Category: health care

Obama Care and Republican Debates

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In all the Republican debates, the Presidential candidates vow to repeal the Patient Protection and Affordable Care Act, or Obama Care, pointing specifically to the provision of the bill which mandates that people have health insurance or pay a fine.  Not once can I remember any candidate advocating the repeal of the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) which mandated that hospitals provide emergency care to anyone regardless of citizenship, their legal status or their ability to pay.  Twenty-five years ago, this law was passed by a Democratic House, a Republican Senate and signed by a Republican President, Ronald Reagan.  The law dictates but provides no funding for its mandate.  Obama Care finally provides a mechanism to fund the 1986 law – a “put up or shut up” provision that a lot of people don’t like.  If Republicans are truly against federal mandates, are truly for more state autonomy, why are they not calling for EMTALA’s repeal?  Although I have not heard Ron Paul recommend repeal of the 1986 law specifically, he has consistently voiced his opinion that the federal government should get out of the medical care business. 

The health care debate is part of a larger issue.  Are we as a people prepared to put up or shut up?  Should hospitals be forced to treat patients?  If so, how to pay for it?  Should Congress be allowed to pass these unfunded mandates?

“Repeal and replace” is an argument I have heard frequently.  Replace with what?  Last March, Bloomberg analyzed various Republican proposals to replace Obama Care and found that it was mostly hot air, saving far less money than the lofty claims.  Again, I ask – are we going to put up or shut up?  Is Ron Paul the only Republican candidate who shows a consistent adherence to principle?  Have we become a nation of people who elect only those politicians who tell us that it really is possible to have our cake and eat it too?  

Health Summit

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This past week, President Obama met with leaders of both parties in a televised summit designed to enable each party to publicly state their positions on health care reform.  Ostensibly, the summit’s purpose was to find common ground between the parties but the only common ground was the line drawn in the sand between the two parties.

The summit did make clear each party’s fundamental view of the role of the federal government.  This debate has continued for two centuries and, as I noted in an earlier post, James Madison crafted the debate into this country’s Constitution as the only solution to keep the confederation of states unified into a single country.

During the seven hour summit, Mr. Obama probably put the core issue most succinctly.  After saying that the public could see the difference in each party’s position, he said “that’s what elections are for.”  He could have been referring to the past election, which gave the Democratic Party a clear mandate for change.  In a subtle way, he may have been referring to the upcoming November elections – let the voters decide which position they prefer.

What muddies the political waters are the independents and the “in-betweeners”, those who think that a limited role for federal government should not be as limited as Republican ideologues argue for.  On the other hand, these “middle-of-the-roaders” may see the large role of the federal government espoused by Democrats as too intrusive.

Politicians are prone to explain things in nutty sports metaphors, as though the general public had only a 4th grade education.  So, in case you have only a 4th grade education or are a lover of stupid metaphors, let me explain it this way:  it’s like there’s cows on one side of the fence and sheep on the other side of the fence.  The sheep believe in eating the grass all the way down to the ground.  The cows believe that they should leave a bit more of the grass blade showing so that the grass can regenerate. A bunch of people sit on the fence trying to figure out which side of the fence they’re going to jump on.

Yee-hah!

Health Horror Stories

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In 2007, USA today reported several horror stories of individual health policy revocations. These stories highlight the root conflict of interest in private health insurance. In case you might wonder why other forms of insurance don’t have these problems, they do. Business liability insurance has its own horror stories. I know of several smaller contractors, newly in business, who simply could not get liability insurance from the more reputable insurance companies for their line of work in construction. The public hears little of these stories. They are told on job sites and in trade journals.

Health Care Conundrum

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In an op-ed in WSJ 10/17/09, Vernon Smith, a Nobel Laureate in economics, explained the problem with health insurance in simple terms that any layperson can understand. Health care provider A recommends to patient B the services that B should buy from A. C, either the government or an insurance company, pays A. “This structure defines an incentive nightmare,” Mr. Smith writes and presents a seemingly unsolvable problem.

The Senate recently passed its version of health care reform. House and Senate committees will meet in January to start reconciling differences in House and Senate versions. During the health care debate this year, and for the past century – Theodore Roosevelt tried to institute a public health care system – the focus has been on solutions to a number of problems: the number of uninsured, ballooning costs, the alarming number of bankruptcies because of medical bills, insured patients who are cut off because their benefits exceeded a lifetime maximum, those people denied affordable coverage because of pre-existing conditions.

Various players in the medical care provider market have voiced objections to proposed solutions when the impact of a solution would be negative on them. Perhaps we should all admit that we will never fix this intractable problem. Like many cancer therapies, the “solution” may be to manage the problem, not solve it. Only when all parties give up the notion of finding a solution will we be able to sit down at the table and come up with a framework for managing this problem.

This idea was first conceived by James Madison, the chief architect of the U.S. Constitution. Unable to resolve the decade old dispute between advocates for a strong federal government and those who championed individual and states’ rights, Madison had the genius to incorporate the struggle between these two ideologies directly into the Constitution, thereby providing a structured debating platform for this continuing argument and struggle for power.

NHS vs US Health

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The good, bad and ugly of the American and British health care systems. In an 8/15/09 FT article, Nicholas Timmins gives a brief comparison of the two systems.

In a 9/15/09 PBS program, “Retirement Revolution”, host Paula Zahn spoke with a doctor who has worked in both systems. The doctor summed it up: The British NHS works well for most patients whose disease presents no particularly difficult or unusual complications. The American system, with much more emphasis on advanced technology and public funding for academic institutions, is better for those patients who do have unusual complications.

At town hall meetings this summer, some Americans touted the U.S. health care system as the best in the world, citing the estimated 400,000 people who come here each year to get medical care. An 8/24/09 AP article cites a 2007 estimate that almost twice that number, 750,000 U.S. citizens left the country to get medical care elsewhere. Estimates by the Medical Tourism Board for 2010 are that 1.6M patients will leave the U.S. for care outside the country.

Public Option

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Some people in this country have expressed concern that a “public option” in health care would drive out private insurance companies. The warning is repeated over and over again as though this prediction were fact. We have a history of a public option competing with private insurance companies – Workmen’s Compensation Insurance. Has it driven private companies out of the market? No.

In an 8/16/09 San Diego Union Tribune article, Dean Calbreath relates the early history of Workmen’s Comp insurance and the criticism that Pres. Woodrow Wilson endured from conservatives for initiating a public medical plan for workers. Dean recounts the century long struggle between private insurance companies and the California State Fund in this insurance market. The result? Private insurance companies in California dominate the Workmen’s Comp insurance market. Yet there are those clamoring that such a thing is impossible.

Were we to have a public option in health care insurance, a plan covering basic insurance needs, we might expect that private insurance companies would design insurance plans that filled the gaps left by such a public plan. Just as workmen’s comp insurers did in California, health insurance providers will offer competitive pricing to larger companies and command the majority of the market. Like the workmen’s comp example, the public health insurance option will appeal to small businesses and those individuals who have difficulty getting affordable insurance.

Had they been born a hundred years ago, those arguing against a public option today probably would have argued against Workmen’s Comp then. This debate is less about public insurance options and more about the role of government, a long and fierce argument that began before the founding of this country and continues to this day.

A hundred years ago, Andrew Carnegie was criticized by conservatives for his support for the use of public taxes for libraries. Public libraries did sometimes swallow up the collections of social libraries that charged a subscription fee to members. However, libraries whetted a desire for books, and private booksellers fluorished in larger cities to meet the demand for popular newly published books, a need that libraries were not designed to satisfy.

In smaller towns like Kankakee, Illinois, citizen-initiated drives for a public library were met with resounding support from their neighbors; private donations of books and land helped launch the library in 1896. Does President Obama hope that this kind of community spirit is still smoldering in the hearts of Americans?

How can any company possibly compete with a public entity as large as the Post Office? UPS, FedEx and other private mail and package delivery companies have met the challenges of this competition and fluorished. The once stodgy Post Office, in turn, has offered new services and products to compete with these private companies.

In the 1850s, conservatives protested loudly at the use of public dollars to fund free education for children. Has public education led to the demise of private schools? No.

The competition between a public option and private companies in insurance, libraries, mail delivery and education have promoted a vigorous environment which offers better choices to the public. To those who predict that a public option will kill the private insurance market, history replies, “You’re wrong.”

Healthy Americans Act

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I’ve been a bit too busy lately to keep up with this blog. This blog is a good update of the continuing saga of health care/insurance reform in this country.

Ron Wyden, a senator from Oregon, initiated Senate bill 334 in 2007 and added several amendments in March 2008. The Congressional Budget Office’s analysis of the proposal found that it was revenue neutral within two years.

Likes: Basic plan is the standard basic Blue Cross/Blue Shield plan offered to federal government employees. State administered private insurance pools to spread the risk to insurers. Individual mandates to purchase insurance. People with low incomes are partly subsidized. Automatic enrollment if an individual makes no choice and no penalty to an individual who fails to make a choice. Ability to buy a more expensive policy if one can afford it. Leaves alone existing insurance policies negotiated as part of a collective bargaining agreement – the unions will like that. The basic plan is indexed to growth in GDP, not medical costs.

Dislikes: The basic plan is indexed to growth in GDP which is sure to grow less than medical costs. Private insurers will surely increase deductibles or reduce coverage for some services to offset the actuarial difference. The plan still involves employers who will pay a sliding scale tax (deductible) on the number of employees they have. However, with medical premiums increasing by 7 – 12% every year, I suppose that a sliding scale tax will at least be a known cost. It also evens up the playing field between larger companies, who pay more than smaller companies.

Of all the proposals I have read, I like this one the best for its fiscal soundness and it’s realistic approach to the competing interests of all.

Health Care Reform – For Real

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It was the summer of 1973. I was working in emergency room x-ray in a teaching hospital in New York City. Back in those good ole days X-Ray techs had to know a lot about MA and KV, exposure time and soft tissue absorption and diffusion of X-rays. Developing x-rays required a knowledge of silver emulsions and development time. Now digital cameras make a lot of those judgments.

The word came down from on high – the top management of the hospital. From then on, all patients who came into the ER with any kind of fall were going to get a basic set of skull x-rays. What precipitated this nonsense, we wondered?

After a fall, a patient had come into the ER with a possible ankle fracture. His ankle was x-rayed. He had a sprain. He had some small skin scratches on his forehead, elbow and hand. These were cleaned and bandaged, his pupils and eye response were checked and he was discharged. A day or so later he was admitted with a brain hematoma. He sued the hospital. Under the new policy, a small child with some cuts and scratches on his knee got a set of skull x-rays. Neither the patients, doctors or staff liked the new policy. It was the dawn of defensive diagnostics. The legal department at the hospital was now making medical decisions.

Today, 36 years later, the House of Representatives passed a health care bill. You can read the jist of it here along with the 537 (and still counting) comments, some of them quite vituperative. No one has been predicting that this House version would be even close to a final version of a health care bill but it has kicked the discussion on health care reform into high gear. The Senate is working on a more moderate proposal. This bill is not about health care reform. It is about health insurance reform.

What is getting far less attention is the utter failure of the Congress to agree on real health care reform – the HOW of health care delivery and the legal environment in which health care is delivered. The Senate Committee on Health, Education, Labor and Pensions killed even a modest limited trial of tort reform, refusing to entertain the idea of special courts to try malpractice claims. Special courts for income tax cases, bankruptcy and workmen’s compensation are common in this country.

Until there is some attempt to slow the huge expense of defensive diagnostics, the ordering of tests to protect the doctor against possible lawsuits, health care costs will continue to climb at a rate far exceeding the consumer price index.

Pres. Obama is asking citizens to encourage their Senators to pass a health insurance reform bill. We need to be encouraging our Senators and Congressmen to pass a real health care reform bill, one that includes at least an attempt at tort reform.

Health Care Costs

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On Sesame Street, he’s called the Count. In Washington, it’s called the Congressional Budget Office or CBO. Both are good at counting, but there’s a difference. On Sesame Street, everyone loves the Count. In Washington, many politicians grumble about the CBO’s counting.

On June 15th, the CBO responded to Sen. Edward Kennedy’s draft proposal for health care reform. Estimated increase in federal deficit over the next ten years: $1T. But wait – there’s more. The CBO estimates that 10% of those under 65 would still be uninsured. And there’s still lots more. Kennedy’s proposal had so many blanks and “I dunnos” in it that all the CBO could do was count the holes, acknowledging that it needed more information on a number of issues, many of which the CBO had specified in a paper last December.

On June 16th, the CBO sent a response to Republican Senators Kent Conrad and Judd Gregg about the impact of doing nothing. The short and sweet? The country has to do something to reform the system – and soon – before health care spending in this country becomes the Blob that ate the budget.

You can see a number of links to issues that the CBO considers key to resolving this complex problem at the health care policy page. We’re big kids now. We can figure this out as long as everyone doesn’t expect to get all they want. It’s the principle behind the founding of this country.

Health Care Solutions

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In the search for effective solutions to health care, the grocery chain Safeway has adopted a simple, time tested approach: base premiums on behavior. This is the fundamental model of the the auto insurance industry.

In a 6/12/09 WSJ op-ed, Steven Burd, the CEO of Safeway, details Safeway’s four year long experiment with this model. While American companies have average a 38% increase in health care costs since 2005, Safeway costs have remained flat. Like many large companies, Safeway is self-insured, giving them data on actual medical claims turned in by employees.

Employees who don’t engage in risky behavior, like drivers who don’t speed, pay lower premiums than those who do. The program is voluntary at Safeway but most employees rated the plan good to excellent and the participation rate is 74% for non-union employees. Employees who reduce their weight or give up smoking are rewarded with lower monthly premiums. Safeway is currently negotiating with the union to introduce a similar program for union employees.

This year, the Federal government is likely to step in to the health insurance market to attempt to solve problems so seemingly intractable that the private marketplace and the individual states have failed to address them. Older employees become slaves to their employer. On an individual plan, a woman who had breast cancer 10 years ago may pay four times the premium charged an employer for a plan with the same benefits. How many states have high risk health insurance pools as they do for auto insurance? Year after year small employers, patients and lawmakers have acknowledged that the current system is broken. Suggestions are made. Discussions and arguments follow and little is done.

The Federal government has a poor record of solving problems. That there is enough support for a Federal government solution to the problems in health care insurance says more about the failure of the private marketplace and the state legislatures than an endorsement of the Federal government.