Medicare and Medicaid
OK, How About Sebelius for HHS, Then?
Published February 18, 2009 @ 09:28PM PT
Note to self: just stop writing about the Secretary of Health and Human Services until that position is filled.
During Daschle’s troubles, I erroneously predicted that he would likely be confirmed anyway, only to have him remove himself from consideration the next day. Today, I’ve written a post saying Howard Dean should get more than a cursory look as HHS Secretary. A few hours later, The New York Times reports that the president has settled on Kansas Governor Kathleen Sebelius as his choice. Let it not be said I’m not the first to admit when I’m an idiot. Luckily for us, Kathleen Sebelius is not only a good manager, she has health care street cred from taking on insurance companies – and winning.
There are few positions in the Cabinet that Kathleen Sebelius wasn't rumored to be in the running for. Before that, she received strong VP consideration for both John Kerry in 2004 and Barack Obama in 2008, especially after she endorsed Obama early and enthusiastically during the primaries. She even had some (mild) buzz as a presidential candidate herself for 2008, though clearly nothing came of it. Most pundits focus on her management skills – reducing state debt, fighting waste, balancing the budget and even expanding funding for education without raising taxes in her two terms in office – and a bipartisan track record essential to getting anything done in still-conservative Kansas. Dramatically, both Lt. Governors who served under her have been Republicans.
But none of that – except for the close relationship with Obama – makes her a particularly good candidate for HHS Secretary. The politics of the pick is debatable. Bipartisan in Kansas does not necessarily translate to bipartisan in Washington, and tapping Sebelius would flip the governorship to a Republican and remove the best chance for Democrats to take a Kansas Senate seat in 2010.
But Sebelius is not just your average governor, and she did more than just find ways to improve Medicaid and health care services in her state. She gained prominence as the State Insurance Commissioner from 1994 to 2002. Before Sebelius, the position had been rather cozy with the insurance companies and HMOs operating in the state. But during her improbable first run, Sebelius refused to accept contributions from the insurance industry – a foretaste of things to come. When Blue Cross Blue Shield of Kansas wanted to merge with an Indiana insurer, she not only refused to rubber-stamp the deal, she blocked it. She turned the office of the Insurance Commissioner into an activist regulator, pursuing HMOs who denied care and pushing for cheaper prescription drugs for seniors. And here’s the kicker – she did so while also reducing the operating budget by 19% over her tenure.
An HHS Secretary who knows how to take on insurance companies, understands the prescription drug issue intimately, and knows how to do more with less? OK, if you insist.
The timing is intriguing, since Kansas has just resolved its budget crisis this week whereas it was still in progress when Obama made his other appointments. We’ll see if she finally makes the leap to the Executive Branch this time. I expect to see a lot of grumbling on Daily Kos about the Senate race in Kansas. But that's massively underestimating the potential of this appointment at this moment in the health care debate. If Democrats don’t increase their majorities in 2010, one seat in Kansas won’t be the sole reason. More importantly, being 1 Senator out of 100 (as Obama himself learned) does not compare with the amount of good that can be done by an HHS Secretary with insurance-fighting cred who’s looking to take on the problems of Medicare Advantage and the prescription drug waste of Medicare Part D precisely at the moment when reforming Medicare will do the most good to health care reform in general. No Sebelius isn't Howard Dean... but her record is enough to make you dream about what tomorrow may bring.
(And if Sebelius doesn’t take the job, I’m going to keep my damn mouth shut until someone does and gets confirmed by the Senate. No more egg on the face for me!)
(Photo credit: WEBN-TV on Flickr.)
Why Not Howard Dean for HHS Secretary?
Published February 18, 2009 @ 03:44PM PT
Whenever you hear about Howard Dean's prospects to replace Tom Daschle as the White House's pick as HHS Secretary, he's always labeled the "dark horse," with most stories overly dismissive of his chances. He's on bad terms with Rahm Emmanuel, we hear, or he and Obama were never close. Although I buy into these political considerations when it comes to managing the White House Office of Health Reform, it's just not compelling to also keep Dean from being considered more seriously for HHS Secretary.
I will concede that I just don't see Dean taking over for Daschle as Obama's health care reform wingman. On that front, Daschle's political acumen was as important as his policy background - indeed, probably more important. He had the relationships in the Senate and knew all the parliamentary ins and outs of getting legislation passed. He was an affable and compelling salesman to the public, but also unquestionably Obama's man. He had strong relationship with all the players in the health care debate (including the insurance companies) and was the consummate inside-the-Beltway professional - ironically, the very reason why his nomination got torpedoed. Absolutely none of this describes Dean. He's clearly more comfortable playing the outsider game than the insider game, his relationships with Congress are questionable, and we'd be in for a gazillion "can these guys get along" process stories about whether Dean was pushing Obama's health care agenda or his own.
Plus, Dean's presidential campaign was discouraging on the topic of universal health care. If you're a single-payer advocate, perhaps you remember his bald statement from 2003, "I do not believe in free health care or free anything. If you want to totally reform the health care system, I'm not your guy. Just expand the system we already have to include everybody. I'm not interested in having an argument about what the best health care system is." What Dean proposed during the campaign was an incremental approach to improve access, based largely on tax credit subsidies and public programs, but he did not sell it well during the debates, particularly when confronted with the bolder plans offered by Dennis Kucinich and Dick Gephardt.
But running the agency that is responsible for Medicare, Medicaid, the FDA, the Center for Disease Control, the National Institute of Health and others plays remarkably well into Dean's strengths. As many have observed, Dean's track management track record is as good as his record avoiding conflict with the power players in Washington is bad. His years managing Vermont's budget were both excellent and marked with surprising fiscal conservatism - 11 balanced budgets while also paying down much of Vermont's debt. His tenure at the DNC and institution of the 50 State Initiative, although controversial, proved to be a wise strategy to turn the DNC into as prodigious an organizing institution as it was a fundraising institution which helped enable the successful campaign of 2008 on all levels. Even more relevant is how Dean was able to lower the percentage of uninsured in Vermont from 12.7% to 9.6% (during the campaign, Dean cited another assessment that 96.4% of Vermonters had coverage) -- by leveraging the power of existing programs, primarily Medicaid, to cover nearly all children and pregnant mothers, and doing so without busting the budget. He proved adept at promoting public health not with a bureaucrat's eye but a physician's eye, focusing on primary and preventative care. Is that not exactly the perspective we'd like to see in the man in charge of Medicare and Medicaid?
Ironically, I didn't like Dean as a presidential candidate. And I'm not in a position to say Dean is automatically the best candidate (Kansas Governor Kathleen Sebelius also has excellent credentials and perhaps warrants her own post), but he is more deserving of a look as Tennessee Governor and former insurance CEO Phil Breseden. HHS Secretary might not be as glamorous a job as Obama's Health Care Reform Quarterback, but Medicare has a big role to play in reforming our health care system to make it cheaper and more efficient. Dean's experience should trump the politics. After all, could he possibly be more disruptive to Cabinet meetings than Judd Gregg would have been?
(Photo credit: drummajorinstitute on Flickr.)
The Presidents Who Took Us the Closest to Universal Health Care, Part 2
Published February 16, 2009 @ 06:06PM PT
We covered Roosevelt, Truman and Kennedy’s attempts to expand health care coverage in part 1. In the second half of the 20th Century, health care reform saw it’s greatest triumph to date – the creation of Medicare and Medicaid as part of Lyndon Johnson’s “Great Society” – but mostly saw the same arguments, the same fights and the same inevitable failures that have dogged it nearly every time.
Lyndon B. Johnson
What JFK started, LBJ finished. Even though the two men had been political rivals and not particularly close, Johnson was able to turn the tragedy of Kennedy’s assassination into a national impetus to complete the fallen president’s legislative program. The earliest success of this drive was the Civil Rights Act of 1964, but Medicare was not far behind. The main obstacle in Congress was also the man who could make it happen, conservative Democrat Rep. Wilbur Mills, chair of the powerful Ways and Means Committee. It’s clear he got “the Johnson treatment” for most of 1964—a wave of constant attention combined with good cop/bad cop techniques (when there’s only one cop!) that had served LBJ so well as Majority Leader of the Senate. While constantly impressing on Wilbur the need for Medicare to be a top priority, Johnson also clearly gave him wide latitude to construct the bill and take the credit.
The real tipping point occurred on Election Day, 1964, when Johnson’s landslide (61% of the vote) and the subsequent Democratic majorities in the House and the Senate brought with it an enormous mandate. LBJ artfully arranged for the bill amending the Social Security Act to create the Medicare program to be HR 1 in the House and S 1 in the Senate, dramatically illustrating how much of a priority this program was for his administration. Wilbur, for his part, took the three proposed models of Medicare – a single-payer option where the government would pay for a fixed number of hospital days for the elderly, a more robust program that would allow for physician coverage, and a program where the federal government would give money to the states to each set up their own programs – and created a “layer cake” incorporating all three. Medicare part A would cover the hospital stays, Medicare part B the physician coverage, and the federal-state partnership would evolve into Medicaid. Although the deliberations and the legislative language were drawn up in Congress, LBJ’s political fingerprints were all over the pressure that allowed the bill to pass in 1965.
The Presidents Who Brought Us the Closest to Universal Health Care, Part 1
Published February 16, 2009 @ 02:59PM PT
In honor of President’s Day, here’s a two part run-down of the presidents who took us closest to the goal of universal health care. I'm not including those who introduced a new benefit to an existing program, or created favorable business conditions for the private insurance industry to innovate, or proposed universal health care during the campaign but never reached the Oval Office (a tradition dating back to Theodore Roosevelt’s third-party run in 1912), but those men who proposed or actually pushed for a comprehensive set of health care benefits for every citizen in the country. For those who might only remember the health care fights of the 1990s, you’ll soon realize just how much of this is the same old fight, destined to be repeated every few decades.
Franklin D. Roosevelt
Yes, the man who brought us the New Deal and the creation of Social Security, and guided us through World War II very nearly made health insurance for all citizens part of the social contract from the get-go. Indeed, drafts of the legislation for the Social Security Act from 1935 included language that would have created a compulsory national health insurance, very loosely modeled on Germany’s decades-old universal health care system, but far more familiar in general structure to what single-payer advocates have proposed ever since: government would amass a pool of insurance money based on taxes, and from that pay every citizen’s medical expenses. What stayed FDR were political concerns – specifically that overburdening the Social Security Act would make it too difficult to pass. Plus, with an overwhelming focus in the public’s mind on the economy, and without an immediate association between the economy and health care, it seemed better to push it off for a more welcoming political climate in the future. (Watch for this to be a recurring pattern).
Instead, FDR created an ad hoc committee called the Interdepartmental Committee to Coordinate Health and Welfare Activities whose study of the health care issue and recommendations were intended to pave the way and create support for universal health care. However, the committee’s report in 1938 instead gave a number of recommendations that fell just short of a mandate for universal health care, but focused primarily on federal grants to the states to develop their own programs for the disabled, the elderly and the needy.
Now Let's See What Coordinated Care Can Really Do
Published February 13, 2009 @ 01:02PM PT
The results of the Medicare Coordinated Care Demonstration, as reported in the Journal of the American Medical Association, can't easily be characterized. On the one hand, it would seem to be a failure - after all, of the 15 care coordination pilot programs that began in 2002, only 2 of them demonstrated an ability to produce better health outcome with fewer hospitalizations and less money. But on the other, those two are a pretty big accomplishment, with ample lessons that can be applied to the future tests programs being rolled out both through Medicare and the private insurance industry. So although by pure success standards, this is a mixed bag, the learning opportunities are huge.
By testing coordinated care, the Centers for Medicare and Medicaid were basically testing what many are calling "the medical home." Patients have a single provider or coordinator who is responsible for coordinating all of their care, rather than bouncing on their own from primary care provider to specialist to hospital. Entities like the Mayo Clinic and the V.A. already operate along these lines. Groups like the Sustinet movement in Connecticut and the soon-to-be pilot program in Arizona prompted by IBM favor this approach because of its potential upside in terms of customer satisfaction and cost savings. But the idea is even more important for those with chronic conditions and diseases like diabetes, heart disease, etc. The chronically ill account for a large percentage of the health care dollars spent, particularly in Medicare, and are the unfortunate recipients of much of the inefficiencies and waste built into our system. In a study by the Commonwealth Fund, 1/3 of U.S. patients "encountered poorly coordinated care, including medical records not available during an appointment or duplicated tests." More disturbingly, 1/3 of those surveyed, "experienced medical errors, including delays in learning about abnormal lab test results." Coordinating care, and compensating providers based on how well they coordinate, holds out the hope of reversing these trends.
Medicare gave those participating in the trial wide latitude to come up with their own program, and the JAMA article is clear that some of the programs were bound to fail the way they were set up. For example, the two successful programs included in their mix of patients those whose monthly expenditures were $900 to $1200 - essentially, they went often enough to the hospital before the trial that it was noticeable when they were hospitalized less, but weren't so seriously ill that no new care program could decrease how often they needed to hospitalize. That's a design flaw - easily fixed in future trials.
But the other lessons from the successful two programs are even more intriguing:
- "Relatively frequent in-person contacts maybe necessary to develop the level of trust that patients and their families need to consider the care coordinator..." When you're trying to create a bond of trust so the patient actually follows the non-physician coordinator's advice, you can't phone it in. It's cheaper, but it doesn't work.
- Teaching patients how to treat their medication rather than assuming they'll know how to do it counts for a lot.
- Care coordinators who worked closely with local hospitals and shared information freely and quickly had a big impact on patient care.
- Regular contact with primary care physicians and nurses by both the coordinator and the patient was essential to success. For the patient, it validated the recommendations they got from the coordinator. For the coordinator, working with the same physicians and developing a team relationship clearly helped them do their jobs.
These may seem like "No duh" lessons to learn, but there's an obvious incentive to have coordinators off-site, interacting by the phone and not doing the little things to establish a relationship with the patients - it saves the hospital money. Fostering teamwork and a face-to-face rapport with patients takes time and a personal touch - time that current compensation methods don't take into account, particularly for the primary care provider, whose buy-in is crucial. You can't do coordination on the cheap, or in the call-center model of profitability. Instead, we need to break down the old habits of our fee-for-service system to really establish coordinated care that leads to healthier patients.
So initial overwhelming success, no. But, to riff off Aaron Sorkin, there was a time in the history of everything that worked when it didn't work. We've learned, as the Center for American Progress puts it, "we can't simply apply a band-aid and call it coordination." Now we need to absorb these lessons and really see what the coordinated care model can do.
(Photo credit: Liberal Democrats on Flickr.)
SCHIP for Kids! (Sadly, the Rest of Us Are Still Being Ripped Off)
Published February 04, 2009 @ 09:05PM PT
Although I’m thankful for what turned out to be a swift passage and signing of SCHIP today, a rapturous “We did it” post is certainly not what you expect from when you hop onto this blog. It many ways, my relief translates to a “Thank goodness we did it!” – because let’s face it, if we couldn’t pass such a widely hailed and successful project, that’d be a sign that the fight ahead for health care reform would be worse than we’d imagined. Plus, if you’re looking for eloquence, it’s hard to top our President… so I won’t even try.
In my own quirky way, I would like to honor the minimum 4 million additional children expected to be covered by the expansion of the program with a reminder of what the rest of us are still facing. So here it is: The Top Four Rip-offs of the Private Insurance Industry… From TODAY!
1.) Insurance Companies in Medicare Advantage programs raising premiums on seniors!
What’s that, you say? The Medicare [No] Advantage programs that offer virtually identical benefits but charge the taxpayers an extra 12.4% per enrollee (somehow convincing us that private insurance must be more efficient… after all, it costs more)? Yes, that’s right. And the story gets even worse, as detailed on Bloomberg.com today. Humana, HealthNet and others are raising 2009 premiums on seniors by as much as 13% -- 5 times as much as last year’s increases – so they can rip off Uncle Sam and Great Aunt Ginny at the same time.
The best quote of the article comes from an 85 year-old professor emeritus from Harvard Medical School, who says, “Medicare Advantage is a rip-off. I cannot see that they do anything better than public insurance does, and they do a lot of things worse.”
2.) Insurance companies fess up to ripping off college students!
From the Harford Courant today, “Aetna will reimburse more than $5.1 million on 73,000 health claims for college students it underpaid between 1998 and April 1, 2008, under a nationwide agreement announced Monday by New York Attorney General Andrew M. Cuomo.” We last mentioned NY’s Attorney General for causing a settlement with United Health whereby the acknowledged that faultiness in their database information on what constituted “a usual and customary charge” caused them significantly underpay on claims. This is a similar deal.
Students went for out-of-network care. The insurance company reimbursed for the “usual and customary charge” with the student making up the difference out of pocket – except not so much. Instead the insurance company reimbursed for much less, and the student paid much more out of pocket than they should have. Because if there’s one demographic that has a lot of cash lying around, it’s college students…
3.) In Wyoming, your claim is denied… just because.
The Wyoming Senate passed a law which goes to the House today to finally change what have to be the laxest oversight of the insurance industry in the country. Until such time as this bill becomes law, there’s no external review process to challenge denied benefits in Wyoming… at all. There’s no state law definition of “medical necessity” which insurance companies have to provide care for. And there’s no prohibition on a clause in your insurance contract denying you coverage at any time, for any reason.
Which basically means in Wyoming, you can be denied medically necessary care for no reason, and with no appeals outside your insurance company’s claims process.
Something tells me if John McCain was president and his “allow people to buy insurance across state lines” platform was enacted, you’d see the capital of insurance shift from Connecticut to Wyoming in about a month.
And finally, our last rip-off from the insurance industry today:
4.) Insured cancer survivors are going without care because they can’t afford it.
From Health Day News today, an estimated 2 million cancer survivors – the majority of them with insurance – do not get the care they need because of cost, according to a Centers for Disease Control report. The details may not be surprising, but they are sad. Many of them are in high-deductible plans, which is what tends to happen when you have cancer in your medical history. Many of them can’t afford the co-pays that mount up throughout the year. And ancillary care – particularly dental – is the first to go. It goes without saying that Hispanic and African Americans are twice as likely as whites to go without care – well, up until age 65. Why is age 65 such a social leveler? Oh, that’s right. That’s when they’re eligible for Medicare.
So thank goodness millions of American children can look to us and know we’re going to take care of them. But the rest of us still need help… and badly.
If the Stimulus Goes Down, So Do Hospitals
Published February 04, 2009 @ 04:53PM PT
I’ve talked about the Medicaid provisions in the Economic Recovery Act. A lot. And a lot. And a lot. But somehow the Senate and the media have entered the funhouse mirror of public debate where we’re asking existential questions like “What is stimulus?”, “What is spending?”, “What is this ‘economy’ that you’re trying to save?” So let’s make one thing abundantly clear. The Economic Recovery Act contains $87 billion to increase the share of the federal funding in Medicaid, meaning states who are also trying to close their budget deficits can pay less for Medicaid without cutting services. It’s time to ask about consequences. What happens if the narrowest definition of “stimulus” carries the day, and either the Economic Recovery Act goes down or the Medicaid provision gets stripped from it?
Hospitals close. It’s as simple as that.
In many states, the governors and the state legislatures are playing a wait-and-see game to determine when and if more federal money for Medicaid will be forthcoming, so the details of what these cuts would look like is shrouded in speculation. Not here in New York. When the financial crisis first hit, Governor Paterson immediately offered up a package of cuts to trim down the potentially exploding state deficit – cuts in health care, education and other state spending that we already swallowed in 2008. But events have deteriorated even further, and Gov. Paterson released a proposal of further cuts with a collection of small-bore tax increases ranging from the actual useful (the soda tax) to the mere nuisance (the iTunes Tax) to the “we’re going to jack up this fee, since we can.” The target number for cuts to New York’s share of Medicaid spending? $3.5 billion.
Nice to have a number. So the Greater Hospital Association of New York worked through how those cuts would work out for each hospital in New York State. They sent the info to Crain’s NY Health Pulse, who has very exacting copyright and reproduction standards… meaning I’m hoping GNYHA self-publishes the numbers on their site soon so I can link to it. In any case, I had a normal human reaction – let’s see how the hospitals I use will be affected.
