed indivduals would have portability, assuming that they want to purchase insurance.

5. With appropriate pooling schemes, made possible by liberating the insurance market to actually compete, across state lines, all individuals who want health insurance can purchase it, at the most economic price available in the market.

The public option is a real deal killer, becasue it does not contain costs, except through mandatory rationing, and it will indeed kill off the private insurance market. All it really does is soak the middle class to pay for those who refuse to pay for their own health insurance.

I should add that any reform that does not control the trial lawyers, with tort reform, is disingenuous. The hidden costs of defensive medicine are enormous. I have not heard a peep about this in the current proposals supported by Congress or the Executive.


Posted by R Wray, a resident of Midtown
on Aug 6, 2009 at 9:43 am

Keith, be careful, you're too logical, I may report you to the Obama propaganda czar.


Posted by Perspective, a resident of Midtown
on Aug 6, 2009 at 12:56 pm

Keith: Run for Congress! Senate! Your rational. AMERICAN approach, one that addresses the issues we have without destroying all that is the best in our system, is a breath of fresh air and one that America is crying out to elect!

Hear, Hear!

Be sure to set up a defense fund to get you out of wherever they hide you once your IP address is handed over to the Flag site at the White House ( I have already alerted everyone I know to search for me in the White House dungeons somewhere if I disappear one night).

Thanks!


Posted by Keith, a resident of Midtown
on Aug 9, 2009 at 3:51 pm

Paul L.,

I could be wrong, but I think the public option is going to be killed off in Congress. I think this is very good news. I much prefer an approach, like HSA, because this is a logical approach, invovling individual incentives, that actually does achieve cost savings in health care.

What are your views on HSA? I would also invite Mr. Levy to give his views on HSA.


Posted by Paul Losch, a resident of Palo Alto
on Aug 9, 2009 at 5:25 pm

Paul Losch is a registered user.

Keith,

If your suggested approach can meet the objectives that I perceive to be agreed to by most policy makers involved in this, it needs to be seriously included in the conversation. As I said, I am not well versed in health care from a policy standpoint, and so while what you suggest seems reasonable as you describe it, I am not sure my passing judgment one way or the other on it holds much water.

The was an editorial in today's Sunday NYT about how things are going in Massachusetts since they enacted the equivelant of universal coverage when Mitt Romney was governor a few years back. While it was typical NYT lagubrious editorial, and consequently confusing, it did leave me uneasy about what it going on there. Mixed results, from what I can tell. My key take aways were that they have nearly everyone covered, but the private insurers still have escalating fees, and costs from the health care providers are not going down either.

Lessons to be learned, and applied/not applied.


Posted by R Wray, a resident of Midtown
on Aug 9, 2009 at 6:28 pm

The liberal/progressives are not likely to give a straight answer because they are after control not care. See Thomas Sowell's recent column
Web Link


Posted by stephen levy, a resident of University South
on Aug 9, 2009 at 6:48 pm

stephen levy is a registered user.

Keith,

HSAs are a legal option available today. Are you proposing something different? You seem to treat HSAs as a choice that is not available today but it is available as are employer co-pays.

They are a reasonable option that self employed people or small business owners might choose. You need to be able to fund the savings account and handle a high deductilbe insurance policy.

Are you arguing that everything but HSAs should be prohibited and everyone should be forced to use an HSA?

Here is the U.S. Treasury website on HSAs. What would you change?

Web Link

Steve


Posted by Keith, a resident of Midtown
on Aug 10, 2009 at 11:45 am

Mr. Levy,

The current HSA system is highly conditional, and it does not provide incentives to NOT go to the doctor. For example, all of the tax-free money must be used for medical expenses, and there is a 10% penalty for not using it for medical expenses...ergo, there is strong incentive to spend it on medical expesnes, which is exactly the opposite of bending the cost curve. The current HSA system does not allow the money to be used to pay health insurance premiums. Again, this is a disincentive to shop for the most competitive rates.

The system I envision, as I have already mentioned in a thread (above), is one that incentivizes the HSA participant to cut his/her medical costs via an anuual refund of tax-free dollars that are NOT spent on medical care. The current use-it-or-lose-it scheme does just the opposite.

I know that you are concerned about the costs of medical care. So am I. However, I am offering a scheme that would actually incentivize to reduce those costs, becasue there would be less use of the medical system. In essence, it would be preserved for the serious medical conditions that require a doctor. As an example, I have a friend who cajoles his doctors into running every conceivable test, becasue he is currently covered with an insurance policiy, and he has already paid his deductibles. As he told me, "why not, they're free?!" Imagine if knew that he would get tax-free income back to him, if he stopped demanding every test?


Posted by Palin, a resident of Midtown
on Aug 10, 2009 at 8:17 pm

The first step to fixing the health care system is to start telling the truth about what is broken and about proposed plans to improvement. All the lying going on is making things worse, not better. Here is a good example of a big name politician caught in another lie: Web Link


Posted by Keith, a resident of Midtown
on Aug 10, 2009 at 10:00 pm

Rationing is a fact of life in the British National Health Service ( Web Link ). Ezekiel Emanuel, Rahm Emanuel's brother, is a major health advisor to the Obama administration, and he also recommends rationing, especially for the disabled. Sarah Palin is not too far off the mark.

Now, let me admit that I also want rationing, because it will reduce costs. I just want it to be a personal choice.


Posted by GS, a resident of Barron Park
on Aug 11, 2009 at 5:45 am

Keith,

You already have rationing here. It's based on luck and wealth.


Posted by Paul Losch, a resident of Palo Alto
on Aug 11, 2009 at 4:26 pm

Paul Losch is a registered user.

There is too much "scare tactics" going on around this matter. For people to be shouting and angry and being so uncivil suggests a pernicious aspect of this that end the end of the day is unproductive.

Sarah Palin is a very strange woman. She had the responsibility as a state governor, gave it up, and is making bizarre comments about what is going on with health care policy reform. Does not come across as having any idea what the bills say, just spout off, uninformed.

Jon Stewart on last night's Daily Show had a good juxtapostion around her "Death Panel" notion and her comments several days ago about the press "just stop makin' things up."

This is not entertainment, but the discourse around it suggests that it has deteriorated to that level.

I go back to what I teed off at the beginning of this blog. This does not need to be an all or nothing program, and I don't detect much content that describes a game plan that takes things a few steps at a time that eventually meets the objectives that I have cited.


Posted by Keith, a resident of Midtown
on Aug 11, 2009 at 5:15 pm

Paul L.,

I think I have provided such content, through the use of HSA. You may not agree, but you have provided no substantive criticism, either.

I have already explained why I think the public option will lead, directly, to single payer. Single payer, if it is to add more clients, yet remain cost neutral, as promised by Obama, will involve rationing. Just like the British and Canadian systems do. Following the rationale of top Obama health advisers, it will be the most productive citizens that get the most resources, while the weak and neurologically damaged will get the least. Not exactly a death panel, but pretty close.

Rationing, which I support, should be voluntary and incentivized.

May I suggest, Paul L., that if you want the discourse to improve on your own thread, that you start to make substantive criticisms? I have put time and effot into trying to provide an alternative to the Obama plan, and I think I deserve a serious attempt on your part, not just some complaining about deterioration to the Jon Stewart level. If you are going to tee up a thread, then you should be willing to make a good faith effort in providing some answers.


Posted by Paul Losch, a resident of Palo Alto
on Aug 11, 2009 at 6:03 pm

Paul Losch is a registered user.

Hi Keith,

My primary role, as I see it on my blog site, is to tee up ideas and questions, not debate what others offer up around a topic I post.

I have in this case cited what I perceive to be the most important objectives around this matter, and expressed my concerns about how the conversation in general around the country is getting less productive, not more so.

You have a strong POV around how this policy matter can be addressed, and as I responded to you previously, I do not think I have sufficient depth of expertise to provide a useful response to your specific ideas. I am learning here as well, and I thank you for that.


Posted by Keith, a resident of Midtown
on Aug 11, 2009 at 6:31 pm

Paul L,.

Part of your learning curve should, imo, involve delving deeper into the underlying issues, so that your criticisms and questions have more substance. It is one thing to mock Sarah Palin, as an easy target, but she is closer to the substance than you appear to be. Her "death panel" statemnt is too strong, but not by much. I think it is incumbent upon you to understand why. This invloves doing your homework. For example, you might want to follow the teachings of Zeke Emanuel, one of Obama's top health care advisers, and the brother of Rahm Emanuel. At least at that point, we could begin to talk about rationing of health care in a rational way, without invoking a fool like Jon Stewart.

I can appreciate that you tee up interesting and topical ideas, but I think you should be willing to put some real effort into them, perhaps before you tee them up.


Posted by Paul Losch, a resident of Palo Alto
on Aug 11, 2009 at 6:58 pm

Paul Losch is a registered user.

Hi Keith,

I have more first hand experience than you care to know about end of life decisions about both my parents, the health care programs and insurance that they had and did not have, hospice, Medicare. I have a brother without insurance and a son who is about to lose his coverage from his parents as he has just finished college. I own a small company and to cover employees' health insurance is a huge cost.

Hospice is something that saves a great deal in Medicare costs, is a compassionate way to transition the last part of life. I have read so much the last few days about how there is something going on that is less than a peaceful end to life. It angers me, as I went through the decisions with my parents.

Don't criticize me, Keith, for professing what I don't know, and confessing what I experience.


Posted by R Wray, a resident of Midtown
on Aug 11, 2009 at 7:04 pm

Rationing applies to dividing up a fixed amount. In a government system the amount of health services is fixed (provided by someone?). In a free market system supply increases to meet demand--rationing does not apply. There is plenty of evidence that in a free economy the pie continues to increase as the demand increases. Marx was wrong.


Posted by Keith, a resident of Midtown
on Aug 11, 2009 at 7:16 pm

Paul L.,

I went through the end with both of my parents. Very emotional. I still cry when their birthdays come around, and I open up the scrapbook to remember them. They both had supplemntal insurance, and it made things somewhat easier. You are not the only person to suffer through the end with his or her parents. My daughter is a life-long asthmatic, and I also understand that issue. She has learned to manage the risk factors, at least mostly. I can feel you pain and your concerns, but you are not so special, in these regards, Paul.

The question is how do we pay for essential health care for those who are willing to be insured, and willing to pay for it. Until you get to that point, in your thinking, we are just talking past each other. If you can, then I think there are rational appraoches that can cover all willing participants, and protect small busineeses from ruinous insurance health care plans. Are you willing to dig deeper?


Posted by Keith, a resident of Midtown
on Aug 13, 2009 at 12:44 pm

I have made my case, best as I can, for HSA. Now I would like to add an additional approach that makes eminent sense to me. I am talking about voluntary assisted suicide. The Oregon law makes complete sense to me. I would not want it imposed, without my agreement ahead of time (death panel), but I would gladly sign up for it, if it was available in Caliornia. I think we should all have that choice. It would also save a lot of money, thus helping to bend the cost curve.

Combining HSA with a request for assisted suicide, if I am disabled, should allow me to get lower insurance premiums. Add in a 'hold harmless' agreement, towards doctors, and I have suddenly made a voluntary agreement that allows significantly reduced premiums.

Add on top of all this, tort reform that prevents outrageous judgemnts, thus creating huge defensive medicine costs, and we are seriously on our way to bending the cost curve.


Posted by R Wray, a resident of Midtown
on Aug 13, 2009 at 1:59 pm

I would like to ask someone on the Obamacare side what they mean by "quality adjusted life year". What do you think Paul L.?


Posted by Keith, a resident of Midtown
on Aug 13, 2009 at 2:35 pm

R Wray,

The following from the Daily Kos, which strongly supports the single payer system, and is trying to shoot down critics of same:

"The National Institute of Health and Clinical Excellence (Nice) decides whether new drugs represent value for money for the NHS in England and Wales. It replied: "This is a gross misrepresentation of how Nice applies health economics to try and address the central issue: how to allocate healthcare rationally within the context of limited healthcare resources. Nice assesses the cost of a treatment in terms of a cost-utility analysis which takes account of the quality adjusted life year – the amount and quality of extended life it is hoped the patient will gain. The current ceiling is £30,000 but exceptions are made."

Web Link

Obamacare leads directly to single payer, as I have already explained. Single payer care does, indeed, put a price on life care issues. This is the equivalent of a death panel (cheaper dead than alive). I don't think Americans will buy into this deal, but I do think we will be willing to accept rationing, if we are given the choice, along with the incentives.


Posted by Paul Losch, a resident of Community Center
on Aug 13, 2009 at 4:29 pm

I am going to share some recent personal experiences around my now deceased father (2008) to engender more conversation.

First, my father had incredible, frankly excessive, health coverage. The employer from which he retired paid in full for private health care insurance until the day he died. As a WWII veteran who was nearly killed and was awarded a Purple Heart, he got full, no payments by him for the VA System' services, and while he was under my care, I got to know that place very well. When we reached the point where hospice was indicated, it was completely covered by Medicare. Triple full coverage!

Pretty lucky man, my father. Pretty lucky me, his son, that I could deal with other aspects of the end of his life, although I did get into a couple major fights with his private health insurance carrier over the 4 years I managed his affairs.

Here are a few observations, and some data points:

1. My dad was triple covered on some things. Talk about wasteful
2. VA doctors (and my ex is one, so I know how to deal with them) ordered procedures that did not make sense for a man my father's age. Some I was able to fend off, but I consented to one that took him down several pegs, and he never fully recovered from it--it led to hospice. And these are docs who don't have to worry about malpractice--they work for the VA.
3. Had I not had the legal authority to deal with my father's end of life circumstances, and had he and I not sat down and discussed it and created a binding legal document about it, a difficult set of circumstances would have been much more difficult, if not impossible.

I am not going to get into some of the absurd suggestions that have made the news this week about how people who are elderly or have other incapacities will be covered or treated. It is pure BS. What I will say is that a responsible family member, be it a son like me or a parent with a child with health risks, MUST think through with medical and legal advisors what the options are with a loved one should that person encounter circumstances that call for life making decisions.

I had it with my dad, I did not have it with my mother, and both were painful, but it was easier since my dad and I had had the discussion.

If this one little clause in one of the bills teed up by a GOP Congressman that pays for a conversation to take place between a doctor, an older person and a designated loved one is viewed and portrayed the way it has this last few days, I say "walk a mile in my shoes."


Posted by Keith, a resident of Midtown
on Aug 13, 2009 at 5:35 pm

Paul L,

Your circmstances, and my own, are very similar. However, I fail to see how our own circumstances apply to the general model. Can you explain that to me?


Posted by R Wray, a resident of Midtown
on Aug 13, 2009 at 7:36 pm

This "quality of life adjusted year" concept shifts the value of an individual life to that of a mere cog in the collective. Americans won't buy it. The way things are going it looks like Obamacare will be defeated--let's hope so.


Posted by Paul Losch, a resident of Community Center
on Aug 13, 2009 at 7:37 pm

Hi Keith,

Someone who has triple coverage--does that not seem wasteful?

Someone who has doctors doing procedures that are not truly indicated for someone the age my father was at the time?

In m mother's case, MD's trying to persuade my family that she could survive yet another major operation, although they openly admitted her quality of life would be significantly compromised if she survived the procedures? My brother, to his credit, said "let her go, it is her time." That was a family decision, but the way we interacted with the medical team was very problematic.

I do not know what the "right model" is, but I do know from personal experience that the current "model" has serious flaws. You have asked me to provide my POV on the right solution and to respond to your purported approach. I do not have the background to do that, and I respectfully request that you stop asking me to do so, and instead allow the discourse to continue without expectations that I need to have a specific point of view around various approaches that address this matter.


Posted by R Wray, a resident of Midtown
on Aug 13, 2009 at 7:53 pm

Regarding those who say how complicated and how much background is needed to have opinions on the health care debate, consider this story I read on the Internet.
-------
But to those adults who assert that "it's complicated," I offer the
following anecdote from an eight year old student of mine:

Back in early June, one of the parents of my kids came to pick up
their child at the end of the school day. The father asked me what
I thought of Obama's health care bill. Generally, I don't engage
parents in such things, but I decided to address his question. I
stated that "the government has no business telling me what doctor
and I can or cannot see. It's a form of force and coercion."
Before I could continue, my student Michael (not the father's kid)
politely chimed in and in a very casual manner said: "Mr. Modell,
what you just said about the government telling a person which
doctor he can or cannot see goes against individual rights."

That's from an eight year old.

Complicated indeed!
---------


Posted by Keith, a resident of Midtown
on Aug 13, 2009 at 8:05 pm

[Post removed by Palo Alto Online staff.]


Posted by Keith, a resident of Midtown
on Aug 14, 2009 at 12:22 pm

John Mackey, CEO of Whole Foods, recently wrote an editorial in the WSJ in which he gives a number of alternative approaches to insurance coverage. HSA are at the heart of his thinking.

Web Link

Already, he is being boycotted by the Obamacare fanatics. Web Link These people are not very open minded.




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