It’s Christmas Eve and the Senate just passed a major health reform bill. Personally I think the reforms in it are relatively minor, but the passage of the bill itself is a screaming big deal. When I say minor, what I mean is that we’re leaving in place the inefficient employment-based health benefits system, and we’re expanding insurance mostly by putting more people into the separate but equal Medicaid program.
But this bill is a statement, and an important one.
For the first time we’re acknowledging that everyone ought to have health insurance and that those unable to afford it should be subsidized by the government. We’re also saying that insurance companies should take all comers at a consistent price without respect to health condition (and hopefully we’re implying that their job is to manage care not risk-select). Finally we’re saying that the majority of the cost can be paid for by redirecting inefficient spending within the health care system, and by taxing benefits that are only tax-free because of historical accident.
I finally got around to reading Atul Gawande’s New Yorker piece on why the current reform bill mirrors early 20th century agriculture. I learned lots about the role of the Department of Agriculture in teaching farmers what to do. In post-war Britain the radio soap opera The Archers did much the same thing.
I was actually encouraged to remember that in almost every industrialization process, intelligence, leadership, and usually money, from the government was a key factor.
But I felt very uncomfortable with the analogy. First, the incentive for the farmers was to be more productive—even if in the long run productivity meant a relative fall in the price of food and eventually the rise of agri-business decades later. If they did things right there was an immediate market reward. Whereas we know that (from the Virginia Mason and Intermountain examples) increasing quality and productivity in health care leads to negative financial consequences.
Secondly, Gawande seems to be fine with saying that “we don’t know how to be more efficient, productive and effective, so let’s do pilots for years and figure it out.” This is just crap. We’ve both done pilots for decades, and have examples of organizational forms (you know who I mean!) that get it right. It’s just made no sense for most of the health care system to adopt those techniques and organizational forms because they make more money by doing what they’re doing—and government and employers keep paying them.
I was going to write a long piece detailing my complaints blow by blow, but luckily Alain Enthoven has done it for me!
This doesn’t mean I’m against the current bill as I suspect Enthoven is. There is some hope that ACOs and other modern terminology for the types of organization he’s espoused over the years, will arise more quickly from the “pilots” in the bill than Enthoven suspects. But more importantly, I support the bill because the saving money part is the second of my “two rules to judge a bill.” The first and most important rule is
Rule 1 A health care reform bill needs to guarantee that no one should find themselves unable to get care simply because they cannot afford it. Neither should anyone find themselves financially compromised (or worse) because they have received care.
And the current bill just about does that….although Maggie Mahar is pretty doubtful, especially for near-seniors in the first few years.
One of the most remarkable talks I heard this year wasn’t about health care. It was about food. Of course, food is very, very closely related to health and health is at least tangentially related to health care.
So I invited Alan Greene of drgreene.com (who is a friend and has spoken at a couple of Health 2.0 Conferences) to tell me about the new book, Raising Baby Green. It really is a potential way to change how Americans (and everyone else) eat, and to use the most important years (the ones we can’t remember!) to do it.
Most importantly Alan is starting a viral campaign to get this information into the hands of expectant mothers. For anyone who knows an expectant mum or someone who might be one someday, this book is very important. And the message needs to get out and get mainstream quickly.
Here’s the interview in which Alan explains how to feed kids right, and we do a little plotting in how to get this into mainstream child-raising.
As it's a work day for the Senate worth reporting here that Ben Nelson’s vote has been bought for more Medicaid spending for Nebraska and a complex formula for States to opt out of exchanges being able to fund abortions. So presuming there’s no problems in reconciliation we can expect the reform bill to be done relatively soon. Full details on what’s in the new bill on Think Progress’ The Wonk Room.
The netroots left has been complaining loudly over the last couple of days since Lieberman was bought off by dropping the public option and the Medicare buy-in. Howard Dean and Markos of Daily Kos both called for massive changes to the bill, or killing it and the debate between the “sensible left” and the “this is a sellout to insurers” has got a little silly. However, (unless Bernie Sanders pulls fast one) none of the more left wing Senators (Sherrod Brown et al) are going to vote against the bill, so what we see now is what we get.
The real issue will be when the voting public finds out that nothing happens for 3 years.
As many involved in the worlds of Health 2.0 and Information Therapy know, some of the most interesting experiments in the world of patient-physician engagement have been happening in the somewhat unlikely environs of small town Oklahoma. There the City of Duncan has put its employees (and their providers) into a system that incents (but doesn’t mandate) physicians to practice according to accepted guidelines, and incents (but doesn’t mandate) patients to read information prescribed by their physicians about their treatments (and tests them about it). The system then asks each party to rate the other.
It sounds simple and frankly, compared to much in health care, it is. The system is supplied by MedEncentive, an Oklahoma City firm led by the charming and engaging Jeff Greene. While I remain fascinated by MedEncentive’s program (and FD MedEncentive has sponsored the Health 2.0 Conference in the past), it’s perhaps grown a little more slowly than Jeff and other fans might have liked—given the scope of the problem.
But the results have been impressive in reducing costs (mostly by reducing hospitalizations) and increasing patient involvement. Yesterday MedEncentive released a five year retrospective. The key finding?:
City of Duncan costs for the most recent year was 8.6% less than five years ago prior to implementing the Program, which is 34.9% less than the projected costs. The resultant four year savings equates to an 8:1 return on investment. (emphasis added)
Jeff abandoned a lucrative business in physician practice management to have a go at this intractable problem. Five years on he deserves plaudits for what he and his team have achieved, and hopefully we’ll see much more innovation like this mushrooming in the future.
Given the relatively lightweight nature of the intervention, I’m amazed that many much larger payers/employers haven’t given it a try. After all, whatever else they’re doing doesn’t seem to be exactly working too well!
From a deeply depressing survey of the unemployed in today’s NY Times:
Nearly half of respondents said they did not have health insurance, with the vast majority citing job loss as a reason, a notable finding given the tug of war in Congress over a health care overhaul. The poll offered a glimpse of the potential ripple effect of having no coverage. More than half characterized the cost of basic medical care as a hardship.
Meanwhile what is Joe Lieberman concerned about? Playing politics against liberals who, correctly, think he erred terribly in his support for Bush’s war and McCain’s candidacy.
And even if we pass legislation, when does the help arrive for these unemployed? 2013.
So maybe the two parties are coming together on health reform after all. Last night we learned that after days of “secret talks” among the “gang of ten” the Democrats have reached agreement to restructure their health care proposal. The changes are significant:
– ditch the already-watered-down public option plan;
– create a new insurance exchange “option” for individuals and small groups consisting of a nonprofit plan as negotiated by the Office of Personnel Management;
– expand Medicare eligibility to cover uninsured individuals aged 55-64.
What does the Democrats’ “public option ultralight” compromise have in common with Republicans’ alternative universe? Well, consider the latter’s proposal to open interstate competition for all health insurers–a move they promise will immediately lower health care costs. Besides being shameless attempts to offer simple solutions to complex problems, the two proposals are guilty of the same fundamental misunderstanding of health insurance. Simply put, they both ignore a critical economic truth of health insurance today: insurers require a provider network of hospitals and doctors or must have market leverage in order to negotiate for lower provider prices and for controls on excessive volume.
So today’s news is that the gang of ten have come up with something. (If you haven’t been following along, the gang of ten are the five “liberal” Democrats and the five DINOs asked by Harry Reid to come up with something to break the deadlock and get some type of compromise that will pass the Senate). More details are here from Brian Beutler at TPM
So it might vanish like a Clinton-era trial balloon, or it might be a stayer, but the core of the new concept is to allow the 55–64 crowd to buy into Medicare, and to ask/allow/mandate a non-profit insurer(s) to provide a substitute public option. Exactly what the second point means is unclear to me. It may turn out to be some collapsing of Kent Conrad’s notion of the cooperative with an extension of the Federal Employees’ Plan (presumably minus the for-profit carriers) and somehow cramming that into the exchange. Of course providing something like the choice among private plans that Federal Employees now get was at the heart of Ron Wyden’s plan. We’ll see if it can last a couple of days scrutiny, or the wrath of the House Democrats.
The Medicare buy-in seems both sensible politics and half-decent policy.
Maggie Mahar, Jon Cohn, Jon Nichols and Olga Pierce hang out with Laura Flanders on the amusingly titled GRITtv and discuss how screwed up the politics of health care are in the Senate. Twenty minutes of amusing chat without a “moderate” or a Rpublican in sight. (Can’t get the video to embed here, so sneak over there).
Paul Starr and I have been agreeing a lot lately. Not that Paul knows or cares what I think or say, but a while back we both expressed fear that private health plans will end up channeling bad risks into the public option. That time I beat him to the punch (but I happen to know his piece was on the way before I hit “publish” on mine).
This time he was out first. Last Saturday he reminded Democrats that the big deal is not what happens with the public option, but instead what matters is how aggressive and effective Federal regulation of insurance (via the exchanges) will be.
For these reforms to succeed, there needs to be effective regulatory authority to prevent insurers from engaging in abusive practices and subverting the new rules. The bill passed by the House would provide for that authority and lodges it in the federal government, though states could take over the exchanges if they met federal requirements. The Senate bill would leave most of the enforcement as well as the running of the exchanges to the states. Yet many states have a poor record of regulating health insurance, and some would resist passing legislation to conform with the new federal law.
Of course Paul was a major author/player of the Clinton plan in 1993–4, which had it been enacted would have been way more extensive and impactful than the current legislation—and in a good way. I fear that this time his influence will be equally lacking in terms of the end result. Which is a big pity.