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Business As Usual: California’s Reform Proposal – Brian Klepper

Brian_klepperIn the world of health reform wonks – the writers on this blog qualify in spades – all eyes
are on California at
the moment. His Republicanism notwithstanding,
Governor Schwartzenegger has developed a generous $14 billion bill that
would extend universal coverage to all Californians by 2010.

Now
that the plan is set, the special interests are lining up. Most of the
health care groups – the physicians, hospitals, the health plans (with
the interesting exception of Wellpoint) – are supportive, fully aware
that if more money can be found for health care, they’ll be the
recipients. Also in the mix are two prominent unions: SEIU (the Service
Workers’ International Union) and the American Federation of State,
County and Municipal Employees. They are both key supporters, each with
health care workers who would benefit from the deal.

Now it comes out
in the LA Times that the Governor’s ally in the reform package,
Assembly Speaker Fabian Nuñez, sweetened the deal for these unions’s
members with millions of dollars in workers’ training and benefits. Here at The Health Care Blog, SEIU Executive Vice
President Mary Kay Henry, posted a piece called "As Goes California, So Should The Nation," hawking the reform proposal, but conveniently leaving out that SEIU’s members will get special benefits in the deal.

I
got calls from several reporters yesterday asking about the prospects
for real reform in California. Alas, as much as I would like to see it,
it seems very unlikely. California’s reform proposal is all about
universal coverage, and almost – not quite, but almost – absent
meaningful cost controls. It finds new money from purchasers to pay for
the care, but extracts virtually no concessions from the health care
sector on how that care will be supplied or delivered. It will remain
impossibly expensive. A couple making $54,000/year – more than the
subsidized 400% of poverty – will be required to come up with $12,000
for health care, or more than 1/5 of their income. Pretty onerous.

None
of this is lost, of course, on the business sector, which has not yet
begun to flex its influential muscles. Assuming that the reform
proposal is pushed out to a referendum, it will become a battle of the
propogandists. My bet is on the businesses who comprise 6/7 of the
California economy, and who will feel that the cost is too lopsided and
too excessive, that too little has been asked of the health care sector
and that no disciplines have been demanded.

The jury’s still out,
but I can’t believe that meaningful reform will win out in California.
Because, in the end, the ways that it is playing out is unchanged from
the core of the problem itself. There is little consideration of how
best to provide health care, but who will win the biggest purse. And
that approach never really solves problems.

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Sebastian LEDERERHerbert Rubin, M.D.pcbTom Leithbev M.D. Recent comment authors
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Sebastian LEDERER
Guest

A group of French students will come to the Silicon Valley in the first week of june.
We will discuss the subject “Access to Health Care for everyone”. If you want to participate in our project (whether you like to meet us or you want to give as an advice), dont hesitate to contact us.
http://www.le-moho.com/
sebastian.lederer(at)student.ecp.fr

Herbert Rubin, M.D.
Guest

Interesting that this “Universal Health Insurance” scheme was killed in the very liberal Health Care Committee of the California Lesiglature, headed by Rep. Sheila Kuehl, a long-time advocate for universal care. Even she gagged on the back-breaking price tag, when the state already has a $14 Billion budget deficit, growing daily.
Los Angeles today announced the closure of all their health clinics. No money.
Any bright ideas by you wonks?

Anthony Wright
Guest

To Brian: I didn’t question your credentials, experience, or intent; there’s not need for you to do so toward me. I merely responded that your post dismissed a major health coverage expansion that would provide significant benefit to millions of Californians. And I acknowledged it wasn’t perfect, but that advocates were working to make it better. What I didn’t see in your post is what you would propose in its stead. By all accounts, in your post, you support major components of the proposal. I just don’t understand why this is an either/or proposition. It seems that many reforms are… Read more »

pcb
Guest
pcb

“Looking at the bigger picture, I do believe that medical care should be given with the patient’s entire picture in mind. For instance, my father’s doctor once wanted to give him coumadin for atrial fibrillation even though he was going to die fairly imminently from metastatic cancer. Coumadin requires careful monitoring with frequent lab tests and significant risk of bleeding. This made no sense for my father’s quality of life. This is what I mean by mindless application of guidelines, and I am beginning to suspect it occurs for financial motives – unacceptable in my view.” Just wait until Barry’s… Read more »

bev M.D.
Guest
bev M.D.

Tom; Your point is well taken. What I left out were 2 things: 1. defibrillators are widely overused; e.g.implanted in people with a very small chance of needing them, enhancing my suspicion in this case; 2. the patient was unable to give informed consent for a procedure which was not without pain to him and, indeed, suffered a complication which caused him more pain and actual risk to his life. It’s not like someone just refused to give him a routine medication or something; this is a procedure that requires a careful cost benefit analysis in an alert patient also.… Read more »

Tom Leith
Guest
Tom Leith

> Dr. Kibbe’s example of the defibrillator in the > demented patient illustrates just how broken the > physicians’ side of this situation is, also. Ummmmmm. Of course we do not know every detail of this case, but “severe dementia” is not evidence of “overutilization”. If the cardiac condition this poor man apparently suffered would not interfere with his daily activity or pose a serious risk to his life, then the overutilization charge might stick. Otherwise not. I do not want a world in which some combination of “demented” or old or mentally retarded or fat or Jewish or poor… Read more »

bev M.D.
Guest
bev M.D.

Barry; I agree with you. I think some docs would welcome more studies on comparative effectiveness (which everyone agrees are sadly lacking in today’s corporate-controlled medical research) and would make an earnest effort to incorporate the findings into their practices. Those who don’t must be incentivized to do so – although having to be forced is, in my opinion, already a sign of lapsed ethical behavior. However, guidelines can be mindlessly applied, also. An example is my 86 yr old mother who has been in a vigorous and formal exercise program since her 60’s, owns and operates a sailboat, etc.… Read more »

Barry Carol
Guest
Barry Carol

Bev, When I read Dr. Kibbe’s post about the defibrillator implanted in the patient with severe dementia, I was appropriately outraged as a taxpayer. At the same time, it also appears that there is a lot of low hanging fruit to be harvested if and when we get serious about determining comparative effectiveness and rewarding best practices. A Comparative Effectiveness Institute, in addition to evaluating drugs, devices and therapies against alternatives, could also examine treatment strategies for specific conditions in the other OECD countries. In other words, how do doctors in other countries define good, sound medical practice under various… Read more »

bev M.D.
Guest
bev M.D.

Barry;
Well said, as usual. However, Dr. Kibbe’s example of the defibrillator in the demented patient illustrates just how broken the physicians’ side of this situation is, also. Watching my own family receive poor medical care adds to my impression that, as my (also retired M.D.)husband says,
“Doctors have given up medicine.” We need something drastic on their side too, something like DRG’s for doctors. I don’t see P4P, as it is currently structured, being effective.

Barry Carol
Guest
Barry Carol

Brian, I have a little different take on this. With respect to the CA proposal, the biggest hurdle is likely to be winning voter approval for the various funding mechanisms, and we won’t know how that plays out until November, 2008. Assuming something like the reform package passed by the Assembly also makes it through the CA Senate, and voters approve the funding mechanisms, the uninsured population still would not be eliminated but it probably would drop into the mid-single digits as a percentage of the state’s population. At the federal level, post the 2008 election, I can envision something… Read more »

David
Guest
David

Just my point as well we are a nation under the control of Corporation. We fear our jobs and make the decisison for these corporation even if its against our moral values. People working for these Ins.Company’s will go home each night thing what a Great job they did at the end of each day without having a second thought. The Corporation have us wright were they want us, we the people and employees are under their control. It’s sad to no that people will do anything reguardless of the outcome even if they know it may affect there own… Read more »

Brian Klepper
Guest

Eric,
This is the critical, core point that you and I agree on. So long as health care is structured to benefit its professionals and corporations more than its patients, it will continue to weaken the fabric of the country. It is impossible to fix health care until we fix America first.
B

David
Guest
David

Insurance Company Greed There are many that would say the Heath Care Insurance Company system is broken an is in the need of a overhaul, I disagree the Insurance Company has been spending big money over the years in the overhauling of their system for many years now. They have spent big dollars writing disclaimers to their policies. Insurance Company makes Heath decision based on your coverage or what coverage they can deny. The cost of writing those disclaimers is past on to policyholder as a cost of Good Business. Corporative greed drives good people to make money at any… Read more »

eric Novack
Guest
eric Novack

Brian- the seiu issue is not a side point— it is THE issue. Whether it is the SEIU, hospitals, doctors, insurers, oxygen suppliers, or home health care– the problems come from investing power in a bureaucracy that will have control over a budget that, in many cases, will exceed the entire budget of any state currently. The SEIU may be the “flavor of the month” this year, but things change, and the next group will get the special deals at the expense of you, me, and everyone else being able to make our own health care choices. Freedom has been… Read more »

Peter
Guest
Peter

Posted by: Anthony Wright “It contains significant language to introduce cost and quality transparency into health care, and a large purchasing pool that will have the ability to bargain for better cost and quality.” Anthony, Who would that large purchasing pool consist of – individuals? If individuals, how would they have the ability to bargain collectively for that, “better cost and quality”. There is a large individual market now that hasn’t been able to crack the cost factor and doesn’t know the quality factor until it’s too late. Would the insured be able to get quotes from hospitals on procedures,… Read more »