OP-ED

Saving Health Care, Saving America

So far, Congress’ response to the health care crisis has been alarmingly disappointing in three ways. First, by willingly accepting enormous sums from health care special interests, our representatives have obligated themselves to their benefactors’ interests rather than to those of the American people. More than 3,330 health care lobbyists – six for every member of Congress – contributed more than one-quarter of a billion dollars in the first and second quarters of 2009. A nearly equal amount has been contributed on this issue from non-health care organizations. This exchange of money prompted a Public Citizen lobbyist to comment, “A person can reach no other conclusion than this is a quid pro quo [this for that] activity.”

Second, by carefully avoiding reforms of the practices that drive health care’s enormous cost growth, Congress pretends to make meaningful change where little is contemplated. For example, current proposals would not rebuild our failing primary care capabilities, which other developed nations depend upon to maintain healthy people at half the cost of our specialist-dominated approach. They fail to advance the easy availability and understandability of information about care quality and costs, so purchasers still cannot identify which professionals and organizations are high or low performers, essential to allowing health care to finally work as a market. They do little to simplify the onerous burden associated with the administration of billing and collections. The proposals continue to favor fee-for-service reimbursement, which rewards the delivery of more products and services, independent of their appropriateness, rather than rewarding results. Policy makers overlook the importance of bipartisan proposals like the Wyden-Bennett Healthy Americans Act that uses the tax system to incentivize consumers to make wiser insurance purchases. And they all but ignore our unpredictable medical malpractice system, which nearly all doctors and hospital executives tell us unjustly encourages them to practice defensively.

Most distressing, the processes affecting health care reflect all policy-making. By allowing special interests to shape critically important policies, Congress no longer is able to address any of our most important national problems in the common interest – e.g., energy, the environment, education, poverty, productivity.

Over the last four years, a growing percentage of individual and corporate purchasers has become unable to afford coverage, and enrollment in commercial health plans has eroded substantially. Fewer enrollees mean fewer premium dollars available to buy health care products and services. With diminished revenues, the industry is unilaterally advocating for universal coverage. This would provide robust new revenues. But they are opposing changes to the medical profiteering practices that result in excessive costs, and which often are the foundation of their current business models. And these two elements form the troublesome core of the current proposals.

Each proposal so far contemplates additional cost. But we shouldn’t have to spend more to fix health care. Within the industry’s professional community, most experts agree that as much as one-third of all health care spending is wasted, meaning that a portion of at least $800 billion a year could be recovered. There is no mystery about where the most blatant waste is throughout the system, or how to restructure health care business practices to significantly reduce that waste.

Make no mistake. A failure to immediately address the deep drivers of the crisis will force the nation to pay a high price and then revisit the same issues in the near future. It is critical to restructure health care now, without delay, but in ways that serve the interests of the nation, not a particular industry.

Congress ultimately must be accountable to the American people. The American people must prevail on Congress to revise the current proposals, build on the lessons gleaned throughout the industry over the last 25 years, and directly address the structural flaws in our current system. True, most health industry groups will resist these efforts over the short term, but the result would be a more stable and sustainable health system, health care economy and national economy, outcomes that would benefit America’s people, its businesses and even its health care sector.

Finally, the American people should demand that Congress revisit and revise the conflicted lobbying practices that have so corroded policymaking on virtually every important issue. Doing so would revitalize the American people’s confidence in Congress, and would re-empower it to create thoughtful, innovative solutions to our national problems.

Brian Klepper is a health care analyst and industry advisor. David C. Kibbe is a family physician and a technology consultant to the industry. Robert Laszewski is a former senior health insurance executive and a health policy analyst. Alain Enthoven is Professor of Management (Emeritus) at the Stanford University Graduate School of Business.

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47 replies »

  1. I dont think we’re going to get the results we want but, this healthcare is getting outrageous its unfair to those who cant afford it. People are dying daily and it need to be addressed now the company has made there billions cut our people some slack !

  2. pbnesbitt I think I actually listed other alternatives no? two of them. Far from failing to see them 6 days a week I am actually implementing them. If your aware of any I missed please do share, I can always use a new method to reduce cost; even a tenth of a percent is a huge vistory these days.
    I am actually a huge fan of immigration, please try to avoid the liberal fall back of calling someone racist or nativist when you lack any other argument. I think we should have open borders for scientist, researchers, people with business ideas and the money to fund them, and models. I know this doesn’t fit in the nice little box liberals like to peg people to avoid an honest discussion but it can be a growing experience. I just don’t see the logic behind importing low wage gardeners and nannys.

  3. I am continuously amazed by Nate. I’m reading his rather condescending argument against Maggie only to find myself reading a diatribe against immigration.
    Actually, he’s quite accurate in his old school view of provider negotiations. It’s just that in his arrogance, or is it frustration, he fails to see that there may be other alternatives.

  4. “Private insurers already follow the Medicare fee schedule–adding a % to each fee. So if Medicare cuts by 6%, they’ll cut by, maybe 5%.”
    And Maggie knows this from all the contracts she has with hospitals. All those thousands and millions of claims Maggie has processed prove she is correct.
    For anyone that cares Maggie is full of BS and doesn’t have a clue how contracts come to be. Private insurance fees have next to no relationship with Medicare fees in being set. Medicare fees might be used as a reference point but lowering Medicare has the opposite effect on insureres being able to lower private insurer rates.
    If there is only one hospital in town you pay the rates they tell you to regardless of what Medicare pays them. If you have two systems, like Cleveland with UH and CC politics will again dictate you pay what the system your in bed with tells you to.
    In the very rare circumstance you have multiple unaligned provider systems competing for volume you contract first with the one most desperate for business, use them as the stalking horse, them use that contract to pressure the other systems to come down. This is extremly risky and can blow up big time on the payor if one of the systems walk and your left with the least desired health system.
    If Maggie had the slightest clue what she was talking about she would know instead of cutting PPO reimbursements the trend is doing away with the PPO. The other solution dejour is going back to slim networks aligned with one system and letting the health systems fight each other, again a contract that has no relation at all to Medicare fees.
    Finally instead of Medicare rates we are looking at cost plus pricing these days. Maggie you know it is almost 2010 and not 1990 right?
    Sooner or later it becomes about our values, I hope there are still enough people left with Old American values that when that fight comes we win. Looked at from the macro perspective allowing all these migrants in and skewing our immigration to the lowest classes of society was a great way to dilute the values we once held. If you speak english and your college educated or want to come here with money in hand to start a business you wait years in line. If your uneducated and posses no desired skills you have immediate entry. What’s really ironic is the poor citizens of this country who’s potential jobs and ooprtunity are being taken away by this support it. It’s amazing what a poor public education system can accomplish.

  5. Nate,
    This is not about healthcare. You know that. It is about shredding the Constitution and moving into the post-American era.
    Medicare is toast no matter what. Insurance still leaves you subject to financial ruin, so why even bother with it?
    No one hs to take “no” for an answer anywhere in this country regarding healthcare. Just go to an ER and bring up EMTALA, tell them you are not stable yet. You will get treated until the cows come home. (They are working for the government, too).
    Pass the free cheese, while you’re at it.

  6. Peter–
    Thanks. Here’s what I forgot to add: Private insurers have been chafing at the bit to reduce fees for diagnostic testing (another WSJ article) And private insurers have told MedPAC that if Medicare cuts fees for docs, they will follow suit. They just want Medicare to provide political cover.
    Private insurers already follow the Medicare fee schedule–adding a % to each fee. So if Medicare cuts by 6%, they’ll cut by, maybe 5%.
    This means that by the time we roll out the public option (in 2013) fees for many procedures will be much lower–and fees for primary care will be higher. When
    the public plan “negotiates” fees with providers it will be operating in that context. Cardiologists and oncologists will not get the fees that they were getting from Medicare last year.
    So this will bring down your costs.

  7. As a nation, the thought “our collective intellect is but a cork, floating on the global ocean of emotion”, is hearkened, as we churn through the frustrations of pulling disparate private sectors and elected officials interest’s, into some form of a “healthcare delivery system”.
    Each segment responds according its primary interests, as do we all, yet indignation drives much of our discussion. It makes little sense to privately finance elected officials and expect voting behavior not reflective of those interests; short of the voting constituency overruling financially rationed “free speech”.
    Similarly, within healthcare silos, on balance, why would provider, underwriting, or supply industries move towards competitive integration from what has generously rewarded each, often within various degrees of monopsony and monopoly leaning market segments, where the consequence of supply and consumption are largely isolated from price?
    For those of us within the industry, self-serving dialogue, even well informed, fuels polarization when delivered judgmentally to bolster the interest of our primary constituencies. Although the populace isn’t likely to scour Medpac, CBO, CMS, or the myriad of journals, over time, people will respond to facts if provided respectfully, within a reasonably objective frame.
    Votes trump money but emotions drive voting unless a voter is secure enough to consider facts. Local online news outlets across the country are laden with reader comments that can be nurtured to consider facts. Think of the possible impact, if most of the participants on THB invested some time engaging the broader community with a range of facts, not just those that support a vested slice of the health care industries.
    Although the issues discussed here are often intellectually interesting, and, with some obvious exception, professionally discussed, at times it seems closer to an echo chamber of positions more than an incubator of thought.
    I am interested to continue listening to the perspective of others, raised in a civil and professional fashion.
    David

  8. Maggie if reform really is a long process that will come in steps why didn’t your einsteins in congress start with reform everyone agrees on like tort and medicare fraud. They could build trust and save billions and everyone would be happy. Instead they pick the handful of ideas most controversal and least likely to improve anything or save money and you applaud them…

  9. “one of the most impressive speakers talked about the need to recruit more low-income students, even if their GPAs and test scores are a tiny bit lower (which,on average, they are.) Low-income students are far more likely to choose primary care–and to go back to the inner city or rural areas where they grew up.”
    This worked great with teachers, can’t imagine it failing as bad with doctors as it has with education. As they recruited more teachers with lower scores and IQs they surprisingly did a poorer job.
    “all I can say is that after 12 years at Barron’s, covering both Wall Street and Washington I know more about how corporations think and what industry lobbyists do and don’t do than most.”
    Just like with healthcare Maggie never ran a business, she just sat on the outside and studied it and from that thinks she knows more then all those who actually ran the business. This arrogance is the same she exhibits in reagards to HC and Insurance. FYI Maggie, talking to people that do it for a living in no way begins to equate to actually doing it. No you don’t know more then most, you don’t even know as much or half as much of most.If you want to talk about writing then sure you might know more, actual subject matters, not even close.
    “Right now, the health care industry is running. scared.”
    Not even close to true, a small segment of the health care industry is scared, the vast majority are just waiting to see what happens then will adapt like we always do.
    “First, the American public loathes insurers.”
    As usual Maggie you couldn’t get a fact if it hit you upside the head.
    “Our recent survey of voters nationwide found fully 88% of voters are currently covered by
    health insurance and the vast majority (72%) is satisfied with their coverage.”
    “you will be punished for supporting reform.”
    BS propoganda Maggie and you know it. They will be punished for supporting reform that benefits no one but themselves and will bankrupt the county. If they supported reform people wanted they would be carried through the streets like heros. Tort Reform, Medicare fraud reform, etc would all garner wide bi partisian support. Try to remeber that next time you feel the need to post.
    Reformers need to slow down on their rush to toss out FFS, You seem to forget we tried capitation and it failed miserably. I would hope providers more then anyone would know primary care is not the same as specialist and hospital care. Why would you expect the same payment methology to work for the entire system?
    If we want PCPs to maintain health that sounds like something that should be capitated, you get X to keep people healthy. When you get to specialists and hospital care that should be an acute event, treatment reverts to PCP, and you can’t capitate an acute event, well you could but you shouldn’t.
    I would suggest, my contribution to suggestions that have been proven, that we capitate primary care, outside of insurance, and keep FFS for most other care. Let individuals pay for their own basic care, they can either do it on an eposodic basis or if they are more comfortable directly capitating providers. Insurance would reimburse on FFS basis those services rendered by specialists and hospitals.

  10. “I have had many long talks with primary care physicians. Five to 10 pecent, plus bonuses for joining accountable care organizations, or managing chronic diseases, etc. sounds like a good start to them.”
    ‘Here’s what Ted Epperly, board chairman of the 95,000-member American Academy of Family Physicians, told Bloomber “It’s a great step forward.” ‘
    As a practicing family doc for the past twenty five years, I have not met anyone who would agree with either of these two statements. If you honestly think this represents what primary care MDs are thinking, you are truly out of touch with the reality of primary care in America.

  11. Maggie,
    I will admit I don’t know any Congressmen or Senators and I don’t hang out with CEOs and I have no inside sources. I am just an average American from the Midwest, a.k.a. the suckers that pay the bills for all this secretive wheeling and dealing.
    But I do know a little bit about business and it does not take much knowledge to understand that companies do not consistently invest in something that has no ROI. If lobbying had no effect, there will be no “contributions”, certainly not to the tune of billions. I happen to think that this is undue influence and not too terribly inclined to trust that the Congress folks are so shrewd that they take the money but really do the voters’ bidding.
    The Democratic chapter in Montana made it very clear that that constituency wants a public plan. Didn’t do much good now, did it?
    Why do we have to wait for 2013 to see the beginning of a public plan? Does it take 3 years to set that up? Or maybe because 2012 is a big election year and we can campaign with statements that we fixed health care and made it available to every American…. just wait until next year….the “don’t change horses in the middle of the race” sort of argument. All that BEFORE it becomes evident that the “help that’s on the way” took a slight detour for the next decade or so.
    I apologize for the cynicism and maybe you know better from your sources, but I am not optimistic.
    And why wouldn’t a President want to exert his leadership on this subject? He is the President of the United States. He was elected partly based on his position on health care. He is supposed to to lead the country (not impose his ego). It’s his job.
    Hillary was not an elected official, that’s why that one backfired.
    I don’t know, but I expect more of this President. He is capable of so much more and it’s not too late.
    I have to agree with Peter on the over emphasis on Medicare. The perceived issue with quality of coverage was in the private sector. Maybe I missed this in the thousands of pages of the bill, but are there minimum limits for coverage defined anywhere? Are they, as promised, similar to the FEHBP? Are the premiums capped so middle America can afford them? Are all payers going to be mandated to offer these policies and nothing less?
    You may also want to check again with Primary Care docs. 5% increase amounts to about $2.50 per typical office visit. I doubt that this will entice anybody to throw out that Dexa machine and concentrate on cognitive services.
    As to oncologists, maybe I have the wrong information, but the last one I talked to said that he has to pay for all the drugs upfront to the drug company and Medicare barely covers his cost. He was considering early retirement. Maybe there are Oncologists reading this that would like to pitch in….

  12. Maggie, long posts are exactly what is needed here (except rants by Nate) but you point out that these changes are for Medicare, not the care I will be able to access or the long suffering premium payers that will not get subsidies from this plan. I see shifts from Medicare cuts to private pay – that’s me! Medicare already takes care of seniors, so why is it important to just highlight Medicare reforms when all the abuses in the system are for non-medicare beneficiaries if you discount the cost to the taxpayer, which by the way I will pay more in taxes and penalities for not buying into just another corrupt plan? Let me into Medicare and I will pay attention to the reforms there. I also post this link: http://www.msnbc.msn.com/id/33564275/ns/politics-health_care_reform which shows that the public option, which would benefit everyone if it had teeth, is largely ceremonial and to placate lefty Democrats. Again spineless and dishonst Democrats ( I know Republicans are already dishonest) shoot themselves in the foot and look like part of the swamp not the solution to it. Kay Hagan will not get my family’s vote again as she is just playing to BCBSNC and their campaign donations.

  13. DCK, Brian, Peter, Margait
    DCK–
    I have had many long talks with primary care physicians. Five to 10 pecent, plus bonuses for joining accountable care organizations, or managing chronic diseases, etc. sounds like a good start to them.
    (And in fact, the first in a series of hikes comes next year– see below.
    They also always stress the need for scholarships and loan forgiveness for med students who go into primary care.
    Though few have commented on that section of the legislation (I suppose because few have read it) the
    aid for med students is substantial.
    In addition, even before the reform legislaiton takes effect, the Obama administration is shifting money from speicalists to primary care. Over the next 4 years, it has announced that Medicare will be cutting cariologist’s fees by 10 percent, and cutting fees for cancer specialists by 10 percent .Next year, cardiologists will see a 6 percent cut.
    Meanwhile, family practioners get a 4 percent increase in Medicare reimbursements next year. And this is just the first of many expected hikes (including the ones described in the legislation.)
    Here’s what Ted Epperly, board chairman of the 95,000-member American Academy of Family Physicians, told Bloomber “It’s a great step forward.”
    If the administration and Congress had made a deal with the wealthiest specialists’ organizations, why is it cutting fees? (Congress has only 60 days to repond.)
    In terms of restructuring delivery, everyone agrees that primary care docs are much better off in large multi-specialty groups where they can enjoy the eocnomies of scale (in terms of administrative costs) and support from specialists. Their hours are regular and they are on salary.
    I’ve talked to Christine Cassells, president of the American Baord of Internal Medicine about this (do you think she is “completely out of touch” with the eonomics of primary care ?) and I’ve talked to docs at places like Peguot Sound, Kaiser (Nothern Cal), etc. I read magazines like “Pulse” where doctors (many family practiioners) tell their stories.
    I’ve been writing about heatlh care, interviewing a enormous number of docs, for more than six years. Before than, I spent 12 years at Barron’s, writing about the economics of virtually everything– including health care.
    To suggest that I’m “completely out of touch”— that’s the type of language I would expect from someone else, David, not you.
    Brian–
    Sorry you feel a need for personal characterizations and attacks.
    I wonder– if I were a man would you find me “particularly irritating?” This seems to be a phrase that men often use when referring to women– as if they were swatting flies that were “in their face)”
    Usually you’re very polite. What I said must have been true enough to really get under your skin . . .
    What’s most telling is that you fail to point to a single part of the Senate or House bill that represents a clear WIN for lobbyists. Which provisions did they write?
    I can point to plenty of provisions where lobbyists LOST. (Amednment in House Bill that would let Medicare negotiate drug prices (doon’t know if it will survive, but I’m pretty sure Medicare will begin negotiating in next three years); very small penalty for people who decide not to sign up for insurance, a national public option with an “opt out” rather than “opt in” that gives states (and their citizens) a year to see how they like the public option before states opt out.
    No the 5% to 10% pay raise is not enough to make droves of med students choose primary care.
    But if you follow the market and read Bloomberg, you would know that the administration has aleady announced a 4% increase in what Medicare pays family practitioners next year– the first of many expected hikes, including those specified in the legislation. (See my comment to David above)
    Moreover, these hikes are on top of the bouses for primary care docs outlined in the legislation. Meanwhile, the adminsitration is cutting Medicare reimbursements for cardiologists and cancer specialists. (see my comment to David)
    Cardiologists and Oncologists represent powerful, wealthy lobbies. But the administratoin knows that at least 1/2 of the angioplasties adn 1/2 of teh bypasses that we do are ineffective, or only temporarily minimally effective. They don’t save lives. The administratoin also knows that, as an oncologist put it on my blog “Oncologists are making stacks of money on chemo that does no good.”
    Experience shows that when you lower fees for certain tests or procedures, volume levels off. Less over-treatment. Fewer patients exposed to unncessary risks. Huge amount of money saved.
    Finally, loan Forgiveness and Financial Aid –which you neglect to mention– is the most important provision that will drive med students into family prctice. Have you spoken to many med students lately? I have. This, they say, will make all of the difference. .
    Not long ago, I spoke at a Mayo Clinic conference on how we need to change med school education, and one of the most impressive speakers talked about the need to recruit more low-income students, even if their GPAs and test scores are a tiny bit lower (which,on average, they are.) Low-income students are far more likely to choose primary care–and to go back to the inner city or rural areas where they grew up. This is part of what the Obama adminsitration will be doing.
    Brian, I imagine you have a very good business model for on-site medical care for employees.
    Unfortuantely, this doesn’t begin to address the biggest needs in primary care– the needs of the unemployed and the poor. (I know, I know, I’m being “ideological,” not to mention “irritating” by bringing up the poor.)
    The legislation provides for more community clinics
    It also lifts salaries for teachers at nursing schools. We have many qualified applicants for nursing school, just not enough teachers becaue the pay is so low. . As we train more nurses, many will wind up delivering primary care at community clinics.
    As for what lobbyists are and are not getting, — all I can say is that after 12 years at Barron’s, covering both Wall Street and Washington I know more about how corporations think and what industry lobbyists do and don’t do than most. (Btw Alex Gibney, who produced my film–Money-Driven Medicine–will be coming out with a film about lobbyists soon. It will be an eye-opener.)
    Right now, the health care industry is running. scared. See what has happened to insurance stocks.
    Of Course Health care lobbyists poured money into Congressional coffers this year. What else could they do? They were hoping to get anything they could.
    Based on my experience at BArron’s I know that lobbyists spend more when they expect less. They spend more when they know they are up against an administration that is not sympathetic to their hopes and dreams. It’s all they can do.
    But the lobbyists are not in a strong position to demand a quid pro quo for a number of reasons.
    First, the American public loathes insurers. It dislikes drug-makers. It is becomming increasingly suspicous that hospitals are gouging us. It doesn’t much like anyone who is profiting on healthcare –except doctors.
    Secondly, Peter ORszag will be key to health care reform. He understands that health care inflation is “the single greatest threat to the economy” and that the health care indsutry’s revenues cannot continue to grow. Pharma is enjoying a 16% profit margin. This is excessive.
    Of course politicians will take whatever money the health care industry decides to hand out. THAT DOESN’T MEAN THEY HAVE PROMISED ANYTHING IN RETURN. DO YOU KNOW ANY HONEST POLITICIANS– PERSONALLY? THEY DO EXIST. THEY DO TAKE ANY CAMPAIGN MONEY OFFERED TO THEM BY MORE OR LESS LEGITIMATE ORGANIZATIONS (PFIZER and Wellpoint, not the KKK)
    But politicians know that when push comes to shove, votes matter more than campaign contributions. All the money in the world won’t save you if the voters
    in your state decide to vote the bum out.
    Finally,–you speak of the need to replace fee-for-serivce. If you have actually read the House bill,
    I wonder how you missed the entire section which talks about Medicare moving away from fee-for-service, and putting more emphasis on primary care, paying bonsues for primary care, etc.
    There are many things that reformers do not want to spell out in the legislation. Voters do not want to read that at some point (when we have enough primary care docs) Medicare patients will need to get a referral to see a specialist. (I have this on pretty good authority.)
    I know you are in touch with many corporate CEOs, Brian. That’s your world. And you believe that means you have your finger on the pulse of power. But they are the ones who are out of touch. They are losing their grip on the country.
    Who is in touch with the goals of reform, and what is implicit if not explicit in the legislation? The folks at MedPAC, people at places like IHI and Dartmouth (Don Berwick, Elliott Fisher), ATul Gawande, people within the FDA, people working on reform at Consumer’s Union and other places, doctors and nurses who comment on my blog; reformers who come out to see the film of my book (Money-Driven Medicine); the dozens of doctors and others who came up to talk to me after I spoke at Matthew’s conference (to thank me for talking about things that no one else was talking about), staffers from House committees, as well as doctors and hospitals who were part of the recent IHI conference “How Did They Do That?”
    These are the people I talk to. They keep me “in touch.”
    The House Bill (the only bill with detail on the public option) makes it clear that the public option will incorporate Medicare’s reforms.
    Finally, on the flag-waving.
    If you wanted to save America, where were you when Bush and the Republicans were running Washington?
    That’s when the country really needed saving.
    Somehow I don’t remember long posts about corruption in Washgington then. Brian–it’s quite possible that you did write about the topic and I missed it. (I mean that sincerely)
    But did you take a stand against the war in Iraq?
    So few in the media stood up to Bush (with the exception of very left/progressives in the blogosphere.)
    Now that we have a Democratically-controlled Congress and an intellligent Democrat in the White House, the attacks are daily, and they are fierce.
    No the reform bill isn’t perfect. For something put together in 10 monthes– in the face of oppositoin backed by real money — they have done very well. They have another 3 years to improve on it.
    A post like this one confirms what conservatives are trying to tell legislators: “In the next election, you will be punished for supporting reform. Even the liberals aren’t happy with what you are doing. They say you have been bought off. You have made deals with lobbyists. ”
    Why should a legislator continue to stick his neck out for reform if even the refromers are attacking him?
    Perhaps you and Bob think that reform should meet your specs. But that’s not going to happen. It’s not going to meet my specs.
    It’s going to be what they can manage through a very messy process (our legislative process) in a nation that has been corrupted by money at almost every level of society.
    I’m surprised and pleased by how much we (reformers) have gotten so far. . .
    Peter– Thanks.
    Yes, Obama is only one man. And it is terribly important that he make sure that this reform is not seen as “Obamacare.” If it is, he will be blamed for everything people don’t like about reform –and it will blow up in his face, probably be repealed
    IT is very important that he not be seen as imposing his ego on the country. (I’ve talked to people in DC about this.) Once Clinton’s plan became Hillarycare it was doomed.
    So it is essential that Congress “own” the bill. That’s why, the other night Obama said “I am glad the Senate has chosen the public option.”
    Given the Congress that he has to work with (a mediocre Congress) I’m amazed that they have done as much as they have.
    Remember, Obama and his people did not elect this Congress. The American public did. Just as it elected Bush twice. Just as it elected REpublicans, year after year.
    Now, somehow, Obama is supposed to turn the beltway into an enlightened community bent on the public good???
    There is no way that he could get the reform bill that I would write out of this Congress. If he had tried, they would have turned on him. He played this cleverly, with superb impulse control. And he got more than I would have thought that he could get out of this group.
    Are individual Congressmen corrupt? Of course. Does this mean that the lobbyists wrote this bill? Of course not.
    And Brian wasn’t able to point to a single part of the legislation that looked like it was the handiwork of lobbyists.
    In a year when major legislation is in the works, the lobbhists who will be effected always increase their contributioons. It’s all that they can do.
    It doesn’t make sense to say this is a bill written to please the lobbyistis– or a quid pro quo. There is too much in the bill that lobbyists fiercely opposed– and I can’t really see a big win for insurers, pharma, hospitals anywhere . …
    Peter– I agree with what you say in your second (oct 31) post. And that is exactly what the people implementing reform plan to do. Not all of it will be spelled out in the legislation.
    But it’s already happening: The administration has annouced that next year, cardiologists’ and oncologists’ salaries will be cut; primary care docs Medicare reimbursements go up 4% next year (the first of a series of hikes); Medicare is slashing fees on CT scans, MRIs, and tests doctors perform in their offices with their own equipment (self-referring–it doubles the volume of tests done.) Medicare won’t be paying for an excessive number of preventable hospital admissions. And this is just the begining.
    Yet Bob, Brian, etc. claim that refomrers are not saving money.. . . ignoring what is already happening.
    Margait– Republicans and conservatives Democrats who opposed reform Are representing their constituency.
    If you look at the polls, you will find that a great many Americans are fearful of reform, fear that they will lose something . . Among upper-middle-class Americans (over $75,000) universal coverage is not that
    popular. That group wants to see its own medical bills lowers. That’s what they are enthusiastic about.
    Many Americans don’t want to see waste cut out of the system. They don’t want to be told that they don’t need an MRI.
    So, to be perfectly fair, those legislators are represnnting their people.
    But the country has been changing in the past 2 years.
    Today, less than 20% of Americans identify themselves as Republiicans. (Washington Post/ABC poll Oct 28 http://74.125.93.132/search?q=cache:aLHe3TWSD4YJ:www.huffingtonpost.com/2009/10/20/fewer-people-identify-as_n_326971.html+identify+and+Republicans+and+%2220+percent%22+and+poll&cd=1&hl=en&ct=clnk&gl=us
    AN NBC Wall Street Journal poll in Sept. said 18%–the lowest share since 1983.
    That’s a huge change.
    And, at some point, I think that clear-thinking Congressmen have to lead us forward, even if they are drafting laws the public isn’t ready for (civil rights, for example)
    But the majority of people in this Congress were elected during the Bush years. These are the folks who voted to go into Iraq. These are the folks that voted for tax cuts for the wealthy. These are the people who have turned their back on the poor.
    Why would you possibly expect that they would suddenly change and draft the health care bill that you and I would write?
    Obama is working with the Congress he has, not the Congress he might like to have. And not all of them are corrupt. Though by and large they are mediocre– followers, not leaders, lazy thinkers. .
    Still I’m happy to see that people like Jay Rockefeller have hung on all of these years, and are still willing to go out on a limb. I’m impressed by how strong Nancy
    Pelois turned out to be. I’m suprised that Harry Reid finally stood up.
    Healthcare reform is going to be a long, slow progress.
    If we wanted universal coverage in 2010, we should have voted for it in 1994. We’re trying to transform a $2.6 trillion industry that affects everyone in this country.
    That’s an enormous challenge. And we have to do it without creating chaos– or people will die.

  14. The only way to decrease total costs of widgets is either to have less demand for them or to have lower cost of production with no increase in demand.
    I am a widget maker.
    If the brown shirts come and force me to make widgets, I will be a very slow widget maker. They may not be very good widgets.
    If the looters come to steal them, I will guard them like diamonds, for they are difficult to make. They are all custom made, built to order by a proprietary process.
    If people can’t get enough of them,, the price per widget will go up. I will work longer hours to make more of them, for the mutual benefit of me and my customers.
    If I get to pay higher taxes because I work harder and am more successful, then I may make more widgets, but not as many more as if my tax rate was left the same as before.
    If my widgets are no good, then I will either go broke or learn to make them better.
    If my widgets might harm someone, which happens rarely, I will have to have insurance for protection. I will need to test every widget more thoroughly.
    If, despite an appropriately made widget, there is a bad outcome, I will need the extra test data to show that my widget caused no harm.
    My widgets will cost more and more as the technology for testing widgets gets more and more sophisticated and more expensive.
    Not all widgets are the same. Some are simple, some are complex and some are very fragile.
    I can make many more simple widgets than delicate, fragile, complex widgets, shich need a lot of remakeing and maintenance.
    Maybe I should require prepayment, like a dentist.
    I will need assistants who will help me make more.
    Boy, this is getting expensive.
    What do you mean I cave to give them away. Go back to the top. Figure out where you got lost.

  15. Unfortunately, no surprise there! Congress is pathetic and, to date, totally unaccountable for any of its actions. There more to the bill too.
    MEDICARE AND MEDICAID BENEFICIARY ABUSE: IS THE BENEFICIARY TO BLAME?
    The Center for Medicare and Medicaid (“CMS”) lays the ground work for providers and physicians committing fraud and abuse within the Medicare and Medicaid system. Provider and physician fraud accounts for between 60 to 100 billion dollars per year. However, CMS makes no provisions for abuse committed by the beneficiary. Yes, the recipient of emergent or urgent medical care may be guilty of abusing the healthcare system thereby costing the government sponsored and private healthcare plans millions of dollars.
    Check out my blog at http://www.lawdocblog.com for more details

  16. “but I still have never seen a single proposal from any of them that was tested and had a realistic chance of containing the costs of medical care. It’s easy to shout, “Control the costs”, but more difficult to show how to actually do it.”
    Canada, United Kingdom, France, Germany, Holland, Taiwan, Japan.
    “We must go to the medical community and ask for their assistance in forming a new, non-profit Agency to coordinate and manage medical care.”
    Using a single government agency (in each state) to manage a national universal program of controlling universal budgets/prices/reimbursements will leave medicine to doctors but leave the financing control with voters. Hospitals will quickly learn that not aligning care with costs will have consequences. If voters want more medical care, appropriate or not, they will have to vote to add it to their own taxes.

  17. Bravo indeed. The authors are spot on with most of their comments. Unfortunately I fear that we need campaign and election reform before we will every see congress working for the people instead of the corporations on this and many other important issues. We need a 911-like commission to look at health care in our country and then get congress to make the needed changes that will actually make a difference. Our health and how much we spend on it are issues of national security and important factors in our being or not being competitive in international markets.

  18. If Washington was not about to take control over every one of the $2.4 trillion spent on health care — the lobbyists would not be there.
    Since we actually, you know, have a representative democracy, and petitioning the government would seem to be a basic right, the money will go where the power is.
    The only way you will ever reduce, and not increase (remember candidate Obama’s pledge to not give into the entrenched interests? That was right before cutting deals with AHIP, PhRMA, AMA, AFL-CIO, Trial Attorneys, …) lobbying power is to take power away from Washington.
    and David, while we likely disagree on much, you are absolutely right — primary care is collapsing, and the “+5%” or 10% means nothing, as the new regulatory costs will be so much more than that — here in Phoenix, excellent primary care doctors are leaving every week… and care is suffering.
    and, the federally driven EMR/CPOE revolution has mean that nurses spend more time, and care more, about ensuring the right boxes are checked and completed than actually providing care. They have no choice– their jobs are safe if they complete the paperwork, while patient care has little reward in the eyes of an administration that measures success by compliance that gets it more government dollars.

  19. Admittedly, this is a high powered health care/insurance bunch. But again, the talk is about process and not the type of reform which will save health care. They say we need to contain costs, but make no realistic suggestions as to how we can control costs in a trillion dollar system. The paucity of realistic solutions disappoints. With a lack of realistic cost containment proposals, we can easily understand why the politicians simply keep shuffling the same deck.
    I don’t mean to be excessively critical of “experts” but I still have never seen a single proposal from any of them that was tested and had a realistic chance of containing the costs of medical care. It’s easy to shout, “Control the costs”, but more difficult to show how to actually do it.
    Over the past year or so during which I have been writing about medical cost containment, I have had to modify my views somewhat, taking into account some of the critiques, as well as thinking through the implications of a very large system. I note that my experience was with a much smaller system, almost a pilot project. In any case, here are my suggestions for a patient-physician based health care system.
    This is a post from http://www.leanmedicalcare.org.
    TIME FOR DOCTORS TO STAND UP
    Health care, universal or otherwise, should be focused on one overriding mission: To assure that all patient’s receive appropriate care. By this, I mean that it should be necessary and sufficient to bring about the desired recovery. We all know that much, if not most, health care in this country is not appropriate which is the main reason it costs so much. We must address this in any health care reform proposal.
    Doctors learn in medical school how to provide appropriate care. The schools do not teach them to over-treat or under-treat. They are taught to form a diagnostic impression from the clinical findings and then apply the appropriate treatment. If we are to reform health care, we must restore medical care to this foundation.
    Due to the scattered nature of our current health system with multiple private and public insurers, reforming medical care on a national scale will be difficult but not impossible. Let me explain what we can do.
    First, trying to coordinate and assure appropriate care among multiple insurers is a problem. They have multiple policies, procedures, medical networks, etc. Much of their information is considered confidential and competitive. Instead, you will need a single controlling independent medical entity responsible for all medical care in the United States. The good news is that insurers don’t provide medical care, care providers do so that you do not need to deal with eliminating private health insurance. Let the insurers be insurers.
    Second, it is time for the medical community to step up and take responsibility for medical care. The medical entity should be managed by the medical community, not insurers and not government. It must be paid for by insurers but not controlled by them.
    Before going on to explain how to implement this change, lets explore further why we need this single entity. Medical cost are a function of price and utilization. Ideally, if every patient had appropriate care then the cost of care would be optimized insofar as utilization is concerned. Likewise, if fees are fairly negotiated to reward doctors for treating appropriately and not over-utilizing, fees would also be optimized. The cost of care can be optimized, therefore, if we can build a system to bring it about. We could try to do it piece meal, insurance plan by plan but that does not offer the real benefit of a coordinated national effort and there is no assurance that the insurers would participate or get it right. Insurers are unlikely to share information and treatment data since they are in competition for policy holders. Any advantage they can gain in treatment protocols would be considered proprietary. Piece meal also allows larger provider groups to play insurers off against each other in negotiating fees. In the end, the advantage goes to the single medical Agency controlling medical care for all insurers. So, how can it work; what would it look like?
    We must go to the medical community and ask for their assistance in forming a new, non-profit Agency to coordinate and manage medical care. There are many effective and capable executives and managers in the health care fields who could take positions of responsibility in this new medical Agency.
    The suggested guidelines for new health care entity are:
    1. The Agency coordinates and manages all medical care for insureds.
    2. All insurers, government and private, send insureds to care provided by the Agency.
    3. All care providers seeking to treat insured patients must belong to a single network operated solely by the Agency. No insurer may operate a separate medical network.
    4. The Agency negotiates provider fees with all care providers ensuring that they are paid fairly and promptly.
    5. The Agency never refuses to pay a medical bill unless fraud is suspected.
    6. Each care provider gives the Agency an agreement in which they voluntarily agree to practice appropriate care with patients. Providers understand that failure to abide by the agreement can result in their removal from the system.
    7. The Agency reviews and coordinates care with providers and patients as is needed to assure appropriate care.
    8. The Agency collects treatment and outcome data to build best practices and evidence-based protocols for ensuring appropriate care (lean medical care).
    9. The Agency submits medical bills with a small surcharge to the insurers for payment.But only the Agency pays medical bills.
    10. A medical malpractice claim filed against any care provider is a claim against the Agency. It will defend.
    It is really fairly simple. Have a system that pays primary care providers fairly and promptly. Don’t ask for pre-certification or approval before treatment. Allow physicians to be the final arbiters of care – not insurers, private or government. Give providers the time needed to both understand the patients and diagnose their conditions. NEVER DENY PAYMENT OF A MEDICAL BILL UNLESS FRAUD IS SUSPECTED.
    In turn, ask the providers to treat appropriately without the unnecessary MRI’s, studies, tests, and referrals that plague the current age of medical care. Why not ask them? My own experience tells me that providers are more than willing to practice appropriate care if paid fairly and treated as independent professionals who are responsible.
    Lets provide support to help coordinate care (a real weakness among many practitioners). Have backup when that aggressive patient demands the MRI. In other words, be part of an organized support medial community that will work with the patients when necessary and take some of the burden off the physician.
    Lets collect national data on treatment and medical outcomes without worrying about competitive use of the information. Use the data to inform providers uniformly regarding best practices. The current health care system completely fails in this mission.
    Medical malpractice reform is intrinsic to this model. Treating patients appropriately will reduce the incentive to sue. Won’t eliminate it but will reduce it. Furthermore, since the care coordinating entity is accountable to patients for ensuring appropriate care, liability is, in my view, also shared. Just another example of having someone cover your back.
    The real benefit of a non-profit medical Agency in charge of medical care is that it avoids the political Scylla and Charybdis of private versus public health insurance. A medical agency run by the medical community avoids the pitfalls while bringing the best and most experienced medical minds to running medical care. Note: not running health insurance, running medical care. We can keep all the current health insurance plans in place.
    In conclusion, an independent medical agency can assure appropriate care, optimize medical costs, and save our economy from eventual melt-down. Not bad for a day’s work.

  20. Although I respect and read Maggie’s views and analysis I must say that I have no faith this bill was not a result of lobby/money/corporate influence. I point to the latest unauthorized revelation of dozens of congressmen/women who are under “secret” investigation” by the house ethics committee. http://online.wsj.com/article/SB125694460088919841.html If guilt is found we may never know what if any punishment was given as this body operates in secret for itself, not the american public. Can anybody, other than congress, justify this? For a country that elected a black president so relatively quickly following the civil rights struggle I don’t take heart that we can actually drain the swamp in as much time. If congress was made up of Obamas we would get true reform, but he’s only one man that is falling short of our expectations of his influence and.

  21. I suppose I am obligated to respond to Maggie’s particularly irritating and ideological diatribe/justification of the current proposals. In it, she makes several assertions, a couple of which really show how marginal her on-the-ground HC experience has been.
    First, as someone who has closely followed primary care (PC) reimbursement for some time, and as part of team that develops and manages onsite/near-site comprehensive PC clinics, I have more than a passing interest in the topic.
    As tcoyote correctly points out, only the truly clueless believe that a 5%-10% PC pay increase will 1) keep current PCPs from burning out and 2) lure med students into a specialty that now recruits only 2% of them. PCPs currently make between 1/4th and 1/10th the incomes of their specialist colleagues, but the ever-growing body of knowledge they must keep up with is greater. Most community-based PCPs I know work very long hours, and are extremely disspirited. They think of the 5%-10% proposed boost as a very pathetic bandaid.
    My clinic firm pays our PCPs at 1/3 more than community-based PCPs make in that market (e.g., $200K vs. $150K), with no administrative responsibilities. They spend 20 minutes on avg with each patient for an established visit, vs 8.5 in the field. They have case loads of 1,600 pts vs 2,500-3,500 in the field. Their practices all have modern HIT tools – e.g., analytics; EHRs with lots of decision-support – so they don’t have to work solely out of their heads. We give them the authority and the time to reach out to and collaborate with specialists, so that a check and balance is maintained between PC and the specialists who have a perverse financial incentive to do unnecessary care.
    Perhaps most important, they operate outside a fee-for-service reimbursement system. They are salaried, with incentives for quality and volume targets, but they have no incentives to 1) deliver unnecessary care or 2) deny necessary care. In other words, there are LOTS of things Congress could do to re-empower primary care, if only it was interested in actually following the lead of innovative market-based programs.
    BTW, eliminating co-pays for PC is a fine idea, so long as the payment doesn’t come out of the hide of the PCP, which it usually does. And while it modestly opens up access, its a particularly lukewarm tactic. In our clinics, visits, standard drugs and labs are all free. This induces very high PC utilization, which in turn produces tremendous impacts downstream.
    Next, lets talk about the ludicrous assertion that lobbying hasn’t influenced policy. Why do you suppose the industry continues to contribute if it doesn’t generally get its way, not on every single point, but on most things? In my experience, large, experienced successful businesses typically don’t keep spending money on approaches that don’t work.
    And do you really think the public option is a meaningful issue, or that the health plan industry will be crushed by it. In my view, this is a surrogate issue, one that has been visibly raised so that we don’t have to talk about things that actually matter, like releasing the Medicare physician data, or substantively paying PCPs more.
    In the worst case scenarios, the senior execs of the major health plans know that they’ll administer the public option. It would be useful for you to remember Peter Orszag’s chart, presented to the Senate Finance Committee in his testimony of July 2008, showing that Medicare cost growth over the past 30 years has nearly exactly tracked that of commercial coverage. The drivers of Medicare inflation, influence, are different than those in the private sector, of course, but the impact has been the same. There is NO REASON as far as I can tell to believe that a public option would have any different result, unless we change the rules that apply to influence.
    Next, I take particular umbrage to your nasty assertion that Bob Laszewski is a partisan, and that he “likes” or “dislikes” proposals based on an ideology (as you apparently do). In reading Bob’s analyses for several years now, I find them scrupulously structural in nature. He analyzes how things will play out, and he does so without prejudice. This is why he’s so highly regarded as an analyst in DC. His work is unfailingly independent, and can help policymakers and corporations understand what the true impacts of things will be.
    Back to the core arguments of our article, the current proposals do little if anything to correct the 3 most important structural underpinnings of the current crisis: fee-for-service reimbursement, transparency, and specialist-dominated care. The proposals all but ignore everything that progressive health care practitioners have learned over the last 25 years about how to best manage the care process. The most straightforward and logical reasons for the disconnect between what many of us interested in reform for many years and the current process is that change in the public interest would drive significant dollars away from the special interest.
    While you’re not required to agree with that thesis, you should be bound by journalistic integrity to defend your position more substantively than by charging that we’re “Obama-bashing.”
    Look again at the article containing the Public Citizen quote. It is most certainly NOT about Orrin Hatch, who is mentioned at the beginning along with Max Baucus. It is about the influence of lobbying.
    And finally, the reference to “Saving America” refers to the fact that so long as policy is driven through contributions for the special rather than the common interest, the foundations of American democracy will continue to erode. If that’s flag-waving, then so be it. I for one think it would be a terrible tragedy if the American experience were dragged down purely by the selfish, cynical gain of its leadership.
    I stand by everything we said in the article.

  22. Maggie: A 5-10% increase for primary care physicians’ practices is like putting a band-aid on a knife wound to the carotid artery. You are completely out of touch with the economics of primary care and primary care as a system of assuring the public’s health, if you think that any of the reforms in the current bill(s) adequately address the structural problems and imbalances. Please, go find a practicing primary care doctor, a family physician or general internist, and have a sincere, long talk with him or her.
    Kind regards and thanks for your comments. DCK

  23. Senator Kay Hagan wrote this to me;
    “In order to ensure that the Community Health Insurance Option competes on a level playing field, I insisted that it meet federal and state solvency requirements, that payment rates be negotiated, rather than tied to Medicare as some suggested, and that doctors and hospitals be free to choose whether to participate.”
    Maggie, did you see this clause in the public option wording of the bill? If so why would you believe that a public option stands a snowball’s chance in hell at having any significant impact on costs and access?

  24. The unions and large employers prevented Wyden Bennett from getting a fair hearing. Purchasing the support of the major interest groups for broadening coverage was very expensive and crippled Congress’s ability to really change anything. Agree with authors about how broken our political system is.
    If Maggie thinks a 10% increase in primary care comp gets it done, she needs to visit a doctor (and learn to edit her interminable posts). I’m also a lifelong Democrat and an Obama supporter, but he was sadly overmatched here. Losing Daschle really hurt. This will be a VERY expensive piece of legislation and all the wrong people are going to be feasting on this bill . .
    Maggie seems like the only person happy with the legislative hairball (1900 pages indeed) we’re getting. Just don’t call it reform, baby.

  25. All the reasons that are Congress’ response to the health care crisis are really interesting. So I’m sad to report that even in the midst of the coming crisis they correctly predict, I’m not sure we’ll get the changes they’re looking for. But right now they’re not really on the table.

  26. There is no sustainable free healthcare. Get used to it. If you think healthcare is worth it, then buy it yourself. Don’t make me buy it for you. I know it is not worth it.

  27. Maggie, please….
    I have been a voting Democrat for my entire life and I am the most hopeless bleeding heart liberal you’d ever want to meet. I have nothing but the utmost respect and highest hopes for President Obama. I believe he is doing the best he can under the circumstances.
    The problem is that the circumstances are dire. Watching Senator Baucus on C-SPAN, voting down both Senators Rockefeller and Schumer’s amendments, with that condescending and dismissive little smile, was a bit more than I can tolerate.
    These folks are making laws. It is inappropriate, to say the least, for them to accept “contributions” from entities that will be affected by those laws, regardless of the final outcomes.
    I am sure that many representatives are people of integrity, but some are not. When every vote counts, even the appearance of impropriety is more than we should tolerate.
    This bill could have been a lot stronger if Democrats would have acted as true representatives of their constituencies (and Republicans too). The President indeed gave them a lot of latitude, probably more that expected or needed, and the resulting traveling circus didn’t do much to help any of us.

  28. We need a group of women to push. Ever have a baby? Women we need to push to be heard. By large part we aren’t being heard and we need our joint efforts in knowing what pushing is ladies to push….right now! Not tomorrow…not in a week. NOW TILL THE END OF NEXT WEEK. Women everywhere need to push back and take action till we are heard.
    They say women can lift a truck off their child. Now is the time that we put that much effort into fighting to actually be heard and to fight back on what is right and what is truth. Not tomorrow, we need to do this today.
    Come on women. Get Up, NOW!

  29. “The Republicans now represent less than 20% of the nation.”
    Maggie its no longer worth pointing out all your errors, the question now is have you ever been right about anything in your life?
    “Thus far in 2009, 40% of Americans interviewed in national Gallup Poll surveys describe their political views as conservative, 35% as moderate, and 21% as liberal.”
    “Thus far in 2009, Gallup has found an average of 36% of Americans considering themselves Democratic, 28% Republican, and 37% independent.”

  30. Great article. Why all those publications you mentioned ignored it is beyond me. The suggestion to send it all the congressmen and the White House is great.
    ON THE OTHR HAND, always remember Ted Kennedy’s statement that his greatest regret was not supporting (and actively sinking)Nixon’s health care proposal. Take what you can get and keep fighting for more. Democracy is messy; ours is downright dirty. Why? Bill Maher didn’t mince any words: “Americans are stupid”.

  31. I just looked up the quote you use from a lobbyists from Public Citizen to support your allegation that Congress has been “bought off”: “A person can reach no other conclusion than this is quid pro quo activity.”
    Here is the actual context of the quote: The story is talking about Orrin Hatch and the reporter writes:
    Hatch is far from unusual. Many of the key players in both parties, including Senate Finance Chairman Max Baucus, D-Mont., have seen a spike in health-care related contributions.
    “But government watchdogs say it appears unseemly.
    ‘This is a flood of money coming in from the health care industry coinciding exactly with the drafting of the health care bill’ said Craig Holman, a lobbyist with the Public Citizen advocacy group. ‘A person can reach no other conclusion than this is quid pro quo activity.’
    The context: the amount money Baucus and Hatch– and some other key people– are receiving.
    Did the lobbyists get a quid pro quo for their money?
    Baucus totally lost control of the Senate Finance bill. Reid ultimately took charge, and the Senate bill will contain a public option–precisely what Baucus and the lobbyists did NOT want.
    Did the lobbyists get a quid pro quo for the money that they gave Hatch? Hatch is very much opposed to the bill that is coming out of the Senate.
    No pay-off there.
    I guess you know that insurance stocks plunged when Reid announced the public option. Do you think that’s the quid pro quo the insurance industry had in mind?
    I have to object to the way this quote was plucked out of context– to suggest that Public Citizen agrees with the authors thesis that Congress has let special interests shape critical pieces of reform.
    In fact, Public Citizen supported the Public Option–and we have it.
    In addition the legislation does address fee-for-service, making it clear that Medicare and then the publc plan will move away from fee-for-service.
    As for malpractice, the president has made it clear that there will be a separate investigation of how to best rein in defenseive medicine. We know caps don’t do it. (See Texas).
    You’re right the legislation is not bi-partisan. And I know that Bob L. has said repeatedly that health reform legislation COULD NOT HAPPEN unless it was bi-partisan.
    But the fact that Bob was wrong doesn’t meant that Congress let special intersts shape the legsilation.
    Finally, I could do without the flag-waving “Saving America.”

  32. Excellent post.
    Besides the facts that the “government-run option” will not lower costs and taxes will be passed on… the item that gets my blood boiling is the 2:1 age rate maximum.
    Do these young people who got Obama elected know they are being screwed by the Baby-Boomers, again?
    Health insurance costs are about 5x higher for 60-64 yr olds than 25-29 yr olds. Shouldn’t the premiums reflect that?
    Not only that, 60-64 yr olds generally have more $$$ than 25-29 yr olds, so this is regressive.
    Finally, since 20 somethings are going to be forced to have insurance, it is really necessaery to overcharge them, too.
    Shameful.

  33. I realize that Bob L. has been opposed to the liberal health care reform for some time.
    But I’m very suprised to see his co-suthors put their names to a post filled with so much misinformation. (I know and respect each of them).
    You’ll be glad to know that I don’g have time to discuss each piece of misinformation.
    Let me just comment on the first one: “, Congress pretends to make meaningful change where little is contemplated. For example, current proposals would not rebuild our failing primary care capabilities, which other developed nations depend upon to maintain healthy people at half the cost of our specialist-dominated approach.”
    Have you read the bills? Do you realize that primary care physicians receive a 5% to 10% hike in Medicare fees (depending on location) PLUS bonsuses for chronic disesase management, collaborative efforts (i.e. joining accountable care organizations) and other bonsues for quality.
    Secondly see loan-forgiveness and financial aid for med students who choose primary care. The increases are huge We haven’t seen money like this since the late 1970s.
    Third, Pay increases for nursing school teachers– which means we can admit the nurses now waiting on line to get in, incrase the number of nurses, and use them to deliver primary care.
    Fourth: No co-pays for primary care. (This applies to private insurers as well). This is huge.
    For a great many working-class and middle-class people, a co-pay is a barrier. Often, people aren’t enthusiastic about going to the doctor in the first place, and a $15 or $20 co-pay tips the decision. In Europe this is usually no co-pay for primary care.
    The VA saw patients begin to line up for smoking cessation clinics after it dropped its co-pay.
    I’m curious: what else could Legislation do to beef up primary care?
    There are many areas of reform that cannot be legislated–i.e. changes in the culture of medicine.
    You have No Evidence that Special Interests shaped this legislation.
    Do you Really Think that Pharma Inserted the provision that gives Medicare the authority to negotiate for discounts on drugs? (I was talking to a Congresswoman about this earlier this week.) It’s in the House bill.
    Do you really think the insurance industry is happy with the public optoin–even if it has to negotiate rates and states can opt out (which they won’t–as Al Gore recently pointed out.).
    I’m sure it wasn’t intentional, but this post begins to sound a lot like Obama-Bashing. Obama is being paid off by special interests. Obama is making deals with lobbyists. Obama lies.
    At this point in time, attacks on health care reform feel very much like 11th hour attempts to “break Obama” –and break voters’ confidence in him. As you know, conservatives are less opposed to healthcare reform than they are opposed to having Obama in the White House.
    That’s where all of the “the fix is in” “the White House has made a deal” smears are coming from. I’m sure you don’t want to be a part of that, but inevitably, posts like these are used to firm up that agenda.
    I realize that there are businessmen out there who would like to pretend that healhcare informatoin can be be made transparent–so that they can sell that information. (More Money-Driven Medicine). But it just isn’t true. Insofar as performance ratings can be done when evalutaing very large medical centers and all of the doctors working in them, I would greatly prefer to get my information from Dartmouth, AHRQ, or another non-profit.
    We don’t need info generated by for-profit companies–and all of the kick-backs that follow. (I wrote about this at Barron’s in the early 1990s, when companies were popping up to evaluate HMOs)
    Finally, have any of you looked at the IOM commentary on the House bill, saying that it DOES save a great deal of money–and that it will NOT add to the deficit?
    Luckily, at this point in time, I don’t think that all of this negativity will stop health care reform.
    But reform will be a process, not an event.
    Many details will be fleshed out over the next few years, and many revisions will be made in the years that follow as we learn how to rein in health care inflation. Much public education will be needed– and changes in the way we educate doctors.
    The only alternative: Matthew’s solution. Wait until the whole system blows up. Then fix it.
    The problem is that this would cause an unacceptable amount of pain for working class and middle-class people. As Atul Gawande has pointed out, if we invite chaos, people will die.
    Finally, I know that Bob L. is particularly unhappy about raising taxes on the wealthy to pay for reform.
    But at this point it looks like hikes for those earning over $500,000 (individuals) and $1 million (couples) will go forward.
    This is just the beginning of much-neeed income distribution.
    Forget about bipartisan proposals The Republicans now represent less than 20% of the nation. And they’ve made it clear that they never wanted reform. They–and the people they represent–profit from the status quo.
    There era is over. A new demographics is taking over the electorate. The folks who elected Obama (and the ones who stayed at home because they thought their vote didn’t count) will be coming out, in force, in future electoins. They’re not going to be voting for conservatives.
    Obama’s election marked a pendulum swing in American history. You have a hard time understanding his strategy becuase this adminsitration is not like other administrations. Obama understood that he needed to involve as many people as possible in “owning” this legislation. If it’s seen as Obamacare — if he is seen as imposing his ego on the nation– then when people dont’ like some aspects of reform (and they won’t) reform will blow up in his face.
    Clinton’s healthcare reform was doomed as soon as it was labled “Hillarycare.”

  34. Has anyone noticed that (as of June next year) the government has directed that certain benefits will no longer be available under any Medigap plan? No longer will preventative care and home care benefits be included in any supplemental plan. The government, however, is adding a hospice care benefit, that is an end-of-life benefit.

  35. Margalit Gur-Arie, I share your resignation. I have also lost any fire in my belly to go out there and slay dragons. I even plopped down a sixty dollar donation to my local library to persuade them to get a dvd of the documentary of Maggie’s book. But after getting clear signals from those timid library administrators who seemed frightened that I would start something controversial “right here in River City.” and figuring out that with Tom Price is our elected representative, I decided I was peeing in an ocean. I never bothered to follow up, but at least I get a tax deduction for the donation.
    When the Senate bill finally squeezed through and I started seeing the phrase “behind closed doors” in the news, at that point I threw in the towel and started praying instead of agitating. I realized, as the game says, “The avalanche has already begun; it’s too late for pebbles to vote.”
    The day will eventually come when lawmakers wake up to the realization that they are stirring a revenue stream that only looks like progress but is, in fact, just another expenditure of taxes. The insurance people have been salivating over the idea of universal coverage from the start. What’s not to like about several million new customers? Especially, as Maggie says, with vouchers in hand. Jeez.
    In time the turnip will yield no more blood and the percentage of payroll taxes collected for Medicare will have to go up, likely about the same time the cap on Social Security “contributions” (neat euphemism for taxes, no?) will have to increase significantly as well. One of the unmentioned elephants in the room is the putative source of funds for these programs. My guess is that ninety percent of Americans make no distinction between their payroll taxes (which they seem never to think much about) and income taxes.
    It’s not unreasonable that most of us forget about those two tax streams since for the last two decades surpluses collected for Social Security have been tossed into the general fund and spent along with everything else. Heaven forbid anyone would think of actually using that surplus more constructively for anything like Medicare or CHIP entitlements.
    The more I follow the debate the more cynical I get.

  36. Absolutely wonderful statement and true to the last detail. Hope indeed springs eternal.
    A year ago, I would have reacted like Bev and been all fired up and ready to take some action. I will credit this blog almost entirely for showing me the errors of my ways. Every time I would post something along the lines of this article, someone would immediately reply with good advice like follow the money, get off the soap box, in Washington they make sausage, there is reality and there is naivete, liberal propaganda and so forth.
    The simple fact that I’ve learned to accept is that Wall Street and its corporations are de facto running this country. Elected representatives are nothing more than commodities to be bought and sold in the flourishing influence industry (I wonder if they have a tracking board somewhere).
    The health care reform saga is nothing but a symptom of Degenerative Loss of Democracy. Nothing will be resolved. We will have a certain segment without decent health care and learn to live with it, just like we have homeless and hungry people and entire school districts receiving sub standard education. It will be attributed as usual to our constitutional freedoms and the ever increasing laissez faire capitalism that we all cherish.
    Yes we do need campaign funding reform and term limits, but who is going to champion that effort when all the champions had their campaigns handsomely funded? It’s like hoping that McAllen doctors will suddenly decide to champion reform of the Medicare reimbursement model.

  37. Right on – this hits the nail on the head. And it sets up the agenda for Health Reform 2.0: working to fix the problems created by the current version of health reform proceeding through Congress.

  38. Bev and KayJay:
    In fact, we wrote this several weeks ago and then submitted to the WSJ, WashPost, LA Times, Miami Herald and Health Affairs. Not only were we not accepted, but we were ignored. Not one paper even formally rejected us.
    We finally gave up and decided to move ahead and move on by publishing on THCB. If anyone has a way to pragmatic move this message along, we’re certainly game.

  39. We need some kind of easy way to make our views known to Congress and the Prez. Like a copy of this post attached to a list of all our senators/congressmen and the White House email address so we can email it to them? I for one have never contacted my representatives about anything, and don’t know the process. Yes, I could look it up myself, but there will be far greater #’s if someone could just tell us all how to do this in 3 easy steps.
    You know – sort of like how all the special interests make it easy for people to send in stuff to their reps, like canned emails and petitions. (:

  40. This may be the most powerful team ever writing on THCB! And of course everything they say is totally correct. I’ll have a longer comment on this soon but I’m afraid that while I agree with absolutely everything they say, it’s too late for the substantive changes they’re talking about this time around. It’s possible (and we should all lobby for) real payment reform as part of the final bill compromise. But right now the question is, do we get behind the more modest reforms in front of Congress or not?
    I’ve said before and I’ll say again, the kind of substantial reforms Messrs Klepper, Kibbe, Laszewski & Enthoven advocate would only be available to the American people after a major crisis.
    And just think, despite what happened last year we still do NOT HAVE any real reform of our financial system. So I’m sad to report that even in the midst of the coming crisis they correctly predict, I’m not sure we’ll get the changes they’re looking for. But right now they’re not really on the table.

  41. Bravo. I think that the quid pro quo nature of this critical effort illuminates the need for congressional term limits and campaign finance reform. The legislative branch has been reduced to a simple marketplace for economic influence. The rhetorical debate is just window dressing for the bribes.

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