State and Local Efforts
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How to Shame Senate Healthcare Obstructionists
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5 Healthcare Lessons in Possible Grocery Workers’ Strike
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Is National Healthcare Reform Repeating Massachusetts' Mistakes?
Pay For Performance: Why You Should Care (Part 3 of 3)
Published October 27, 2009 @ 06:00AM PT
Part 3: What IS That Noise?
In Part 1, we introduced P4P and mentioned some loud screeching that now accompanies it (that’s Screech up above, by the way.) In Part 2 we showed you how to use its basis, quality measurements, to get better care regardless of where you live. But now back to the noise. As we know, the healthcare industry is notoriously resistant to change. The entrenched M.O. is to sit back, wait for it and reactively dig in heels -- with as much sensationalism as deemed necessary. Healthcare leaders know reform strategies have been studied and generally talked to death for the last 16 years. Still, most resist forcefully when innovation stops being voluntary and is instead mandated. Enter Massachusetts, stage right.
In 2005, it became the first state to require health insurance coverage for all residents, with hardship exceptions. Massachusetts is now drowning in healthcare costs. Its residents are covered and 70% of doctors support the program, but the great fee-for-service “quantity over quality” healthcare juggernaut rolls on. It’s time for step 2: rein in those costs with a combination of global payments and P4P – secret code for payment based on quality, coordinated care.
Pay For Performance: Why You Should Care (Part 1 of 3)
Published October 16, 2009 @ 07:00AM PT
Part 1: What Is It?
Earlier this year, amid all the yelling, name calling and finger-pointing, there was a small quiet force moving through US healthcare. It was the early adopter crowd of doctors, hospitals and health systems, girding up to become providers of coordinated, quality, and evidence-based care. I called this little-noticed movement the Silent Revolution. That loud screech I'm now hearing is the revolution reaching the mainstream.
We’ll get to the noise in Part 3 of this three-part series. First, today we’ll dig into what Pay For Performance (P4P) actually is, and in Part 2 we’ll look at how it can empower you as a patient.
Senate Finance Committee Weakens Insurance Exchanges
Published October 06, 2009 @ 06:00AM PT
Goings-on in Maine are taking a deserved media hammering this week. First Brave New Films puts out a hard-hitting clip about Wellpoint suing the state to increase its profits. Then it leaks out that last Thursday, Maine Senator Olympia Snowe was the main reason Massachusetts Senator John Kerry's amendment to strengthen insurance exchange consumer protections in the Senate Finance Committee (SFC) bill didn't pass. I'd hate to find out those two things are related.
First, a little background. Maine is a guaranteed issue state, meaning insurers may not deny you coverage based on health status. They must also offer policies with standard benefits, co-payments, and co-insurance, and may only exclude pre-existing conditions for 6 months (this is sounding pretty good, no?) Anthem, a Wellpoint subsidiary, in return asked the state of Maine to guarantee it at least a 3% profit margin off its just 12,000 members. Maine said no. So Anthem is suing the state.
Now, about Kerry's proposed SFC bill amendment. Called "Empowering State Exchanges to be Prudent Purchasers," it sought to protect consumers with stronger state standards for insurance exchanges. HR 3200 and the Senate HELP bill have these protections built in; the SFC bill creates more of a Wild West of insurance exchanges. Just what we need.
3 Recycling Blunders in Failed Healthcare Policy
Published October 05, 2009 @ 06:00AM PT
Washington, D.C. denizens have done it again. Under the guise of innovative compromise, they have recycled Bush Jr.’s failed “Great Healthcare Bailout of 2002.” Never heard of it? Well, bailouts weren’t the Hollywood stars then that they are today. They called them strategies instead. This one went straight into the failed policy bucket.
Observe: In 2002, Bush tried giving away $40 million in grants to high-risk pools "as part of the Bush Administration's broad strategy for expanding access to health care for the more than 40 million Americans without health insurance." Um, the plan was to spend $1 per person? Really? But I digress.
Can't Make Your Policy Federal? Empower the States.
Published October 01, 2009 @ 05:54PM PT
It’s been a dominant theme in how Congress has handled health care since the creation of Medicaid. Can’t find a way to federalize your policy? Then downscale it to empower states to take it on themselves. That strategy was on full display today as members of the Senate Finance Committee, unable to overcome stiff resistance from a more-or-less unified Republican nay-saying, and the strangely conservative votes of one Sen. Blanche Lincoln, opted to kick it to the states. It’s like sending a baseball player to the minors -- flourish there, and you may actually make it back to the Big Show to become federal law.
Two amendments and one proposal yet to be drafted as an amendment made this “Empower the States” day in the Senate Finance Committee.
Sen. Ron Wyden (D-OR), a creative and progressive force on the issue of health care, got an amendment pass that might well be called the “You show us how it’s done” amendment. In the Baucus bill, states are given a certain amount of federal money to create the Exchanges. Rather than one big Exchange, each state has its own -- granting it greater autonomy in terms of design, making sure all plans abide by state-level regulations, etc. Wyden’s amendment takes it a step further. So long as the states create coverage for all of its citizens that’s as affordable, comprehensive and high-quality as an Exchange would have been, and has all the protections in terms of insurance reform and caps on out-of-pocket expenses that the plans in the Exchange would have had, and the legislature and the governor agree to apply for a waiver to the Secretary of HHS... you can do whatever you want.
So your state could create an Exchange, like Massachusetts. It could add the uninsured into the existing program for state workers and retirees, like Sustinet in Connecticut. It could create a state-level public option. Hell, it could create a statewide single-payer plan like many states (including New York) are already contemplating. Those with long memories will remember this was a scarcely-noticed but important provision of the Wyden-Bennett health care bill as well. It’s not just punting the tough decisions to the states. It’s giving them the ball and giving them the money to make it happen.
Not quite as comprehensive is the amendment by Sen. Maria Cantwell (D-WA), which passed with the support of all Democrats except -- you guessed it -- Lincoln. Washington State doesn’t have a public option or anything remotely like it. What they have instead is something called Washington Basic Health, where the most likely to be uninsured are eligible to purchase private insurance. Essentially, the State of Washington acts like a mega-employer, with the uninsured below 200% of the poverty line (about $44,000 for a family of four) as its “employees.” The state uses the size of its pool to negotiate great rates on premiums from four insurance companies -- much cheaper than this population could afford on the open market, with better coverage and smaller deductibles and out-of-pocket expenses. The individual or family gets to choose which plan they want.
Cantwell’s amendment allows states to set up their own version of Washington Basic Health. The rest of the Baucus bill already provides Medicaid for up to 133% of the federal poverty line, so this Basic Health plan would cover those between 133-200% where, as Sen. Cantwell notes, “75 percent of the uninsured population lives.” There would be extra protection for individuals -- participating plans would have to spend 85% of the cost of premium on health care, more stringent than plans in the Exchange. The state would get the subsidies that would normally go to individuals of that income range in the Exchange and use them to subsidize the cost of the Basic Health plans. On the plus side, this has dramatically saved money in Washington State, as they’ve negotiated for fantastic discounts. On the minus, if a state set up a Basic Health system of their own, people in that income window couldn’t opt-out and get a plan on the Exchange. The state gets the subsidies, not them. Plus Washington Basic Health itself is demonstrating the problem with relying on a state solution during a time of economic crisis. Go to its Web site and you’ll see a waiting list to get into Washington Basic Health and a warning of jacked up rates – both the results of the state’s fiscal crisis.
Finally, we’re hearing more and more of a proposal by Sen. Tom Carper to empower states to produce state-level public options -- a much less effective version that has popped up from time to time from the likes of Secretary Sebelius, Tom Daschle, and Bob Dole, among others. Carper’s exact plan is as yet vague, but it reinforces the trend of the day.
Relying on state governments for what you can’t push through at a federal level may have some downside, but its biggest upside is it allows the more progressive states the opportunity to lead. We could look to Canada, where their single-payer system spread province-by-province. But better examples are right here in the U.S. After all, Medicaid is set to federalize coverage to 133% of the poverty line -- a threshold that some states have already reached. The concept of the Health Exchange is liberally borrowed from Massachusetts (Utah has its own Exchange, and California tried to get one in its health care reform attempt in 2007-2008). Today’s minor league players may be tomorrow’s rookie of the year.
(Photo credit: http://www.flickr.com/photos/aurenh/ / CC BY 2.0)
"You Mean My Treatment ISN'T Based on Evidence?": The Best of the Weekend
Published September 13, 2009 @ 11:13PM PT
Every weekend, I present the three articles or videos that best enhanced my own understanding of the myriad issues that go into the general umbrella of health care reform. While most reports this weekend were focused on political strategy, shades of grey, and exactly how pompous Sen. Kent Conrad can make himself sound on television, there was also plenty of nuanced, thoughtful analysis, particularly on how we can improve the quality of the care we receive.
1.) Health Care Policy and Marketplace Review, “What Voters Really Think About Evidence-Based Care”
I don’t always see eye-to-eye with Bob Laszewski, but he knows his stuff and has an uncanny ability to cut through the bull and focus on what will really reduce costs and improve quality. His commentary on the Campaign for Effective Quality’s recently-released poll of California voters about their attitudes towards "evidence-based medicine" -- the notion that treatment options should be grounded in the latest scientific evidence and not just “Well, this is how we’ve always done it” -- is nearly as insightful as the survey results themselves.
The bad news is that patients think their health care treatment is generally evidence-based even though that assumption is highly questionable. The good news is that patients want it to be evidence-based.
At a time when we hear anecdotal evidence, particularly from town hall meetings, that people don't want any "interference" between them and their doctors they do seem to appreciate the need to get all of the facts when making a treatment decision.
Read the whole blog post on Health Care Policy and Marketplace Review.
2.) Boston Globe, “Vermont tests team approach for aiding chronically ill”
I’ve mentioned the “medical home” model of delivering care a few times. Since the bills moving in Congress would include more pilot programs to test out the medical home in Medicare and the public option would do likewise, it’s worth seeing how we’re implementing them in a few areas -- including Vermont -- today. A lot of people think the notion of having one doctor as a “home base” to coordinate all specialist care sounds uncomfortably close to managed care. In practice, however, it’s almost the exact opposite experience.
But when [diabetes patient Rita Pinard’s] blood sugar shot up in January, her doctor took more aggressive action, turning her over to a nurse, a dietician, and a diabetes educator who nagged and encouraged her to try to control her disease.
The extra help is part of a state effort to improve care and reduce costs for the chronically ill in Vermont. Under the approach, primary care doctors get extra money to put together teams to treat people with illnesses such as diabetes, asthma, and heart disease. They get bonuses if their patients show progress.
This coordinated approach, called “medical homes,’’ is being tried in Pennsylvania, Wisconsin, Maryland, and other states, and Congress is considering adopting it nationwide as part of the health care overhaul being debated in Washington.
Read the whole article on Boston.com
3.) NY Times, “In Health Care Battle, a Truce on Abortion”
In writing about this weekend’s anti-big-government protests in Washington DC, Matt Yglesias noted that the mood seemed to be as much anti-abortion as anti-health reform. He makes the observation, “Except for the fact that the health reform plans in congress wouldn’t actually do this. The anti-abortion side, in other words, already won this argument. Except nobody told them.” Actually, it’s more remarkable than that. As NY Times “Beliefs” columnist Peter Steinfels shows, health care reform has given rise to a fragile and remarkable between pro-choice and pro-life communities -- but one that could fall apart at any time.
Administration foes, like the National Right to Life Committee or the Catholic League for Religious and Civil Rights, were quick to declare that the president could not possibly mean what he said [when he said no federal dollars will be used to fund abortions].
But others, like officials of the United States Conference of Catholic Bishops and some religious leaders with concerns about abortion, welcomed his words. When it comes to health care overhaul, a surprising number of people on both sides of the abortion war have declared a limited truce.
The key words are “abortion neutral.”
Read the whole article on NYTimes.com
(Photo credit: http://www.flickr.com/photos/thenationalguard/ / CC BY 2.0 )
Why Health Insurance Dergulation Ain't Enough
Published August 22, 2009 @ 09:37PM PT
It was a central piece of John McCain’s health care plan and is usually offered as one of the conservative alternatives to health insurance reform. Instead of adding additional regulations to prevent discrimination on the basis of pre-existing conditions, rescissions, and the practice of charging different premiums on the basis of gender, age and health status, the argument goes, let’s do the opposite. Let’s open up insurance so it can be bought across state lines. What this means is bypassing the various state laws and regulations that require all insurers within that state to provide minimum coverage for "optional" items like mental health, mammograms, prostate cancer screenings or hearing aids. The basic theory is people should be able to purchase less insurance, no matter what the state says. Less regulation means less cost, right?
The problem with this theory of deregulation is it’s testable. We know what the different configurations of state mandates for health insurance look like right now. We also have a good estimate from the Congressional Budget and other sources on what these mandates cost. Removing them wouldn’t drive costs in aggregate down. It would just lead to more underinsured and likely more medical debt-related bankruptcies. (Swell.)
The state with the fewest mandates and regulations is Idaho. In theory, if you opened up insurance to be purchased across state lines to avoid mandates, here’s where you’d shop. So let me start with the bad news. Between 2000 and 2007, Idaho’s premiums have gone up 122%. That’s four times the increase in people’s wages. Ah, but wait, let’s compare free market Idaho with the cruel government regulation in Minnesota, the state with the most regulations. During 2000-2007, Minnesota actually added a couple of mandates, yet their premiums went up 74%. The net result is that Idaho is still cheaper for an average family of 4, but it’s hardly a bargain: $11,432 to $12,090 for Minnesota. Although it has more mandates than Idaho, Wyoming is generally considered one of the least regulated states for insurance – they don’t even restrict insurance companies for denying you at any time, for any reason. The reward for their loose hand on the reins is that premiums have gone up 129%.
So why isn’t less regulation leading to cheaper insurance? In no small part, because these mandates mostly apply to the individual insurance market – the most abusive market, but also the one with the fewest enrollees. Employer-based insurance, by contrast, tends to insist on things like coverage for chemotherapy (only mandated in MN, NY, OR and TN). So long as approximately 160 million Americans continue getting their coverage through work, you’re not going to see much in terms of transformative change. But you’re also not going to see much savings, even within the individual market. The CBO took a look at the most expensive state-based regulations, including coverage for alcoholism and drug abuse treatment, mental health parity (now a federal regulation, then a state one), seeing a chiropractor, and continuation of coverage/guaranteed renewal. Their bottom line: “Those calculations suggest a range of 0.28 percent to 1.15 percent as the effective marginal cost of state mandates.”
But one thing we can be guaranteed – removing consumer protections and regulations by allowing for the purchase of insurance across state lines will lead to more people being underinsured. Medical debt-related bankruptcies is up to 62.7% of all personal bankruptcies. 78% of those families had insurance – just not the right kind or not enough. The sad fact is until you actually get sick, you’re unlikely to know which of these state mandates you’re giving up is going to eventually apply to you.
Deregulation isn't always a bad idea. It can even be inspiring in that whole “Let the market decide” kind of way. But it's not going to work for health insurance. Put it another way: if you’re going to convince me to shred our consumer protections on health insurance and trade in my New York regulations for Idaho’s, I’m going to need to see that it actually solves the problem first.
(Photo credit: Great Beyond on Flickr.)
