Change.org's Health Care Blog

Senate Health Bill: Less, Later, and Holy Complexity Batman (P2)

Gillian Hubble — 2009-11-20T11:15:00-08:00

We covered the good parts of HR 3590, the new Senate healthcare reform bill, in Part 1. Now, on to the Less, Later, and Holy Complexity Batman aspects.

Less

Numbers: HR 3590 costs less than the House bill, $849 billion vs. $894 billion. It lowers the deficit less, $127 vs $139 billion (see more dollar comparisons here.) It manages this by covering less of the population (94% vs 96%) and delaying major insurance reform. That costs less, but it also does less. There are also unintended consequences like skyrocketing insurance premiums prior to 2014 due to implementation of consumer protections in 2010. Hey, if private insurers have to pay out and can’t get rid of you, they are going to charge more. Plus in 2014 they’ll have to take riskier customers. Their business is to make money, not spend it; they’ll circle the wagons.

Coverage: Fortunately for insurers, this bill lowers coverage levels. They only need to spend 80% of group premiums and 75% of individual premiums on claims, compared to the typically reported 85% in group coverage now. Additionally, there are tiered plans starting at only 60% actuarial coverage for bronze plans, up to 90% for platinum. Again, typical coverage is at 85% now. Ack – that’s a big new gap in coverage for regular folks (I won’t go into subsidies and out-of-pocket costs, as Tim Foley is doing a series on HR 3590 affordability.) I’m also going to bet platinum plans conveniently fit into the Cadillac bracket so a 40% excise tax applies.

Mandates:There is less mandate burden and, for employers, more penalties. Individuals only have to pay $750 by 2016 for deciding to go bare; not a big incentive to reduce their potential burden on the public. For businesses it’s the opposite. Employers aren’t mandated to provide coverage but are fined if even one employee qualifies for subsidies on the exchange – and the fine is based on total employees, not per subsidized employees. That may keep the Walmarts of the world more honest. Finally, the mandated public burden of providing reinsurance to early union retirees is half that in the House bill, $5 billion.

Wishing For Less: Also, perhaps I’m getting cynical with all the healthcare bills that have come out, but this one seems especially laden with overly smarmy buzzwords and phrases. For example, Medicare being a “sacred trust”, helping those with pre-existing conditions avoid “medical bankruptcy” through risk pools (hey, the premiums alone can lead to bankruptcy!), and “cracking down” on waste, fraud and abuse. This bill really goes for shiny popular phraseology that I would like to see less often.

Later: Fair access is delayed, just like in HR 3962. Also, the public option, state-based exchanges, potential co-ops (I’m wincing at the $6 billion in funding), and other potential state programs for those 134-200% of the poverty line won’t start until 2014. That’s a year longer than HR 3962, and is a long time to be stuck in current private insurance programs and interim risk pools. Remember, Congress wants the federal government’s budget to look good, not yours. Also, since states can opt-out of the public option, 2014 means four long years for special interests to make the rounds and convince states (some, like Texas, don't need much convincing) to pass a law to opt-out. That makes a weakened public option a guaranteed-to-fail public option with a "See? We told you so" tag line.

Holy Complexity Batman: Did I mention the state opt-out public option, state-based exchanges, state co-ops, optional state semi-indigent programs, CLASS long-term care, Medicare, expanded Medicaid (to 133% of the poverty level), S-CHIP, and oh yes, inter-state and even national private policies? This bill is as far from single payer as you can get. I don’t care how much administrative simplification you try, it's still a provider’s (and patient’s) bureaucratic nightmare. Imagine trying to get paid or avoid going out of network in an even more complex mess of an insurance web than we have today. It’s not a good use of valuable tax dollars either – although CLASS doesn’t use public funds, because it is strictly self-funded by its customers.

Overall this bill has good features, but it does not make good use of tax dollars. It tries to please everybody in Washington, especially special interests, so it ends up far more complicated and obtuse than necessary. When you raise taxes on the wealthy, institute a hefty Cadillac benefits tax, and raise Medicare payroll taxes, taxpayers should expect more for their money. It was only realistic to expect the duct tape and baling wire solution that was rolled out though.

So what’s next? Harry Reid has filed for cloture, with a procedural vote scheduled for 8pm ET on Saturday. This is a critical test of the Democratic caucus, because all 58 Dems and 2 Independents who caucus with them must be on board for the 60-vote supermajority necessary to ward off a filibuster. Ben Nelson seems to be in, while Blanche Lincoln and Claire McCaskill are still unknowns. Joe Lieberman has made his position all too clear. Republican Orrin Hatch took it a little too far by saying he would participate in a “holy war” to delay the bill if the decision is made to move forward. Great, so we have radical extremists on the US payroll now too?

Photo kevindooley // CC BY 2.0

Does the New Senate Health Care Bill Get the Job Done?, Conclusion

Tim Foley — 2009-11-20T10:05:00-08:00

In part 1, I looked at joy with some of the provisions in the new Senate bill to make coverage more affordable, and shouted “Woohoo!” In part 2, I looked at some other less impressive policies and shrugged, “Meh.” But the fun times must come to an end.

I had three big “Aw Crap!” concerns while skimming through the new Senate bill. These aren’t just qualms. To my mind, they’re major problems. We’re talking “Tom Hanks is on the phone with Houston and they need to put a square peg into a round hole in order to get breathable oxygen in the Apollo 13 module” problems.

The simplest is the most inexcusable. The Senate bill delays opening the Exchange, providing individuals and families with these very affordable subsidies insurance plans, and creating a public option to bring some competition to private insurance -- all of that is delayed until 2014. Why? To get a better CBO score -- that’s all. We’ve hit the real failure of our health care debate this year square in the mouth once again: “more affordable” in terms of a prettier price tag for the federal government can only come at the expense of “more affordable” in terms of making coverage affordable to Americans.

While we’re talking about the good deals on that subsidized insurance in the Exchange -- yes, there’s a catch. Although the Senate bill makes insurance more affordable, the House bill is much better at making care more affordable through a better consumer protections on out-of-pocket expenses. Remember, of the staggering number of personal bankruptcies involving medical debt, more than three quarters were people who had insurance but got clobbered by co-pays, deductibles and out-of-network costs. The House bill does a much better job shielding low-income families from this financial peril by setting a limit on their out-of-pocket spending. That family of 4 making $44,000 may not notice the difference in premiums between House and Senate, but their House insurance plan would cover 93% of their medical costs; the Senate insurance plan would only cover 80%. Even more alarming, the House’s cap on total out-of-pocket spending per year, the strongest defense against medical bankruptcy, seems to be entirely absent from the Senate. I really hope I’m just overlooking it in the bill. If not... dude, where’s my cap on out-of-pocket expenses?!

There is a real disturbing trend towards making it more likely for people to buy insurance policies at the expense of making it less likely they’ll go broke when they get sick and their insurance doesn’t cover everything they need.

Worst of all, Reid has kept the “Free Rider” provision in the Finance bill -- another obvious nod to Olympia Snowe, who first championed it. I and many other have mentioned the folly of a complicated policy that only requires employers to chip in if and only if their employees receive the tax credit subsidies instead of a more balanced approach that would have nearly all employers (except the most vulnerable small businesses) share the same responsibility to provide benefits or pay into a fund. For one thing, it creates a perverse incentive against hiring low-income workers, especially since most undocumented workers will continue to be uninsured if this bill passes. For another, the administrative difficulties in keeping track only of Free Rider employers will make enforcement tricky. Reid has made a tweak aimed at netting more money -- if a company has even a single employee without benefits receiving a subsidy from Uncle Sam, they either have to pay $3,000 per employee who gets a subsidy in the Exchange or $750 per every employee in the company. As Jon Cohn has noted, that’s an important change. But it still doesn’t come close to netting the money of a true employer mandate. For comparison, the Senate bill’s Free Rider brings in $28 billion over 10 years which can be used for subsidies for individuals and families, the House “pay or play” $135 billion.

And here’s where the Free Rider really falls down -- it doesn’t do enough to prevent employers from “dumping” their employee benefits. The tale of the tape is the CBO score. A strong “pay or play” mandate like the House bill prompts the employer to think, “If I have to pay most of the cost, I may as well play the whole thing.” As a result, the CBO score for the House bill projected that the number of people in employer-sponsored insurance would not only remain stable, it would increase slightly each year. The opposite is true for the Senate bill, where the number in employer-sponsored insurance would decrease by 5 million starting in 2016. By 2019, the House bill covers 96% of Americans, including 21 million in the Exchange. The Senate bill has more people in the Exchange -- 25 million in the Exchange -- but only covers 94% of Americans. Why doesn’t everyone who gets dropped by their employers find their way into the Exchange? Chances are because they can’t afford it.

The Senate bill Reid unveiled this week isn’t as bad as the Baucus bill. But these red flags aren’t done for policy reasons, and they’re not tradeoffs to improve some other part of the bill. They’re political calculations, pure and simple -- and many Americans will suffer for them unless they’re corrected in time.

(Photo credit: http://www.flickr.com/photos/talkradionews/ / CC BY-NC-SA 2.0)

Senate Health Bill: Less, Later, and Holy Complexity Batman (P1)

Gillian Hubble — 2009-11-20T06:00:00-08:00

The wait is over, the latest bill is out. If I had to sum up the difference between the Senate and House healthcare reform bills in three words, it would be ‘less’, ‘later’, and ‘holy complexity, Batman’. Fine, that last one is not a word, but it is accurate. Considering I’m comparing a 2,074 page Senate bill to a 1,990 page House bill, that’s saying something. Yes, HR 3590, the Patient Protection and Affordable Care Act (lots of info at this link), is an interesting exercise in playing with numbers and perceptions even compared to HR 3962. However, there are also some very good aspects to the bill. We’ll cover the good here, and the rest in Part 2.

The Good

Public Option: HR 3590 actually has a public option, a national public option. Yes, it’s a weakened negotiated rates version like the House bill has (leading to higher premiums), and all a state has to do to opt out is enact a law doing just that. But – and here’s the good part – it is not limited to certain participants. Nope, unlike HR 3962, not just the uninsured and small businesses can opt in to the public option. Anyone can. That’s a victory, folks. It was won at the expense of some highly complex additional private insurance options and general neutering, but it’s still a win. You just have to wait until 2014. That may be why only 3-4 million (compared to HR 3962’s 6 million, or 2% of the population) are expected to sign up. States also have the option to provide innovative, alternative coverage, but not until 2017 (an 8 year lag is innovative?)

Primary Care, Quality Care, and Medicare: Also, considerable funds and initiatives are aimed at improving and expanding access to primary care. There is $125 billion to improve primary care capacity, plus another $50 billion in grants for nurse-managed clinics (think retail clinics like Minute Clinic.) Additionally, there is $120 billion to extend primary care within current health systems and a 10% payment increase for primary care physicians and nurse practitioners. That’s a big investment in primary care. There are equal measures aimed at measuring and improving the quality of care and improving Medicare through a super-MedPAC, though payment-wise there are only pilot Medicare pay for performance programs. At least there is a focus on catching the $98 billion worth of Medicare waste, fraud and abuse we saw last year alone. Meanwhile there is an effort to reduce the Medicare Part D donut hole for seniors by $500.

Abortion Status Quo: On abortion, HR 3590 reverts to the federal status quo. Exchange plans must offer two plans, one with and one without abortion coverage, so subsidized women must choose the one without coverage while those paying full premiums can opt for one that does coverage reproductive rights.

Otherwise many of the bill features are very similar to HR 3962. Consumer protections like a recission ban, abolishing annual and lifetime benefit limits, and extending young adult coverage under parental plans until age 26 go into effect in 2010. Baseline benefits are defined, though grandfathered plans never have to comply with them. Hopefully people will be informed enough to abandon them?

Stay tuned later today for the Less, Later, and Holy Complexity Batman aspects of HR 3590. Meanwhile, in other good news, the House voted 243-183 for a stand-alone doc-fix bill that prevents a scheduled 21.2% Medicare payment rate decrease set for January. The bill revamps Medicare's sustainable growth rate formula, something the Senate refused to do. Just thought you would want to know.

Photo Center for American Progress Action Fund // CC BY 2.0

Does the New Senate Health Care Bill Get the Job Done?, Pt 2

Tim Foley — 2009-11-19T12:37:00-08:00

In evaluating the new Senate bill, I’m defining “get the job done” not through how well it does on creating the tools for serious cost control (Ezra Klein is your man for that), nor am I defining success as winning the enmity of health insurance companies, although Wall Street clearly hates this bill -- in and of itself reason to be optimistic about its effect for Main street! No, for right now I'm solely looking at the bill through the lens of whether it does enough to make health insurance affordable both to those who already have it and those currently uninsured who would get it under the Health Exchange.

In Part 1, I shared my relief at some strong changes Sen. Harry Reid had made to his predecessor bills from Senate Finance and Senate Health, Education, Labor and Pensions, causing me to say, “Woohoo!” But there are other elements of the bill that should help keep coverage affordable for the vast majority of Americans, even if they're less spectacular.

Under “Meh,” we have one bad idea from Finance that’s been kicked to the curb, provisions for Medicaid which, after much ado, are exactly where we thought they’d be, and Reid’s compromise “state opt-out” public option, which is slightly worse than we thought it’d be, although it's less because the idea is unsound and more because we're making it compete with one arm tied behind it's back.

The bad idea that is no more is the "Young Invincibles" policy from the Finance bill, in which the young and healthy could say decline to buy comprehensive policies and instead purchase high-deductible plans that would cover prevention and catastrophes... and that’s about it. It never made much sense to prioritize standard, comprehensive benefits for everyone, only to then exempt a sizable chunk of the population that, because of their youth and relative health, are actually fairly cheap to cover already. Indeed, enrolling young healthy people helps subsidize older, sicker people who are also in the plan. That’s how insurance works, kemosabe. Although some young people might be tempted by the lower costs of catastrophic only coverage, the real winner would be the insurance companies, for whom these semi-worthless plans are big money-makers. Instead, the new Senate bill now allows people under the age of 26 to stay on their parents’ insurance plans.

Correction: 11/20/09 at 10:39 am PT -- The catastrophic-only plan is still in the bill, as pointed out to me by a reader who happens to be a member of the advocacy group named, ironically, Young Invincibles. Even though it offers substantially less coverage than the standard benefits plans offered by the Exchange, those under the age of 30 are able to purchase it instead of a standard benefits plan. However, the policy of allowing those under the age of 26 to remain on their parents' plans is much more sound and efficacious in the states that have already implemented something similar, and hopefully decreases the likelihood that these plans will be widely used.

Not much has changed in the Senate’s approach to Medicaid since deliberations first began this spring. The bill would expand eligibility to 133% of the poverty line (about $29,000 for a family of 4) for everyone, with nearly all of that cost borne by the federal government. But just because it hasn’t changed doesn’t mean it should be neglected. That change alone would give 15 million more uninsured Americans comprehensive coverage through a strengthened Medicaid (as part of a number of reforms to the program’s financing, Medicaid reimbursement rates will be substantially increased for primary care, which should make it easier to find a doctor who accepts the program).

I expect many to go ballistic at the CBO’s projection that the Senate version of the public option will have, at best, a meager effect. Indeed, CBO projects only 3-4 million people would enroll in it. But honestly, there’s no surprise here. The Senate public option, with negotiated rates instead of rates based on Medicare and competing with private plans on a level playing field, is set up similarly to the one that just passed the House as part of HR 3962. CBO only projected 6 million customers for that House public option. Add in a state opt-out clause, whereby Gov. Rick Perry and the Texas legislature (to give one example), could pass a law to say they didn’t want none of that cost-savin’, quality-enhancin’, guvmint-run health care in their state (except for Medicare… and Medicaid… and SCHIP… and the VA… and for the Armed Forces...), and the lower enrollment number makes sense. Is it even worth it to have this Joe Lieberman-opposed public option, then? Well, Jacob Hacker, the economist who first theorized about the public option, likely will think its “institutional check on private plans” is definitely still worth it. That’s good enough for me... for now. If the public option is weakened even further during the floor debate, however, it's likely to be just short of useless... sort of like Kent Conrad's co-ops. (Yes, they're still in the bill. And yes, they're still useless.)

Up ‘til now, I must admit at being pleasantly surprised, and would have loved to have written a much shorter post congratulating Sen. Reid for crafting a fine bill. But I can’t. Check back tomorrow for the affordability provisions in the bill that can only be described as “Aw crap!”

Update:

Read Part 3, Conclusion

(Photo credit: http://www.flickr.com/photos/americanprogressaction/ / CC BY-ND 2.0)

The Prescription for Revolutionary Healthcare Delivery Reform*

Gillian Hubble — 2009-11-19T06:00:00-08:00

*Sorry, it's not the Senate bill!

Hidden among the 1990 pages of HR 3962, there are some provisions to tinker around the edges of healthcare delivery and bend the cost curve to a minor extent. There are Medicare payment bundling and pay for performance pilot programs, comparative effectiveness research, and of course Medicare rate cuts. The combined Senate bill should have similar features. In truth, no one expects these strategies to have a big impact over the long term. As the photo translates, “Without theory, no revolution.” But what if we used the aggressive pursuit of four goals to revolutionize US healthcare delivery and bend the cost curve? A recent Health Affairs article explores what it would take to reach these far-reaching goals:

1. Improve the science of healthcare delivery

The US must prioritize developing a science of healthcare delivery, which is currently a black box. Patients with the same condition are treated in many different ways, depending upon the physician. Rarely does that physician do much research to determine what the most effective and cost-effective treatment might be. For example, many years ago I worked in two cardiac rehabilitation practices on opposite sides of town. The patients in each practice were on completely different blood pressure medications, depending upon which pharmaceutical reps visited which side of town! Less than 10% of the patients had their hypertension adequately controlled.

Electronic health records (EHRs) also aren’t typically deployed to help analyze the link between care and outcomes. They must support the incorporation of patient-reported health status and ongoing outcomes. I can tell you from long experience in EHR deployment that clinical decision support aids like these are “maybe some days” that are quickly forgotten once the EHR goes live. Focus shifts elsewhere. EHRs must be rolled out intelligently and progressively to enable safe, quality, scientific care.

2. Foster the expansion of organized systems of care

This goes back to the coordinated care model, where there is one accountable organization that coordinates comprehensive care to the patient for a bundled payment. Adhering to high-quality clinical processes, achieving high-quality outcomes, and providing a high-quality patient experience are rewarded with bonus payments (pay for performance.) This will rein in excess utilization – otherwise known as the quantity of care juggernaut – while improving the quality of care, especially for the chronically ill, who account for 60% of Medicare spending. It’s a model that will require a learning curve and frequent adaptation.

3. Establish informed patient choice as the standard for elective surgeries, tests, and procedures

The devil is in the details on this one. When they sign an informed consent, patients routinely don’t know what they are signing up for, and may not actually want what’s offered if they could actually understand it. This increases care costs and can lead to malpractice suits. Centers for Medicare and Medicaid Services (CMS) needs to develop standardized approaches to informing patients, not just obtaining their consent. States need to redraft their informed consent laws to focus on informed choice as the standard of practice. Finally, CMS needs to reimburse physicians for time spent on shared decision-making, reward high quality as in #2, and require hospitals and ambulatory surgery centers to support it if they wish to be Medicare and Medicaid providers.

4. Constrain undisciplined growth in healthcare capacity and spending

If we could slow Medicare spending growth by even 1% it would save $1 trillion over the next 15 years. Imagine the impact on healthcare spending as a whole. This goal relies on both carrots and sticks. The carrot is preferential treatment for superstars in #2 through pay for performance programs. The opposite also applies. Areas like McAllen, TX, where per capita spending has gone through the roof, are penalized. Even if only highest-cost hospitals are targeted, it might rein in out-of-control hospital construction (a record-breaking $50 billion worth in 2008) to more rational and population-based levels. Shrinking reimbursement in these areas would encourage more providers to transition to the coordinated care model with its quality-based performance incentives, or even just encourage hospital mergers to reduce unnecessary capacity.

Additionally, we don’t need more physicians generally; we need more primary care physicians. Specifically, we need more well-trained primary care physicians in under-served areas. Shifting residency slots to rural, understaffed, and the best teaching hospitals would fill that need. Finally, and of extreme importance, we need to fill in the big utilization cost black hole. For all the outrage over the Dartmouth Atlas Medicare spending findings, did you know there is no similar index for private health plans? That’s right: we have no idea of the overall healthcare spending patterns across the US. Just imagine the graft and waste going on under the radar. I’m betting there are a lot of cockroaches under them floorboards.

Photo srbyug // CC BY 2.0

Does the New Senate Health Care Bill Get the Job Done?, Pt 1

Tim Foley — 2009-11-19T01:05:00-08:00

Senate Majority Leader Harry Reid scheduled a press conference for this Thursday to formally unveil the long, long, LONG-anticipated full Senate bill. Which of course means it all leaked semi-intentionally Wednesday night. (Man, I’m glad the Senate isn’t in charge of keeping state secrets… oh wait…)

The initial reporting will largely focus on the sheer scope of reforms in the bill and the superficial price tag as scored by the Congressional Budget Office -- $848 billion over 10 years while reducing the deficit by nearly $130 billion. Democrats will champion the expansion of coverage to 94% of Americans and how the cost-controls in the bill reduce the deficit even more past the 10-year window. Republicans will blast the sheer length of the bill (2,074 pages, which honestly seems like a bargain considering the complexity of the issue) and their usual nonsense about government takeovers, death panels, and how cutting a single dollar from Medicare waste will make the Virgin Mary cry. And of course those not content to actually talk about reforming our morally and economically bankrupt health care system will get drawn into sideshows about Reid reverting to the same abortion language we’ve talked about all year, or the titillation of something we’ll all come to know as “the Botox tax.”

But before the madness of political punditry overtakes us, allow me to focus on one key question that will unquestionably get lost in the shuffle. Does this new Patient Protection and Affordable Care Act do enough to put quality health care coverage affordable to low- and middle-income families? At the end of the day, if we haven’t made standard, comprehensive coverage within reach of the pocketbooks of working families in America, we just haven’t gotten the job done.

I’ll say this for Reid -- clearly he’s been focused on the affordability question, and he’s made some substantive improvements over the mess that was the Senate Finance Committee bill. For ease of reference, I’ve broken my snap analysis into three categories: “Wooho!”, “Meh” and “Aw crap!”

Under “Woohoo!”, we see some downright surprising strength to this new bill. For those who will purchase their insurance plans through the one-stop-shops known as the Health Exchange in each state, they’ll find the tax credits to help subsidize the cost of their premiums to be much more generous than the previous Senate Finance bill, more generous than the previous Senate Health, Education, Labor and Pensions bill and yes, even more generous than the House bill! The credits are offered on a sliding scale based on income, and go all the way up to 400% of the poverty line (about $88,000 for a family of 4) -- much better than the Finance bill and equivalent to the HELP and House bills. On the low end, individuals and families will only need to pay 2.8% of their income on premiums for a comprehensive plan. On the high end, it’s 9.8% -- an improvement over the 12% maximum in the House bill.

Indeed, the Senate bill is unquestionably more generous on premiums than the House for middle-income families. As an example, let’s use 2009 dollars and some back-of-the-napkin math. A comprehensive family insurance plan today averages $13,375, according to Kaiser Family Foundation. If we waved a magic wand and had the Exchanges this year, a family of 4 making $44,000 wouldn’t notice much difference between the two bills: the House premium would be roughly $2,400, the Senate about $2,100. But a family making $77,000 would see a huge difference: $8,500 for the House and $6,000 for the Senate. Who saw that coming? I’ll tell you who -- Olympia Snowe. One of her main critiques of the Finance bill she helped put together was that it wasn’t doing enough for families above $66,000, who received no subsidy at all. I think Harry Reid got her attention!

Another major weakness/”giveaway to the insurance companies” in the Finance bill was the weakness of the regulations against price gouging people because of age. The House and HELP bills limited premiums based on age to a 2:1 ratio (e.g., a plan being sold to a 25 year-old for $5,000 couldn’t be sold to a 60 year-old for more than $10,000), but the Finance bill allowed a leap of 4.5:1. The new Senate bill is closer to the House with a ratio of 3:1, and includes a modest 1.5:1 ratio for tobacco users. Of course, all the bills would eliminate different pricing based on gender, occupation, health status or salary -- regulations that are long, long overdue. Even better, it maintains the strong regulations against discrimination on the basis of pre-existing conditions, rescissions, refusing to renew coverage because the customer gets sick, makes lifetime benefits caps illegal and has a host of regulations to foster transparency and efficiency. Just as in all previous bills, co-pays and deductibles for preventative care will be no more. But you don’t hear about them that much, largely because they’re not controversial.

That’s a strong start, but the story doesn’t end there. Check back later for the affordability provisions that made me say, “Meh” and “Aw Crap.”

Update:

Read Part 2 -- the "Meh" policies

(Photo credit: public domain)

5 Steps to Get Americans on Board With Health Reform

Gillian Hubble — 2009-11-18T06:00:00-08:00

The latest AP poll repeated the same tired trends in public healthcare reform sentiment. We are generally for it, until pollsters start presenting aspects as trade-offs. Once they hit one that resonates with one of us, we will promptly be against reform. We really can’t help it. As Change.org members regularly point out, we’re not a country that values solidarity, social worth or even basic human rights when they interfere with profits and self-interest. The United States is the nation of Me, not of Us. So, given we are unlikely to change our basic fabric any time soon, how do we get the public on board with meaningful healthcare reform?

I have the solution, and all it takes is 5 simple steps in public education. Before any of our brethren is allowed to answer another popular opinion poll regarding healthcare reform, they will be required to dig up one simple piece of information and digest 4 more. Follow these steps, and I predict a 99% "for healthcare reform" rating in the next poll.

Know Your Full COBRA Premium: For those insured through an employer, call up Human Resources and ask what the full monthly healthcare premium is (your employer’s and your contribution, combined.) Now, add 2%. That is your monthly COBRA premium, should you be separated from your employer. Will you pay that or the mortgage?

Know Pre-Existing Conditions That Insurers Deny: So, you think buying an individual policy is a better deal? You’d better be sure you don’t have one of the umpteen conditions that insurers will use to deny you benefits, before or after you buy coverage. There’s a basic starter list here, courtesy of the California Department of Insurance. But don’t forget the combinations of conditions that will also bar you from the Wild West of the individual health insurance market. For instance, say you have had back pain (80% of Americans) and also have diabetes, asthma, high blood pressure, or take prescriptions for just about anything. Sorry, you are the weakest link. Goodbye.

Know How Poor You Must Be To Receive Free or Indigent Care: Many people stand by the myth of free care at community hospitals, or use their belief in the Medicaid safety net as comfort. Guess what? Many community hospitals are NOT required to provide care regardless of your ability to pay, aside from EMTALA regulations that provide for care only in life/death or labor situations. Can’t pay? Try Medicaid. Do you make one dollar above the poverty level, or perhaps own a home or have a little savings stashed? Sorry, you don’t qualify. Oh, and by the way: you are now responsible for the entire bill, not just the pennies on the dollar that Medicaid is allowed to pay. So get extremely familiar with those poverty guidelines and make sure you stay within them. Or if you have a disease, just don’t get it treated.

Know The Cost of Cash Care: Now that you’ve seen your coverage options disappear, it’s time to get familiar with the cash prices you will be paying. It’s also helpful to see what a typical private insurer and Medicare would pay for the same services and prescriptions. Comparing costs to those in other countries might be helpful too. Ready? Take a look at average cash costs for an ER visit, an MRI, a routine hospitalization, a week in the ICU, breast cancer treatment, and heart attack and ongoing heart disease treatment (sorry, I don't have a list handy.) Oh, you didn’t know you’d be paying over 44 times more than Medicare and private insurers? Cash discounts don’t cut it in US healthcare. Those Medicare rates are looking mighty efficient compared to private plans too.

Know Medical Error Statistics and Local Quality of Care: Now that you’re feeling a little squeamish about the princely cost of care here in the Land of the Free, and how easily you can become a bankrupt cash cow, it’s time to get familiar with what you’re paying for. As the Institute of Medicine’s 1999 report, To Err Is Human, revealed, 44,000-98,000 preventable patient deaths occur each year due to medical errors, at a cost of $17-$29 billion. Much activity has taken place since then, but the 4 main drivers (fragmented care, licensing inattention to it, malpractice climate, few purchaser-based incentives) remain. Quality of care varies dramatically among hospitals and physicians alike, and even more so among different regions of the country. Generally it’s not nearly what it could be (and if you're uninsured, you're nearly twice as likely to die in the hospital as someone who has insurance anyway.) So check before you need to be seen, because #4 applies regardless of whether you receive safe, quality care.

So, now that you know how tenuous your grasp is on affordable access to quality care, you’re ready for the next poll. It’s not about “their” welfare (unless you’re among the wealthiest 1% who can afford healthcare regardless of the cost), it’s about yours. How do you feel about wholesale US healthcare reform?

A bonus Billionaires For Wealthcare song for you:

Photo woodleywonderworks// CC BY 2.0

How to Shame Senate Healthcare Obstructionists

Gillian Hubble — 2009-11-17T06:00:00-08:00

Remember Rachel Maddow announcing a 3-prong Democratic strategy to get healthcare reform passed last month? The audacious “shame them, demote them, and do an end run around them” strategy seemed lifted right out of the Tea Party sensationalistic playbook. The basic approach was to 1) do good while shaming those Congressional representatives who would deny their constituents affordable healthcare, 2) relieve obstructionist Democrats of their committee chairmanships, and 3) use reconciliation as an end run around Republican obstructionism. Well, we haven’t heard much about demotion and reconciliation lately, but the shame part is full steam ahead.

Yes, we’ve asked thousands of times for his removal, but Joe Lieberman’s Senate Homeland Security and Governmental Affairs Committee Chairmanship seems sacred to his Democratic Senate brethren. Even though Lieberman is an Independent, his obnoxious pro-filibuster stance against anything to do with a public option deserves a quick and decisive amputation from his leadership position. Ain’t going to happen, apparently.

Perhaps it’s because, if they are anything like their House counterparts, Senate Democrats knowingly have a tremendous amount of conflict of interest in their policy positions (see Change Congress’ video on Lieberman and Evan Bayh for examples.) Did you see that Genentech managed to insert its pre-scripted language into the House “debate” register via 42 Representatives? It was bipartisan representation too – 22 Republicans and 20 Democrats parroted Genentech’s positions. That’s disgusting.

Maybe that’s why John Dingell’s amendment to ward off predatory insurance rate spikes didn’t include the pharmaceutical industry, which has conveniently raised prescription prices 9% in the last year. That little rate hike will cost us $10 billion this year, dwarfing the $8 billion the industry has agreed to cut from overall drug costs. Less means more, apparently. But on to the happy news, where those who have less coverage will be receiving more care.

Thanks to the National Association of Free Clinics, the “shame them” strategy is in full swing. NAFC represents 1,200 free health clinics that care for those in need across the country. The Shame idea is to leverage NAFC’s experience to hold massive free health clinics for those who can’t afford healthcare in states whose Democratic senators oppose wholesale reform. These types of mass events have been held in Florida and California, and are heart-wrenching to behold. One in Florida turned Wendell Potter, a former health insurance executive, against his industry. Seeing the damage inflicted by his cherry-picking, bonus-driven bosses, he now actively campaigns for a public option to keep private insurers more honest.

These same types of free clinics are now coming to Louisiana (New Orleans, 11/14), Arkansas (Little Rock, 11/21), and Missouri (Kansas City, 12/9-10.) Their purpose is two-fold: provide care to those who need and can’t afford it, and demonstrate the enormous healthcare black hole that exists in obstructionist senators’ districts. Here’s looking at you, Mary Landrieu, Blanche Lincoln, and Claire McCaskill. If they have any shame at all, we may soon see a Potteresque turn in their positions. If not? At least thousands of their constituents will have received a little needed care. Because given the rate of Senate non-progress, it may be a while before they get any more.

The National Association of Free Clinics also has a community here on Change.org, and you can join and/or contribute to the cause.

Photo Doug20022 // CC BY 2.0

4 Potential Healthcare Roadblocks in the Senate

Gillian Hubble — 2009-11-16T06:00:00-08:00

What can we expect on the Senate healthcare reform front this week? Besides the usual political shenanigans, I mean, like John McCain telling a bunch of his constituents to tear up their AARP cards because AARP supports the House bill (so proud to live in Arizona.) Well, here is a hint. The Senate may win one of those ‘last runner to cross the finish line’ awards, after its members take many byzantine detours along the way. After seemingly falling into a black hole last week, the Senate’s drafting and debate over its combined healthcare bill won’t be making up any time. Insiders don’t expect a test vote before Thanksgiving, making a bill before Christmas a very faint possibility. So why is that?

There are 4 big issues Harry Reid needs to negotiate around:

CBO Score: Expect a public score this week. It’s not that the CBO hasn’t provided a financial score on the costs and benefits of the proposed legislation yet. It has, a few times. Reid is trading policy proposals and cost estimates with the CBO, trying to come in under the $900 billion mark. That’s not a great sign for the Senate bill’s viability, given CMS has already released a Republican-commissioned report on HR 3962 indicating it will increase costs by $289 billion over the next decade, basically due to the Massachusetts Effect. That would raise healthcare’s share of the GDP above current projections. Then again, don’t look to CMS for financial genius: it allowed millions of dollars in Medicare fraud to continue for years, even though it was warned about multiple $1 million scams. Apparently only those that turned themselves in were “caught”, like Kaiser Permanente’s $1.8 million fine for hospice care charges on non-certified patients. It’s definitely time to tighten up the ship over at CMS.

Who Should Be Subsidized: Reid is apparently set to propose a Medicare payroll tax increase of 0.05% for those earning more than $250,000 a year. It’s expected to raise $40-50 billion annually. But don’t get too excited about expanded subsidies to those who can’t afford health insurance. No, Reid probably isn’t trying to make up the gap between the Senate Finance Committee’s $461 billion in subsidies and the House bill’s $602 billion. He plans to weaken the excise tax on Cadillac health plans, raising the premium threshold from $21,000 to $23,000 for family plans, which would eliminate $54 billion in revenue annually. Why would he do this? Apparently he is bowing to union pressure to leave their plum benefits alone (despite high-risk workers already being exempted from the tax.) Yes, unions are being preferentially subsidized over the general population, which doesn’t have a lobbying allowance.

Who Should Be Mandated: The individual mandate has and will continue to be a sticky issue. It is necessary to get people into the insurance pool BEFORE they get sick (similar to requiring people to purchase life insurance before they know they are going to imminently meet their maker). But the 2.5% penalty may hit those who can’t afford insurance in the first place. Then there’s the issue of employer responsibility via providing healthcare coverage or paying a fee, which the Senate is calling “Pay or Play”. Either individual or employer penalties will be portrayed as new taxes and will continue to be used for partisan sound bites, guaranteed.

Public Option: Ah yes, I saved the best for last. The state opt-out version in the current bill is sure to be under fire. Joe “Big Mouth” Lieberman has said – loudly and often – that he will filibuster a bill with a public option. Blanche Lincoln is an unknown. We know how Republicans feel – filibuster or bust. Olympia Snowe poses a particular challenge with the possible reintroduction of her trigger plan (a very bad idea and underhanded political trick.) Then there are moderates like Jay Rockefeller and Sherrod Brown who say they won’t vote for a bill that doesn’t contain the public option. Expect the option to be substantially remolded as the slow process grinds on. The issue could be easily put to rest by doing cost comparisons on identical coverage via a public plan and a private one, but that wouldn’t be politics, now would it? Easier yet would be to request Medicare waiver signatures from all Senators who wish to block “government-run” healthcare. If it’s that scary, we shouldn’t be paying for their future coverage. There, make-or-break issue solved.

Photo http://farm3.static.flickr.com/2521/4013939756_6b88e9941d.jpg // CC BY 2.0

Lies, Damned Lies

Gillian Hubble — 2009-11-14T11:00:00-08:00

Many of us acknowledge that the passage of HR 3962 last Saturday was not an altogether positive thing. The bill does provide consumer protections not currently available, and will expand coverage to many currently uninsured. But it also mandates a captive market for private insurers and provides an exceptionally weak public option that’s expected to cover 2% of the population and cost more than outrageously expensive private coverage. Worst of all, Stupak's last minute amendment strikes down women’s rights as a trade-off for universal healthcare coverage. It’s ugly. Not as ugly, however, as the Republican lies that tried to defeat it.

Now, I don’t expect the GOP to sing HR 3962’s praises. That would be unpartisan, not non-partisan. So we won’t hear Republicans talking up the recission ban (they actually tried to remove this feature with their own amendment), or the prohibition on coverage denials due to pre-existing conditions (ditto.) Likewise, they will be mum on premium subsidies, minimum benefits standardization, elimination of annual and lifetime maximum benefits, and providing CLASS as a long-term care option for the disabled.

You would think that they would hammer on the inconvenient truth that expanding Medicaid will likely result in a covered population with nowhere to go for treatment but the ER, thanks to pathetic provider reimbursement levels. Or that the public option will become a glorified risk pool due to negotiated reimbursement expense and strictly limited enrollment eligibility. That would take actual knowledge of the US healthcare industry, and specifically healthcare economics, though. What we’ve got in Congress are glorified Tea Partiers, ignorant to the subject matter but corruptly passionate due to special interests lining their pockets.

So Republicans stuck to the simplistic party one-liners. There’s the government take-over, the deficit explosion, breaking small businesses, losing your current health coverage (okay, they're right--it's happened to most who lost their jobs!), and cutting Medicare benefits – death panels have gone out of style, apparently. It sounds trite just writing it, but it’s more amusing to watch it repeated, puppet lawmaker after puppet lawmaker. Do you THINK they’re following a script? Thanks to the Democratic Call ‘Em Out campaign for this weekend diversion.

Now if you're wondering what the Democrats had to say during the pre-vote "debate", it's safe to say they couldn't get a word in edgewise in the initial stages. Take a look at the video at the end of this previous post, if you haven't already. It will give you a full flavor of the thoughtful, educated debate that isn't happening in the capitol.

Also this weekend, we can look forward to the Danville TEA Party hanging Representatives Nancy Pelosi and Tom Perriello in effigy. I guess when you have nothing more to offer in your organization than Truthers, Tenthers, Palinophiles and party liners, you have to go for shock value. Now, on to the slooooow Senate process of round-filing healthcare reform while clogging the federal legislative pipeline for other pressing issues. We’ll look at the road ahead on Monday.

Photo http://farm1.static.flickr.com/215/506425051_739f71b2ff.jpg // CC BY 2.0

5 Healthcare Lessons in Possible Grocery Workers’ Strike

Gillian Hubble — 2009-11-13T06:00:00-08:00

Whether or not United Food and Commercial Local 99 workers will walk off the job at 6pm today due to contract disputes with Arizona Fry’s and Safeway grocery stores, there are healthcare lessons hidden in the saga. The union has had contract disagreements with management over many salary and benefit issues for a year now, but the main stumbling block is healthcare. More specifically, the disagreement is over “free” healthcare. Welcome to American healthcare drama, union-style.

Until now, the companies have paid all healthcare premiums for their workers. Now they are asking individual workers to pick up $5 per week in premiums, married workers to cover $10, and workers with family coverage to pitch in $15. That’s extremely small potatoes in the world of super-sized US healthcare costs. But for the hourly workers this union represents, including checkers, stockers, meat cutters, and produce workers, it’s not insignificant. For those like a friend of mine who has worked for Fry's for 20 years, is eligible for a pension next year, drives a Porsche convertible and plans to retire with a small beach-based business in the tropics, it actually is insignificant. Plus it doesn’t apply to him (see Lesson #3.)

I do admit to some Scrooge-like tendencies. Even as a graduate student long ago, living on Ramen Noodles, a part-time paycheck, and student loans, I paid more than $5 per week for healthcare coverage. Now it’s closer to $100 per week, for a plan with a $5,000 deductible. Local sentiment is similar: get real. Tucson is an entry-level worker haven for the service sector (it used to be the call center capital of the US) and as such its wages tend to be on the low side. In this economy, people are glad to have jobs without benefits.

To be fair to the union position, Safeway leadership has been more than a little disingenuous. In a video actively promoted on Safeway’s website, CEO Steve Burd brags that Safeway’s healthcare costs have actually decreased and that he’s a strong believer in market forces shaping healthcare. So now he’s asking workers to pitch in more so “market forces” can further decrease Safeway’s healthcare bill? Maybe unions shouldn’t have actively encouraged worker dependence on employer health benefits. Which leads me to our first lesson.

Unions are not interested in the realities of healthcare market forces
While decrying management’s refusal to shoulder more healthcare costs alone, union leaders are conveniently forgetting their activities earlier this year. That was when unions actively campaigned against Wyden-Bennett’s Healthy Americans Act. You see, it would have dismantled employer-based healthcare coverage and given workers the premium money directly, to purchase insurance on the exchange and pocket savings if they chose. Unions said absolutely not. This "me first" attitude is mirrored in our Congressional representatives, who conveniently forget their constituents' needs amid re-election and contribution concerns.

Healthcare is not free
There is no free healthcare; someone always has to pay for it. Guess who pays for union workers’ free healthcare? Customers and taxpayers, that’s who. Higher grocery prices are a no-brainer. Look further, deep inside HR 3962, and you will find a $10 billion allocation to provide reinsurance (stop-loss insurance) for early union retirees. Specifically, for the ones formerly employed by bailed-out automotive dinosaurs that agreed to fund future healthcare coverage for which they didn’t have money. Not paying anything for benefits, or not having visibility into the full cost of those benefits, furthers the misconception that healthcare is free. Far from it—it’s the most expensive facet of everyday American life.

Current generations are passing on our healthcare insolvency to the next generation
The strike threat is interesting because the healthcare contribution sticking point, the $5-10-15 factor, doesn’t apply to any current union members. It only applies to future new hires. Current workers still won’t be contributing anything to their healthcare premiums. In the general population, seniors pay Medicare premiums while younger generations provide subsidies. We all age, we will all experience more health problems as we age, we will all pay more for coverage as a result. Surely a fair society’s values aren’t all or nothing though. We should all take responsibility for the accumulating healthcare red ink.

We cannot afford market healthcare costs in this country
By not paying anything for health benefits, grocery workers have actually been getting about a 10% raise every year, based on recent healthcare inflation. We should expect employers to shoulder some of the cost burden, and the $5-15 per week proposed new hire contribution amounts to 1-4% of worker gross pay, based on the $9-12/hr that most Fry’s employees make. That’s not unreasonable. But imagine if those workers were to become eligible for COBRA or try to buy healthcare coverage on the individual market. They would be forced to go bare. We also know what paying healthcare premiums does to Fry’s and Safeway’s competitiveness, compared to market king Walmart, which conveniently dumps most of its employees into subsidized public programs.

US healthcare is not equitable
Much like air travel, where we are well aware that flight passengers pay widely divergent prices for their seats, US healthcare has its free riders and those being scalped. It’s even got a blacklist of those not allowed on the flight unless they pay a ransom. Moreover, the price has nothing to do with the quality or value of the care provided. More visibility into these inequities would go a long way to increasing public solidarity.

Photo http://upload.wikimedia.org/wikipedia/commons/thumb/1/17/070710_gdl_strike_leipzig2.jpg/800px-070710_gdl_strike_leipzig2.jpg // CC BY 2.0

How NOT to Measure Healthcare Quality

Gillian Hubble — 2009-11-12T06:00:00-08:00

Guess what? Only 1% of hospitals are below average! At least that’s how chairmen of non-profit hospital Boards of Directors see it. Apparently they live in Garrison Keillor’s Lake Wobegon, where all the children are above average. Patients, well, we live in real towns. If you ever wondered why hospitals were such dangerous places to be, we can now give you a big hint.

Of 722 hospital chairmen surveyed in a Harvard study, 99% thought their hospitals performed as well as average. The scariest finding is that fully 100% of hospital chairmen for hospitals that perform the worst think their hospitals perform at least as well as average or typical hospitals. Ironically, that means the 1% who thought they were below average actually underestimated their hospitals. But that still leaves an incredibly significant number of chairmen who seem to live in an alternate universe.

We know it’s not because quality isn’t being measured. Whether for National Committee for Quality Assurance, Joint Commission, Medicare or a local quality program, hospitals have had entire departments devoted to abstracting quality information for 20 years. The data used to determine actual quality at the dope-smoking chairmen’s hospitals was taken directly from the federal Hospital Compare site, available to the public. No wonder so little has changed since the Institute of Medicine published Crossing the Quality Chasm in 2001.

Hopefully that quality feedback actually does see the light of day within hospitals’ clinical departments, nursing units and specialties. But hope won’t help you or a family member who unwittingly stumbles into one of the below average facilities. So do yourself a favor and check out local hospital scores. Because at the hospitals studied, quality was one of the top two priorities in less than half. It was important in evaluating the CEO’s performance at only 44% of facilities, and quality performance was on the Board agenda of only 63%. Apparently that performance wasn't benchmarked to anything, based on chairman perceptions of quality.

It could just be that these chairmen spend all their time and energy on Planet Financial Balance Sheet – financial performance is consistently on the Board agenda at 93% of the hospitals (not 100%?) Hospital margins are typically 2-3%, and usually operational efficiency and effectiveness are right up there with private insurers’. Waste is a fact of life that leaders aren’t inclined to handle in resistant cultures. So a tough economy can be hard on these folks. Remember, just because they maim and kill you doesn’t mean you won’t be billed a princely sum for it. That’s a 100% guarantee.

Update: A good article today in HealthLeaders Media discusses a key strategy to overcome the "arrogance of excellence" on many hospital boards: confront them with an actual case of severe harm, preferably including a conversation with the patient or a family member of the patient. "The trustees have to become outraged," says the Institute for Healthcare Improvement's James Conway.

Photo http://farm3.static.flickr.com/2203/2484628164_93af0da1e6.jpg // CC BY 2.0

The Dirty Little Secret of Health Care Cost Control

Tim Foley — 2009-11-11T14:12:00-08:00

The trickiest knot in health care reform isn't immigration or abortion or even a public option. It's who's going to pay for it. We've talked a-plenty about new revenue, be it the House's surtax on millionaires or the Senate's high-cost health insurance tax. But we also need money derived from the savings that can be wrung out of our bloated $2.4 trillion a year health care system (a figure that dwarfs the measly $90 billion a year we'll spend fixing it.) Half of the costs for each of the health care bills -- and more than half of what the Obama Administration has proposed throughout the year -- are recouped by policies that "bend the curve" of our accelerating health care costs. Indeed, Republicans have made bemoaning the proposed $500 billion over 10 years of cost containment provisions in Medicare into high kabuki theater. Nonetheless, we're hearing a new "conventional wisdom" that the reform plans aren't good because they don't do enough to control costs -- and some who push this thread into hyperbole by claiming there's no cost control at all.

Here's the dirty little secret of cost control at this stage of the game: most of the politicians making the claim that the reform bills don't do enough to control costs wouldn't be caught dead voting for the ideas that really will control costs!

Don't believe me? Well, let's take Mark Warner or Susan Collins or one of the other senators now looking to poke holes in a reform plan while being secretive about what their own method for controlling costs will be. Which of the following ideas would these so-called "fiscal conservatives" actually vote for?

First, there are the elements that we know with certainty that the Congressional Budget Office would score as an aggressive way to control costs. We can start with ending the program for overpaying Medicare Advantage for-profit HMOs per customer compared to traditional Medicare -- a proposal in all the bills that the CBO guarantees will cut costs but which the insurance industry and most Republicans and moderate Democrats are fighting. Or there's the "Cadillac" tax in the Senate Finance bill, itself a somewhat lame iteration of removing the tax exemption on employer-provided insurance, a guaranteed source of revenue that also exerts downwards pressure on the cost of insurance. Or how about a public option that pays Medicare-based rates, a tool that the CBO has repeatedly scored as a cost-saver and a significantly higher cost-saver than one with negotiated rates (Warner only supports the latter, Collins supports neither of the above)?

Second, you know what else would substantially save money? Having the federal government negotiate and/or set the rates for health care services. That's how every single-payer system, from Europe to Asia to Oceana, achieves the bulk of dramatic savings. That's how hybrid public-private systems like Japan have achieved such efficiency that our per-person costs are three times as much as theirs (if we waved a single-payer magic wand tomorrow and removed the administrative costs of private insurance, we'd still have 2.5 times the costs of Japan). That's even how the conservative and wholly privatized model of Switzerland operates. And I would have a heart attack and die if I saw a single centrist Senator propose it.

Finally, there are the cost control measures that will likely save money but which the Congressional Budget Office will score as netting very little savings. These are likely the proposals a Collins or a Warner will champion. But because the CBO is doubtful that they would produce guaranteed savings, we could implement them all and still be open to the charge of "This bill doesn't do enough to control costs." For example, many -- including Bob Laszewski -- are hailing the idea of either a bipartisan Congressional commission or an independent MedPAC-like board to propose and implement cost-control tools for Medicare free from the politicking of Congress. It's a good idea, but one that the CBO is not likely to score well (interestingly, because they don't think it will generate more savings that what's already included in the bills -- natch.) Investments in prevention, primary care, coordinate care, the medical home, electronic health records -- all elements that we know save money in state Medicaid programs, closed systems like the VA, and state-of-the-art high-quality health systems like the Mayo Clinic, all likely to leave the CBO unimpressed. Reducing hospital readmissions, making adjustments for productivity changes at hospitals, and allowing trimming waste, fraud and abuse? Already in the bill, chief. Tort reform? Fuggedaboutit.

I would love it if the reform bills in Congress did even more to reform the way Medicare delivers its payment systems, blazing a path for private payers to follow. Real cost containment won't come from a single bill but from creating tools that allow us to adjust and bend the curve next year, and the year after that, and the year after that. It's not that the proposals on the table do nothing -- that I fear is about to become an often-repeated lie -- and it's not like we don't know what we can do to bend costs even further. But getting these options past the so-called fiscal conservatives who should be championing them? That's the true Gordian knot.

The dirtiest secret of all is that in health care, one man's waste is another man's profit margin... and still another's campaign contribution.

(Photo credit: http://www.flickr.com/photos/13061661@N08/ / CC BY-ND 2.0)

China's American-Style Healthcare Dilemma

Gillian Hubble — 2009-11-11T06:00:00-08:00

As we wait for the CBO to score the special interest-heavy Senate healthcare bill so the wheels of reform can begin to slowly grind again, it’s nice to know the country that owns the US now finds itself in a similar healthcare situation to ours. Largely because it followed our capitalistic, private-enterprise lead, China – which owns the largest share ($797 billion) of the US $3.4 trillion publicly-held debt – has a healthcare system in disarray. While some of the details are different, the themes are eerily familiar. No, we aren’t alone, but we might learn something from China’s dilemma.

China’s now diversified economy has left 300 million and counting of its 1.4 billion residents to rely on a porous government insurance program that only pays 60% of hospital bills. For medication and outpatient services, people have to fend for themselves. Although the government sets prices for all medical services and doctors’ salaries, when per capita income is about $5,000/yr it doesn’t leave people much to pay for healthcare. Take retired hydropower worker Shen Baohou, whose stent implants totaled $15,000.

Before 1980, when market reforms began, state-owned companies offered lifetime care to China’s residents. The benefit was one among many, including education grants and pensions. Chinese National Petroleum Corporation actually owned 50 hospitals to which it sent its 1.5 million workers. Then the workforce aged, retired, and required more expensive care. But younger workers went to work for private companies, leading to highly divergent risk pools. In 1981, 71% of Chinese had access to state health facilities; in 1993, only 21% did.

In 1994 China tried city insurance pools (200 million people are now enrolled) and separated hospitals from company ownership. It used a 6% employer tax and a 2% employee tax to pay for care. But medical inflation greatly outpaced wage and tax inflation. In 2005, people’s out-of-pocket expenses were 100 times what they were in 1980.

So in 2003, the government allotted more money for rural health cooperatives and gave farmers subsidies to buy insurance. Though the program covers 25-30% of hospital care and little outpatient care, 850 million people are enrolled. In 2007 China extended the program to urban workers; 120 million signed up. Some areas provide additional subsidies, and people can buy private insurance policies, if they can afford them. But their benefits are only good where they live – if they travel, they are officially “out of network.”

There is also a growing gap in quality of care. At Peking University People's Hospital there are electronic medical records, GE scanners, elite doctors and a fancy ward where the wealthy pay a princely sum for private suites. Community clinics, on the other hand, in both cities and rural areas, tend to be understaffed and poorly equipped. Worse, Beijing resident Helen Ye says people go to the clinics for colds, “but we don't trust the doctors because they are all being paid by the drug companies and so they over-prescribe. So most Chinese people, if they don't feel really sick, do home treatment and try to cure themselves."

China has an American problem that thankfully doesn’t involve as many profit-driven middlemen as ours. But it’s a lot bigger. What are they going to do about it? Frankly, Chinese leaders don’t know what to do. Some policy experts like economics professor Gordon G. Liu at Beijing University's Guanghua School of Management encourage letting the rich pay more for care, so doctors would work harder to get paid more. This theory relies on rhetoric that more doctors mean more care even for the poor, who can’t pay for it. Better yet, invite Kaiser Permanente to build hospitals in China, bringing in foreign investors. Other experts believe Liu’s theories would lead to doctors seeking out rich patients and ignoring the poor (do you think?)

So the State Council has set up pilot projects in multiple cities, and expects the experts to report back in three years. Some pilots will free up doctors to work at for-profit ventures, some will transfer them to community clinics without losing their government jobs, others will stick to the government-run model of fixed salaries but expanded care. The US could learn from this approach. Our leaders tend to sit on their hands, debating and spreading academic or just plain political rhetoric while some cities, states, and Medicare programs take the initiative. Instead, as a nation we could Get Off Our Buts, as the Roger and McWilliams book says. We just might come out ahead of China.

Photo http://lh4.ggpht.com/_jmb8njXy57I/STAk4D3rz9I/AAAAAAAABow/QxIHHHB-Fuw/s720/DSCF4668.JPG // CC BY 2.0

Is National Healthcare Reform Repeating Massachusetts' Mistakes?

Gillian Hubble — 2009-11-10T06:00:00-08:00

So where are we, as a nation, on health reform? You can compare the plans currently in play in an excellent summary here. But I can sum it up in two words: Massachusetts 2.0. Remember, MA was the first state to require all residents to have health insurance, with hardship exceptions. This was coupled with an employer mandate. It now has the highest percent insured population in the country, 97.4%. It is also drowning in healthcare costs, and looking for ways to cover them. The basis of its model: expand private insurance and use public insurance as a safety net. That has a familiar homey (or should I say House-y) ring to it, doesn’t it?

Given that Obama has studiously avoided talking about, much less praising, the MA effort, it’s ironic that Congressional efforts have mirrored this universal coverage pilot so closely. For instance, MA took the Congressional approach of tackling coverage first, and costs later. Nearly five years after its inception, MA universal healthcare is encountering steep resistance to proposed measures that would bend the cost curve, like Pay For Performance programs. As a result, insurance premiums continue to rise. They are expected to go up 10% for 2010. That’s not a good omen, as both chambers of Congress rely primarily on Medicare reimbursement cuts and pilot P4P programs to achieve cost savings.

More ominous yet, doctors in MA are cherry-picking patients based on their insurance plans. In MA as everywhere else, there is a shortage of primary care physicians. When demand is greater than supply, power shifts to those who provide the service. The complexity of the insurance behemoth wasn’t addressed during the MA overhaul, and it was in fact strengthened by a coverage mandate that did nothing to decrease insurance administrative bureaucracy. So doctors continue to pay for their correspondingly large administrative staff by preferentially seeing private plan patients. Some actually refuse to see poor patients on state-subsidized public plans.

Put another way, in 2008 20% of adults reported being told a doctor wasn’t seeing new patients or patients with their insurance plan. But poor residents (who receive free public coverage), or others up to 300% of the poverty level who selected subsidized public Commonwealth Care insurance, were TWICE as likely to be rejected as higher-income residents with private coverage. The benefits package in public and private plans is identical; it’s just the reimbursement that differs.

The House is following this model too – standardize benefits, but put the poor in Medicaid, the almost poor and riskier in the Exchange where they’ll likely choose a public option, the disabled in CLASS, the pre-existing conditions folks in temporary risk pools, and don’t let the currently insured switch from a private plan. Guess what we can expect from this “divide and conquer” approach? In MA, because of the provider cherry-picking, ER use for non-emergencies hasn’t decreased. Among low-income residents, 23% have used the ER for non-emergent issues, identical to 2006. That’s some very costly care.

From an employer-based insurance perspective, there’s actually good news out of MA. Contrary to fears, employers neither dropped coverage nor scaled back benefits. In fact, access to employer-based coverage increased, and employees rated the quality higher. The authors of the annual MA study, Sharon Long and Paul Masi of the Urban Institute, put it perfectly: “Although major expansions in coverage can be achieved without addressing health care costs, cost pressures have the potential to undermine the gains.”

So after so many months of debate, and with so many successful international models of universal healthcare to emulate, how did we get here? The simple truth is that reform has been in the hands of special-interest driven politicians who know nothing about healthcare. They are more focused on political positioning than fixing a crisis. Take Republican Mike Pence’s post on his website, denouncing the passage of HR 3962 and claiming "I am proud that all House Republicans stood by the American people in opposition." Facts be damned, apparently. Turns out Pence posted this gem hours before the final House vote. Thanks for declaring defeat in advance, Mike, and as for that solidarity play, well, big double oops.

So the blind and corrupt in the Beltway are leading the (mostly) just blind nationwide. ‘It’s politically expedient and it sounds good’ is not usually a recipe for success. MA deserves better than to see its challenges repeated, because it continues to work on its issues and share its lessons learned. If only our lawmakers would listen.

Note: MA actually has a leg up on D.C.: Commonwealth Care actually covers women’s reproductive rights.

Photo http://farm4.static.flickr.com/3267/3120225899_6e6e546c72.jpg // CC BY 2.0

House Health Reform Passes! An Early Start to the Holiday Season

Gillian Hubble — 2009-11-09T06:00:00-08:00

We got an early start to the holiday season during an exciting and historic weekend. Obama reminded House Democrats that they have developed more comprehensive reform than any Congress in the last 70 years, and that it was a historic opportunity to pass it. Democrats responded by passing HR 3962 by 220-215 (two more votes than necessary) and with one Republican to make it “bipartisan”. Like Thanksgiving, though, it didn’t happen without a lot of carnage beforehand. Now the rude and boorish relatives are settling in until the New Year.

First, if you missed the Republican “debate” on the bill, you can see it at the end of yesterday’s post. Apparently acting like a bullying child in response to women exercising their right to free speech is what passes for public representation now. The GOP alternative healthcare reform “plan” was just as hollow, and following an amusing rant by Education and Labor Chairman George Miller, below (“Wanna buy it? Wanna try it? Wanna sell it? Come on America, buy this one. You're guaranteed to be left behind if you're left behind today."), the House duly rejected it 176-258.

Second, one destructive plan that did pass was the anti-abortion Stupak amendment, which seeks to bar abortion services within any plan participating in the Insurance Exchange, ostensibly to avoid federal funding of abortion. When the effect is to eliminate this service from private plan benefits just because some plan members may receive federal subsidies, it goes too far. You can tell the administration so here.

Third, Dennis Kucinich and Anthony Weiner had their single payer bill and amendment mistakenly lost, then deliberately fire bombed, by Nancy Pelosi. As a result, Kucinich voted against HR 3962, because it is legislation “ … in which the government incentivizes the perpetuation, indeed the strengthening, of the for-profit health insurance industry, the very source of the problem.”

Regardless of the carnage, a healthcare reform bill did pass one chamber of Congress. Truman didn’t accomplish that. Neither did Nixon, Carter, or Clinton. Now we can bask in the tryptophan glow before heeding Obama’s call to “pass the baton” to the Senate. I'm not sure what kind of relay he thinks Congress is running – the 4 x 1600 backwards mosey? The Senate, especially, is looking more like the Yankees every day.

There is a reason for that. The Senate holds lots of rude and boorish relative types, and here comes one now. It’s Joe Lieberman, opening his big mouth again. Sunday on FOX “News” he renewed his pledge to filibuster as a matter of conscience (I didn’t know he had one) if the Senate healthcare bill has a public option, because it’s just unnecessary. Yes Joe, putting effective cost containment measures in legislation does seem over the top, doesn’t it? You can tell him so here. Then brace yourself for lots of family infighting as Harry Reid tries to get the Senate bill to the floor before the end of the year.

Update: Find out how your representative voted on women's reproductive rights and take action to thank them or spank them here.

Photo Pete Souza, The White House

Canadian Healthcare Equality Meets H1N1

Gillian Hubble — 2009-11-08T06:00:00-08:00

Events in Calgary last week provided a stark illustration of how Canadian healthcare values differ from American ones. As we’ve seen here in the US, H1N1 (which some health workers now call “heinie”, because patients tend to think it’s spelled HiNi) vaccine has been delayed and in short supply. The CDC has determined some vaccination priority groups in the midst of the pandemic. But none of us would really be surprised to find out that the wealthy and powerful, sports stars and celebrities were able to jump the line. Canadians generally would be mortified by this. But provincial health officials don’t just get mad – they get even.

Initially Canada believed it would have enough vaccine for everyone. So it opened clinics and vaccinated people on a first come, first served basis. Then it discovered the laws of (short) supply and (high) demand and regrouped. Meanwhile, a health service worker in Alberta decided (perhaps with a little financial help?) that the National Hockey League deserved preferential access to the scarce H1N1 vaccine. So Calgary Flames players and their families were duly jabbed.

Unfortunately, the worker chose the day before public flu clinics were closed due to the vaccine shortage. So as hours-long queues of residents were turned away, the NHL was safely put out of harm’s way. It turns out Canadians’ love of all things hockey only goes so far. Amid public outrage, health officials in Calgary duly fired the worker. Then the head of Alberta’s health service released a totally un-American statement:

“Our policies on vaccine distribution are designed to ensure an equitable distribution of the vaccine to all Albertans. The special treatment for the Flames and their families is unacceptable to us and contrary to all of our existing protocols and processes. I apologize for this breach of our duty to Albertans."

Equitable distribution of health services? Breach of duty to citizens? Firing a worker for making a profit on healthcare? What? Yep, it may sound like Greek to us, but in other developed nations healthcare is a right. This small breach of healthcare equality is something at which American healthcare bodies like the CDC don’t bat an eyelid (hence Goldman Sachs getting priority delivery, through regular channels, of enough vaccine doses to serve a hospital, while some hospitals went without.)

Of course, Canada's H1N1 response wasn't nearly as organized and equitable as many European nations. Britain sent vaccination invitations to high priority groups only, easily identified in their national health record. So did Germany, Sweden, Denmark, Finland and France. All of these countries have universal healthcare systems, what many Americans disparagingly dismiss as "socialized medicine". Here in the US we believe those with money, power, and status should get the first and the best care.

Dr. Steve Field, president of the Royal College of General Physicians in Britain, puts it bluntly. He clearly points to Britain's socialized system as allowing the country to serve those who need care first: "It's not like the U.S., where it's the survival of the fittest and the richest." Our H1N1 vaccinations have indeed been a free-for-all. I wonder if we would change our minds about egalitarian healthcare in the middle of a severe pandemic -- perhaps heinie came too late (er, at the tail end?) for the great healthcare reform debate of 2009.

But speaking of rear ends and free-for-alls, here's a rude reminder that Tea Partiers didn't stop at town halls. No, it appears GOP "representatives" (in the true meaning of the word, unfortunately) behaved like complete heinies when the Democratic Women's Caucus took the floor to voice how healthcare reform would benefit women. Yes folks, it appears children run rampant in the capitol. These people are responsible for voting on serious issues?

Photo http://farm4.static.flickr.com/3166/2628787345_2a2e3083e5.jpg // CC BY 2.0

The Senators -- and the Yankees -- Need to Get On With It

Tim Foley — 2009-11-06T19:03:00-08:00

The New York Yankees may be World Champions, but they’re noteworthy this year for another reason: they have come up with the most obnoxious way to prolong games. All other teams in baseball have “mound conferences” -- timeouts when the catcher, the pitcher and sometimes the pitching coach meet on the pitching mound to make sure they know how to handle the next batter. But the Yankees do it with chutzpah -- all of the infielders are there discussing what pitch to throw next. I guess they think the second baseman might have a good idea on whether the hitter is thinking fastball or curve. Even that may be ok, but the Yankees also do it with shocking and excessive frequency -- including eight times in a single inning for one World Series game. The delays not only make already-long games much longer, but they’re prompting Major League Baseball to consider rule changes and disciplinary action.

I say if MLB does find a solution to the Yankees having Tupperware parties on the mound every time the score gets close, we should use it on the United States Senate.

If all goes well, the U.S. House of Representatives will vote on a historic comprehensive health reform bill tomorrow night. If all isn’t well, it may take a couple of extra days, making this the first health care deadline that the House leadership has missed in this months-long process. But the Senate is a different story. Despite a Senate Health, Education, Labor and Pensions Committee bill that was finished in mid-July and a Senate Finance Committee bill that was finished over a month ago, Majority Leader Reid still has given no clear indication of when a Senate debate is likely to start, let alone end. The same Senate health care bill process that Sen. Max Baucus once confidently predicted would be over by the Fourth of July will now be lucky to finish by Christmas -- but, the Majority Leader cautions, don’t hold us to that.

To be clear, I’m not advocating a “rush it and get it wrong” approach like what the Bush Administration and Republican-controlled Congress did with Medicare Part D, introducing the bill and passing it within hours. Despite the Republican nay-sayers channeling their inner Simon and Garfunkle and proclaiming, “slow down, you move too fast” no matter what deadlines the Senate Democrats blow through, we’re far, far away from anything that could remotely be considered rushing. As Ezra Klein points out, “If you're tracking Obama, then he's been moving on health-care reform for 29 months. If you're tracking the congressional process, then it's 17 months. If you're tracking the first new bill introduced in this round, then it's 33 months.” As Obama liked to joke about the presidential campaign during its final months, “There are babies walking and talking who weren’t even born yet when we started all this.”

More to the point, although the extra consultation time may help the Yankees make a perfect pitch, more time does not guarantee a better result for the Senate. Instead, it means more time for industry lobbyists to get to work on undermining the financing provisions. It means more time for recalcitrant centrist Democrats to up their own importance by publicly expressing their doubts. It means the continued clogging of the legislative pipeline, kicking other priorities like job creation, financial regulation, climate change and more down the road. It means continuing to paralyze states, who need to reform their own health care budgets in the face of their rising budget deficits but are afraid to make a move until they know how the federal reform will affect them. And, worst of all, it means delaying further the positive effects of reform at a time when the country is still shedding jobs and with them, benefits (albeit at a much slower pace than a few months ago). It means more going without care and yes, more literally dying because our dysfunctional health care system leaves them behind.

Maybe Robinson Cano and Derek Jeter know how to get Lincoln, Landrieu, Nelson and Lieberman to vote for cloture. Let’s call a timeout and ask them. Or, better yet, let’s start the debate on the damn bill.

(Photo credit: http://www.flickr.com/photos/chrisptacek/ / CC BY 2.0)

Your Doctor's Health Advice, Brought to You by Coke

Gillian Hubble — 2009-11-06T06:00:00-08:00

We are on the eve of a historic House vote for a healthcare reform bill that, while it addresses some healthcare issues, carefully avoids the profit elephant in the sector. Now would be timely for another exposé, yes? This time it has nothing to do with greedy insurers. No, the latest absurdity comes straight from those who generate the vast majority of healthcare charges. Lo and behold, a sugar-sweetened baby elephant just turned up in your doctor’s office.

The American Academy of Family Physicians recently announced a six-figure deal with Coca-Cola Corporation. The alliance deals with (of all things) consumer educational materials on soft drinks for the AAFP health and wellness website. AAFP CEO Douglas Henley of course assures us that the deal won’t affect family physicians’ public health messages. I’ll bet.

Harvard nutrition expert Dr. Walter Willett begs to differ. He says the AAFP has muzzled itself when it should be a vocal critic of products like Coke. Sodas “cause enormous suffering and premature death by increasing the risks of obesity, diabetes, heart attacks, gout, and cavities.” Well, cigarettes have similar negative public health effects, and that didn’t stop paid physicians advocating mild cigarettes as safe in 1960s advertisements.

Fortunately this time there has been more outcry. Twenty-one doctors near San Francisco resigned their AAFP memberships in protest. Another 22 health specialists sent a protest letter to Henley urging him to abandon the Coke deal, as they question the safety of artificial sweeteners and feel the AAFP should be strongly speaking out against sugary drinks.

Coke spokeswoman Diana Garza Ciarlante says all this criticism "misses the point of the partnership which is to provide education based on sound science." Yep, just like the Healthy Choices program was all about promoting healthy eating via Froot Loops. The AAFP’s president-elect Dr. Lori Heim confirms it: the idea is to “to develop educational materials to help consumers make informed decisions so they can include the products they love in a balanced diet and healthy lifestyle."

All of this is pretty ironic, given the latest Commonwealth Fund study released. The survey of over 10,000 primary care doctors in 11 developed countries (US, Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden and the United Kingdom) again repeated that the US spends more than twice what other countries do, while lagging on quality measures. But more specifically, it found cost and access to care were the major primary care barriers in the US – 58% of doctors say their patients struggle to pay for medications and care.

So why doesn’t the AAFP suggest Coke sponsor medication subsidies, health fairs, or free health clinics? It could hand patients free samples of new Coke Zero on their way out the door. I guess that wouldn’t send the same subliminal “AAFP wants you to incorporate Coke products into your diet” message as educational pamphlets. I keep forgetting, it’s about profits, not health.

Photo http://farm4.static.flickr.com/3632/3559771258_5bac2c6891.jpg // CC BY 2.0

Kucinich Tries to Kill Vote on Medicare For All

Gillian Hubble — 2009-11-05T18:33:00-08:00

In a stunning about-face, Dennis Kucinich made a statement questioning a scheduled stand-alone vote on HR 676, Medicare For All. It was to be voted on Friday. Then he sent an email to supporters urging them to convince congressional leaders that now is not the time to vote on the single payer bill. Why would he try to kill his own baby?

It appears the House weakened the bill beyond recognition, as Kucinich says:

"... we want to offer a strong note of caution about tomorrow’s vote. The bill presented tomorrow will not be HR676. While we are happy to relinquish authorship of a single payer bill to any member who can do better, we do not want a weak bill brought forward in a hostile climate to unwittingly accomplish what would be interpreted as a defeat for single payer."

There has been no Congressional debate over HR 676. There has been no mark-up of the bill. The CBO apparently scored a weakened version of the bill unfavorably. This is of course after Nancy Pelosi inexplicably removed Kucinich's state single-payer amendment from HR 3962 after the bill had been released. She disengenuously called it a "mistake" at the time, fooling no one. Then she didn't allow it back in via manager's amendment (somehow it was okay for the Republican "plan" to get in via manager's amendment, even when the CBO thrashed it.)

Overall it seems a patented "kill switch" political trick to do a test vote on HR 676 now. Pelosi killed state single payer by playing dirty pool. Now she's trying to kill single payer, period, by forcing a phony vote on a weakened HR 676. That is why Kucinich is now calling on his support base to temporarily surrender rather than go down in flames. Sadly, it seems Congress is hell-bent upon passing weak healthcare reform, no matter what dirt it has to pull out of its bag of tricks.

You can send an email to your representative here.

UPDATE: Anthony Weiner's amendment to HR 3962, which was a substitute for HR 676, has now also been sacrificed. Nancy Pelosi convinced Weiner to accept a no-vote for the good of overall reform. Her argument is not to let perfect get in the way of pretty good. In this case it would be more accurately stated as not letting good get in the way of pretty weak.

Photo http://www.flickr.com/photos/rustydarbonne/2099154382/sizes/m/ // CC BY 2.0