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The Right Prescription
A Triple Threat to Patients
Courtesy of Obamacare’s unconfirmed czar, Donald Berwick — a first order business from the next Congress.
If and when a new Congress comes in, the fastest way to eliminate Obamacare will be by shutting down its “operating system” the Centers for Medicare and Medicare Services and investigating its unconfirmed director, Donald Berwick. And it should start by pulling the plug on Berwick’s Triple Aim Program and the billions of dollars he has for implementing it.
The Triple Aim Program (TAP) focuses on “improving the patient experience, improving population health and lowering per capita health care costs.” Berwick claims that all three are achievable not through consumer driven healthcare. In various speeches and slide presentations, Berwick claims there are isolated examples of private health plans delivering quality care at a lower cost through something he calls an “integrator.” Berwick believes that America provides far less health for too few people at twice the cost as Europe and Canada. The Triple Aim is Berwick’s master plan to remake American healthcare into Britain’s National Health Service.
In advancing TAP Berwick often invokes Garrett Hardin’s Tragedy of the Commons, which held that people seeking their own self-interest will deplete limited resources. As Hardin wrote: “Freedom in a commons brings ruin to all.” In his grand scheme the “integrator” in TAP will save us from ourselves.
The Triple Aim is the organizing principle of Berwick’s work at CMS. Indeed, it is rumored he was hard at work with CMS and other administration officials before the President rammed through his recess appointment without any confirmation hearing. Absent a congressional hearing where records, emails, pay stubs, etc., are made available, the extent of Berwick’s involvement — if any at all — is unknown.
What is evident is that Berwick arrived at CMS with the resources and individuals needed to rapidly implement TAP already allocated according to plan. Over $1 billion was allocated for comparative effectiveness research. The money is intended to compare high cost to low cost treatments and identify geographic differences in spending. The Dartmouth Atlas claims that nearly one third of all health care treatments are unnecessary. That’s TAP’s underlying assumption even though the Dartmouth map fails to control for differences in patient needs or degree of illness. Indeed, one specific TAP goal is to eliminate regional variations in per capita healthcare spending by bringing spending down to what it is in Dartmouth’s lowest spending region.
While there is great debate about the validity of the Dartmouth approach, there is no CER money for such discussion. Rather, as is the way of Washington, 90 percent of the $1.1 billion in CER funding will go to confirming the Dartmouth-TAP ideology. And 90 percent of the CER money — controlled by Berwick and the Agency for Health Research and Quality (AHRQ) — is going to individuals and organizations that have either received it in the past, help AHRQ decide who gets money, or were part of the Obama administration’s “expert” panel that determined that CER money should be spent on, well, what the money is being spent on. Berwick knows, has worked with, or funded all these individuals and groups in the past. That is not just collusion requiring investigation of AHRQ and other agencies funding CER. It also reflects how Berwick, Team Obama, and various “stakeholders” use federal grants as patronage to reward “friends” and punish anyone who doesn’t agree that CER can save the planet.
Initially Berwick and the Medicare bureaucracy will use CER to reinstate something called the “least costly alternative” (LCA) policy. This policy — struck down by a federal appellate court — allowed Medicare to pay for the cheapest version of a product it regarded just as effective as other products. The court said Medicare was denying necessary care as defined by the doctor. Now Medicare wants Congress to rewrite the law to reintroduce LCA based on CER and through decision-making guidelines developed by the Dartmouth group (for a huge profit).
Berwick once said: excellent health care is by definition redistributional. And ultimately, CER will be used to steer health spending into what Obamacare regards as valuable. Berwick’s close Dartmouth associate Jonathan Skinner wrote CER can be used for “reallocating resources from cost-ineffective treatments for late-stage pancreatic cancer to cost-effective treatments for diabetes may improve health outcomes in the aggregate but not for patients with late-stage pancreatic cancer. “
Under TAP, late stage pancreatic cancer patients will just have to take one for the commons. That is, unless Congress pulls the plug on CER, TAP, and Berwick, in that order. Doing so will gut Obamacare while allowing the development of better approaches to bringing affordable coverage to those most in need.
About the Author
Robert M. Goldberg is vice president of the Center for Medicine in the Public Interest and founder of Hands Off My H ealth, a grass roots health care empowerment network. His is new book, Tabloid Medicine: How the Internet is Being Used To Hijack Medical Science For Fear and Profit, was published last month by Kaplan.
Letter to the Editor View all comments (44) | Leave a comment
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Bill Hussein O'Stalin| 10.25.10 @ 6:13AM
In the meantime many companies in America are already dealing with the reality of government dictated health care.
Many companies are developing plans to simply pull the plug and are simply waiting until after the elections to make the announcements.
It isn't just Berwin. There are many other evil characters operating right out of the White House who know that many companies are already making plans to dump employer plans.
By 2012 few companies will offer health care to new employees and those that do will have much higher costs.
In essence, Obama destroyed the best health care system in the world. No matter what is done now, health care is changed forever, and not for the best.
http://news.yahoo.com/s/ap/201.....alth_plans
SonOfSam| 10.25.10 @ 10:11AM
This reminds of that episode of "Family Guy" where the dad goes into "Cheesie Charlies" (a spoof of Chuck E Cheese) and you see a kid at the counter trying to trade in his tickets for a toy. The man behind the counter says "Oh I'm sorry Timmy, it costs FIFTEEN tickets to live!"
I'm sorry, John Q. Public, you're not federal employees, so you don't qualify for an actual doctor!
Deborah D | 10.25.10 @ 6:19AM
Very confusing read. What the heck is CER? Did I miss where you defined that term? I'm all for ending Obamacare via defunding as a first step, but tell me what CER is?
Thanks.
Bill Hussein O'Stalin| 10.25.10 @ 7:04AM
CER=Comparative Effectiveness Network. You could also call it socialism, or "it takes a village", etc.
Tim*| 10.25.10 @ 7:17AM
That's A Bureaucrat Acronym for Bureaucrat Babble " Comparative Effectiveness Research " which for We,The Great Unwashed means " How Effective Different Treatments Are."
Obama Isn't A Doctor . He Just Plays One On TV.
The Tea Party Rebellion Escalates.
Rise Up In Rebellion !
Bill Hussein O'Stalin| 10.25.10 @ 7:24AM
Thanks for the correction. I was thinking research but typed network. Actually it's all a con job no matter how it's referred to by the politicians.
Tim*| 10.25.10 @ 7:41AM
Indeed Bill .
It's Socialistic Crap Sold By The Snake Oil Dude .
Bill Hussein O'Stalin| 10.25.10 @ 7:24AM
Thanks for the correction. I was thinking research but typed network. Actually it's all a con job no matter how it's referred to by the politicians.
Deborah D | 10.25.10 @ 8:12AM
Thanks to both of you for clearing that up! I appreciate it. I have trouble with so many alphabet soup descriptions anyway, but when it isn't to be found in the body of the story, I really have problems! :)
jawin| 10.27.10 @ 1:08PM
Agreed, Deborah. The article could have been easier to read and, therefore, less confusing if it simply included the fact that Comparitive Effectiveness Research (CER) will be used to economically "justify" the rationing of healthcare.
By the way, an additonal, real problem is that CER will result in fewer and fewer advances in American healthcare. Advances in healthcare necessarily takes great amounts of funding and, when developments in healthcare are found, they are initially very expensive. If the vast majority of healthcare is provided by the government (as obamacare is intended), how will those new developments achieve widespread use so the costs can be lowered? Answer: Nyet!
Sue| 10.25.10 @ 12:05PM
Comparative Effectiveness Research is being used to eliminate treatments that the bureaucrats deem "unnecessary and ineffective." The problem is, unnecessary and ineffective to whom? The first action they took was eliminating "bone cement" being used by thousands of physicians to treat spine disorders of the vertebrae. The elimination was justified on studies conducted in the UK, Indonesia and elsewhere. Not studies done here in the US. The real issue was the government did not want to pay for "ANY" treatment, therefore, ANY study that will support and eliminate the treatments will justify the bureaucrat's actions. In actuality, it's "cost elimination research."
Booger | 10.25.10 @ 6:40AM
From the desk of Center for Unified Universal Health Services Czar Donald Berwick:
Dear Staff,
Since the implementation of my Triple Action Plan we have begun to see some reduction in costs and a more efficient delivery system for health care. Unfortunately, we still have not reached the level of efficiency needed to meet our short or long term goals in savings. Hence I would like to implement the following changes to our triage system:
1)Incentives. Many relatives of long-term patients who are unlikely to recover are holding up the process of end of life procedures through such as meddling as lawsuits, pickets, and even direct interference with medical professionals attempting to provide compassionate end of life medications. I would suggest that it would be cost-effective to provide incentives to the patient's legal guardian to "go along" with the process in these instances. For example, if long term care is running at $3500.00 per day, a one time cash payment of that amount to the legal guardian might convince them that termination of services really is the best option for the patient. Paying the $3500.00 on a one-time basis to make the family go away is certainly less expensive than paying it for the average of twenty-three days that many of these patients loiter around clogging up our facilities. As a side note, under our new power to enable and enforce guardianship orders, if the current guardian is still unwilling to co-operate, we can simply designate another relative, or social worker if need be, as the patient's guardian. This will be in the best interest of all involved.
2. Dealing with "super bugs". There are a number of new bacteria out there highly resistant to all of our current antibiotics. While this was initially a concern for many of our doctors and nurses, some of our new health professionals from end of life services have found a way to "make lemonade out of lemons", so to speak. They have suggested the surreptitious introduction of these bacterium into our long-term care wards, to clear things out, to use a vulgar but understandable phrase. Patients who are infected with an incurable, flesh-eating bacteria should also be much more amenable to end of life compassion services. We will be shipping vials of the necessary bacterium nationwide beginning next week.
3. Triage, triage, triage. Let's understand something people. There is a time when true compassion is letting go. This time is when dealing with the very old, the very young, the infirm and the weak. We need to get back to practicing medicine the natural way. In nature it's the very old and very young, the weak and the infirm, that pay the price for the rest of the herd. We should learn from this. We need more natural medicine. Triage will save us money.
4. Please remember to make reference to your affirmative action in quality care cards when making your triage decisions. We need to remember that certain racial groups have, in the past, unfairly exploited the resources of others to gain what should have been unaffordable health care for themselves. This must end. Historically under-served races should now be given first preference. Additionally, historically under-served groups should be given preference in our limited medical resources. Thus, homosexuals should be given first preference at treatment, especially as they do not insist on over-burdening our system by constantly churning out new pediatric services consumers.
5. Elimination of pediatric services. This one has been highly controversial, and, as you know, unpopular in many quarters, but it is essential. Face it, if they can breed one pediatric unit, the parents can squeeze out another. We just cannot afford the prices for these little parasites. The romantic notions held by too many of our populace about health care for pediatric consumers must be set aside for the greater good. They are simply too expensive for the benefits they provide.
I hope these guidelines have been helpful. I am certain that if we implement them immediately we can achieve our savings goals. And remember, under our new executive orders, you can always refuse services to one of those awful tea-baggers.
Sincerely,
Center for Unified Universal Health Services Donald Berwick
Deborah D | 10.25.10 @ 8:22AM
Wow, in response to #1-- don't give them any ideas! Once again, well done, Booger. Oh, and number 2, 3, 4 and 5 as well. Those, I'm sure are already at the top of their list. I mean, #5 is just an abortion after the fact of birth...nothing to quibble about there, is there? Scary....
Petronius| 10.25.10 @ 9:01AM
Too verbose this time Booger. It should have been a curt little memo to Berwick from Barry telling him to "be my Mengele and implement the final solution, since the Supreme Court scotched the Right to Life back in 1973." Cheers anyway.
Deborah D | 10.25.10 @ 11:07AM
Oooh, I have a great name for #1 -- "Cash for Corpses." Sick...but it would fit.
Booger| 10.25.10 @ 2:56PM
Dear Deborah D,
Cash for corpses? I have been totally one-upped on my own post. Oh the humanity!
Cordially,
Booger
dw| 10.25.10 @ 1:53PM
From the desk of President B. H. Obama
Dear Donald,
I have reviewed your Five Point guideline submittal to your staff. As we have discussed, if I am to save this country from the transgressions of its past and the evils of capitalism I will need the support of people like you.
Let me briefly comment on your ideas.
#1. Instead of positive incentives in the form of cash payments, I suggest we threaten those who would prolong treatments with IRS audits.
#2. Great idea-let's develop this
#3. We can call this "Organic Medicine". It will be especially attractive to those personalities who embrace the "spiritual" aspect of life. We can cull many of those maniacs on the far left with this tactic.
#4. We will need to generate a priority list for preferential treatment to include, not only those you identified, but also donors, VIP supporters of my regime and those in influential positions that can benefit my ongoing ability to implement my programs.
#5. Birth restrictions are an important aspect of the global disruption strategy. Not only does it help from your end but population reduction will benefit the enviorment by reducing consumers. This is another area where we can engineer policy that will favor those who support me and by doing so, build political capital that I will use to ensure my ongoing authrority.
I have more thoughts on this and would like to meet with you after I get back from India.
Thanks,
Barack
Tellthetruth| 10.27.10 @ 8:22PM
Aah...Booger...once again, you've illuminated on the intent of Berwick...and as any of us who have read his philosophical meanderings...can Mengele be far behind?
Appleby| 10.25.10 @ 6:54AM
The inclusion of Canada as a shining star regarding health care is a product of overwhelmng ignorance.
Google the subject and restrict it to coverage within Canada and you will discover that this is something you do not want.
Carol| 10.25.10 @ 6:55AM
American Spectator:
Make sure the GOP reads this ASAP.
They can use this in the remaining days of their campaigns.
If they don't quit funding NPR forget about them defunding CommieCare.
Clinton nee Publius | 10.25.10 @ 8:27AM
As a health care economist I can tell you that it is the structure of the capital finance plan and not this kind of chicanery that dictates the outcomes of the plan' implementation. Currently, we use the insurance care model and it became obsolete around 1965 as we realized the Baby Boom generation would grotesquely distort the model's ability to keep up with service demand. Today we see the nose of the Baby Boomer "football" start to crash through the system and neither Obamacare nor the insurance model can deal with this problem.
Universal health care is something we can have any time we want it, but we will not get it with government running it or using the government as the payor for the system. In point of fact, I have repeatedly demonstrated a universal health care model that does not discriminate, provides no coverage exclusions of any kind and has built-in cost controls and relief for liability exposure to health providers.
The cost?
$30 per person per month. The co-payment is only 2% on everything but electives (and even electives have a ridiculously low 7% co-payment).
How you structure the game determines the outcomes and as long as you are going to use the financial equivalent of the buggy whip, then the inefficiencies have to be part of the deal.
It's the math thing, stupid.
Steve A| 10.25.10 @ 8:53AM
Clinton, Come on man, really? Simply impossible to provide any decent coverage for $30 / month with no ability to exclude pre-existing conditions. Oh, I get it. The coverage limit on the policy is also $360 annual. Maybe that would work.
kerry| 10.25.10 @ 11:13AM
No, he is expecting that every citizen MUST join. That is the key. You are forced to spend 30 dollars a month, whether you want to or not.
Steve A| 10.25.10 @ 11:32AM
I don't care if you get everyone on the planet to join & only pay for those in the US, the math is not there. It's nonsense.
Clinton nee Publius| 10.25.10 @ 2:06PM
And yet you would be wrong. This is NOT the insurance model. The math is there - you just aren't smart enough to understand it. The only nonsense is continuing to use an obsolete approach to the problem. Really, Steve. You need to grow up and acknowledge the reality that mandatory anything doesn't work and the solution for the problems we face have to come from outside the Beltway and can't be what we have already tried and failed to do. If you aren't smart enough to get it, that's okay, but at least get out of the way of the professionals who do know what they are talking about.
Clinton nee Publius| 10.25.10 @ 2:07PM
And you would be wrong too. No mandatory anything. In fact, if you don't pay the $30 per month it still works, it's just that your co-payment on getting services jumps to the 7% bracket. No mandatory participation - that's the INSURANCE capital finance structure model and that won't work due to the demographics we are facing (that stubborn football created by the Baby Boomers).
Clinton nee Publius| 10.25.10 @ 2:04PM
Yep. It's the STRUCTURE of the capital financing that dictates the outcomes. You structure all plan costs using defeasance (look it up, nothing fancy, we've been doing it since 1984) and this leaves no deficits unaccounted for. It really is simple.
STeve A| 10.25.10 @ 2:59PM
Well there Clinton. Take a deep breath & calm down pal. I have a simple question for your bullet proof plan. What is the cap on payout, annual & lifetime?? I happen to think the current legislation is a complete disaster. No fan at all, by the way.
I have been in the insurance business for 15 years there buddy & happen to grasp a few "basics" with my limited mental capacity. I do know, for SURE, that if you take on a known, massive risk, with GUARANTEED, massive payouts, you blow the reserve pool all to hell. Especially if you simply charge your magical $30 fairytale rate. You must work at one of those classy firms that I see offering "affordable" coverage stapled to telephone poles.
mstahl| 10.25.10 @ 8:29AM
What is never mentioned by these socialists is the fundamental difference between our healthcare system and all the others. No, it is not "cost" or "access' or "quality of care". It is parasitical plaintiff's lawyers. Have you noticed that neither CER nor Obamacare address this problem in the least? As far as these people are concerned the healthcare problems are somehow the fault of insurance companies or greedy doctors who must be reined in. And we are supposed to let Dr. Berwick make all of our decisions for us. Of course he is a non-practicing physician who made millions of dollars working for a "non-profit". Heaven help us!
Alan R.| 10.25.10 @ 8:55AM
CAUTION! This article has dangerously confused two very different things: the very good idea of the “triple-aim” in health care, and the very bad idea of misusing it to impose socialism ala Obama/Berwick.
"Triple-Aim" is the useful generic idea that true health care improvement needs to be mindful of cost effectiveness, patient health, and patient satisfaction – all at the same time. In other words, you can’t ignore patient health in pursuit of cost cutting, or build Cadillac satisfaction for people who can only afford a Chevy, etc.
I am an analyst at a private non-profit health coverage company (sort of an HMO), and I am RIGHT NOW at this very moment building an excellent PRIVATE, FREE-MARKET triple-aim program. It works like this: we identify areas of care in which there is a wide variation in cost between different doctors, with no apparent difference in patient health or satisfaction (e.g. some doctors treat mild low back pain without using any MRIs, other doctors give everybody an MRI). We provide information to the doctors about who is expensive and why. We let them know that eventually patients who pay may decide find another doctor.
Doctors have been very interested in this information, because up ‘til now they have not had a good idea how their price/value compares to other doctors, and many are worried about staying competitive in a market where more and more people pay out of pocket.
In other words, instead of dictating what doctors may and may not do, we are lubricating the market with the information necessary so they can do what happens in every other industry: compete on price and quality. We’ll let the doctors decide what is cost-effective. The one useful thing government could do is provide infrastructure for the free flow of information. It is not necessary for the government to dictate what should be evolving decisions made by practitioners in the field.
Troy| 10.25.10 @ 9:09AM
You know, that triple-aim idea makes me think of something I learned in computer programming, "On time, under budget, or no bugs; pick two." When you have multiple standards that must be met and limited resources then by definition you will have to short at least one. This goes back to the two choice model, "Rob Peter to pay Paul" and would continue no matter how many goals you had. The current US model is "Quality, Satisfaction, Low Cost, in that order." While I don't want to dismiss your experience, setting a goal of meeting all three is logically impossible without introducing a fourth metric that will not be met (such as low govt. interference); if you aim to level them all then you get mediocrity, which will leave no-one happy.
Pecos Pete| 10.25.10 @ 10:19AM
"many are worried about staying competitive in a market where more and more people pay out of pocket."
I pay cash for dental and eye care and would consider having an health insurance policy for disaster coverage only.
Appleby| 10.25.10 @ 4:46PM
This is what I would prefer to do -- rather than, as I am forced to do in Canada (where private insurance is illegal), pay for everything from boob jobs for convicts to in vitro fertilization for welfare queens.
If I were allowed to pay for insurance that covers only those services that are likely to bankrupt me (e.g. massive heart attack, run over by brat text messaging on bicycle on the sidewalk -- a woman was actually killed here in TO by such a brat) and have a deductible that would exclude the things I can pay for myself -- and would NOT cover anybody else's care but mine -- I'd be a happy camper. I believe this used to be called an HSA with a high-deductible umbrella.
P.S. It amuses me, member of the Baby Boom that I am, that whatever age plateau our gang reaches, everybody else is unprepared and taken by surprise. We have been here for 65 years now, boys and girls. Were you honestly expecting all of us to die before we reached the next level in the game?
Ken (Old Texican)| 10.25.10 @ 9:51AM
Friends,
This is simply the "Umbrella organization" and the pre-game show for:
DEATH PANELS.
Get the headline right and the rest is easy to understand.
bcintn| 10.25.10 @ 12:50PM
Unfortunately, you are exactly on point. Note the names of the "operating centers" - Centers for Medicare and Medicare Services - in other words, the seniors.
Since abortion's already a given, they plan to move on to weed out the old folks, then can continue with the "undesirables" - the weak and infirmed, etc.
The soul of our nation is at stake here. I hope and pray we rise to the challenge.
Fairbanks99| 10.25.10 @ 3:25PM
Progressives and Eugenics have a long and bloody co-joined history. From the turn of 20th century to the late 30’s eugenics was a very popular concept in the U.S. and Europe. Many reputable individuals and universities funded research and supported its goals. Eugenics focused on “improving” the human race through selective breeding and elimination of “undesirables”. Twenty nine states passed legislation allowing forced sterilization. Many people were sterilized, with California leading the way. Among individual supporters were Theodore Roosevelt, Woodrow Wilson, Alexander Graham Bell and Margaret Sanger. Margaret Sanger said “Fostering the good-for-nothing at the expense of the good is an extreme cruelty. There is no greater curse to posterity than that of bequeathing them an increasing population of imbeciles.” Universities included Harvard, Princeton, Yale, Johns Hopkins and Stanford. Leadership of the eugenics movement shifted to Germany in the 1920’s. The Rockefeller Foundation was so enthusiastic, even after the gassing of “defectives” began that it continued to fund high level German research up until the war started in 1939. This “scientific” theory that lasted for decades, ultimately resulting in the death of millions, had no basis in science whatsoever. It was politics and agenda masquerading as science, a very dangerous combination. Global warming, anyone?
sam vaughn| 10.25.10 @ 10:24AM
Typcial management from afar using stale statistical analysis rather then local experience. Top down management from DC always screws up. Example, recent flood plain map revisions moved property that people have been living in into different floodplain designations. The ecnomomic consequences and subesequent loss of property rights is incalculable. A giant land grab. Beware when bureuacrats who have never lived outside of DC decide your fate using made-up data.
hunter| 10.25.10 @ 10:37AM
I am surprised Dr Kervorkian hasn't been appointed to a seat on Obomba's "health care train. But am sure that was a oversight that will be corrected in a timely manner when approprate.
Rmm| 10.25.10 @ 11:06AM
In most cases guys like Berwick are talking to a select crowd who may understand wtf he is talking about. But for most of us 'normals' this might as well be Greek! Bring it down to street level to make things clear and precise. Otherwise, pull an Obama and speak in tongue.
Kent Lyon| 10.25.10 @ 11:50AM
The Tragedy of the Commons only occurs in a socialized or collectivist system. It does not occur in a free market system. Berwick's perceived need for a centralized authority to redistribute healthcare derives directly from a socialist system of healthcare, e.g., the Cuban-Venezuelan model, aka Obamacare, in which patients and doctors will be told what they can do, and lose any discretion regarding treatment or care (not to mention in their insurance options), as in the "Least expensive alternative", which may indeed long term prove to be the most expensive alternative--research won't ever look at long term costs or benefits, as the government is focused on the existing budget, not on the overall well-being of the nation. Thomas Jefferson said, "Were we directed from Washington, when to sow and when to reap, we should soon want bread." In this circumstance he likely would have said, "Were we directed from Washington for our medical care, we should soon be sicker or dead." That actually seems to be the goal of Dr. Berwick.
mames| 10.25.10 @ 2:31PM
If the GOP knows whats good for thier political future they will act on these issues soon and decisively - otherwise it will be RINO barbeque time! Y'all hear that house and senate leaders?
PattyMor| 10.25.10 @ 3:21PM
Wow this policy is a three-fer: after grandma dies,
we need no longer pay for medical expenses, nursing home care, nor social security. Imagine the cost savings from all that!! All this Berwick, can proclaim while he enjoys a special medical plan which was given to him by his former nonprofit employer. What excellent timing...seems a lot like "special" treatment for Soviet swells.
Emma| 10.25.10 @ 5:25PM
So suicide will become a form of patriotism. Maybe it could be the basis for a tax credit of some kind for immediately family members?
The better the tax credit, the more likely they would be to help off Grandma.
ghostwriter| 10.26.10 @ 12:51AM
I am wondering why employees of all the corporations that are eliminating health care insurance can't do what unions have been doing for years - simply walk out en masse. STRIKE!
How long could 3-M make sitcky note pads if EVERYONE walked out tomorrow? They might gear up in a month, but they could not stay rolling tomorrow.
Remember - no, you probably don't - the UAW mechanic who locked himself in the room that controlled the electricity for the whole damned assembly line and operation until their demands were met? Probably one of those demands was full pay, even when they were got to stay home because no automobiles needed building right now - a perk they enjoy now.
It is truly stunning how quickly a union will throw a hired -to-picket line around their enemy, the employer and decent workers would never do that. Hired-to-picket? Yes, union members rarely walk the line themselves. They are home with a six pack watching TV.