Posts by Timothy Foley
-
Does the New Senate Health Care Bill Get the Job Done?, Conclusion
-
Does the New Senate Health Care Bill Get the Job Done?, Pt 2
-
Does the New Senate Health Care Bill Get the Job Done?, Pt 1
The Dirty Little Secret of Health Care Cost Control
Published November 11, 2009 @ 02:12PM PT
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)
The Senators -- and the Yankees -- Need to Get On With It
Published November 06, 2009 @ 07:03PM PT
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.
6 Treats in the New House Health Care Bill
Published October 31, 2009 @ 08:38PM PT
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 Red Flags on Taxing "Cadillac" Insurance Plans
Published October 28, 2009 @ 10:42AM PT
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.
"Doc Fix" Shows (AGAIN) Why the House's Health Reform Bill Is Better Than the Senate's
Published October 21, 2009 @ 11:03AM PT
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.
Insurance Companies Are Cutting Their OWN Benefits: The Best of the Weekend
Published October 04, 2009 @ 10:10PM PT
Every weekend, I present the three articles or videos that best enhanced my own understanding of the myriad issues wrapped up in our national health care debate. All three selections this weekend made the list for one simple reason: much like the Spanish Inquisition, I don’t think anyone ever expected stories like these!
1.) Bloomberg, “WellPoint Cuts its Own Health Benefits as Recession Trims Sales”
In Will Ferrell’s celebrity-studded and satirical public service announcement, “Protect Insurance Companies,” actor Jon Hamme pointed out that health insurance companies needed to make millions and billions in profits... to pay for health insurance for their employees. Well, it turns out that’s not a joke. Given that WellPoint has also been at the forefront of creating “astroturf” consumer-friendly Web sites, ad campaigns and push polls to activate its customer base against health care reform, one could be forgiven for thinking this is but poetic justice.
The company will also raise deductibles and premiums for some of its employee health benefits, the Indianapolis-based insurer told workers in a memo today obtained by Bloomberg.
WellPoint, like its competitors, has seen health plan enrollment shrink this year as employers cut jobs and benefits amid the recession… In the memo from Randy Brown, WellPoint’s chief human resources officer, the company said it would lower its contribution toward worker premiums and raise deductibles in two of its three benefit plans. “Your cost per paycheck will probably increase,” the memo said. WellPoint has 42,000 employees.
(By the way, in case you’re wondering what the heck the picture on this post is, it’s a “Medical Data Loss Dress,” designed to incorporate private medical data that WellPoint carelessly left unsecured on its Web site for 13 months. Good times.)
Read the full article on Bloomberg’s Web site.
2.) Swampland, “Bill Frist on Health Bill: I'd Vote For It”
So let me get this straight. Former Senate Majority Leaders for the G.O.P. Bob Dole and Howard Baker not only have spoken in favor of health care reform (and endorsed a plan through the Bipartisan Policy Center that closely tracks the proposals in Congress), but now Bill Frist has, too? This would be the same Bill Frist who was not only one of the Republican Congressional leaders for years, but also was a heart and lung transplant surgeon? The one whose conservative credentials are so rock-solid he nearly ran for president last year? That Bill Frist?
And yet we’re thinking the chances of a Republican not from Maine voting for this same reform bill is between slim and none?
OK, just checking.
However, he strongly supports other aspects of the bill--most notably, its requirement that individuals be required to purchase coverage, if they do not receive health insurance through their employers or under government programs. And he also lauds the provisions that would eliminate practices that allow insurance companies to discriminate against people based on their health history, including pre-existing conditions.
Frist also faults some in his own party for injecting alarmism into the debate. "Clearly, the death panels and public plan arguments have been overblown," he says. Frist noted that Republicans themselves voted for a Medicare prescription drug bill that would have established a version of a public plan--with the government negotiating directly with drug companies--if private-sector competition had failed to materialize.
Read the whole blog post on Swampland.
3.) Nicholas Kristof, “Dad’s Life or Yours? You Choose”
There are so many basic injustices and indignities with the way our insurance industry operates, it’s hard to know where to begin. But clearly at the top of the list is the injustice of rejecting coverage for those with pre-existing conditions -- discriminating against the very population most likely to need health care, because they’re most likely to need care. Kristof today supplies a dramatic example where pre-existing conditions actually impeded two generations from getting the care they need and the preventative care they still might need.
Mr. Waddington has polycystic kidney disease, or PKD, a genetic disorder that leads to kidney failure. First he lost one kidney, and then the other. A year ago, he was on dialysis and desperately needed a new kidney. Doctors explained that the best match -- the one least likely to be rejected -- would perhaps come from Travis or Michael, his two sons, then ages 29 and 27.
Travis and Michael each had a 50 percent chance of inheriting PKD. And if pre-donation testing revealed that one of them had the disorder, that brother might never be able to get health insurance. As a result, their doctors had advised not getting tested. After all, new research suggests that lack of insurance increases a working-age person’s risk of dying in any given year by 40 percent.
“At the time David needed a transplant, the people closest to him couldn’t even offer a lifesaving donation -- for insurance reasons,” said Mr. Waddington’s wife, Susan.
Read the full column at NYTimes.com
[Programming note: This is my last blog post as the primary editor of this cause for Change.org. Thanks for reading! However, I’m leaving you in the more than capable hands of Gillian Hubble. I’ll be guest blogging in this space in the weeks and months to come, though not at my usual frequency. Whether you’re a health care reform skeptic or activist, we are truly in unprecedented times. There simply has never been as good a chance of having a comprehensive health care reform bill passed by Congress and signed by a president. But stay vigilant and stay active -- we still have a long way to go, and much work to do to ensure it’s a bill we can all be proud of.]
(Photo credit: http://www.flickr.com/photos/plurimus/ / CC BY 2.0)
Making the Opposition to Reform a Punchline
Published October 04, 2009 @ 07:33AM PT
The disruptive town halls made for good theater on the nightly news, but scarcely seem to have made a dent in the momentum for health care reform. Once the hot August was over, the president made his address to Congress, Sen. Max Baucus got off the dime and released his bill, and we were back in business. A march on Washington by some million 100,000 50,000 people with a somewhat incoherent message that didn’t do anything to impede progress, or even slow it down. And now that the Senate Finance Committee has all but completed its work, we’re moving to unprecedented floor debates in the House and the Senate.
So what did they accomplish, other than ratings? Well, they seem to really have challenged progressives to open up their vast reservoir of sarcasm.
The rock video “We’re Number 37” was of course a direct reaction to the town halls. This new video, “Don’t Ruin American Healthcare” is more of a direct-to-camera PSA, in the style of Will Ferrell’s “Protect Insurance Companies.” But it doesn’t take much to take some of the actual talking points you hear from regular people whipped into a furor over the prospects of reform, and make them laugh-out-loud funny.
