By THCB Staff
Now that the results are in and the United States has officially elected Barack Obama as its next president, what does that mean to you and what will that mean for health care in America?
After nearly two years of campaigns, countless pages of material written about Obama’s health care plan and the possibility of reform, the U.S. has elected a Democrat as president and put Democratic majorities in both the House and Senate.
What do you predict the next four years will bring?
This is your space to reflect, comment and debate. Please share your thoughts, and let’s get a vigorous discussion going.
Categories: Uncategorized
I hope that President Obama will read Robert J. Samuelson’s article in the January 19, 2009 edition of Newsweek. Every point is well taken.
I AM UNCONFORTABLE WITH ALL THE TALK ABOUT COMPUTERIZED SHARING OF MEDICAL RECORDS. I FEEL THIS WILL MAKE IT EASIER FOR INSURANCE COMPANIES TO DENY COVERAGE FOR PRE-EXISTING CONDITIONS.
Given the current economic crisis, I find it extremely difficult to believe that any health care proposal which expands coverage through government management will find consensus support in the legislative body. What I hope… no, what I pray is that Obama’s message of change reflects a true desire to find new solutions to our complex economic and social problems. I invite the readers on this site to visit my website (www.containedcapitalism.com) and review an economic theory that provides, among other things, a unique solution to the health care crisis. I am NOT selling anything; I only ask for your support. Thank you!
ITS THE HOSPITALS, STUPID!
Honestly consider the following:
Most doctor visits really cost at most $120.
I don’t know about you, but I don’t go to the doctor that often. Maybe 4 times a year. I can afford that, same as I can afford to fix my car. It is unpleasant. I’d rather spend my cash on other things, and I maintain my car so it won’t happen too often. BUT!!!!
HOSPITALS SCARE THE CRAP OUT OF ME. I don’t know how they get away with charging what they do.
Let me explain: As a purchaser for a medical office I know what medical supplies cost. At a recent visit to a hospital I saw them marking up products 7000%!!!! So when a “charity” hospital hits me with $120 for a CBC lab that I know costs under $2, I have to wonder, “Why isn’t this illegal price gouging?”
(If I were in need because of a hurricane, and my Quick-E-Mart tripled the price of water bottles, there would be outrage. I maintain that a person in medical need is just as desperate as a thirsty disaster victim. Demand is just as fixed. Yet the hospital is allowed to price gouge the sick.)
THE ONLY REASON I NEED INSURANCE IS BECAUSE HOSPITALS ARE ALLOWED TO PRICE GOUGE.
Truly, if their markup were just average retail (50-100%) most of us could break a leg without fear of bankruptcy. If hospital charges were transparent, predictable, and reasonably marked up, we would not need insurance.
And since government is already in the medical business up to its elbows, let’s allow more than the current 13% of healthcare dollars to make it to the patient. Instead of allowing insurers, billers, coders, extra staffers, and EMR designers to abscond with this money, just open government clinics. Many, many doctors would be overjoyed to work 9-5 for a straight salary and no fear of lawsuits. Those outside the system would have to answer to their paying customers, the patients, or lose them.
The breathtakingly simple solution is often the best.
Does it make sense to try and jump start an ailing economy by focusing on the implementation of a “universal healthcare plan” for every U.S. citizen? At this critical time in our great country’s history, is it time we resolve these tumultuous challenges with equally breathtaking solutions? From private industry to public education, from small businesses to giant corporations, from young to old, literally, from the cradle to the grave, a country as great as ours needs to figure out a way to ensure the wellness and security of all of its people. With the gargantuous “bailout” package waiting in the wings and trickling down to a lucky few, perhaps it is time to link healthcare coverage for all with a economic stimulus package that cuts across all ages, all socio-economic boundaries, all areas of the economy both public and private, and assist every industry, by assisting every individual in this country with securing the dreams of our founding fathers to pursue the happiness and prosperity alluded to in our Constitution, and extending a helping hand to our fellow citizens by implementing a “universal healthcare policy” within the first 100 days of our new administration. This effort, if successful, would lift the chains of healthcare costs off of the backs of millions of individuals, school districts, and businesses, and set us free to jump start our ailing economy by freeing up the current dollars we are allocating and spending on healthcare coverages across the land. These dollars would be used by millions to pay off debt, save, purchase goods and services, and invest. Every American would benefit from a “healthcare bailout package”, not just the sacred few on or near Wall Street, although they too would be benifactors of such a plan. This plan wouldn’t have to cover 100% of all healthcare costs. People could still purchase “catostrophic coverage” or additional coverage, if they so choose. People will argue that taxes will go up in order to cover this plan. That may be true. However, will it be more costly than your current healthcare coverage, if you can afford it? We are already paying for the medical costs of our most disadvantaged via welfare expenses, or in our current healthcare coverage fees. What would it really cost? Instead of bailing out a few of us who need it, why not bail our all of us who need it. Has the time arrived for “universal healthcare for all”? A county which looks out for all of her citizens, is truly a great country.
Much of what Jill presents as issues is correct, pre-existing complaints, delayed claim payment, issues surrounding group coverage and local marketing. Fraud is factored into all premiums at a rate that would astound many and this factoring includes a profit margin for the insurer. Jill calls for grass root attention to the problem, says that waiting for Washington isn’t an answer but in almost the same breath asks for congressional hearings.
I would suggest that some of the results demonstrate an opportunity. I agree that the current state of affairs with healthcare being addressed through states and even local markets is a problem. I would go a step further and identify that allowing the insurer to create its own risk pool based on employer groups, zip codes and other self-serving factors is a major portion of the issue. It allows the insurer to “cherry pick” in a locally allowable fashion. End this form of discrimination by disallowing all “pre-existing” conditions, define risk group as all residents of a state irrespective of employer, etc. and mandate that any insurer selling health insurance in the state must offer and allow purchase of the same health coverage to all residents of the state.
If one looks at the health care coverage that is offered by the insurers, one will find countless plans that vary in actual coverage, vary in the amount that is covered, how much is obligated to contribute in co-pay, vary in amount that must be first spent by the insured before coverage takes effect, and on and on. Define a single national healthcare package and mandate that coverage for all residents of the US. Not possible many would say, but it is already happening and has been in place for over 40 years. It is called Medicare and those companies paying such large CEO salaries and bonuses operate successful and profitable Medicare programs on just a percentage of the Medicare premium. It is doable if the various legislative bodies would simply act in a rational fashion that would serve the American population. This is where hope exists in the Obama mandate.
Create a system which must meet certain requirements such a med loss ratio of 85% of all gross premium dollars. Coverage can be extended to all and contrary to a decrease in quality, insurers will be forced into higher quality performance of they do. That is to provide coverage at a reasonable premium and not measures of hospital and provider duties.
In a blog it is not possible to fully define the necessary steps but merely to introduce a concept. The real work is to take that concept and build a functioning system. Our current system functions very poorly and it is contributing in a major fashion to the current economic problems.
It is imperative that all the bloggers here- obvioulsy you care enough about the issue to opine your views, contact you local doctors, hospital, town boards, county commissioners, state government and yes, your congressinal representatives to urge (better yet demand) the formation of a Healthcare Reform Coaltion that begins its work at the grassroots level.
A complete fact finding commission needs to be conducted of the issues facing patient’s and providers at each state level at the very least. The isurance and pharmacy industries are well represented by lobbyists but patient’s and providers are not. Further, our healthccare system has been state and even locally based. In other words, it is different in every state and can be different in various regions within a state. For instance, each state has its own legislation that governs the health insurance industry and claims process. If we leave the issue of determining what the problem is and ultimately what the solution should be to Washington, any new system will be fraught with failure from the get go unless the current comprehensive system is addressed and its current problems revealed. I would even advocate congressional hearings to do so especially to determine insurance policies and practices much less a meaningful discussion of premiums paid versus claims paid. FYI: Cigna CEO paid $15 mil in 2006; Aetna $32 mil and profits projections the same year were $15.39 billion for the insurance industry-wide. No wonder the insurance lobby works hard to keep the status quo.
What most patient’s dont know – 1) providers pay a 20% discount to insurance companies for the ability to accept their patient’s insurance, this discount is most often NOT passed on to the uninsured, underinsured or patient with a deductible- the cash patient and in fact providers are advised it is “illegal” (insurance fraud”) for us to do so. In fact I have been advised I cannot advertise a cash patient discount and I cannot have a fee schedule with reduced costs for cash patients’; 2)claims are routinely denied for false reasons (cannot verify patient’s sex on non-gender realted claim); 3)claims are continually denied for pre-existing conditions on long term policy holders; 4) claims are allegedly never received (despite electronic verification) 5) claims are delayed unreasonable periods of time (90 to 120 days for payment on $42.00 claim). This is just the provider side. 6)All claims are scheduled per insurance company so even if the provider increases their rates, the insurance company does not pay the increased rate unless negotiated by contract which may only occur annually or every 2-3 years.
In some states group health insurnace policies attempt to protect patient’s from pre-existing conditions. If you change insurance from one employer to the next, you go “group to group” and by state law no pre-existing condition can be assessed. Patient’s claims are routinally denied as pre-existing unless they submit a certificate of continuous coverage. Most patient do not know what this is, its difficult to get and are billed when the claim is rejected without any attempt to obtain the verification.
The insurance and pharmacy industries are quick to blame the high cost of healthcare on the providers (overcharging, unnecessary procedures etc.) and the patient’s (unnecessary visits for routine matters). If the patient population is to take back its own healthcare in America a major unveiling must take place of the current smoke and mirrors that is taking place.
I have read multiple books (dated since 1992) stating they have discovered the problem and know how to fix it and not one author has yet to reveal the comprehensive picture. So far all the pro-offered ideas are problematic: 1)health savings plans to avoid employer based plans will allow high premiums to continue without addressing the very poor claims process, pre-existing conditions will be the norm, discounts will be horded by the insurance companies only; 2) universal health care insurance will perpetuate all the foregoing as well as potentially cap fees for providers to Medicare level. A $42.00 office fee is paid as $20.22 under Medicare. Only a non-profit subsidized health care provider will stay in business at that rate. Which may not be a bad idea, but immediate concerns arise as to the quality of health care that can be provided when a clinic only takes in $20.22 to pay for doctors time, staff time, facility bills, taxes etc.
This is an extremely monumental problem that cannot no longer be ignored any more than the economy or the environment. The above blogger notes “look in the mirror”. This is to say, we are only to blame ourselves for where we are and where we will stay if we choose to do nothing. Ask your local physician what they are doing to get involved, ask your local town and county council members what the local government is doing and demand that the state and national governments start the process to listen and learn what is wrong, formulate reasonable, necessary and meaningful new policy to correct the problems and move forward to better the system. This will take more than 4 years, or even eight. If may take as long to fix the current health care system as the time within which it took to create.
I think the problem with this whole discussion is that it assumes that insurance is necessary in the field of health care. People “insure” events that are truly accidents or freakishly happenstance incidents, like a house fire or car collisions. Health care is not a rare occurrence or unpredictable, it is needed from the moment we are in the womb. We are on a course toward death from the moment we are born, and to introduce and willingly invite a complicated entanglement like insurance and the salaries of all those additional paper pushers into every simple transaction is part of the very problem. We are making a contract with a company whose bottom line is ironically dependent on honoring as little of the contract as possible. Once a costly medical condition is learned of, the company can simply drop you after the coverage period expires and or affix your premiums such that you are essentially paying for your own disease thereafter. Not to mention the buffer insurance creates between the end user and the outrage that should occur over cost, since medical provider related costs have no actual value to the services rendered. Because of these endemic flaws, at some point, this discussion needs to escape the insurance paradigm altogether and start calling the health care community to account for their costs for certain procedures, lab tests, pharmaceuticals, and stop hiding behind R&D, plaintiff lawyer driven malpractice rates, etc.
As a card carrying conservative and a pro-free marketeer, I think it is logically consistent to say that the entire health care industry should simply be taken over on the basis that they are essentially behaving like monopolies. There is a bit of hypocrisy in weilding the free market club on cost-affixing type regulations, when we already tolerate so many other regulations, such as who can practice medicine and whether certain pharmaceuticals can be received without a prescription, how many hospitals will actually get CONs, etc. When a hospital receives a CON (Certificate of Need) to set up, it prevents any other hospital from competing against it within a certain radius. (How about that– we give them a street corner monopoly and then tell them to divine their own “fair” prices for services rendered). The AMA artificially limits the number of doctors that can graduate, makes them endure unnecessarily tiresome residencies, all in an effort to increase their fees later with a smaller pool of physicians. We can’t have these kind of practices undermining the affordability of health care and then selectively argue that government should stay out of private enterprise.
The issue is not whether health care is an entitlement or a privilege. The issue is what does it say about our culture that the treatment of the infirm and the weak has to be done at such an exorbitant cost and with essentially no oversight, since an insurer technically has a perverse incentive to want higher health care costs, as it will simply be reflected as higher premiums. If we are to call ourselves civilized, where we do look out for the interest of the weak and feeble, we would never tolerate usury in loans, yet we do not blink an eye and simply accept the high costs claimed by the medical establishment as proper, necessary and fair.
One can never have affordable health insurance until health care itself is affordable. This should be our battle cry, and for Congress to start regulating the cost of medical procedures, pills, lab fees, etc. We could do this like other countries, where a family will pay in about $200/month, and then the government informs the industry that that’s the pot, now let the industry figure out who gets what.
Neither the out of touch Republicans saw this issue as is made clear by McCain’s seriously deficient proposed plan, nor Obama in his Harvard professor concocted, just as expensive, no caps plan. Ralph Nader’s observations about Obama’s actual willingness to do anything meaningful to remedy the situation or side with the big HMOs and PPOs is yet to be seen. As another article put it, it will be interesting to see if Obama can actually do something to rearrange the food supply for this $2.5 trillion dollar monster before the monster can organize and prepare the masses to sing the woes of Canada, as the public blindly ignore the real enemy.
I like to think that the “hope” that Obama talks about goes hand-in-hand with public responsibility and participation. Obama talks about listening to the people, and insists on public responsibility. If anything, the hope door that he opens should be seen as one where the public is expected to take more active participation in the process by contributing ideas, and getting involved. At least he gives us the idea that he will not ignore us, and that he does expect us to talk to him and his administration.
At the same time, I can’t help harbor a gnawing feeling of potential betrayal, as an old curmudgeon that I am, It’s not easy for me to trust, not even Obama’s powerful words. Nevertheless, I think I find myself compelled to give it a final try before I check out, in the hope to leave something useful for our future generations.
If we as citizens stay in touch and tell things to power as we see it, we have a chance to get what we want.
Most people I know spent their lives telling themselves and others, “Nothing will ever change, and there’s no use in talking or writing or complaining…” I like to think that what we saw in the last election was the power of the people, not so much in electing a good man, but showing that in unison we can make our power count. Add to our resources the fact that we can use Internet to communicate to many quickly, and we have a good chance of winning for ourselves and ours.
We’ve often been shy to say things because we saw ourselves as closet left or closet liberals, and the previous conventional wisdom hammered us into believing we’re a minority.But here’s another thing this past election shows us… and that is, that we are not a minority.
Has anyone seen a universal health care plan in the proposed stage?
I think it would be rational to create such a plan, or if it does exist, review it and comment and so forth. I think popular participation and knowledge will be important in creating a system based on people’s real experiences and needs, instead of waiting for Congress to propose something and then react to theirs, with not enough time to debate issues which should have been debated earlier.
What I hear from most people is that they prefer a single payer system, with proportional contribution based on income.
My question is how to integrate the existing infrastructure of HMO’s and Insurance companies into a single payer system. As noted in the above comments, the health business is profit driven, rather than any overwhelming social mandate. So a question to answer is: Can the existing infrastructure be encouraged to change it’s purpose from a profit driven one to a social benefit? I think such would have to be legislated, which I doubt would happen. On the other hand, the Health System Administration would be obligated to purchase the necessary infrastructure from existing HMO’s and so forth.
I like to hear other ideas of how a single payer system could work.
Peter, now you are completely off track. Based on my personal knowledge as an insurance executive, I can assure you that that premium costs, coverage and the entire system of control is driven by profit in the insurance industry.
You are so far off base with respect to a single payer system and nothing about it would fit the American scheme or marketplace. What I suggest is competition among the insurers based on their premium, coverage and service in a free marketplace. Insurers are not providers. Insurers are payers and that is all. Let them compete on what they do, not on the coat-tails of physicians and hospitals.
Insurers will drive down costs in order to increase their volume and hence their gross profits. It is the same thing that they have been doing with physicians for years. Medicare promised a reduction in paper and it is now one of the most bogged down tree wasting organizations in the US. I can fully attest to that as a physician and as a former physician executive and physician reviewer for Medicare.
What I have proposed in my original comment is not a patchwork but a 180 degree change in the system and one that has many other aspects. It is based on over twenty years experience in healthcare administration and finance. All I have provided is the initial steps. Go back and take a look at it again.
Richard, I think you’ll find as has been dicussed here before that insurnace profit is not what drives costs, or at least the bulk of them. I certainly think that getting rid of all insurance companies (through single-pay) would not only get rid of profits but also reduce paperwork and overhead, a better way to reduce insurance costs even for providers. You will not get competing insurance companies reducing their reimbursments to drive down costs because providers will just not use them and we will have a worse provider patchwork than we do now.
Peter, I agree that leaving it to Insurers alone would not produce the desired result. The fact is that they would drive down the costs of provider payout but with a constraint on their profit margin being required to show that 85% of all premium dollars would be used for provider oayout. Any surplus would offset the following year’s premium and not accepted into their profit margin. Their profit growth would be based in volume of dollars and not as a percentage of premium. In the ideal, the administrative costs of a health insurance company should be approximately 10% leaving a respectable profit margin of 5%. It is respectable but not sufficient to excite Wall Street.
In part, these constraints will produce a more competitive industry on their product which infact is cost of coverage. My experience in the healthcare system and the insurance industry confirms this.
Insurers are not providers of care and it is time we stop handling them as such.
Richard, trying to rely on insurers to control costs will not work. They simply pass costs on and have shown they have no desire to control costs – except their own health payout costs. If you want “risk” leveled by state I think the insurance companies will gladly do it – by raising premiums. Using taxes to pay for healthcare is something I support, but when not done through a single-pay system would not reduce costs, no matter how many insurers compete for the business the input costs will still be the main driver.
The economic situation we are facing will have a significant impact on any likely health reform.
Here are some things that need to be addressed:
-Defining the fragmented health care industry
-Controlling the inflated health care prices
-Pass SCHIP
-Study the success of other countries’ health care delivery system, but have it tailored to the U.S. as it grows in population. Maybe consider health reform from a state level vs nationally.
-Empower individuals to set up proper health habits so to reduce chronic conditions and other preventative ‘diseases.’ This in turn will reduce the number of hospital visits.
Those who think the French have a more efficient healthcare system need to consider that the French have likely a much more healthy lifestyle and less exposure to enviornmental health deterants.
The real problem with healthcare in the United States has gone completely unaddressed by all: Chronic Illness is more likely to happen to an American than to a French citizen. Why? The answers likely lie in our food supply and in our permissive attitude toward enviornmental toxins etc — but special interests will keep this discussion from entering into the political discussion.
Change and Hope are the two words and the essence of what Barach Obama has offered to the populace. Yet within healthcare we continue to muddle along with the same old concept of financing which has been patched so often, it is no wonder that there are more leaks developing.
I would propose that rather than patch the existing system, attention should be paid what is meant by costs and how to share those costs equitably. There is the cost of delivery by the provider and the costs associated with that delivery (therapeutics, pharmaceuticals, supplies, etc.) and then there is the cost to the payer for what is delivered by providers including all of the above. The insurer can embelish or add to that basic plan based on their competitive advantage in the state or region but not at any increased in the basic premium. The same is done in Medicare and payers still profit.
The payers have developed unique and self-serving means of addressing their costs and assuring their profitability. One of these is the use of risk pools. Others include co-payments, uncovered services, preferred provider networks, just to name a few. These adjustments would be eliminated except as defined by the national oversight group.
The largest insurer in the U. S. A. is Medicare and it has attempted to control costs by addressing the providers and history continues to bear out that while control at this level initially shows a positive gain that over time it does not work. Interestingly, many payers even accepting only a percentage of the premium of Medicare A and B are able to generate profits. Risk pools do not apply to the Medicare population indicating that it can succeed.
What I would propose to the new administration is a fresh approach to health care financing that would apply to all residents of the country. I am not in favor of a single payer system but I do believe that some control and containment must be placed on the the existing payer system in addition to containment at the provider level as promulgated through Medicare.
I would propose a national referendum that would require that any payer seeking to sell health insurance in any state or region (an area composed of more than one state)be required to offer that insurance to all residents of that state or region as members of the same risk pool thereby eliminating zip code and all other false and dubious means of creating a profit/loss center and at the same premium level. Sveral payers might compete within a state or region based on their product and how well they can contain and control costs.
I would further suggest that the insurers be required to provide a single basic national health coverage plan which for argument sake might be exactly what is provided to members of the Senate and Congress of the USA. The definition of this national plan certainly could be addressed by the oversight health care group bproposed by the president-elect.
As to payment for this system, I would propose that be a state or national tax applied to all individuals (both real and legal)and a matching tax by the employer and there would be no opt-out for any individual, employer or employee irrespective of the number of employees. These tax dollars would be distributed as premium for each resident insured by the payer for that region. The payer would be required to maintain and 85% med-loss ratio on these premium dollars.
The “uninsured” population is a tricky problem today since it includes healthy young adults who have elected not to have coverage, so called “illegal aliens”, health insurance risks, and the un-employed and unemployable. By having contribution when employed as mandatory and removing any option then we will eliminate a significant percentage of the current “uninsured” and provide a better defined group that can be assured coverage through a program like or or similar to Medicaid and defined as a “national risk pool”. Also with one risk pool we eliminate those being currently denied coverage because of their health status.
This basic approach is “CHANGE” and it opens the door to making health care available, affordable and guaranteed to all residents of the USA.
The healthcare system is complex and the intial beginning briefly laid out above does not pretend to be the complete answer but it is a starting point from which true costs can be defined and controlled.
Has anyone mentioned that Obama did not mention healthcare in his victory speech?
Not once.
He talked about investing in schools, infrastructure and alternative energy. He talked about Iraq–and other challenges–but not healthcare.
Why? Because to many people “healthcare reform” means promises of universal coverage, and Obama knows that he cannot do that right now.
He also knows that investing in healthcare would not create jobs. If reform were done right it would eliminate some jobs (closing hazardous hospitals, curbing proliferation of reundant technology) while also creating some jobs (for instance community health centers.) But net, net, there would be a job loss.
(It would be nice if we could hire more nurses and primary care docs, but no one wants the jobs . . )
MOreover, Obama knows that pouring money into healthcare is pouring money into a broken system–sending good money after bad.
I agree that there are some things he can do: eliminate the windfall for Medicare Advantage Insurers, expand SCHIP, redistribute the dollars on the Medicare fee schedule (in a budget neutral way) begin experimenting with other ways of paying docotrs and hospitals for outcomes (in a budget neutral way) . . .
It would be great if we could invest in electronic medical records. But the other priorities–getting soldiers out of Iraq, poverty, the 10% unemployment that is probably in our future— these will be immediate problems that have to come first.
Maybe the administration can figure out ways to motivate the private sector to invest in EMRS. Over the next few years, I suspect Medicare will be getting the message out that if you want to do business with Medicare, you will have to have healthcare IT.
Finally, I think Congress will go ahead with the Comparative Effectiveness Institute. There is a lot of good comparative reserarch already out there–done in the U.S and abroad. Medicare just hasn’t been allowed to use it.
Recently Medicare tried to use it to lower fees for much diagnostic testing (of marginal benefit). A court said Medicare can’t do that. The Obama administration should figure out how to intervene.
So much of the problem in our system is the indiscriminate use of advanced medical technology. The
Obama administration understands this. As does CBO director Peter Orszag. I hope he becomes part of the administration. (I’ve been writing about his thoughts recently on http://www.healthbeatblog.org)
My sense is that the new Obama administration will not be able to pass comprehensive health reforms, and they are smart and experienced enough to know this (see Michael M’s comments above). Rather, they will chip away expenses where there is the political will to do so, e.g. reversing privatization of Medicare and giving Medicare the power to negotiate with pharma for Part D benefits. They will likely advocate for greater transparency of health cost and performance data, putting on public display provider-specific information to encourage national debate about value vs. costs of care. And they will push for both increased access to, and fairer compensation for, primary care providers, possibly including nurse practitioners and other mid-levels where they are appropriately supervised. I think that Obama’s health team understands the inherent value of primary care, but they will require a quid pro quo and ROI for any investments that are made in the PC system. This might come as a shock to some people, but it will be seen as enormous opportunity for others who have the business and IT controls necessary.
Most importantly, once the talent and systems are in place to do so, I think the Obama health initiatives will take incremental steps and reward what works, while punishing that which is wasteful or protectionist. It may take a few years, and it may not feel sexy or revolutionary, but I think we’ll see substantive change.
Regards, DCK
“the last thing we should be doing is copying flawed systems.
Deron, you might want to justify the word “flawed”. Below is an excerpt of a Canadian report done in 2002. And here is the link to the whole report: http://www.queensu.ca/cora/_files/MendelsohnEnglish.pdf
Since 2002 and this report much has been done to respond to the problems in the Canadian system, much more reform/change/improvement than the U.S. has done to its system in the same period. You might want to research what the citizens of other countries think of their government run systems as well – and I don’t mean anecdotal, “off-the-cuff, transitory response complaints”. Key point brought out in the report: “Canadians continue to overwhelmingly prefer the Canadian to the American system and reject the proposition that they would prefer to be treated in the United States if they had a serious illness.”
Canadians understand the realistic trade-off between paying for their healthcare and using it, because the cost is very transparent in their taxes.
“Canadians very much like the current Canadian health care system model, with 88% saying that a strong, national, publicly funded system is important to them (Figure 1). They have a strong symbolic attachment to it and overwhelmingly prefer it to others with
which they are familiar. Canadians strongly believe that the government should pay for the health care of all citizens (Figure 2) and believe that the health care system is a public good. During the past decade, however, Canadians have undergone a quite dramatic reevaluation regarding the performance of the system, concluding that the system has deteriorated. While 61% of Canadians thought the system was excellent or very good in 1991 (and an additional 25% thought it was “good”), only 29% shared that view in 2000
(with an additional 34% saying it was “good”) (Figure 3).Despite this perceived decline over the past decade and dissatisfaction with a number of key aspects of the system, this report shows that Canadians continue to prefer the Canadian model. They have reached a mature, settled public judgment, based on decades of experience, that the Canadian health care model is a good one. Some public opinion polls elicit off-the-cuff, transitory responses to recent events, while others represent informed and relatively stable preferences that reflect people’s deeply held views. The
latter can be thought of as “public judgment” rather than just “public opinion,”2 and Canadians’ Thoughts on Their Health Care System although Canadians are still grappling with what to do in the future, they have reached a public judgment about the past: they like Medicare and think it should be preserved.This public judgment is reflected in the fact that the overwhelming response to perceived deterioration has not been to reconsider the model, but, as shown in this report,
to call for governments to fix the system through better collaboration and management, the injection of more funds, and small modifications. Canadians are aware of the challenges faced by the system and are increasingly open to some experimental modifications, but policy debate on potential changes should be predicated on the presumption that Canadians like the Canadian health care model, have an attachment to
the present system, and would like improvements designed to reinforce the system with which they are familiar, not undermine it through radical change. Canadians continue to overwhelmingly prefer the Canadian to the American system and reject the proposition that they would prefer to be treated in the United States if they had a serious illness. The results indicate a strong symbolic attachment to the health care system and likely measure to some extent the importance of Medicare to the Canadian identity, but they also show a real preference for the Canadian over the American system (Figures 4, 5 and 6).
I hope we don’t see the Clintonization of Obama’s administration. No issue pulled at more heart strings on the campaign trail. More stories about working people and families that couldn’t afford healthcare. What happens to all those people while advisors sit around and decide how long to put this issue off. At lease take measures that bring some fairness and affordability to the system while struggling families wait for something more rational.
If there is any big push for universal health care in 2009, it will come from Congress, not the Obama administration. And that push will only happen if Senate leadership believes that 60 votes can be finagled in the Senate. And I suspect that will only happen if the bill is something very roughly like the Massachusetts model (multi-payer, minimal or no changes to the provider payment system).
My hunch is that Obama will go for two relatively easy wins in 09, perhaps both in the first 100 days: universal child coverage through expansion and redesign of S-CHIP, and large-scale HIT infrastructure investment.
Why S-CHIP: Because he told us so, because insuring children is relatively inexpensive, because doing so is a much easier sell with the public than full universal coverage (who doesn’t want to protect innocent children?).
Main opposition to S-CHIP expansion: budget hawks and anti-social program ideologues. Worries about crowd-out effects will be most prominent. At least token efforts will be made to address this, and then the opposition will be overwhelmed.
Why HIT: Because he told us so, because there is a widespread belief that it will have a positive ROI over time, and because it is the kind of investment in upgrading American infrastructure that has become central to Obama’s plan for recovery and growth.
Key item to look for: Does the program have a plan (with money to push and teeth to pull) that creates a functional NHIN within 10 years, in which essentially all providers participate? Without it, there will be no net savings from HIT.
Main opposition: the hospital lobby and privacy advocates. The hospital lobby understands that the bulk of savings from EMRs connected in a NHIN will come from their revenue. It will push for HIT investments that are primarily for EMR adoption, eRx, admin efficiency, and quality improvement. It will resist efforts to require meaningful participation in health information exchange. It may win. The privacy lobby will spread fear of change, as it always does. It’s efforts won’t block an NHIN, but may put up so many roadblocks to efficient and effective use that it is hobbled for the near future, until we get used to it and get over it.
I think there will also be a significant initial effort at payment/incentive reform in 2009 or 2010, but my magic ball is suddenly cloudy on what it would look like.
Deron–Would love to meet for that metaphorical beer. If only we could get Wellpoint/Anthem and others, like my former employer Humana to look past the next quarterly report and really see what they could do to provide meaningful reform. I think the easy way forward for the Feds is to think about allowing aging boomers to opt in to Medicare for a price–thus opening the competition with the insurers–eventually moving the opt-in age down to 55, maybe even lower. Too many people want to retire early or change careers, and health insurance is quickly becoming a set of handcuffs to those who can be more productive elsewhere in their careers. This will be the spark that moves the Feds, so insurors–take the opportunity while you can.
botetourt – I am one of those “market-based” proponents that you were referring to, but I do agree with the points you made. We have a window of opportunity to work something out before the government does it for us? The system isn’t working well and we can blame the industry all we want, but that doesn’t change the fact that the industry knows healthcare better than the government. Unfortunately, we in the industry have been selfish and greedy, and we have not worked well together. That needs to change, and I for one am willing to sit at the reform table and admit my shortcomings and provide input into real solutions. The question is, where are we meeting and who’s buying the beer?
A long, deep recession sufficient to make a significant percentage of the middle class families lose employer-based health insurance would, ironically, give Obama and the Dem-controlled Congress a great opportunity to reform the U.S. health care system. Despite Obama’s considerable political skills, I doubt he will be able to achieve much beyond incremental changes until middle class voters feel that they have more to gain than to lose from fundamental change.
While it’s hard to root for such a recession, it might well be in our country’s long-term best interests…especially if the nadir occurs several months before the mid-term elections. What a political window that would be!
Peter – If you’re setting your sights on the French, German, and Canadian systems, you’re setting your bar pretty low. Their systems aren’t exactly well-oiled machines. If we’re going to engage in real reform, the last thing we should be doing is copying flawed systems.
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“This administration,” not “my/our administration,” my friends (as McCain might say).
I worked as a volunteer for Obama in the health policy group, so my slip into “this administration” is more wishful thinking that we wouldn’t have to wait until Jan. 20 for THIS administration (the real one, of George W.) to end
Well health care companies can rename themselves as banks, financial services firms, or insurance companies and get in line for the bailout. That would get the ball rolling.
On a serious note, the Wyden/Bennett bill would be a good starting point and it could start during the lame duck session.
Wow, did you catch the “this administration” thing at the end of the Millenson post?
Was that cover being blown, the first of several THCB regulars on their way to DC, or what?
“health care will always be an important issue for this administration, even if other issues (war and peace/economic collapse or prosperity) appropriately take the spotlight at various times.”
I think you are on to something here, and it is something more people should take into account. Obama will have a lot on his plate for a while, he’s not going to be able to solve all of our economic problems in one week.
Expecting the worst possible outcome doesn’t really help either. I have a hard time believing that Obama’s Presidency will ultimately mean nothing or that nothing will be accomplished or changed. There are some things he is not going to be able to do, but I don’t see him leaving health care on the back burner for long.
Let’s forget the 30,000-foot analysis for a moment and focus on how the personal is the political.
First, Obama had, as he has related quite a bit, an intense personal experience with how insurance companies can discriminate against pre-existing conditions when his mother had cancer and had difficulty getting her bills paid. That history means he is not likely to be sympathic to Republican ideas of throwing everyone into the individual insurance market.
Also on a personal theme, Michelle Obama’s last job before quitting to campaign full time was with the University of Chicago Hospitals. True, she was head of community relations, but I’m sure as a senior exec she regularly attended meetings where all the challenges of running a modern hospital were discussed. In other words, she has some in-the-trenches insights.
Second, unlike any other president of the United States, Obama has health care policy expertise. He chaired a health care committee in the Illinois Senate and sponsored what became a law requiring hospitals to make their quality of care results public. He introduced a similar bill in the U.S Senate, although it received very little publicity.
Finally, health care “reform,” however one defines it, was a central theme of Obama’s presidential campaign from its very beginnings. When you combine his legislative background, personal feelings and political commitment, you get a clear picture that health care will always be an important issue for this administration, even if other issues (war and peace/economic collapse or prosperity) appropriately take the spotlight at various times.
All the negative comments about the French model forget to mention that for much of medicine the quality of care in that country is better than what most can expect in the US. At about 1/2 of the cost. Not a bad solution, IMO.
I hope that the fiscal impact of the broken healthcare system will force a real paradigm change in the next few years with a switch to a federal system. Airline pilots are federally regulated. Why should the active participants of the healthcare system be treated differently? A federally regulated healthcare system will be able to engage in real reform, across the board, faster than any other one. It sounds completely unpalatable today but another year of unmanageable record deficits may change the mindset of many people in this country.
Correction:
In my last post the last sentence should have read,
“In truth it has been this way for many years’
From HealthTrain Express
The overriding theme of the recent campaign season was and is “CHANGE”. The sea of jubilant Americans, young, older, all races, and backgrounds celebrating this victory of Obama for America demonstrates the power of democracy. Yes, democracy is more powerful than capitalism (run amok) and socialism.
We tend to think of black and white. Either left or right. During the campaign at times it was difficult to analyze the real deep meaning of either candidates proposals. There were many who feared this outcome, however the majority has ruled. It is obvious many of us have been left behind.
The outcome is not the death of capitalism, nor the onset of socialism, it is however the demonstration that capitalism and free markets have exceeded their inherent ability to balance the equation. One can argue that creeping entitlements have led us into this “dead end”. The normal market pressures have become dysfunctional.
George Bush’s policies and decisions ended when we invaded Iraq. We were caught up in a perfect storm of global events and economic turmoil.. and terrorism was the overriding theme for us.
Americans had never been attacked in the underbelly, or the heart of the nation’s highest peak (the World Trade Center). The events of 911 symbolized and unknowingly foreshadowed the events of the past several months. In reality these events were ongoing for considerable time. Our recent financial collapse has been blamed on the subprime mortgage meltdown. This is a smokescreen for what has been ongoing for the past ten or twenty years in real estate, credit markets, the consolidations of enterprises, the greed of the stockmarket, insurance industry, technology whether it was for the good, or for mindless entertainment among increasingly idle Americans, who had lost their direction.
We should have learned that actions should not always be based upon fear. We should also remember not to depend upon one person to lead us and/or save us from ourselves.
At the onset of the crisis I said “look in the mirror, there is the culprit”. Even those of you who are relatively successful depend upon inequality, and greed. How big a house, and how many do you need? How big a vehicle do you want? Is it based upon your life’s needs, or some other motivation. Some families with 2-4 children do need a larger vehicle. Why has the foreign car market exploded? Why have we had to export and/or outsource many of our vital functions?
I am not going to give answers here. I don’t know all of them, But we all, patients, payers, providers, and yes government need to assess what we have done. It has not been done to us. Look in the mirror.
While we have been counting the casualties, worrying about health care financing, the gradual and relentess increases in the cost of energy, and the innumerable eco- disasters the perfect storm arose and devastated capitalism as we knew it.
Our new leader is largely unknown, however he is extremely bright, a brilliant orator and politician. This inexperienced man defeated a powerful political machine, overturning the democratic party, just like a boat in the perfect storm. We must all row the boat together as a team to insure our success. We don’t expect a miracle, but more people now have hope.
No capitalism is not dead, nor is socialism taking over. It is not black and white.
President Obama is the perfect combination for our country, a man of color and white, an immigrant, a man who came out of nowhere, from a very modest background, raised by a single parent and grandparent. How familiar does that sound to you? It is not the American dream, but it is the American Reality.
Hope must come before prosperity. There is no prosperity without hope. As I drive to work through endless homes I always wonder, what is going on in each of those homes. Are they healthy? Do they have jobs? How many are living from paycheck to paycheck, unable to save or follow the advice of financial wizards? How many are sad?
How many have dysfunctional families? How many alcoholics and drug dependent people are in those homes? How many don’t have insurance? How many live in fear of losing their homes and/or their transportation. How many have latchkey children?
There are many more questions than answers. Statistics don’t tell the real story. They indicate the enormity of our problems, however as I drive through the neighborhood I feel the pain.
We as providers face these situations on a daily basis, unable to respond effectively for our patients, unable to commit sufficient time to analyze problems of poor health based on economics, family structure, anxiety and/or depression, limited income in a country with supposedly unlimted financial resources. In truth it has not been this way for many years.
I believe that the first step to improving the healthcare system is a national mandate for self-reporting of quality and all-payer cost data by providers of care and publication of national provider cost/quality scorecards.
Without a transparent ability of consumers to make educated cost/quality choices, market-driven reforms can’t work. Let’s roll up our sleeves and do the dirty work to establish a cost/quality database that will help consumers make educated decisions about where and how they get care. Providers of care need to stop standing in the way of the quality improvement that inevitably comes with public accountability.
Well, personally I would love to see Obama practice the diversity theme by enabling the states to have their own universal healthcare programs, including state versions of Medicare.
t
For many of the reasons stated above, there will be no real reform in his first term. In true American fashion, the pain threshold in healthcare remains bearable in the near term, and it won’t be until Obama’s second term that true reform begins to happen. The current (semi)market-based system has us spending well over two trillion bucks per year, with lackluster outcomes at best, so if tcoyote and his/her market-based friends have some real healthcare solutions, make sure they get some air time in the next couple of years–as those solutions haven’t worked yet. This is a time for the government and industry (especially big insurance) to start thinking together if the ultimate solution is not simply going to be big government. Let’s hope our insurors have learned from the auto industry–that the landscape can change very quickly and very catastrophically–if you don’t plan and act while the opportunity exists. We still have another few years to go…. and then the earth moves.
Personally, I would love to see Obama practice the unity theme by appointing a moderate Republican as Secretary of Health & Human Services. Medicare and Medicaid are a great place to start work on health care reform, and moving these two programs towards improved quality of health care and a patient-centered care model is within his adminstrative and legislative ability in a first term despite the economic crises facing the new administration.
“…with solutions developed by those that actually understand how a healthcare system should work.”
Like the French, Germans, Japanese, Canadians, Taiwanese?
I don’t envy the job he has in front of him and he’s not going to be a miracle worker. Certainly moving money around will be key, the Fed thinks that’s the way to do it. Maybe we can stop moving money to people (and corporations) who don’t need it to people who do – after all it’s “Country First” isn’t it. If McCain had won and lived up to his, “slash spending” promise he would have angered the same people. But growing deficits to fuel the economy and two wars may be at an end – thankfully. It’ll be interesting to see if Democrats will also want reform now as well, and what form they see it should take.
Polarized, left wing dominated Congress and a trillion dollar deficit are going to limit his ability to “unite” anyone. He’s going to have to cut federal health spending to pay for his promised tax cut for 95% of Americans and the host of domestic spending initiatives has promised. Yet cutting spending will anger seniors, hospitals and doctors and advocates for the poor. This is not an appetizing set of policy choices.
If he doesn’t “move money around”, he won’t have any money to address expanding access to care, a promise he adhered to through the end of his campaign. Congressional leadership will be anxious to reauthorize and expand S-CHIP despite the fiscal climate, as well as to punish the drug companies and health plans that were favorites of the Bush administration. Calling all of this “reform” will satisfy the Democratic base and accomplish very little in actually changing the system.
If Barack Obama is truly the “uniter” that he claims to be, then the best thing he can do for healthcare is unite the various stakeholders in the system and get them discussing real reform. We don’t need him devising solutions and moving money around. We need him creating a climate that is conducive to real reform, with solutions developed by those that actually understand how a healthcare system should work.
It probably means very little in reality. Recall all the hoopla about President Clinton’s healthcare plans which went nowhere.
I think an Obama administration will find its hands tied by an unstable economy which cannot support the increases in taxation required for his healthcare ideas. Remember too that Clinton and the Democrats controlled Congress and couldn’t agree on a bill. The Congress is even more polarized now and there is no indication that he will be able to deliver.
– More government-funded healthcare programs, which either means higher taxes or greater deficits for lower quality health care
– As government controls more and more of the health care system, they will control more and more of my personal health choices (a la France or Japan)
– Continued (or even accelerated) proof of the inefficiency and uselessness of the government