Impediments to Reform
100 Surprising Days of Health Care
Published May 02, 2009 @ 08:13PM PT
I tend to not put much stock in evaluating a presidency on a hundred-day timeline. Suffice to say, 1933 was a unique time in American history and comparing any president’s 100-day legislative accomplishments to FDR is about as relevant as comparing the number of books any president has written to Teddy Roosevelt’s record (35, by the way). Still, this is a good time to reflect on the progress of getting real health care reform done in Washington – and on the top 5 surprises in our national debate so far!
5.) Single-payer as persona non grata
To be clear, I did not expect good news for advocates of single-payer this year in general. Obama had consistently said, “Love ya, but no thanks” during the campaign (or, more particularly, “If I was starting from scratch, maybe… but since I’m not…”). He was always very clear on what was in his health care plan and what was not. Sen. Baucus released his white paper on health reform, which largely agreed with the Obama plan. We were told that Ted Kennedy was “working closely” with Baucus. And the big pre-inauguration shake-up in Congress saw single-payer supporter John Dingell ousted as chair of the Energy and Commerce Committee by Obama-plan supporter Henry Waxman. So the lay of the land was not good. Plus, there was always going to be a strong chance that the support for single-payer in the House would erode as it actually became likely the legislators there could do something about it. It’s easy to say you’re for something when it has no chance of being signed by President Bush, less so when Democrats are in charge. Consistent support in the House has somewhat been a positive surprise all by itself.
But even I have been taken aback by how needlessly the White House shut out the single-payer perspective in their kickoff events. To be clear, I’m not at all surprised at it being shut out of Senate hearings or Ted Kennedy’s closed-door sessions – the senators in charged signaled as much early and often. But Obama specifically ran as the “I will meet with everyone” candidate. The initial exclusion from the White House Health Summit of any single-payer advocate was unnecessarily insulting and the rush to include someone a rare misstep.
4.) The “Freaky Friday” switch between House and Senate Republicans
You expect certain things. The sun rises in the east. It sets in the west. And the worst opposition to reform comes from the Senate. Not this time! Although there are plenty in the Senate – Mitch McConnell for one – who are taking a more aggressive posture, the most important Republican senators are still being cooperative in working on a comprehensive reform bill. Sen. Orrin Hatch has been decidedly low-key, which suggests he’s playing well with old friend and legislative partner Ted Kennedy on Health, Education, Labor and Pensions Committee. Sen. Max Baucus and Sen. Chuck Grassley are practically having a bromance in the Senate Finance Committee. Sen. Specter is being so accommodating that he switched parties! The biggest pains in the butt to date haven’t been Republicans – they’ve been Democrats like Sen. Evan “I agree with health care reform but don’t agree we should pay for it, but do agree that we should cut the estate tax for those with over $7 million – that TV camera’s on, right?” Bayh and Sen. Ben Nelson, whose opposition to the public plan is bizarrely more stringent and less logical than most conservatives.
Bill Parcells vs. Bachmann: "You Are What You Are"
Published May 01, 2009 @ 10:05AM PT
I take no delight in informing you that Rep. Michele Bachmann has a reality-challenged view of the U.S. health care system. I’d be happy to never mention her on my blog. But periodically we get commenters jumping on the site to voice the largely-discredited adage that the American health care system is the best in the world. But just saying it doesn’t make it so.
After calling for the media to investigate who in Congress was anti-American, defending the massive increase carbon dioxide in the atmosphere causing climate change as “a natural part of nature,” and doing many other things that cause Keith Olberman’s voice to quake with disbelief, Rep. Bachmann published a health care puff piece in Wednesday’s Hill blog. Steel yourself for an argument from the 20th century:
From Canada to Cuba to countries across Europe, the results are all the same: a lack of doctors and nurses (particularly well-trained ones), bed shortages and long waiting lists for treatments and surgeries, and rationed care. While our current system is not perfect, it’s the best there is.
Hoo, boy. Well, really, I would invite the Congresswoman to come to Queens, which her first sentence describes better than it does any countries in Europe. Queens has lost three hospitals within the past year, with the attendant bed shortages and long waiting lists for treatments and surgeries. Queens is also experiencing rationed care, much like the U.S. does – if you have insurance, you get care. But also, if your insurance covers what you need, you get the treatment you need. Everyone else does not. Other industrialized countries may not be as quick as the U.S. to embrace the latest cutting-edge treatments, but only the U.S. rations essential care, including, at times, emergency care (Emergency Room diversions, anyone?) Don’t even get me started on the doctor shortage – except to say that with 2.4 doctors for every 1,000, our ratio beats only Canada, Japan and New Zealand, and is bested by at least eight other countries.
As for being the best there is, I’ll let Tom Daschle rebut this from a speech given yesterday (h/t Ezra Klein):
But for every king who may come to the United States, there are thousands of people who leave the US to get medical care elsewhere. They call it now medical tourism. Thousands of people leave the United States because the quality and the cost is better in other countries. So how do we explain, well we explain by simply stating that we have islands of excellence in a sea of mediocrity.
We are 29th in the world when it comes to infant mortality. 29th. We are 24th in overall women’s health. We rank 31st in life expectancy. On Pine Ridge Indian reservation the life expectancy of an Indian male is 47 years. The same as what it is in Botswana. We rank 37th overall in outcomes. 37th. Below Costa Rica and just above Slovenia. And I would ask how long would this country stand for being 37th in the Olympics? We wouldn’t stand for it long.
Look, I love my country – I wish we had the best in the world. Lord knows we deserve it. But at the end of the day when you look at the numbers, in the immortal words of Bill Parcells, “You are what you are.” Denying the urgent need for change may make you feel better ideologically, but it won’t make you healthier, it won’t make you live longer, it won’t generate more doctors out of thin air, and it won’t solve the problem.
(Photo credit: Dogfael on Flickr.)
"Everybody Knows" Is Not a Credible Source on Canadian Health Care
Published April 25, 2009 @ 09:21PM PT
Canadian health care has a tough time of it on Fox News, crappy Conservatives for Patient Rights commercials and the like. It tends to be based on… well, not much other than conventional thinking, or the old traditional “Everybody knows…” Here’s a hint: in this interconnected age where hard numbers are a Google search away, and people with life experience in a health care system can be easily emailed or Skyped, if someone has to resort to citing “everybody knows” as a source, chances are they don’t know what they’re talking about.
I’m prompted to write this because of a comment by reader Judy Gibson on another post. During the election of 1992, George H. W. Bush would say, “If you think government run health care is so great, talk to a Canadian.” Well, OK, don’t mind if I do…
"I'm a Canadian citizen and a typical one…. I'll be seventy next month and I am fully covered by our 'socialist' health system. When I looked after my husband's relatives in the UK when they were ill in the 1960s and 70s the UK National Health System covered everything--including my own health care.
"Yesterday I had a bone scan; in June I am to have testing for osteoporosis. My husband has chronic kidney disease and soon will go on dialysis, which is free, as is his care by specialists. I hope to give him a kidney; if accepted, we will undergo surgery and followup care which are free. Fifteen years ago my husband had a pacemaker implanted because his heart stopped twice, and he has atrial fibrillation and PVCs; that pacemaker, its installation, and the second one nine years later were free. My mother had Parkinson's disease and a rare form of skin cancer and two hip surgeries; all were free. My sister had a mastectomy; free. My younger daughter goes into anaphylactic shock if she eats peanuts; each hospital visit, doctors appointments, etc. are free. My brother-in-law has congestive heart failure and lung disease; treatments are free.
"As a result, we are a healthy family and have all survived traumas of every description; people have died of old age, in their eighties. My aunt was 91 when she died. Don't give me that 'baloney' about socialized medicine. You should be so lucky!"
Indeed we should, Judy. And in case you think that one family doesn’t make a trend, here are the numbers to back it up. Canada beats the U.S. in life expectancy, infant mortality, obesity, and spend less than half of what we do per capita on health care. Oh, and they cover everyone while we let 50 million citizens slip through the cracks. The most damning failure, cited by Rick Scott and Bill O’Reilly alike, is that the Canadian system experiences longer wait-times for elective procedures, like knee replacement surgery. As I’ve mentioned before, a study in the New England Journal of Medicine took this bogeyman head on. They found that, yes, the surgeries took about five weeks longer in Canada. They also found that patient satisfaction for the procedures was near identical -- 85.3% in the U.S., 83.5% for Canada. So much for unbearable wait times, eh?
They weren’t able to do the follow-up study on the effects on health and patient satisfaction between Americans and Canadians who were denied elective surgery because they have no insurance. They couldn’t find a Canadian to participate.
So yes, please do talk to a Canadian. But don’t take “everybody knows” as a reliable source, and don’t take those who cite it seriously.
(Photo credit: Ian Muttoo on Flickr.)
Political Spin Made Easy!
Published April 23, 2009 @ 03:16PM PT
The Wall Street Journal reported on the trend that private insurers are beginning to notice that, well, their members are disappearing – half a million from WellPoint alone in 2009. Thanks, economy! Since we’ve already hit that point in the health care debate where facts are slightly less important than how you spin them for political advantage, this is your chance to play at home and come up with your own talking points. Politics can be fun!
Here are the facts from the article: WellPoint has 35 million customers. As is common in the insurance industry, their exact number of customers ebbs and flows as people change jobs, get replaced or not replaced, and as their companies switch their benefits plans. What the industry wasn’t expecting in its quarterly projections, however, were the huge number of customers lost because they were laid offs, because their companies dropped benefits altogether, or who drop coverage for some other reason (say, inability to pay the increased premiums). Similarly, United Health claims it’s lost 900,000 already this year, and could lose as many as 1.5 million in 2009 if the unemployment rate continues to rise.
The article goes on to cite the Kaiser Family Foundation rule of thumb that for every 1% increase in the unemployment rate, 1.1 million people lose their health insurance coverage. Estimating that 3.6 million people (!) have likely gone on Medicaid or some other public coverage program since the year began, that would put us square on 50 million Americans without insurance.
Now let’s see what you can spin out of this!
- "The real story here is the drop in customers. How are these private insurance companies to survive with so many people dropping insurance? Don’t these people know that they’re leaving behind a sicker, weaker population and driving up rates for everybody? What, do they expect WellPoint to dip into its $580.4 million profits this quarter so they don’t have to raise premiums? Come on! These unemployed kids probably think they’re entitled and invincible, which is why they were so easy to fire." (Submitted by an editorial page that may or may not resemble the NY Post.)
- "The real story here is how bad the economy is. Ay-yi-yi, think of all the lost jobs this translates to! And health care is one of the few industries that’s been stable! Clearly this means it’s exactly the wrong time to do anything that would raise taxes on any corporation or in any way do anything like an employer mandate that would make companies' lives harder. The real tragedy here is what’s happening to the poor insurance companies: 1.3% drop in income for WellPoint? That’s unsustainable! 50 million uninsured is sad, but not taking the opportunity to cut capital gains tax would be far worse." (Submitted by a Republican member of the House of Representatives who's reasonable and might vote for a health care reform bill… but I doubt it.)
- "That’s pretty terrible. Several million more people uninsured because of the economy! I’m completely for doing something about this broken health care system, particularly if doing something means shaking my head and looking sad. I do have to say, though, now is not the time for any health reform plan that requires money in any way. That I’d be totally against. Hey, where are those TV cameras you said were going to be here?" (Submitted by a Senator who may or may not be described as “moderate.”)
- "You can’t make an omelet without breaking some eggs. If Americans have access to the care they need, that means the Swedes have truly won." (Submitted by an anonymous radio host.)
- "50 million people? Are you freaking kidding me? 50 million? What is wrong with you people?" (Submitted by most of Europe, Australia, New Zealand, the powerhouse economies of Asia, our neighbor to the north, and at least 62% of Americans.)
Please, submit your own!
(Photo credit: JoshSchulz on Flickr.)
Health Care Reform at Warp Speed
Published April 20, 2009 @ 04:05PM PT
It’s official: Sen. Max Baucus and Ted Kennedy today stated their intention to mark up health care legislation in June. If that target date doesn’t slip, this would be an astoundingly quick turnaround for something as complicated as comprehensive health care reform. The question is, will this professed need for speed wind up helping the health care bill or hurting it?
To be clear, today’s letter to the president from the chair of the Senate Finance Committee and the Health, Education, Labor and Pensions Committee isn’t much of a surprise. They key passage, “Both committees plan to mark-up legislation in early June. Our intention is for that legislation to be very similar, and to reflect a shared approach to reform, so that the measures that our two committees report can be quickly merged into a single bill for consideration on the Senate floor,” doesn't present a radically different timeline from what Baucus and Grassley have proposed many times before – a Senate bill by the Fourth of July. The new information is that Kennedy not only intends to match the timeline, but also to employ “a shared approach to reform.” Those holding out hope that Kennedy might come up with a different approach than the Obama-Baucus-Waxman consensus appear set for disappointment. As Ezra Klein calls it, “That means whatever product emerges, it will have to prove acceptable to both the liberals who populate HELP and the moderates who stack Finance.” Given that we know Baucus' thoughts on the topic, that’s not good news for Medicare for All.
There is a concern that haste makes waste. We’ve seen a gazillion anonymous quotes saying something like “Congress isn’t ready for this pace” or “There are so many unanswered questions” or “Slow down/ You move too fast/ You gotta make the moment last,” etc. More importantly the toughest part of the coming health reform fight – how to pay for it – isn’t remotely close to being solved. Indeed, $318 billion in relatively uncontroversial funding from Obama’s health care reserve fund – making a tweak to the charitable deduction formula for the richest 1% of income earners - turned into the biggest fight in the budget. Sen. Baucus can grumble all he wants at the CBO director about how undervalued the money-saving investments in preventative medicine and health IT are in the CBO’s projections, but the simple reality is any reform will require new revenue, if not new taxes, and Congress is gun-shy. A bill that’s not paid for will have a hard time getting passed – I have a hard time believing Democrats will stay united if the answer to health care reform is still more deficit spending. The danger is that by rushing, we'll drive the car right into the guard-rail.
Yet I still think we’re ready for the legislative process to hit warp factor 6. For one thing, the approach that Obama, Baucus and Kennedy are pushing for is not new – we’ve been kicking it around for over two years, since John Edwards first proposed it on the campaign trail. Although the town halls conducted through Members of Congress and the White House Office of Health Reform have yielded stunning stories of economic hardship, there’s not a lot of bright new ideas out there. The funding problems and questions of how you improve the quality of care don’t require outside-the-box thinking so much as political courage. Even more importantly, the forces of the status quo are in disarray. PhRMA President and former Republican Congressman Billy Tauzin bashed the choice of a public plan, but did so while announcing a partnership with FamiliesUSA for expanded Medicaid eligibility. Talk about not getting in a clean hit – he propped up one government program while trying to bash another. The anonymous and attributed internal hit jobs on the lack of a Republican alternative plan have already begun. Right now the face of anti-reform are reputation-poor cartoon villains like Dick Scott and Betsy McCaughey. The momentum is on the side of reform and the resistance is, frankly, somewhat disorganized. But guaranteed this won’t always be the case.
Why give them the chance to get organized?
(Photo credit: papalars on Flickr.)
Baucus and Grassley, What Is Wrong with This Picture?
Published April 16, 2009 @ 10:17PM PT
As promised, the Senate Finance Committee will be diving head-first back into hearings and roundtables aimed at producing health care legislation by the summer. Chairman Baucus and Ranking Member Grassley have sent out their first press release about a roundtable on improving the health care delivery system. Before you get excited, I should warn you: one-third of the speakers at that roundtable have ties to the insurance industry. Awesome times.
The first roundtable is scheduled for April 21 and will focus on the delivery system. As announced in the press release, they're hoping to get a conversation about "improving the quality and efficiency of care through establishing value-based purchasing programs and strengthening the role of primary care, better managing patients with chronic illnesses, facilitating the use of comparative effectiveness research and other tools that support evidence-based care, reducing hospital readmissions, reforming payments to private plans in Medicare, and increasing transparency and reducing fraud and abuse in federally financed health care programs.”
If you were selecting speakers in order to have a productive discussion, who would you invite? Someone to speak for hospitals? Yup, the CEO of the American Hospital Association. Experts on evaluating quality, Health IT and health economics? Sure, they have those. A nurse? Well, sort of – a former nurse and professor at the University of Pennsylvania School of Nursing anyway. Doctors? We have a surgeon for the specialist perspective and someone from the American College of Physicians for the primary care perspective. Curiously, despite the fact that the VA has shown far more success managing patients with chronic diseases and comparative effectiveness research, as well as Health IT, no one from the VA will be present. No one representing coordinated care – not even from the Mayo Clinic. No one to talk about the medical home. No patient advocates. Only one “activist” group in the National Partnership for Women and Families (a great advocacy group, but hardly the first name you think of in the health care reform community.)
Every other speaker has a connection to private insurance. There’s Dr. Allan M. Korn, Chief Medical Office for the Blue Cross Blue Shield Association. There’s Roy Williams, CEO of Aetna. There’s Glenn Hackbarth, who is currently chair of MedPac, the payment advisory committee tasked with analyzing cost and quality of care in Medicare. What prepared Mr. Hackbrath for being able to advise Medicare on, say, how much we should pay the private plans that make up Medicare Advantage? How about some time as an executive for Harvard Community Health Plan? There’s also Dr. Glenn Steele, also with a background as a surgeon, who’s president of the Geisinger Health System in Danville, PA, a network of provider physicians and hospitals, complete with … yes, surprise, the Geisinger Health Plan, selling HMO and PPO products since the 1970s.
That’s four people out of a total of twelve speakers. I understand the insurance industry is involved in these issues and so should be represented. And yes, the largely non-profit Blue Cross Blue Shield might have a different perspective than the ridiculously profitable Aetna. But four? Really? In a roundtable focused on better managing patients, openness, transparency and with so many of the key players and ideas not represented, you found room for four men who could each give you the private insurance perspective?
What’s wrong with this picture, Senators?
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Feel like giving them a piece of your mind? Write both Senators right now!
(Photo credit: essentialfabrication on Flickr.)
The Big Lie in the "Crowd Out" Argument
Published April 16, 2009 @ 11:57AM PT
Words matter. So let me once and for all tackle the argument you will heard constantly from the forces of the status quo, as it was just posted on John Goodman’s blog today by Devon Herrick: “A Lewin Group report estimates that 32 million people would lose their private coverage and enroll in the public plan if it paid Medicare-level reimbursements and eligibility were limited to the small firms, self-employed and individuals.” I know he wanted his readers to see that “would lose their private coverage” line because he made that the hyper-link, so it visually stands out. Here’s the problem: it’s bunk.
(Side note: here’s the other problem. Mr. Herrick apparently didn’t quite understand the two scenarios presented by the Lewin Group’s report. The number he quotes is if the private plan doesn’t pay Medicare-level reimbursements but instead negotiates its rates with providers. As I wrote previously, it doesn’t make much sense to import the Medicare rates. Hopefully future practitioners of the “lost coverage” fib will at least summarize the frakkin' analysis correctly.)
The best way I can explain this is through an analogy.
When I lived in New Hampshire a couple of years ago, my trusty automobile was totaled in a three-car pile-up in which I was the “peanut butter and jelly” in the automotive sandwich. Needing a car urgently and with extremely limited funds, I bought a heavily-used 1990 white GMC Jimmy. Almost from the moment of purchase, the car did not grant me much security – the engine stalled out while on the highway (mercifully moments after I pulled onto the off-ramp, unfortunately not before I was actually off said off-ramp), the brakes needed to be replaced two months later, the gas mileage was abysmal (sorry, Emily), and it abruptly started emptying its anti-freeze into the cabin one cold day. The beast was dubbed “Truckasaurus,” my fiancée declared undying enmity towards it, and I then proceeded to pour money both on gas and to fix the never-ending supply of surprise problems and weaknesses. When I moved back to New York City, I’d had enough. I sold the truck (making back the tiniest fraction of what I’d spent on it) and traded it in for a monthly Metro Card for the New York Subway. Say what you want about the publicly-administered MTA, but it provides me the coverage and security I lacked in my car at a fraction of the cost. I didn’t have to choose it – I could have tried to navigate my NYC transportation needs by keeping my old car. But I didn’t want to. As a consumer, I made the choice that was right for me and my circumstances.
By Mr. Herrick’s rhetoric, as well as the rhetoric of those opposed to the public plan or health care in general, I didn’t make a choice as an informed consumer, a process conservatives and free market economists extol. Instead, they would say I lost my car.
Should a public plan be part of the comprehensive health care reform package, no one loses anything. The consumer – either the employer or the uninsured individual – makes a choice. If it’s structured right, and the situation arises where I’m a diehard private insurance guy but my small business boss buys into the public plan for employee coverage, I have the ability to say no and get my own affordable private insurance. If the Lewin Group with its flawed and questionable assumptions demonstrates anything, it’s that between 40 and 130 million Americans would make that choice.
No one loses coverage. Instead, we gain a choice. Period.
(Photo credit of a similar truck to Truckasaurus: [RoRRo] on Flickr.)
