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What Do We Do Now?

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By David Dranove

Those of you from my generation may recognize the title of this blog as the last line from the movie “The Candidate.”  Robert Redford’s character has just won election to the U.S. Senate and ponders his future.

Supporters of the Affordable Care Act should be asking themselves the same question.  They worked hard to get the bill enacted and then had to sweat out (literally in much of the nation) the Supreme Court decision.  But the bill as it stands will only go so far to cure our nation’s healthcare woes.  Yes it will expand coverage.  And the push for Accountable Care Organizations might reintroduce some of the cost savings incentives enjoyed by HMOs.  But this is legislation that relies on competitive healthcare markets yet does precious little to promote competition. There is a lot more work to be done.

I doubt that the current Congress has the stomach to consider any more healthcare legislation, but here are some recommendations for the next Congress (and for any states that want to make the ACA work for them.)

1)  Limit the tax deduction for health insurance.  Economists have been preaching this for decades and the justification is as valid as ever.  If individuals want insurance that pays for every last dollar of every last medical service, let them buy it with after-tax dollars.  Why should everyone else subsidize their profligacy?  It has been said that Congress can never muster enough votes for legislation limiting the tax deduction.  They said the same thing about comprehensive health reform.  Get this done!

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Is the Center For Innovation Innovating Too Fast?

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By Robert A. Berenson and Nicole Cafarella

One of the few health policy issues that receives bipartisan support is the need to dramatically alter the way providers are paid, shifting from “paying for volume” to “paying for value” to alter the trajectory of health care spending while improving health care quality.

To facilitate this shift, the Affordable Care Act equipped the Centers for Medicare & Medicaid Services with a range of cost-cutting and quality-enhancing tools―the most significant of which might be its new Center for Medicare and Medicaid Innovation. In this blog post, we share insights from recent research funded by the Robert Wood Johnson Foundation on the Innovation Center’s new role, organization, and model selection criteria.

Based on interviews with senior leadership, it’s clear the organization sees its role as two-fold: complementing existing efforts to innovate; and delving into new ideas.

Most of the Innovation Center’s efforts to date have focused on the former―implementing congressionally-mandated demonstrations or ideas that Congress or policy experts have already conceived (e.g., accountable care organizations). More recently, the Innovation Center has begun to seek new ideas from innovators across the country and to promote bottom-up innovation―primarily through its Innovation Challenge.

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A Call For a New Primary Care Society

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By Brian Klepper

The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.

Paul Starr, The Social Transformation of American Medicine, 1984

How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidence compellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require a approach that appreciates and leverages power in ways that are different than in the past.

But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value, and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care’s foundational role in US health care and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.

The consequences have been withering constraints that have diminished primary care’s value, and that have thwarted its roles as first line manager of most medical conditions, and as patient-advocate and guide for downstream services. Combined with fee-for-service reimbursement and a lack of cost/quality transparency, primary care’s waning influence has precipitated a cascade of impacts, allowing health industry revenues to grow at more than four times the general inflation rate for more than a decade, with unnecessary utilization and cost that credible estimates suggest is half or more of all health care spending.Continue reading…

Jeff Goldsmith on what’s next, post-SCOTUS

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By Matthew Holt

Hours after the SCOTUS verdict and about the same time as a feisty (and not too productive) shouting match on the NY Times site between Maggie Mahar & Michael Cannon with commentary from Bob Reich and “expert” Grace Marie Turner, a real health care expert dissected the future of health care.

Here’s Jeff Goldmsith‘s talk (done for Eliza with Queen Bee/Chairman & Chief Visionary Officer Alexandra Drane refereeing). And it’s excellent. (It also has a tad of rambling from me at the very end….). I suggest you spend a chunk of your Saturday morning listening to Jeff tell you more.

 

WEBINARVID from Leigh Eck on Vimeo.

SCOTUS Ruling An Unappreciated Win for the GOP

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By Al Lewis

The ruling upholding most of Obamacare was an as-yet-unappreciated boon for the GOP. A brilliant move by Roberts, he managed to preserve the remaining integrity of the court — and raise his own stature — while at the same time increasing the odds of a Romney win. How?  By recasting the mandate as that third-rail of politics, a tax.  Let’s dissect both these statements.

First, how can we be sure it wasn’t a major victory for Obama, pundits notwithstanding?  There is a “market” in presidential election predictions, www.intrade.com.  One may place bets on candidates and while, like the stock market, it is wrong sometimes, the “price” of each candidate does react to events. So, for instance, Rick Perry’s price fell 75% within seconds of his forgetting the name of the third cabinet department he was going to eliminate.  And yet, a full day after Obama’s “victory” the “price” his re-election chances still has not budged. It bumped briefly and has since fallen back to the same $5.40 (to win $10 if he wins—a 54% probability) that it’s been hovering at for weeks.

Second, was Roberts accurate, or just politically astute, in re-casting the mandate as a tax?   Answer:  The latter.

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The Beginning of the Next Healthcare

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By Joe Flower

What a cliffhanger! It is an historic decision, found on the narrowest possible grounds, with a majority agreeing on the result, but not broadly on the reasoning.

Effects: The principal effects of the finding, from the point of view of the system: They have just avoided enormous chaos over the coming years. The system is chaotic enough already, at a tipping point into an unclear future, with the huge shift in underlying economic factors. These factors include especially the various ways of shifting some economic risk from the payers and employers to the providers and the patients/customers.

Stabilizing: The Supreme Court finding stabilizes the future of the system. The affirmation, combined with the fact that a gridlocked polity in Washington is unlikely to come up with any major change or repeal of the law, and that the major parts of the law are self-funding, means that everyone now knows at least the general outline of what the rules are for the foreseeable future.

Permanent: The law is now likely permanent. To overturn it, you would need President Romney with a filibuster-proof majority in the Senate and a majority in the House. The major parts of the law are self-funding and not dependent on Congressional outlays. By 2016, most people will have experienced the results of the law, and found its benefits far outweigh its costs. Business owners will find that it is not as burdensome as some have feared. It will have become obvious that the experience of the actual law is far different and more benign than the fears that have been drummed up about it politically. Once people experience its benefits for themselves, it will be very hard to gin up a campaign to take it away from them.

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Where’s the Outrage? Government Proposes (Food) Rationing!!!

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By Merrill Goozner

The U.S. Preventive Services Task Force is at it again. This time, the government-appointed panel is on fat patrol. Its review of the medical literature found that diet and exercise combined with group counseling beat popping a pill when it comes to controlling weight.

For those with short memories, USPSTF is the government panel that in the midst of the health care reform debate had the temerity to suggest the evidence was iffy on the wisdom of mammography for women under 50. Check with your doctor before deciding if an early start to routine breast cancer screening was right for you, they said.

Conservatives had a field day. “We don’t know how far government will go in this bureaucracy,” cried Rep. Michele Bachmann, R-Minn., who a few months later launched her presidential campaign. “This is how rationing begins,” intoned Rep. Marsha Blackburn, R-Tenn.

When it comes to obesity, though, a little food rationing is just what the doctor ordered, according to the latest from the USPSTF. How one rations matters, however.

“With drugs, when people stop, they gain the weight back,” said David Grossman, a senior investigator at Group Health Research Institute in Seattle and chairman of the 16-member panel that issued the updated guidelines on obesity prevention on Tuesday. “This is a lifestyle problem. If you don’t change your lifestyle, drugs are not likely to provide a long-term solution.”

Michelle Obama wasn’t taking the easy path when she chose the obesity epidemic and childhood obesity in particular as her main cause. Since the late 1970s, the number of people considered obese grew by half and now totals 32 percent of men and 36 percent of women. One in 20 Americans are now considered morbidly obese. By 2030, if nothing is done, those numbers are expected to grow to over 40 percent obese with over 10 percent morbidly so.
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Supreme Court Upholds Affordable Care Act

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By THCB STAFF

Defying predictions that the Obama administration would suffer a landmark political defeat, the US Supreme Court upheld the Affordable Care Act this morning. The implications for healthcare for the 2012 election are obviously nothing less than staggering.

What will the landmark legislation mean for the healthcare industry? For heath IT companies? For hospitals and health insurers?

We’ll be posting reactions from THCB analysts over the course of the day and in the days to come. In the meantime, if you have an opinion on the ruling, post your comments in the thread below.

If you can’t wait, you can download the ruling here in pdf format.

SCOTUS Surprise

By Robert Reich

Today a majority of the Court upheld the constitutionality of the Affordable Care Act, otherwise known as Obamacare in recognition of its importance as a key initiative of the Obama administration. The big surprise, for many, was the vote by the Chief Justice of the Court, John Roberts, to join with the Court’s four liberals.

Roberts’ decision is not without precedent. Seventy-five years ago, another Justice Roberts – no relation to the current Chief Justice – made a similar switch. Justice Owen Roberts had voted with the Court’s conservative majority in a host of 5-4 decisions invalidating New Deal legislation, but in March of 1937 he suddenly switched sides and began joining with the Court’s four liberals.  In popular lore, Roberts’ switch saved the Court – not only from Franklin D. Roosevelt’s threat to pack it with justices more amenable to the New Deal but, more importantly, from the public’s increasing perception of the Court as a partisan, political branch of government.

Chief Justice John Roberts isn’t related to his namesake but the current Roberts’ move today marks a close parallel. By joining with the Court’s four liberals who have been in the minority in many important cases – including the 2010 decision, Citizen’s United vs. Federal Election Commission, which struck down constraints on corporate political spending as being in violation of the Constitution’s First Amendment guaranteeing freedom of speech – the current Justice Roberts may have, like his earlier namesake, saved the Court from a growing reputation for political partisanship.

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The Supremes Rule: Why You Have to Love Lawyers and Politicians

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By Michael Millenson

Like the hero in an old-time movie, Chief Justice John Roberts metaphorically untied Obamacare from the railroad tracks and, with four of his colleagues, pulled it away from the onrushing destructive force of his right-wing colleagues in the nick of time.  In doing so he also saved President Obama from political disaster.

Alas, just like in the movies, the villains will soon be back.

While the next five months will determine whether the Court ruling upholding health reform was a victory or just a reprieve, the president has been plucked from the perils of a politically ruinous headline: “Signature achievement of constitutional lawyer president declared unconstitutional.”

In doing so, the Court showed why Americans hate the other guy’s lawyer and love theirs. Roberts embraced his inner reactionary by ruling that the individual mandate did not meet the requirements of the Commerce Clause — even though virtually all respected conservative jurists believe it does, and the conservative Heritage Foundation clearly believed it did when proposing the idea under a Republican president.

However, the Court avoided what would look like a political decision overturning the entire law by ruling that the penalty for not buying health insurance was a constitutionally permitted tax. Which made the law constitutional. Game. Set. Match. (Well, unless you were a poor person counting on an expansion of Medicaid. But if you’re poor, you should be used to losing.)

Don’t you love clever lawyers? At least when they’re on your side?

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