Matthew Holt

Reform? Marginal, I fear…

Matthew HoltToday’s news is that there is now a double header running health care with the addition of the 
(notably all-female) team of Sebelius & DeParle joining Orzsag, Zeke Emmanuel and a host of others with influence on the health care policy tiller. We await a CMS leader, and probably multiple other appointments quickly down through the ranks.

However, I remain convinced that not much is going to happen, and that even if Obama’s “plan” gets enacted, it’s a limited reform that is not the big bang we need to do the job.

Thankfully rather than me having to explain why, Bob Laszewski (who makes me feel like an inadequate noobie every time I read his stuff) details the problems over at Health Affairs blog. The Bob L summary?

  1. Obama’s team has not aggressively gone after the hard cost problems as part of Medicare & Medicaid, preferring to trifle around the edges with modest cuts 
  2. For the (these days relatively modest!) $120 billion a year the reforms are going to cost it’s only looking to the health care system to pony up around half of it—the rest (c. $65bn a year) will come from the taxpayer.
  3. The details of the plan are being left to the Congress which means that it’ll be watered down.

As I said in the looooong comment thread on Maggie Mahar’s piece on THCB yesterday—BTW Maggie’s comment on her own piece may be the longest comment I have ever seen on any blog!—there’s no reason that the rest of the economy should contribute more to the health care system. As John McCain might say (albeit with disapproval), we need to redistribute the wealth within the system.

Furthermore, despite Orzsag’s understanding of the long-term impact of health care cost increases, there doesn’t seem to be any indication of how the overall cost increases within the system is going to be ratcheted down. Zeke Emmanuel (echoing Vic Fuchs) has an answer in his excellent book—tie health care costs directly to a visible VAT tax that can only be increased by a Congressional vote. But the Obama team thus far says, we understand the problem, but we want to punt the reform process to Congress. They’re not even apparently insisting on a public plan as part of their package, or at least it’s not in the eight principles.

Now I understand that they don’t want to repeat the Clinton mistakes of taking too long and over-detailing the approach. And I would be OK if they took the LBJ approach and basically bought off all the interest groups and spent that extra money, if we achieved the real issue behind health reform—getting everyone covered in a single social insurance pool. Because if we did that first thing, we could fix everything else later.

But instead we’re going to get some mealy-mouthed version of pay or play which, if it survives the small business lobby (and I doubt it will) will only get us about half way to solving the uninsured issue, and will leave in place the terrible mish-mash of employer-based insurance, private insurers with mixed incentives, competing incoherent benefit packages, and Medicaid as a default and screwed up stop-gap.

And the result of that will be a still large group of uninsured and no real single source for cost-containment. Which (as I’ve said a gazillion times before) means that the system will still be able to increase costs, more people will become uninsured and/or fall into the Medicaid revolving door, and the socio-demographics of being uninsured will shift upwards.

But because we will already have “done” health reform, we won’t have the political will to do it properly when the chickens keep coming home to roost in a few years.

And eventually, we’ll have to go to Medicare for all with de-facto price setting and limited global budgets, and it won’t be pretty. Nor will it be the best solution we could have.

CODA: You want to see opposition to Obama starting already? Former government welfare Queen Rick Scott—yes he of the Columbia/HCA business model of defrauding Medicare and hoping no one notices—has laughably launched a group called Conservatives against health care for poor people Patients Rights , and worse, is starring in his own ads! I guess at least you can’t call it a Great Right Wing Conspiracy when it’s only one guy!

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melissa
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melissa

no help, still only denial,,,,i am so ready to -oo00h- can’t say,,,, they have raised taxes on cigarettes to get ppl to quit smoking and are raising again next month one more dollar, all so they can better health care,,, well ,,, why not helping those that you and i both know qualify for health care and ssi ( I HAVE EPILEPSY,,have had since childhood) , AND START THERE!!!! if they use their brains , that alone will close alot of files and paperwork, hours, and overtime pay. stop throwing our case away only to make us keep re applying… Read more »

melissa
Guest
melissa

no help, still only denial,,,,i am so ready to -oo00h- can’t say,,,, they have raised taxes on cigarettes to get ppl to quit smoking and are raising again next month one more dollar, all so they can better health care,,, well ,,, why not helping those that you and i both know qualify for health care and ssi ( I HAVE EPILEPSY,,have had since childhood) , AND START THERE!!!! if they use their brains , that alone will close alot of files and paperwork, hours, and overtime pay. stop throwing our case away only to make us keep re applying… Read more »

HD
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HD

An honest discussion of American Medicine is not complete without mentioning some responsibility on the patient’s side of the equation. A simple solution, and one that has a great deal of appeal to third party payers and cost containment experts in Medicare, is to deny medical care to those who display unhealthy behaviors such as smoking, drinking, eating fast food, maintaining an abnormal Body Mass Index, failing to excercise, or those who have a genetic predisposition towards certain disorders. Insurers and hospitals are also interested in denying care for those who are injured while engaging in risky activities such as… Read more »

HD
Guest
HD

Addendum:
The underlying issue among uninsured and underinsured persons is being poor. Until we commit our military to the War on Poverty we surely are doomed to fail.

HD
Guest
HD

An honest discussion of American Medicine is not complete without mentioning some responsibility on the patient’s side of the equation. A simple solution, and one that has a great deal of appeal to third party payers and cost containment experts in Medicare, is to deny medical care to those who display unhealthy behaviors such as smoking, drinking, eating fast food, maintaining an abnormal Body Mass Index, failing to excercise, or those who have a genetic predisposition towards certain disorders. Insurers and hospitals are also interested in denying care for those who are injured while engaging in risky activities such as… Read more »

pcb
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pcb

I could not agree more with christopher george’s post above on P4P and the poor. To pretend we have reliable risk adjustment scores for differing patient characteristics is laughable. If P4P goes forward like many would like, it is almost certain that poorer, sicker, more complex patients will become black sheep that few physicians will want to care for. Why shoot yourself in the foot trying to help the most fragile patients when all you are doing is setting yourself up for lower “quality” scores, lower “physician rankings” and lower pay? In addition, good luck with the shared decision making… Read more »

Peter
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Peter

“How do you deny someone access to healthy habits”
You subsidize high carb/fat and don’t subsidize fresh fruits and veggies. You also don’t ensure safe neighborhoods that encourage outdoor activities. The poor also live in old stock housing (lead paint) and more polluted neighborhoods. http://www.nhi.org/online/issues/95/lead.html
I believe HUD had a program where the poor were paid for lead paint abatement of homes in their neighborhood, but that was cancelled.
Yes the poor can make healthier decisions, like moving to better higher rent neighborhoods with health clubs they can join and spend their limited income on healthier, even organic foods.

Deron S.
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“I guess it’s easier to deny proper healthcare coverage to the poor at the same time you deny them access to healthy food/exercise habits.”
Huh??? How do you deny someone access to healthy habits?

jd
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jd

Maggie, My growth numbers were purely illustrative, not meant as predictions. As for physician salary expectations being based on CEO salaries: on one level, I don’t give a rat’s patooty how many hundreds of thousands or millions CEOs or physicians think they deserve. I know many in both groups are milking the system to extract profits that don’t improve the economy or public health. By the way, if physicians are comparing themselves to CEOs and thinking they come up short, they are full of shit. The CEOs who get paid millions are almost all running huge corporations and only get… Read more »

bev M.D.
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bev M.D.

Well, speaking of how to save $$, here’s an article in the New England Journal of Medicine that I read last night, regarding PCI (e.g. coronary angiography with stents) vs. medical therapy alone. Conclusions: “Our study adds to the evidence that in a variety of clinical situations involving patients with coronary artery disease IN STABLE CONDITION (caps mine), a strategy of routine revascularization (e.g. PCI) adds only a modest EARLY advantage with regard to symptoms and functional status, and this advantage is not maintained. Given that this modest quality-of-life benefit was obtained at a cost of more than $7000 per… Read more »

Christopher George
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Christopher George

Maggie, You are aware I am sure of the commodities wager that the limits to growth doomsayer Paul Erlich made with Julian Simon. I propose a similar wager regarding the “corrections” that P4P is going to make for patient condition. I bet the corrections will under correct and result in terrible finacial proplems in hospitals that care for the poor. This will be one more reason doctors can’t afford to take care of poor people. Next time you are at some swanky Manhatten establishment, ask yourself how many 450 lbs diabetics with ulcers and neuropathy are there among superrich women.… Read more »

Peter
Guest
Peter

The poor and obesity; http://www.msnbc.msn.com/id/9505511/ Interesting trend map. http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/ http://www.msnbc.msn.com/id/20461564/ “The five poorest states were all in the top 10 when it came to obesity rates.” So much for low wage policies. “An exception to that rule was the District of Columbia and New Mexico. Both had high poverty rates, but also one of the lower obesity rates among adults.” So, how did these states do it? I guess it’s easier to deny proper healthcare coverage to the poor at the same time you deny them access to healthy food/exercise habits. Think we’d ever bail out the poor like we… Read more »