Change.org's Health Care Blog

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.

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

House Light Hits Predatory Insurers and Complicit GOP

Gillian Hubble — 2009-11-05T06:00:00-08:00

Well at least one of the two manager’s amendments to the final version of HR 3962 could be useful. It addresses the “Wall Street Effect”, most obviously in a section entitled Sunshine on Price Gouging by Health Insurance Issuers. The Wall Street Effect was observed when banks and credit card companies were told regulations would be tightened the beginning of 2010 – they promptly raised rates and found all sorts of fees and penalties they could assess customers prior to that. Expecting private insurers to do the same thing when faced with health reform legislation, John Dingell created preemptive strikes to ward off predatory rate spikes.

His amendment also gives states more insurance oversight power, including up to $1 billion in regulatory grants. Insurers can also be kicked out of Exchanges for bad behavior, similar to non-profit BlueShield of California losing its risk pool participation rights next year for deliberately overcharging members. While risk pools and overcharging go together like peanut butter and jelly, Blue Shield was charging 1.5 to 3 times what the other two insurers in the pool were. This was in direct opposition to state law that premiums be no more than 125% of regular market rates. Worse, it was getting reimbursed similar to the other insurers for its supposed losses.

This sort of bad behavior has a ripple effect. You see, Blue Shield also conveniently used its inflated risk pool rates as the basis for HIPAA insurance rates (an option for those whose COBRA benefits have run out.) Since California law caps HIPAA rates at the average of risk pool rates, Blue Shield was able to milk yet more profit (oops, I mean surplus) from people with no other insurance options. Speaking of having no options, perhaps the most amusing inclusion in Dingell’s amendment is the explicit exclusion of illegal immigrants from participating in the temporary national risk pool. Like they could afford it anyway?

Of course, we have John Boehner to look to on the affordability front. His amendment is called the Common Sense Health Care Reform and Affordability Act. The only problem is it contains no common sense answers or affordability solutions within it. The media and healthcare economists have gone to town on Boehner’s removal of the recission ban, continued tolerance of policy denials based on pre-existing conditions, and risk pool “solution”. I’ve already hammered on his reliance on tort reform, insurance pools and inter-state policy purchases. For those that think Pelosi’s bill is a gift to the insurance industry, take a look at this offering.

Both Dingell and Boehner offer some very reactive solutions to our healthcare crisis. Those are the only two manager’s amendments published and it looks like that's it. Despite protests and arrests, proactive solutions like Kucinich’s state single-payer, which would remove loopholes preventing states from trying the Medicare for All strategy, are still in purgatory. So we’re still focused on keeping the predators at bay.

UPDATE: Okay, this is funny. The CBO just scored the Republican plan, and it isn't pretty. Over 10 years, it increases the number of insured by ... zero (meaning it only makes up for the 3 million more expected to lose their coverage.) Meanwhile, it saves $68 billion compared to HR 3962's $104 billion. So HR 3962 covers 12 times as many people and saves 53% more than Boehner's masterpiece. That's got to hurt! As the bumper sticker says, "There are 3 types of people: those who can do math, and those who can't."

Photo http://farm1.static.flickr.com/47/148665503_cf21216ecd.jpg // CC BY 2.0

Can Children Get Congress To Protect Their Health?

Marian Wright Edelman — 2009-11-04T06:43:00-08:00

Marian Wright Edelman is a lifelong advocate for disadvantaged Americans and is the President of the Children's Defense Fund (CDF).

In 1931, Grace Abbott, the Chief of the U.S. Children’s Bureau, gave a speech about her long and frustrating workdays in our nation’s capital trying to advocate for children’s needs. She said she felt all alone standing with her baby carriage on the sidewalk watching a great traffic jam moving toward the Capitol where Congress sits.

She saw all kinds of vehicles including the tanks and trucks the Army put into the street; "the handsome limousines in which the Department of Commerce rides…the barouches in which the Department of State rides with such dignity…[and] the noisy patrols in which the Department of Justice officials sometimes appear." And so she stood on the sidewalk watching, "because the responsibility is mine and I must, I take a very firm hold on the handles of the baby carriage and I wheel it into the traffic."

And so must we parents and grandparents and child care providers and educators grab the handles of our baby strollers and the hand of our children and walk into the traffic headed for Congress. We must make them hear and respond to the urgent, but still too ignored, needs of our 8.1 million uninsured children. We must break through the political den of powerful special interests like the insurance and drug companies with their fleet of well paid lobbyists.

Today, the Children’s Defense Fund is organizing a Champions for Children’s Health Stroller Brigade in the nation’s Capitol to send an urgent and clear message to our political leaders that real health reform for children must be enacted this year. Children’s unmet health needs have been lost in the debate’s "big" issues. Unless we act now, millions of children could be worse, rather than better off, as a result of pending health reform legislation.

Following tomorrow’s action, D.C.'s stroller brigade will extend to Congressional districts across the country on November 5th through 8th where concerned parents, grandparents, faith, and community leaders will tell members of Congress back home to stand up and invest in an affordable, accessible, and comprehensive child health system. So far, stroller brigades are being planned for Arkansas, California, Florida, Louisiana, Minnesota, Mississippi, Montana, New York, North Dakota, Ohio, and Texas.

It is morally and economically indefensible for millions of American children to be denied critically needed health reform in the richest nation on earth claiming it lacks the money to protect its children.

We need to end the bureaucratic barriers that keep two out of three of the more than eight million uninsured children who are already eligible for either the Children’s Health Insurance Program (CHIP) or Medicaid from actually getting the care they need. A simple, seamless enrollment process like older Americans have for Medicare would ensure our children are cared for and covered. We need to guarantee every child access to the full range of preventive and other health care services they need and that we now provide to all children in Medicaid but not to all children in CHIP or in the proposed Exchange. A child covered by CHIP has the same value as a child covered by Medicaid and all deserve comprehensive care regardless of the program they are in. And we need to provide an affordable national health safety net for children whose families make up to 300 percent of the Federal Poverty Level ($66,000 for a family of four) and eliminate the unjust lottery of geography. Whether a child’s family can afford coverage should not depend on where they live. New York covers children up to 400 percent; North Dakota only to 160 percent; and Massachusetts and twenty-one other states, plus the District of Columbia are already at 300 percent. A child in North Dakota is no less valuable than a child in New York or Massachusetts.

The lives and health of millions of children depend on health reform this year. They will not get what they need unless you speak up and demand it. Children have no other voice but yours. Lift it high and loud. Grab your strollers, your scooter, or your walking shoes, and join our children’s brigades today in Washington, D.C. and in other states across the country November 5-8th. In America, every child should have the health care they need – now. They have only one childhood. Together we can make it happen. To learn how to join a stroller brigade, create your own, or take action online in other ways with simple steps, visit www.childrensdefense.org/strollerbrigade.

Many Roads to Divide and Conquer Healthcare

Gillian Hubble — 2009-11-04T06:05:00-08:00

Have you noticed throughout the healthcare reform debate that most everyone seems unable to see the forest for the trees? We get hung up on illegal immigrants, abortion, the disabled, the poor, the pre-existing conditions crowd, the young, the old, the military, the employed, the self-employed, the government-employed, retired union members, small businesses, and large businesses. So much minutia, so little time. What if didn’t have to be like this?

As we know, there’s a plan for everything. Over 65 or disabled? There’s Medicare and perhaps CLASS. In poverty? There’s Medicaid. Slightly over the poverty line? We’ve got an Exchange for you. Eligible child? Try S-CHIP. Employed? Let’s hope your employer offers one of the 1,300 high-cost private health plans. Self-employed or unemployed? Good luck with that, try the Exchange. Got a pre-existing condition? We’ve got a risk pool with a waiting list that you can’t afford anyway. Work for the government? You’re in luck – it’s got the widest selection of health plans available in the US! All this complexity and division puts patients themselves at a decided disadvantage.

Providers like hospitals and physicians actually have to get paid in the middle of this mess, and some of them have figured out how to game the system by exploiting the out-of-network and cash price loopholes. Most just muddle through with a giant administrative staff and aging accounts receivable. Others like Big Pharma and the medical device industry have used it to make a windfall. Most of all, though, the private insurance industry wins. Under all current legislation, they will continue to win. In fact, Republicans just submitted their 8-months-too-late “cost control” plan to completely hand over the healthcare industry to private insurers (fair access and prohibiting recissions are so last year, apparently.)

Meanwhile senators suddenly discover that private insurers don’t actually spend $0.87 per premium dollar on claims, like they’ve said. For individual and small business plans, it can be as low as $0.66. That means fully one-third of members’ premiums are not being spent on their care. Compare that to Medicare’s $0.97 spent per premium dollar; even adjusting for fraud and abuse, it couldn’t come close to the waste of private insurance.

We all know there’s a simple solution to this complexity and cost. It’s called single payer or Medicare for All. It was soundly smacked down at the beginning of this debate, and Kucinich’s state single payer amendment in HR 3962 is still in the balance as of this writing. Maybe just maybe the public that was initially so afraid of the supposed lack of choice (completely ignoring the plentiful supplemental plans that would have been offered in conjunction with it) is now seeing the lack of change AND choice that the current bills represent. We’ve been divided and conquered. Is it time to let Kucinich’s 4-page evolutionary amendment trounce the thousands of pages of House and Senate “survival of the sameness?”

Photo http://farm4.static.flickr.com/3282/2799180151_82e5bf8f72.jpg

Why Do We Need a Public Option Anyway?

Gillian Hubble — 2009-11-03T06:00:00-08:00

Political games are alive and well in Washington, D.C. First the House releases HR 3962, a disappointing bill with an optimistic and completely misleading name – the Affordable Health Care for America Act. Then the GOP decides it’s an opportune time to release its own bill, which House leader John Boehner says will lower cost and expand access by “making the current system work better” with less government intrusion into the private sector. Sounds great John, only, well, there is no system … and that whole government intrusion line? Well, that brings me to my point. Why do we need a public option again?

It seems politicians on both sides of the aisle have lobbyist-induced amnesia on that aspect. Democrats hope including a public option – no matter how weak and ineffective (a more expensive alternative to private plans that covers 2% of the population? Please!) – is all it takes to please the public, even if it’s designed to fail. Meanwhile, Republicans decry government intervention and propose tweaks around the edges of our disastrous healthcare mess that conveniently avoid touching the profit-driven culprits themselves. In other words, the US has heart disease and our D.C. representatives suggest blood transfusions, an artificial knee replacement and a flu shot.

Case in point: the central aspects of the GOP bill are tort reform, insurance pools, and inter-state policy purchases. Two of the three are already in place in many states – they haven’t budged healthcare costs significantly (tort reform achieves 10% reductions in malpractice insurance, per the CBO.) Tort reform is a good idea anyway, but not for cost curve reasons. The third proposal, while useful, doesn’t help much when insurance costs are out of control nationwide.

Douglas Holtz-Eakin, a senior policy adviser to John McCain’s presidential campaign, knows that now. The same man who touted a $5,000 insurance tax credit per family as the answer to our insurance woes now remains unemployed and his $1,000 per month COBRA is running out. He’s shopping the individual insurance market at age 51 and with a pre-existing condition that insurers cite in denying coverage. Think he’s a bit worried? All politicians should be placed in that situation; maybe they would get a clue.

Anyone familiar with T.R. Reid’s body of work on international universal healthcare systems knows that a public option isn’t a part of many of them (gives “socialized medicine” a rather hollow ring, doesn’t it?) There is a single public payer in some (Canada), multiple private insurance payers in others (Germany, Switzerland) and some countries use a combination (England.) What’s the difference then? Very simply, their ‘private insurers’ are non-profit corporations governed by iron-clad regulations: no loopholes, no kickbacks, no lobbyist favors, no profit or surplus beyond required reserves.

Why is that? Insurers are there to provide payment for the care of country residents, with no deliberate and systematized waste and no tricks. Patients are not pawns in a giant profit mill. Now, does this sound like the situation in the US? It seems like the banks and the healthcare industry own Washington, D.C. While Joe Public pays for congressional salaries and benefits (with fantastic health plan choices), lawmakers actually work for Joe Lobbyist. So whatever regulations are placed around the health insurance industry, we can rest assured they will be weak and full of holes by design.

Making sure people are covered and making sure that coverage is affordable are two different things, a distinction neither party has addressed satisfactorily. A strong public option is just one of two methods to keep private insurer prices and practices in line, regulation being the other. But if regulation is to be the answer, we need a representativectomy and a lobbyist exterminator to spray the capital. That seems unlikely. As Nancy Pelosi “mistakenly” left Kucinich’s state single payer amendment out of HR 3962 (as of scheduling this post, it hadn't been reinstated), we can’t vote with our feet by becoming interstate medical refugees. So I’m still pushing for a strong public option.

Photo http://farm3.static.flickr.com/2579/3883236444_edbc207a32.jpg // CC BY 2.0

It's Annual Enrollment Time: Brace Your Wallet

Gillian Hubble — 2009-11-02T05:00:00-08:00

Halloween tricks were a warm-up. While Congress argues partisan, special-interest driven healthcare reform politics these next few weeks, many employees will be faced with a stark reminder of the need for reform. Yes, November is here – annual enrollment time for 60% of insured Americans. It is rapidly becoming known as “spend more, get less” time for group health plan participation.

Now, Joe Lieberman thinks healthcare reform is going too far, that a public option is “just unnecessary” and private health plan premiums will go up. He’s threatening to join a Republican filibuster because of his “concerns.” Uh, Joe? Don’t you dare. Those premiums have already gone up, with medical costs rising three times as fast as inflation. Premiums are skyrocketing with no public option, and AHIP has promised they will continue to do so. So if you filibuster to strip the people of their power, Joe, we will strip you of yours within the Senate.

But back to reality outside the Beltway. Group health plan premiums have risen 131% in the last 10 years, according to the Kaiser Family Foundation. Employee contributions have risen 128%. Since 2006, the percentage of individual insured employees responsible for deductibles of $1,000 or more has more than doubled, from 10 to 22%. Companies still offering health benefits in 2009 downsized them – 86% now offer only one plan. That group ironically includes Blue Cross Blue Shield of Florida, whose 5,000 employees will now be offered only a high-deductible plan. Meanwhile AHIP is decrying government involvement in healthcare due to supposed lack of consumer choice.

For 2010, the picture gets uglier, according to Time.com. PriceWaterhouseCoopers says overall medical costs will rise 9%. Expect 40% of employers to shift even more premium cost to employees, and 39% to increase deductibles, co-payments, co-insurance, and out-of-pocket maximums. In fact more employers are gravitating to catastrophic healthcare policies that carry deductibles of $5,000 to $10,000 (I’ve been subject to two of these plans in the last 4 years.) Smaller employers are dropping coverage all together.

If that doesn't make you feel queasy enough, I have a challenge for you: ask your HR director how much your entire monthly premium is, before your employer's contribution. Then figure out what it would be under COBRA (i.e., if you left the company, willingly or unwillingly) by adding 2%. Let us know in the comments!

A friend of Change.org member Aaron Sidner, who recently found out she will be furloughed with US Air, was dumbfounded to find out her monthly COBRA premium is $1,000. She had been paying $100 per month while employed, just 10% of the total premium cost. Ouch. Of course, the government is still subsidizing 65% of COBRA premiums for those recently laid off. But that's actually you and me paying the bill.

Now for the hardest reality: no reform proposal being negotiated in D.C. changes any aspect of this dire situation. Except for a potential public option becoming available to small businesses, the employer-based insurance market is essentially left alone. Heck, Ron Wyden’s attempt to address it was soundly smacked down … by unions. I still remember Safeway employees picketing in the Bay Area in 2003 because their new contract required them to pay a small amount – for the first time ever – toward their health coverage.

Hopefully preventive care, wellness programs, and pay for performance programs will one day bend the cost curve. A strong public option available to everyone (the ideal Medicare For Everybody concept) could do more to diminish the financial appetites of an insatiable private insurance machine and “pay for quantity” provider juggernaut. But in the meantime, with nothing like that on the horizon, brace your wallet.

http://farm3.static.flickr.com/2305/3666949887_5c5cd45e98.jpg // CC BY 2.0

Understand Healthcare Reform in 2 Easy Steps

Gillian Hubble — 2009-11-01T05:00:00-08:00

If you’re tired of ignorant political sound bites in the healthcare debate, I have the cure. Better yet, it’s virtually free of public and private insurance discussions, with their associated pointed fingers. The film Money-Driven Medicine explores the reasons why the US spends more than twice what the next developed country does on healthcare, with terrible health outcomes. The story is told by in-the-trenches doctors, patients and their family members, a physician healthcare improvement leader, and a medical ethicist. It’s unique, highly educational and fascinating.

Join the Watch-In! for America’s Health now through November 10 for a systemic look at what’s really driving the cost and quality of our healthcare. Find out what’s compelling our healthcare spending, and why tweaking around the edges of our public health disaster won’t change a thing. In a nutshell, our country is unique in turning patients into profit centers.

Why join the Watch-In? Because Money-Driven Medicine:

“help(s) viewers distinguish between structural change and sham reform. It will convince them that a sound, sustainable medical infrastructure is crucial not just to their personal futures but to the economy and society as a whole – why curing America’s healthcare crisis could be a matter of national life and death.”

I couldn’t have said it better myself. Make a pledge to join the Watch-In! for America’s Health today. Of course, if you can stand more discourse on the insurance industry and public versus private insurers and providers, read and watch on.

I made the mistake of watching T.R. Reid’s special, Can We Really Fix U.S. Healthcare?, about his experience exploring international universal healthcare systems, the night before the House revealed its new bill, HR 3962. As a result, I’m feeling a bit underwhelmed by Nancy Pelosi’s hard-fought victory. The LinkTV special is a summary of Reid’s book, The Healing of America, which explores both the how and the why of these healthcare systems. It’s an excellent primer on the 4 main types of healthcare systems, distinguished by who pays for and who provides the care. Watch it and be both entertained and sobered simultaneously, when you consider how far we have to go to even catch a glimpse of the best ones on the horizon.

Reid is also the creator of PBS’ special Sick Around the World, which gives an excellent summary of 5 international universal healthcare systems. No, it’s not just theory: he took his injured shoulder around the world with him, to see how each healthcare system would treat it.

But remember, before you click over to Reid’s insurer-patient-provider view of true developed nations, join the Medicine For Profit Watch-In for a refreshing, insurance-light look at some root problems in American health "care". Thanks to Change.org member CherokeeGirl for Change, who alerted me to both very worthwhile programs.

Photo http://farm4.static.flickr.com/3174/2689975613_187194cdaa.jpg //CC BY 2.0

6 Treats in the New House Health Care Bill

Tim Foley — 2009-10-31T20:38:00-07:00

For a bill introduced during Halloween week, there was very little to shock and alarm us in the new combined House health care bill, HR 3962, the Affordable Health Care for America Act.

As much as progressive reform advocates rejoiced, there was a touch of anticlimax in the mainstream reporting. The only two parts that attracted media attention -- the price tag and the configuration of the public option -- haven’t moved at all from where we left them at the end of July. I know it doesn’t feel that way, in that said news coverage has made the evolution of the bill both seem like seat-of-the-pants, anything-can-happen toss-up on both issues. But we began August with a negotiated rates public option and a price tag just above $1 trillion -- and end with a negotiated rates public option and a price tag just above $1 trillion. From that point of view, ain't nothing new under the sun.

But that’s a deceptive way of looking at the House bill. Look closely and you’ll see some big surprises -- some vast improvements over the previous version, HR 3200, that was passed out of committee this summer. Here are 6 examples that we’re just not talking about enough when evaluating the impact of this bill, were it to pass.

CLASS ACT joins the party -- This is a huge win for advocates for the disabled, and a huge cost-saver for the bill as a whole. Where currently Medicare’s reimbursement incentives all point towards institutionalization, either in a hospital or nursing home, and private insurance often has no provisions for long-term care, the CLASS ACT would create a new, voluntary, publicly run long-term care program that individuals can buy into with payroll reductions. This will allow more and more disabled Americans who can stay in their homes with regular visits from a nurse or aide to do so, and save a lot of money in the process.

Take THAT prescription drugs! -- Pharma has really had an easy time in this season of reform. Few have been taking their name in vain or burned them in effigy. More to the point, we know Sen. Max Baucus and the White House struck a deal with Pharma over the summer to cap their contribution to reform at some $80 billion over 10 years – enough to partially close the Medicare Part D doughnut hole but not to wring even greater savings out of the system. Well, as Speaker Pelosi was fond of saying, the House wasn’t party to that deal -- and the new bill shows it. Not only does it completely eradicate the payment gap for Medicare Part D seniors over 10 years, but it requiring the Secretary of HHS to actually negotiate for the best drug prices in Medicare, rather than allowing Pharma to name its own price. Imagine that!

The House version of IMAC is an old friend -- The White House originated the idea of IMAC, a board of experts similar to the existing Medicare Payment Advisory Committee, tasked with making changes to Medicare to lower costs and improve quality that have the force of law. The goal is to divorce the policy process of continuing to improve and strengthen Medicare from the political process that helps tilt it towards waste. Well why bother creating a new bureaucracy when you have one that already works great? The House bill gives this responsibility to the long-respected Institute of Medicine.

Republicans get one of their top priorities -- To quote Luke Perry in Anchorman after someone has just cut his arm off, “I did not see that coming!” Conservatives have been clamoring to allow individuals to buy policies across state lines to inject more competition into the market. Well, now, they’ll be able to -- State Health Insurance Compacts will allow state exchanges to link up if both states agree to do so. Practically, this means New York could strike a deal with Delaware whereby an individual or small business who's going shopping for insurance in the Health Exchange would have their choice of any New York or any Delaware plan. You wanted it, Republican House members who won’t vote for the bill anyway? You got it!

A better option than a Young Invincible Plan -- Over 38% of adults aged 19 to 24 are uninsured (that number is similar at 32% for those aged 25 to 29). The reasons are obvious -- some are in college, but most are likely to have shaky finances, low-income and/or entry-level jobs which may or may not come with any benefits. They’re called the Young Invincibles, as though their youth and probable health made them arrogantly spurn unaffordable insurance, but many of them are just Young and Broke. The Senate Finance Committee added an unnecessary level of complexity by allowing people in their early 20s -- and only them -- to purchase substandard, catastrophic-only coverage at reduced rates. The House approach is much simpler, and follows what states like Massachusetts have already tried. Those aged 27 would be able to stay on their parents' plans until they can afford comprehensive insurance or get a job with benefits.

The bill reduces the deficit, more than the Senate Finance Committee bill -- Despite its many flaws and giveaways to the insurance industry, we were told that the Baucus bill should rightly be the basis of the combined legislation because a.) it was bipartisan (where bipartisanship = 1 Republican Senator) and b.) it was the only one to reduce the deficit. Well, not so fast, suckah. The Congressional Budget Office scores the House bill as reducing the deficit by $104 billion over the first ten years, netting even more savings than the Baucus bill. Not only that, it continues reducing the deficit in the second ten years. So do me a favor? The next time someone tells you health care reform can only be done by adding to the national debt, please tell them they’re full of crap. There’s not a bill on the table that adds to the debt.

There are plenty more changes in the House bill, nearly all of which are worth a post in and of themselves. Clearly House leadership has taken their time out of the spotlight to dramatically improve a bill that was already the best proposal on the table. The House bill covers more Americans (96% at the last count) than the Senate bill, gives them more affordable insurance, particularly for the middle class, than the Senate bill, and does not fall into the trap of building their cost containment mechanism on a presumption that the cost of insurance would continue to rise.

They could have rested on their laurels and merely shored up their votes, or focused on getting a public option. We’re all better off that they didn’t. Now we need to hope they're up to the task of negotiating -- and prevailing -- over whatever the far more industry-friendly Senate will pass.

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

8 Things You Need to Know About the New House Health Reform Bill

Gillian Hubble — 2009-10-30T06:00:00-07:00

Nancy Pelosi couldn’t have announced the new House healthcare reform bill, the Affordable Health Care for America Act (H.R. 3962), with any more pomp and circumstance. It was certainly more impressive than the Senate’s mouse-like rollout, apparently intended to avoid rubbing salt in the Baucus “bipartisanship” wound. H.R. 3962 is definitely a major milestone in attempting to reform our broken system-less healthcare; it’s historic, certainly. But no, it’s not the best our legislators could do.

To be fair, House Democrats are being predictably attacked for their effort anyway. There’s the usual carefully contrived “It will raise the cost of Americans’ health insurance premiums; it will kill jobs with tax hikes and new mandates; and it will cut senior’s Medicare benefits.” Thank you Republican John Boehner. There’s also a highly amusing senior’s ad running. Check out this two-faced “how dare you cut (read: wring the waste out of) our government-run healthcare – we’re entitled to it! And by gum you young un’s better be scared of a government-run plan” message.

But ignoring all the hyperbole, here’s the good and the bad you need to know in H.R. 3962.

Good

The Numbers: H.R. 3962 will cover 96% of Americans, at a 10-year cost of “under $900 billion.” It will reduce the deficit by $104 billion over the same time period, and reduce Medicare spending growth 1.3% annually by cutting $400 billion primarily from private Medicare Advantage plans. Don’t feel sorry for them, see #2.

Consumer Protections: Guaranteed coverage, limited premium variations, standard minimum benefits packages and employer/individual mandates are all still included. That last one protects people from medical bankruptcy. But best of all, insurers are now required to spend 85% of premium revenue on members’ care. Currently in private Medicare Advantage plans, it’s almost the inverse; only $0.14 of every $1.00 in premiums is spent on members’ care. The bill also closes the “donut hole” in Medicare Part D, reducing senior’s out-of-pocket prescription expenses. Prevention and wellness services will be provided in all plans at no cost.

Selective Taxation: The bill derives revenue from a 5.4% “millionaire’s tax” on individuals making over $500,000 and couples making over $1 million (0.3% of households in the US, to be exact.) It also taxes medical device makers to the tune of $20 billion.

Choice and Potential Competition: A public option will finally give consumers another choice besides private insurance or nothing. The Insurance Exchange where we can compare plans remains intact. The potential for competition seems pretty slim initially though. See Bad #1.

Insurance Anti-trust Exemption: This feature, unique to health insurance and baseball, is now history. Meaning private insurers are no longer immune to regulations concerning price-fixing, big rigging, and market allocation. The Federal Trade Commission also now has full rights to investigate the industry.

Bad

Weak Public Option: H.R. 3962 contains the negotiated rate version of Medicare Part E. It is both more expensive and more of a burden on the states than the Medicare +5% fixed rate version, as it moves 7 million uninsured (those making less than 150% of the poverty level) over to Medicaid, which is a joint federal/state program. That means the states have to pick up about 10% of the tab. It also means much of H.R. 3962’s cost is due to subsidies to help people afford insurance. Worse, CBO expects that this public option will cost consumers slightly more than private plans, so only 6 million are expected to enroll. How did the House allow this to happen?

Delayed Fair Coverage: Yes, the House thought it a great idea to delay fair access for those with pre-existing conditions until 2013. So they are spending big bucks on risk pools until then, which most people can’t afford anyway. John McCain’s really bad idea lives.

No Doc Fix: The $230 billion “doc fix” was stripped out of the bill. That means doctors treating Medicare patients are left in limbo regarding a 21% January fee cut until House members vote on a separate bill.

Stay tuned tomorrow when Tim Foley will dig further into the new House bill changes from H.R. 3200.

Photo http://upload.wikimedia.org/wikipedia/commons/c/c2/Nancy_Pelosi_0009_3.jpg // CC BY 2.0

Army of Women Aims to Eradicate Breast Cancer

Gillian Hubble — 2009-10-29T06:00:00-07:00

Perhaps you haven’t heard of the Army of Women. The name may strike fear into the hearts of some men, and indeed these women are on the warpath. But their object of destruction isn’t the opposite gender; in fact this group actually includes men within its ranks too. Confused? Let me explain. The Army of Women aims to eradicate breast cancer by changing the face of breast cancer research. In fitting celebration of Breast Cancer Awareness Month (though football players wearing pink is nice too), this group dedicates itself to two revolutionary principles:

Representing ALL women in studies so results apply to all women, and

Studying prevention techniques in addition to treatments.

Yes, those are ambitious goals. To meet them, the Army of Women’s current target is to reach 1 million men and women. This joint partnership between the Dr. Susan Love Research Foundation and the Avon Foundation for Women encourages both healthy people and those already touched by the disease to join ranks and spread the word.

What are they looking for? Women of every age, ethnicity, and breast cancer risk, as well as male breast cancer survivors who want the life-changing opportunity to directly impact breast cancer research. This non-profit venture allows you to partner with scientists and participate in research studies, so you can help determine how breast cancer starts and how to stop it for good.

Better even than early detection, prevention is key. As our Change.org community is well aware, fighting a severe medical issue is just the beginning -- fighting the US "profits over care" system is the 10,000 pound gorilla in the room. The harsh dose of reality in the video below, courtsey of non-profit Talking Eyes Media, follows Sheila Wessenberg through her uniquely American breast cancer journey. It manages to expose just about every fallacy the enemies of reform like to spread, from supposed safety nets to the horrors of socialized medicine. Be sure to watch the whole thing, the punch line is near the end.

Join the Army of Women against breast cancer today, and spread the word. Your physical and financial health, as well as that of your sister, mother, daughter, or granddaughter may depend on it. Take action to prevent and effectively treat breast cancer.

Photo http://farm4.static.flickr.com/3223/2929895042_cc70ea63e1.jpg // CC BY 2.0

The Red Flags on Taxing "Cadillac" Insurance Plans

Tim Foley — 2009-10-28T10:42:00-07:00

There are some relatively popular things I just don't get. The NHL, for example. Jon & Kate Plus 8, for another. But I've been somewhat surprised with the extent to which many wonkish bloggers I enjoy reading have embraced the Senate bill's method of paying for a chunk of reform through an excise tax on so-called "Cadillac" insurance plans -- an idea that I've repeatedly called "lame." Less surprising but still fretful to me is the White House's embrace of the idea, with economic advisor Christina Roemer yesterday calling it, "probably the number one item that health economists across the ideological spectrum believe is likely to stem the explosion of health-care costs."

Will the insurance plan tax raise money for reform? No question. Will it stem costs? Well, I've got some red flags on that which I haven't seen adequately explained.

Now the forebear of this policy idea did made a lot of sense. Currently, employers don't pay taxes on health benefits like they do on salary for their employees -- a historical accident left over from WWII that fosters our dependence on employer-based insurance, with its inefficiencies and drag on our wages. The original idea was to remove some or all of this exemption and use the money to help pay for subsidies for people buying insurance through the Health Exchange -- not a bad trade-off when combined with an employer mandate to get companies to think twice before just dumping their employee benefits because they had to pay taxes on them. When that idea proved politically unpopular, Sen. Max Baucus suggested maybe they'd only remove the exemption for plans whose dollar value is well above the average -- hence, "Cadillac" because they're more expensive.

When that idea, too, proved unpopular, the senators hit upon the idea of taxing insurance companies. It sounds great (yes! Tax those greedy insurers!), but the intent is the same. If your company's benefits plan for an individual costs $9,000 (the national average is $4,500), then the portion above the threshold of $8,000 would be taxed at 40% -- your insurance company would get hit with a $400 tax on your plan. Of course, they're just going to pass that tax on to their customer -- your boss. Your company then has to decide a.) if they make you pay for that out of your employee contribution, b.) they just pay for it themselves, or c.) they go shopping for a cheaper plan that covers less. Those predicting cost control are betting on Option C winning more often than not. (By the way, the Senate Finance bill ultimately lacked the employer mandate to prevent dumping as well, which created a whole host of other problems, but that's for another day.)

Let me first mention the problem you hear the most: just because you have a "Cadillac" plan doesn't mean you have the money to buy a Cadillac car. For decades, unionized workers have negotiated for better health care benefits, particularly as a concession when their employers were intractable on raising salaries. Similarly, the excise tax does not take into account areas that are already high-cost on insurance plans. Combine those two factors and you have a lot of middle-class people whose insurance plans are about to be taxed. That's a big political problem.

But I'm not loving the policy implications either. Because we haven't done anything to change the fact that the decision-maker on for most benefits plans is still the employer, and the decision-maker on what to do about the extra cost is also the employer, I'm unconvinced that we'll see that many employers do the cost benefits analysis and arrive at Option C. For one thing, we know that employers already don't optimize their health insurance choices. Changing the benefits of their employees, with disruptions like having to adjust to a new network of doctors, is more likely to elicit howls of employee protests than increased costs, even where the new plan is not only cheaper but better. In California particularly, Kaiser Permante's more efficient model for delivery of care yield better health outcomes and lower prices on average -- the only insurer in the Bay Area who can give you a lower premium at comparable health outcomes is (natch) the government-run Healthy San Francisco. But, as Kaiser CEO Jon Kingsdale explained yesterday, they're not mopping up the floor with the competition:

The price differences are not translated to the consumer. They go to the company. What is the typical HR officer's decision hierarchy? They have benefits that make most workers happy. The worst thing they could do is introduce a change that make 2 to 5 percent of the workers unhappy. The worst thing you can do in this market is bring change. But what kind of market is that?

Here's another way to look at it: health insurance is already on the rise an average of 9% per year in the private sector. It's why more and more companies drop their non-Cadillac benefits or increase their employees' contributions. Say you own a company that offer a $10,000 benefits plan which is $2,000 above the Cadillac threshold. The tax that your insurance company will pass on to you is an 8% increase. That's suddenly going to trigger your cost-controlling impulse in a way that it hasn't been triggered already?

For some companies, sure. For most, of course not. In fact, the Congressional Budget Office and the Joint Commission on Taxation were counting on not much changing when they calculated this excise tax would generate $201 billion in revenue. In order to net that much, then employers would have to not be choosing Option C in large numbers. The biggest red flag on the excise tax as cost control is that the CBO estimates the revenue would go up every year (pg. 15), from $10 billion in 2013 to $46 billion in 2019. How do you get that dramatic revenue increase and subsequent deficit-fighting superpower? Because more and more benefits plans hit that Cadillac threshold each year.

Revenue generation? Sure. Cost-control? Much like a TLC Marathon of the greatest hits of the Gosselin family, I can't get that excited about it.

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

Triggers, Politics and Party Tricks

Gillian Hubble — 2009-10-28T06:00:00-07:00

A public option “trigger” has received a lot of attention lately. Thankfully Harry Reid bypassed it for an opt-out solution instead, because it’s a proven Really Bad Idea. Since the Wonk Room's Igor Volsky thinks it's a fabulous idea to combine an opt-out public option with a trigger, let's put this one to bed once and for all. Following is a quick lesson in political science, so you can recognize this underhanded trick when you see it in future.

Consider: the intent of a trigger is to activate a remedy (a public option) in the event that certain conditions aren’t met by existing forces (private insurers.) Now, we wouldn’t be considering healthcare reform unless there were already significant, long-standing problems in virtually every aspect of our system-less healthcare. That includes $850 billion of waste every year, almost enough to pay for 10 years of reformed healthcare. The insurance reform gun has already fired. So why design a trigger to potentially address this urgent issue sometime in the distant future when things are even worse, perhaps catastrophically so?

The short answer is that doing nothing is the politically safe route. It’s a proven way to get re-elected by not rocking the boat. Olympia Snowe knows that, and probably hoped a trigger would allow her to claim she voted for a public option (what her constituents want) and at the same time kill it (what most Republicans want.) Under the trigger, a public plan would be created only if private insurers didn’t make “meaningful, affordable” coverage available to all Americans within “several years.” Believe it or not, none of these terms has been defined. So what would trigger a public option? You guessed it – nothing.

Experts have already determined that reform is no cure for 75 years of insurer discrimination. They will still try to cherry-pick by offering certain benefits or advertising campaigns that appeal to the young and healthy. Take Anthem Blue Cross’ website for its Tonik plans: “You're young. You're healthy. You're in shape." Insurers lure healthy seniors by throwing in cheap benefits like health club memberships while requiring members to pay more for expensive chemotherapy drugs, dialysis and long-term care than they would on core Medicare. This type of discrimination will intensify under reform and premiums will skyrocket if there's a threat of a trigger. Yet the trigger delays a remedy.

We’ve seen what didn’t happen with the Medicare physician payments trigger, the Medicare Part D trigger, and the HIPAA individual plan trigger. As Yale Health Policy Professor Jacob Hacker explains, that’s by design, or more specifically lack thereof. A workable trigger needs to accomplish three things:

Establish measurable standards for performance for a specific benefits package,

Assess the standard in a very timely fashion, and

If not met, quickly create a remedy (in this case, a public option.)

We’ve already noted that #1 and #2 aren’t defined for a public option trigger. In fact premium inflation, especially in local markets, and total out-of-pocket costs aren’t even considered. Now, let’s examine #3 – “quickly.” Has the reform process been quick so far? Nope. Will it be quick once the political cast of characters and political conditions change, to focus on other matters of national and special interest importance? Nope. Who would make the decision to pull the trigger? That’s to be determined. How would this public option work? The Senate hasn't completely thought it out. How fast could it be set up? We would potentially find out at some undefined point in the future.

Are you getting the picture? A trigger is more like a kill-switch; it kills the desired change now by promising to fix it in the future. Sorry, more passing of the political buck won’t work. The public needs a public option now, and Reid delivered in the Senate. Volsky would go one step further, by making the opt-out dependent on a trigger -- in other words, states would never get to opt out of the public plan. Sorry, Olympia Snowe, you've been found out.

Photo http://farm3.static.flickr.com/2022/2409976725_f2277403ac.jpg // CC BY 2.0

Pay For Performance: Why You Should Care (Part 3 of 3)

Gillian Hubble — 2009-10-27T06:00:00-07:00

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.

In January, Blue Cross Blue Shield of Massachusetts began offering a voluntary Alternative Quality Contract (AQC) payment model to providers. As of August, 25% of its contracted doctors (or 2,300 doctors caring for 210,000 patients) had signed up for this global payment strategy, which includes a variety of services related to all care for a particular patient. It includes a 10% P4P bonus for meeting quality standards (sorry, no patient incentive payments to use these providers, like in Medicare's pilot hospital program.) Although global payments bear a strong resemblance to HMO capitation of old, this all-inclusive buffet strategy focuses on supporting coordinated care and quality outcomes versus care rationing -- they are calling it payment "bundling."

For instance, Tenet Healthcare (see Part 1) would receive a global payment for a diabetic patient and would be responsible for coordinating all the care that patient needs throughout the healthcare continuum. Reimbursement is also risk-adjusted, meaning caring for more complex (older or sicker) patients brings higher payments. That's good, because we don't want doctors and hospitals dumping our sick and aging in the name of financial survival.

Bonus payments are distributed for meeting process, outcome, and patient experience quality standards. Take diabetes, for instance. Bonus money would depend on performing eye, kidney, and blood sugar testing; keeping a marker of long-term blood sugar control within bounds; and providing good coordination of and access to care. So what providers have signed up for AQC? Those that already manage cost and quality well, or want to but also want to get paid for it. Blue Cross is also encouraging more providers to follow suit with veiled threats of declining fee-for-service reimbursement (didn’t see that coming, did you?)

Now the Massachusetts legislature is considering a 5-year timeline to get ALL providers on quality-based reimbursement. None of this should be new and outlandish to healthcare insiders, right? Guess again. Cue the healthcare executive histrionics: "irresponsible, sophomoric, unrealistic, compromised patient care, it could kill the industry ..." You get the picture. They have requested a flurry of closed-door meetings with government powers-that-be, asking for delays. You see, they feel the changes should happen gradually, voluntarily at first, with pilot programs that incentivize providers to adopt the new payment system.

Did you GET the memo, folks? After Vermont’s Blueprint program, early adopter Tenet, Blue Cross Blue Shield’s voluntary AQC program, CMS’ pilot quality programs, and nearly 20 years of routinely collecting quality data (see Parts 1 and 2), this should be old hat. Right? Well, not exactly. There are some significant challenges in making the switch to P4P, and the reaction in Massachusetts is a preview of national knee-jerks to come. Did I mention healthcare is resistant to change?

However, the dug-in heels apparently aren’t well-educated on P4P. For instance, in the BCBS program, 59% of the ambulatory (outpatient) quality criteria are process-based (did you do it?) while only 16% are based on outcomes (did the care benefit the patient?) and 25% on patient experience (did you provide accessible, coordinated, understandable care?) Similarly, for hospital measures 63% are process-based, 25% are based on outcomes, and 12% evaluate patient experience. So the majority of bonus criteria is based on dotting "i"s and crossing "t"s. If providers have been paying attention to their quality metrics over the last 20 years, none of that should be threatening. Granted, there are also long-standing cultural, process, payment inequity, and, of course, patient compliance issues.

So there is and will continue to be lots of noise around P4P. Mostly it will sound like “Whoa, slow down there. Let’s not rush this!” But realize that it doesn’t matter what the change is; with rare exceptions (thank you, Mad As Hell Doctors) healthcare stakeholders resist it. Gradual, voluntary measures – as we’ve just seen in this series of posts – don’t get us there.

What can we do about it? Stay tuned next time to find out more about challenges in the P4P revolution, and what you can do to promote the spread of P4P.

Photo dcJohn // CC BY 2.0

5 Flavors of Public Option

Gillian Hubble — 2009-10-26T06:00:00-07:00

This week will reveal the frustrations of a representative democracy more than any in recent history. It’s too much to expect our Congressional representatives to vote based on what a majority of their constituents want, a public option that is cost-effective and covers most of the population. Between partisan politics and the measurable effect of even small amounts of insurance lobby money, constituents seemingly can’t make their voices heard. So Congress will be presented with 5 flavors of ice cream from which to choose. Here are the public option flavors of the week, and if you need a little musical flair to get you excited about them, we’ve got that too.

First, from the Billionaires for Wealthcare, who crashed the AHIP annual meeting in Washington, D.C., last week, here is “The Public Option” sung in show tunes:

Now that you’re in the public option mood, here are your flavor choices:

House: Medicare Part E
Under any of the options below, the House bill covers 96-97% of Americans, includes a generous $700 billion subsidy package to help people afford insurance, expands Medicaid, and includes an employer mandate. As far as we know it still includes funds for the “doc fix” so physician Medicare payments aren’t reduced by 21% next year. Bill funding is designed to come from taxing incomes over $500,000. Whichever option is selected will be revealed soon, as Nancy Pelosi intends to release the House bill this week and hopefully hold a floor vote next week. She’s efficient!

Medicare +5%: Pelosi’s favorite, this is the most robust public option under consideration and considered the most ambitious, though it would cost the least. As it stands, it would pay physicians Medicare rates +5% and hospitals base Medicare rates. CBO estimates it would cost $871 billion and be deficit-neutral over 10 years.

Medicare Negotiated Rate: Same concept as #1, except it would negotiate rates with providers instead of having them tied to an existing benchmark. Pelosi considers this option likely to get more votes, and as she caucused on Friday with a “live whip”, requiring each Representative to voice their level of support for each option, she should know. Sorry, no cost estimates on this one, but it would shift more cost burden to the states by raising Medicaid eligibility from 133% to 150% of the poverty rate.

Medicare Trigger: This option would, as the name implies, only kick in if private insurers weren’t meeting pre-determined metrics after a prescribed period of time. It is pretty much dead, as Pelosi is putting together a far bolder package than Harry Reid and company in the Senate.

Senate: Public Lite
As it currently stands, the Senate bill costs approximately $829 billion, covers 94% of Americans, includes a $450 billion subsidy package to help people afford insurance, expands Medicaid, and does not include an employer mandate. There are no funds for a “doc fix” – this provision was included in a stand-alone bill and defeated. Bill funding is designed to come from taxing family healthcare benefits over $21,000.

State Opt-Out: Chuck Shumer’s baby, it’s the “I’m not government-run” public option. A non-profit board would be established and given federal seed money. All states would initially participate in this more affordable insurance option, and would be given the opportunity to opt out in 1-3 years. In a nutshell, this is the Giant Co-op model, trying to establish a new Blue Cross Blue Shield-type insurer answerable to the government.

Trigger: Olympia Snowe’s proposal surprisingly found its way into bill merger discussions. Surprisingly, because she seems to be the only one who supports it. Like the Medicare Trigger option, it is designed to kick in at some point in the future if conditions aren’t met. History has shown that healthcare triggers are destined to fail, including ones in HIPAA individual plans (federal government couldn’t determine that state approaches failed), and Medicare physician payments (set up an annual political battle with no solution.) If you are thinking that this is the “No Public Option” option, you’re right. That’s despite 70% of Snowe’s constituents supporting a public option.

So there you have it, 5 flavors of ice cream. They can be summed up as Mocha (bold and rich), Coffee (bold), Coffee Tofutti (bold but not real), Vanilla Ice Milk (little flavor with sharp ice crystals), and Ice Cream IOU (a worthless piece of paper.)

Photo david.nikonvscanon // CC BY 2.0

What Happened to the Healthy Americans Act?

Gillian Hubble — 2009-10-25T09:00:00-07:00

Watching the Senate difficulties this week – failing to work around fancy math, having to dump fair physician payments as a result, and trying to substitute an ineffective opt-out public option for even more impotentco-ops – it makes you wonder about Wyden-Bennett. Remember S. 391, aka the Healthy Americans Act? It was billed as market-provided “single payer”, supposedly had bipartisan support, and was universally recognized as superior to the Baucus bill. And we’ve heard … nothing. Why ignore HAA (much more personal than a number, no?), a bill with much higher credibility and without a pesky public option at all? The answer turns out to be two-fold.

First though, let’s review what it had going for it. Back in August, HAA had 5 republicans and 7 democrats publicly backing it in an op-ed, including Mary Landrieu and Joe Lieberman (both none too keen on a public option.) However, three of its co-sponsors, Maria Cantwell, Jeff Merkley, and Arlen Specter, were remarkably quiet. It seems they didn’t want to step on any White House dictates, and Baucus’ process was one of them. Still, the bill was truly a bipartisan feat: it incorporated universal coverage in free-market exchanges designed to empower consumers to shop for the best value.

CBO scored HAA as revenue-neutral, the holy grail of healthcare coverage. Further, it empowered consumers to seek out the best healthcare value in a larger pool of Americans that meant better risk spread. And the basic plan was to be equivalent to the Federal Employee Health Benefits Program. Not bad! Even better, premiums could only vary based on geography and smoking status. No age or health status discrimination, period.

But on to the bad news …

1. Real Change
The keystone of HAA was to dismantle the long-standing employer insurance market. Its provisions called for transitioning everyone into state-based insurance exchanges. Basically your employer would give you the money it would have spent on your health plan, and you would in turn use it to purchase portable individual coverage on the exchange, taking a tax deduction at the end of the year. Your employer would be taxed between 3-26% of the national average premium for basic benefits. No more employer-based insurance, and tax employers? Now that’s different. Too different, as it turned out.

Unions ran advertisements denouncing it, because it would change the insurance almost everyone had, whether they liked it or not. Senator Lindsay Graham admitted that some of the “support” for HAA was for political cover, to counteract the Party of No accusations. When push came to shove, these folks would run for cover elsewhere. Obama called it a “radical restructuring” that would encounter “significant political resistance.” Tim Foley himself forecasted HAA’s downfall for this very reason back in January. Political resistance was so high that no one would even consider Wyden’s Free Choice Amendment on the Senate Finance Committee bill, which would have added some of HAA’s best features.

2. Demand-Side Economics
Fortunately there’s also a more logical reason to pass over HAA. A true single payer system controls costs by imposing a budget. HAA would control costs by reducing patients’ incentives and ability to buy benefits. You see, taxpayers’ standard health insurance tax deduction would only increase with inflation. As we know, healthcare costs have increased far faster than inflation. So individuals would progressively have less buying power and would therefore secure less comprehensive coverage. Basically, instead of providers having incentives to offer less care, patients have incentives and ability to buy less care.

Also, as everyone would be moved into a state-based individual market, it puts individuals at the mercy of private insurers and their rate-setting ways. There is no group bargaining process, as with employer-based care. So if HAA limits insurers’ ability to vary rates to only geographic and smoking differences, they are incentivized to raise everyone’s rates. Plus there is still the “divide and conquer” issue of 50 different patient populations pitted against a handful of large insurers. While cost controls are good, cost controls that don’t include insurers are misguided.

So yes, HAA is better than what Baucus proposed. It will probably be better than what the Committee of Three propose too. But it won’t be extracted from the wastebasket any time soon.

Photo pirateyjoe // CC BY 2.0

Meet Medicare Part E

Gillian Hubble — 2009-10-23T06:00:00-07:00

How much time-consuming bluster did it take to get to this simple and obvious option? Open up Medicare to everybody, like Ted Kennedy originally proposed in the Senate HELP bill. Part E does stand for “Everybody.” While it’s only one of the three public options being considered by the House, it’s the strongest. Keith Olbermann gives us a great introduction to the concept in the video clip above. Meet Medicare Part E.

First, some caveats. This proposal wouldn’t cover everybody exactly. It would, according to HR 3200 as currently written, only be available to the currently uninsured and the smallest businesses during the first year. In subsequent years it would open up to larger and larger employers. This is not robust coverage in the accessibility sense. “If you like what you have, you can keep it” still really means “If you don’t like what you have, tough.” But Medicare Part E is better than any other public option under consideration (state-based opt-outs, anyone?)

According to Jeff Goldsmith, leveraging Medicare solves numerous reform problems: speed to results, reducing disruption to markets, affordability, and bending the Medicare cost curve downwards when boomers flood the program over the next decade. Why the last one? Because a 2007 study showed that uninsured people with previous chronic conditions who enroll in Medicare have higher medical costs as long as seven years after enrollment. Basically, early Medicare is proactive Medicare.

All right, so what’s the low-down on Medicare Part E? It’s cost-effective, covering the balance of 97% of Americans for under $9 billion, and it is deficit neutral over 10 years. It’s Medicare – the program that seniors are so vigorously defending against the Sarah Palins of the world. Physician reimbursement would be tied to Medicare rates, so Nancy Pelosi had better address the “doctor fix”, as the Senate failed. Physician support will depend on it. But with reassuring Medicare Part E on the table instead of a terrifyingly fuzzy public option, I look forward to next month’s poll gauging public support. Especially with videos like the one from Healthcare For America Now, below, from their protest outside AHIP's annual meeting in D.C.

Public Option Popularity in Limbo

Gillian Hubble — 2009-10-22T06:00:00-07:00

Consider this a watch list update. Things are looking rosy for a public option right now. The majority of Americans support it, up to 57% from 52% two months ago. Bipartisanship is no longer in vogue, with 51% preferring a public option to a bipartisan one. Nancy Pelosi is rumored to be inserting a strong public option in the House bill, one that may be cheaper and cover more people than the combined Senate bill. Even Harry Reid is considering including “public option lite” in the Senate bill, with a state opt-out clause. So why all the talk about the public option being in limbo, of looking for alternative ways to try and keep private insurers in check?

You would think that the House considering rebranding the public option as “Medicare” (Ted Kennedy is smiling) would be a great sign. But there’s dissention underneath the momentum. Digging a little deeper into the Washington Post/ABC News poll above reveals public dissatisfaction with overall reform provisions: 45% support them, while 48% oppose them. So while support for a robust public option is high, people are lukewarm about reform proposals as a whole. This attitude is mirrored in Congress.

The focus on cost has produced one victim already from our watch list: S. 1776, the Medicare Sustainable Growth Rate (SGR) fix. It proposed to fix the perennial moratorium on SGR. Originally intended to align physician fee growth with GDP growth, it would typically slice physician Medicare compensation. By providing no way to fund the $247 billion cost of S. 1776 and falling short of 60 votes (53-47), the Senate is guaranteeing that physician Medicare fees will be cut by 21% starting January 1. Fortunately as far as we know a fix is still included (and funded) in the House bill.

Because physicians, like patients, should win overall with reform. Pelosi will be counting the necessary 218 House votes to include a public option linked to Medicare rates (Medicare +5%) and she understands that physician participation in that public option is in the balance. We can’t have enrolled patients without doctors willing to treat them. This provision actually addresses those who don’t have political clout but provide the majority of care. Currently politically-controlled regional differences in Medicare rates mostly help bigger healthcare providers like hospitals, not the little guy.

The House seems to have everything just about wrapped up. But the Senate “Committee of Three” continues to negotiate a contentious combined bill that is taking increased heat from AARP and other groups for not making insurance affordable (meanwhile AARP is also campaigning for the SGR fix.) This could take a while. Meanwhile the enemies of reform are kicking into gear. Let’s not pretend that any bill will be perfect. We have plenty of different voices in our Change.org community that confirm that. But this opportunity for change won’t present itself again for a long time.

Have you heard of the “Delay, Define, Derail” campaign, courtesy of Rick Scott’s employee, insurance lobbyist Brian McManus? This strategy amounts to demanding a slow-down in the legislative process (um, this has been quick?) so a clear message can be developed to present whatever plan emerges as a combination of Medicare cuts, tax increases, higher insurance premiums and rising costs.

Funny, since the first is necessary just to keep Medicare operative under steep healthcare inflation. The second ignores our current indirect healthcare tax burden (wage stagnation or unemployment, benefits reduction, and paying more for less – if any – coverage.) And the last two have been accelerating unchecked for over 20 years. But with a coordinated messaging campaign, many people might buy it. With CEOs from all of the major private insurers meeting this week for the AHIP conference in D.C., they’ll certainly be putting their heads together.

So what’s the alternative to a public option? The most popular idea to try and rein private insurers in is the MLR – Medical Loss Ratio. This is supposed to be the amount that insurers pay in claims relative to total premium revenue. But it’s easily manipulated, as New York and Wendell Potter can attest. We’ve already tried tinkering around the edges, mostly with group plans. There’s the 12-18 month pre-existing condition exclusions, ERISA, COBRA, HIPAA plans … each time insurers wiggle around them by – you guessed it – raising premiums. Want to provide fair coverage for individuals? Guess what – more raised premiums.

Bottom line: the more time individual groups have to identify elements they dislike in bills containing a public option, and the more financial magic tricks in those bills, the less likely they are to pass. Who wins? No, not the non-Maine GOP. Private insurers do, because a large captive audience is safely within their profitable grasp. In contrast, Pelosi’s House bill saves money, covers more people AND includes providers as beneficiaries of reform. Pass it on.

Photo wolfsavard // CC BY 2.0

"Doc Fix" Shows (AGAIN) Why the House's Health Reform Bill Is Better Than the Senate's

Tim Foley — 2009-10-21T11:03:00-07:00

The last House committee to work on comprehensive health reform finished at the end of July. The last Senate committee (Sen. Max Baucus's Senate Finance Committee) finished last week. But the House has not been idle. News comes today that an initial score from the Congressional Budget Office says the House has refined its bill to only cost $871 billion over 10 years. Of course that is likely to get overshadowed by the train wreck in the Senate concerning Medicare's "Doc Fix." So many commentators are focused on the political clumsiness of pushing a separate bill in the Senate to fix the Medicare Sustainable Growth Rate (SGR) that they may miss what this Three Stooges-esque vignette tells us about the policy strength of these House and Senate bills.

Simply put, the House has its act together. The Senate's got a lot of work to do.

The SGR was an attempt to curb skyrocketing costs in Medicare which has not only failed, it's become the second-worst accounting trick in the federal budget over the past decade (the worst being leaving the costs of the wars in Iraq and Afghanistan out of the budget every year of the Bush Administration so the deficit wouldn't look so big.) A brainchild of the Gingrich Congress and an amendment to the 1997 Balanced Budget Act, the SGR is a formula intended to prevent physician compensation for Medicare from rising above the rate of growth in GDP each year. If physician fees were threatening to go higher, all doctors' fees across the board in Medicare would be cut to keep them within that limit. Not inherently a bad idea, but it has a huge flaw -- in most years, medical costs rise at several times the rate of growth in GDP whether you're talking public coverage or private insurance. The net result is that SGR would guarantee a major cut to Medicare nearly every year, at least until we get an explosive economic growth like we had in the 1990s. And we're not talking obvious waste like Medicare Advantage subsidies for HMOs or those motorized scooters you see in ads on cable TV -- we're talking doctors' fees. You know, the whole point of having health coverage.

So every year, Congress passes a one-year moratorium on the SGR. Every year, all Democrats in the Senate vote for it. Every year, almost all Republicans vote against the moratorium and for the cuts to take place (including every single one of the conservatives who are making "how dare we cut Medicare in any way, shape or form!" their rallying cry for defeating reform. Gotta love that blatant disregard for consistency.) Every year, doctors' fees in Medicare continue to rise at roughly the same "way, way over inflation" rate they do for private insurance, meaning if the cuts took place this year, it'd yield a 21% cut across the board. But every year, the cut never actually happens. It's like a bad sitcom whose punchline you can see coming from miles away. It's absurd. And it needs to be fixed.

Enter health care reform -- an obvious spot to fix it.

The House bill (HR 3200) does just that. It wipes the slate clean on the SGR, and establishes a new system based on medical inflation (a much saner system -- honestly, Medicare physician fees shouldn't be rising faster than physician fees for private insurance, and generally they haven't). The cost of that fix is about $245 billion, and it was factored into the House bill's original budget of $1 trillion. We haven't seen the details from the CBO, but presumably the so-called "Doc Fix" for Medicare is still in there. But for stepping up and being fiscally responsible, the House bill got mercilessly pummeled throughout the summer. Speaker Pelosi wanted the surplus from another bill (which came to about +$261 billion) to be applied to HR 3200. The CBO didn't want to play it that way, and their formal score said that HR 3200 would add $245 billion to the deficit. That led to a Wild Rumpus where conservatives inveighed against the House bill, including some commenters on this blog, for adding to the deficit -- even though the net result of the two bills would actually be a small surplus. (By the way, I'm not holding my breath for those same folks to embrace the revised House bill now that the CBO says it fixes SGR and reduces the deficit.)

Sadly, the Senate Finance Committee bill, which will be the basis of the Senate bill for all things Medicare, does not fix SGR. All it does is put the same old "stupid accounting trick" of a one year moratorium on it, and then budgets for it to take effect every year thereafter. Which, of course, it won't. But that means the $829 billion total for the Finance bill is also fudged. When Sen. Debbie Stabenow of Michigan proposed S. 1776, a standalone bill that would permanently fix SGR in much the same way that the House bill would, at a similar $247 billion price tag, and Majority Leader Harry Reid fast-tracked it to be considered this week, you couldn't help but notice that they included absolutely no way to pay for it. That's the main reason why this bill seems doomed to failure, since moderate Democrats, including the always peripatetic Kent Conrad, are livid at the thought of more deficit spending, particularly on health care. But even Kent Conrad knows this cut will never take place. It's a political fight over an imaginary number, rather than stepping up and finding a way to fix the problem. Of course, as part of a Senate bill that includes a convoluted "free rider" provision instead of a useful employer mandate, a feeble "co-op" provision instead of a cost-saving public option, fewer subsidies for families to buy insurance, weaker benefits packages, etc. etc.

In summary, when faced with the choice of an $755 billion bill that used the same accounting tricks to hide SGR or a $1 trillion bill that would actually fix the problem, the House bill stepped up to fix the problem, even if it meant getting pummeled. When faced with an $829 billion bill with an accounting trick or a $1.1 trillion bill that would actually fix the problem, the Senate tried to have their accounting trick and eat it too by trying -- and likely failing -- to ram home a standalone bill that undermined their credibility on fiscal responsibility. Once again, we have Senators more concerned with solving the political problems of the United States Senate than solving the real health care problems of the United States.

Riddle me this. Supporters and detractors of the House bill like to refer to it as being "more liberal" than the Senate. When did we change the definition of "liberal" to mean "actually works?"

Update: 4:08 pm ET -- S. 1776 failed to achieve its cloture vote in the Senate, 47-53, meaning the bill won't go forward.

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