Tag: Policy/Politics

Video Collage: KP Center for Total Health

Apr 8, 2011• 4

By MATTHEW HOLT

This week I spent quite a bit of time at the very new and very fancy Kaiser Permanente Center for Total Health in Washington DC. It’s next door to a very large medical office building (110+ docs) in which KP is showcasing its current integrated care model, and how far its come in its mid-Atlantic region. The Center is a pretty fascinating place–part tech and idea showcase and part meeting room. Certainly no other health care organization that I’m aware of has spent so much on a place designed to stimulate the imagination and enhance conversation–under the nose of the folks on Capitol Hill. I won’t get into here whether this is how money should be spent in health care but on balance I’m a fan. (FD KP is a sponsor of the Health 2.0 Conference I co-run). Instead I want to try to give you a feel for the place, and why it fits their vision and what it’s trying to demonstrate.

I took a tour with some colleague journo/blogger types led by the always expressive Robbie Pearl (CEO of the Permanente Groups in N Cal and now DC too–the airlines thank him!) and with Phil Fasano, CIO of the whole organization. Robbie is not shy in voicing his opinions (as you’ll see) and Phil occasionally trots out the voice of caution to reel in Robbie’s vision a tad. It was great fun.

What was also fun was the cocktail party at the grand opening. There I met three of my favorite DC-based ladies in health: Deven McGraw, Regina Holliday & Cindy Throop. So we’ll start with that fun video, and then there’s a whole lot more from the tour of the center after the jump. All these videos are pretty short.

After that fun and games, lets head to the tour. This is a series of videos of me and a few others testing out the displays, and listening to Pearl & Fasano, as well as asking them a couple of pointed questions.

But I’ll take the tour in order….after a quick thanks to Holly Potter, Danielle Cass, Ravi Poorsina & center boss Julie Norris who with a ton of their colleagues worked their butts off keeping hundreds of visitors informed and entertained.

First up, Robbie Pearl on the current state of the KP.org health record and why we shouldn’t have to put up with less; what he called the 19th century state of medicine. And I can assure that is on display in my wife’s OBGYN office every time I visit.Continue reading…

Letter From London

Dec 13, 2010• 5

By BOB WACHTER, MD

I’ve just returned from a few days in London, scoping things out for a planned sabbatical next fall. In what may be a pale echo of the late Alistair Cooke’s always fascinating “Letters From America,” here are a few of my initial observations:

The dominant issue, of course, is the Cameron government’s new austerity program, with its planned deep cuts to government services and benefits. While the program (or programme, I guess I should say) has created some upheaval – witness the recent semi-violent demonstrations by university students, whose tuitions may treble – it has not torn apart the society, the way belt tightening of this magnitude undoubtedly would in America. My sense is that the relative acceptance (yes, I know Charles and Camilla had a frightfully awful limo ride to the West End the other night, but this was, er, theater rather than a defining moment) can be explained the Brits’ stronger trust in their government. It is this same trust that leads to near-universal support for the National Health Service, the UK’s tax-funded healthcare system. This wellspring of support gives the government a little leeway when it says, “We can’t afford to do all this anymore, folks, and we can’t just print money. We must cut programs and benefits.”

In the US, of course, there is no such trust today, nor harbingers of its return any time soon. In a recent issue of Time that outlined this past decade’s mega-trends, Nancy Gibbs observed that the cumulative effect of 9/11, Katrina, BP and the subprime crisis was to markedly shrink Americans’ already scanty faith that their government can do anything competently. So our response to the recent announcement that Chinese kids are shellacking us in educational achievement is hand wringing and statistical nitpicking, not the call for vigorous government action that characterized our nation in the Sputnik era.

American Healthcare X

Dec 6, 2010• 29

By RONALD PIES, MD

“A decent provision for the poor is the true test of civilization.”
~Samuel Johnson

“Joe” has been on the streets now for two months. He’s 35, unmarried, and diagnosed with chronic schizophrenia since age 19. His illness is difficult to manage, even with regular medication, and Joe is subject to hallucinations telling him to “fight off the evil ones”. Like most people with psychiatric disorders, Joe has never been violent—but when his illness is not well-controlled, he can become loud and belligerent.

Despite his many tries at holding down a job, the economic downturn and his worsening psychosis have left Joe jobless and homeless. Joe’s family thinks he is “faking” his symptoms and they are “fed up” with him. They have refused to take him in or help him with his medical care. Joe has no friends willing to help him and survives on the streets by panhandling and dropping in at soup kitchens. The local shelters won’t accept Joe, because he is “too agitated.” Joe sleeps in alleyways, or, when lucky, in ATM stations. In the past month, he’s been beaten up twice by members of youth gangs. Recently, Joe was diagnosed with type 2 diabetes, requiring daily medication and monitoring. Joe says he doesn’t want “charity”, and would like to work again, but doesn’t see how he can.

“Joe” represents many patients I’ve cared for during nearly 30 years of medical practice, and typifies thousands of Americans with severe mental illness. In my previous blog entitled, “The Libertarian Mind”, I posed this question: what is the moral responsibility of federal and state government to help care for people like Joe? I argued that the Libertarian Party platform—calling for the abolition of “the entire social welfare system”, including food stamps—is neither humane nor compassionate.

The Politics of Health Reform

Oct 19, 2010• 44

By JOHN GOODMAN, PhD

There will be two national elections before the new health overhaul is substantially implemented (in 2014) and a third election the year it is supposed to be implemented.

Question: Will the voters reward office holders who supported the Affordable Care Act (ACA), or will they vote for their opponents? In thinking about this question, forget all the public opinion polls. Can you predict the outcome based on what you know about political science alone?

My prediction: Supporters of the new law are going to get creamed. As I explained at my own blog the other day, there are four reasons: The law violates two bedrock principles of coalition politics that have been successful for the past 80 years; it abandons core Democratic constituencies; and it ignores the fundamentals of the politics of the health care sector.

Franklin Roosevelt’s First Principle of Successful Coalition Politics: Create benefits for people who are concentrated and organized, paid for by people who are disbursed and disorganized.

The ACA violates this principle in spades. The main beneficiaries are many (but not all) of the new law are 32 million to 34 million newly insured people who otherwise would have been uninsured. Far from being organized and focused, most people in this group do not even know who they are. Indeed, it is probably fair to say that never in American history have so many benefits been conferred on so many people who never even asked for them!

The Reinvention of Social Progress

Mar 23, 2010• 31

By MERRILL GOOZNER

I watched C-Span through the entire voting process on Sunday night. Socialism? Tyranny? The Republican hyperbole was unhinged from reality.

Democratic claims that the health care reform marked a major milestone in domestic policy were closer to the truth. But billing the legislation as comparable to the advent of Social Security in the 1930s or Medicare and Medicaid in the 1960s simply isn’t accurate.

Why do I say that?Continue reading…

“I Am Not Bound To Win. But I Am Bound To Be True.”

Mar 21, 2010• 40

By MAGGIE MAHAR

So many said it would never happen. But now, on Sunday, March 21, 2010, it appears that reformers have the votes. Rep. Bart Stupak, the leader of the anti-abortion hold-outs, has announced that he will vote “yes.” – under the agreement, President Barack Obama will sign an executive order ensuring that no federal funding will go to pay for abortion under the health reform plan. This really doesn’t change anything. Stupak got nothing except face-time on television.

At last, Congress is about to take the first step toward transforming what we euphemistically call our health care “system.” In the years ahead, the laissez-faire chaos that puts profits ahead of people will be regulated, with an eye to providing affordable, evidence-based, patient-centered care for all.

Over the last three years, I have predicted that Medicare reform would pave the way for health care reform, and this bill makes that possible. Under the legislation, Congress will no longer be in a position to thwart Medicare’s efforts to rein in spending by eliminating waste. Not everyone is happy about this. Over at Politico.com former Republican Senator Bill Frist and former Democratic Senator John Breaux register their protest in a column titled “Keep Medicare in Congress’ Hands.”Continue reading…

Healthcare 2015

Mar 21, 2010• 18

By MICHAEL TURPIN

“This gets back to the fundamental lesson of political survival that Bill Clinton taught me, which is if you make it about the American people’s lives instead of your life, you’re going to be okay.” — Paul Begala

It’s March, 2015. Healthcare reform has now been active for over five years with the majority of reforms kicking in as of January 1, 2014. Several amendments have been proposed and passed in the interim period including the All-Payer Act normalizing reimbursement rates for hospitals between Medicare, Medicaid and private insurance.

The American Family Practice Reimbursement Act promulgated minimum reimbursement levels for primary care providers acting as part of accountable care organizations and included a package of incentives for medical graduates and nurse practitioners to practice primary care. A particular emphasis was paid to establishing federally qualified health centers in urban and rural areas where Medicaid statistics reveal high rates of chronic illness and minimal levels of compliance with requisite preventive care to arrest the erosion of chronically unstable patients into catastrophic illness.Continue reading…

Could It Be That the System (Gasp) Works?

Mar 20, 2010• 41

By BOB WACHTER, MD

Heading into the final weekend of Mr. Toad’s Wild Ride, who could have guessed that in a year that brought us Death Panels, Pickup Trucks, “You Lie”, The Cornhusker Compromise, Bart Stupak (boy, that must have been a tough name to grow up with), and the Senate Parliamentarian-as-Rock-Star, we would be on the cusp of passing a perfectly acceptable healthcare reform bill, a once-in-a-generation legislative achievement.

Unmistakably, the mojo has shifted back to the Democrats – it is amazing how a dour and monolithic opposition can cause even Dems to unite for a common cause. Our President has also learned a few lessons, including the importance of symbols, populism, and singing with one’s diaphragm. (We knew we were in trouble a few weeks ago when Rahm started being criticized for not being sufficiently Machiavellian.) With yesterday’s CBO figures showing that the reform plan will save nearly $150 billion, even fence-sitting Democrats now see more political risk in saying No than Yes. That, of course, is the most relevant calculus, and with it more and more of the Blue Dogs are entering the Yes column each day.Continue reading…

Unstable Public Opinion

Mar 15, 2010• 4

By MERRILL GOOZNER

Joseph White, a professor of politics at Case Western Reserve University, made this interesting observation in his weekend column in The Fiscal Times:

“On most issues, there is no such thing as a stable “public opinion.” People do have general attitudes, beliefs that they can use to evaluate a choice. But often voters hold different attitudes that would lead to different evaluations of the same choice. How they answer a question depends on which considerations have been raised in their minds most recently.”

Therefore the analysts who predict Democratic defeats in November based on negative survey responses about health care reform now are making a fundamental error. The Republicans have shown great ability to raise considerations that push the evaluation in one direction. Yet some of that effort has been encouraged by the concerns conservative Democrats raised during the debate as they tried to make legislation better fit their preferences. They will not be making those arguments as they run for reelection. In the election campaign there would be far more spending on ads to defend the legislation. The press coverage may focus more on the actual provisions of the bill as opposed to the GOP charges. But focusing on the actual specifics will only be possible if there is a law that passed and can be defended. Democrats have to be able to point to something and say: “this is what we did, this is the truth about it, this is how it would help you.”

The Democrats also have to remember that the “losers who can’t deliver” consideration will be far more prominent in November if they pass nothing now. In short, the battle over interpretation of the health care reform effort has only begun. We do not know how it will turn out in November, but there are good reasons to believe the Democrats are better off fighting it with a new law in hand.”

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect and The Washington Post. His most recent book, “The $800 Million Dollar Pill – The Truth Behind the Cost of New Drugs ” (University of California Press, 2004) has won acclaim from critics for its treatment of the issues facing the health care system and the pharmaceutical industry in particular. You can read more pieces by Merrill at Gooznews.com.

Last Helicopter Out of Saigon!

Mar 7, 2010• 47

By JEFF GOLDSMITH

In popular psychiatry, a classic passive aggressive gambit is “malicious compliance”- intentionally inflicting harm on someone by strictly following a directive, even though the person knows that they are damaging someone by doing so. In Washington, the most skilled practitioner of this dark art is Speaker Nancy Pelosi If health reform craters, Pelosi will disingenuously claim that she did precisely what the President asked of her, and blame the Senate and the President for its failure.

In reality, Pelosi’s “leadership” almost fatally wounded health reform last summer. If the process does collapse, the blame should fall squarely on her shoulders. Her poor political judgment led directly not only to squandering a nearly 80 vote majority, but also exposed embarrassing and ill-timed disunity among Democrats on a signature domestic policy issue. It won’t be the Republicans that killed health reform, but incompetent Democratic Congressional leadership.

Last July 14, Speaker Pelosi unveiled the opening bid in the health reform process- HR 3200, America’s Affordable Health Choices Act of 2009. This bill was drafted largely without input from their Republican colleagues or from important Democratic moderates. It also put into legislative language virtually exactly what the President promised in his campaign, without considering seriously the political implications for the actual passage of the legislation- a political form of malicious compliance. Democratic moderates felt their input had been ignored and they were immediately trapped on the wrong side of this issue.

HR3200 had an immediate polarizing effect on the health reform debate, and the damage control process was on. In a sense, health reform has never recovered. Pelosi’s bill summoned the right wing talk radio demons (and the inimitable Betsy McCaughey) out of their caves, reviving long dormant rhetoric about a “government takeover of the health system”. This label has clung stubbornly to all subsequent versions of the legislation.

Unfortunately, the critics weren’t too far wrong. HR 3200 effectively federalized the employer health benefit. It mandated that employers offer a “one size fits everyone” health benefit to their workers, the benefit precisely defined by federal statute. It imposed an 8% payroll tax on employers who did not provide the benefit, pushing their federal payroll tax to 23% if you include Social Security and Medicare. It also moved the top tax rate for federal income taxes for businesses filing as “subchapter S” to 46%, a level not seen since Jimmy Carter was in the White House.

Given unemployment was climbing toward 10% at the time, HR3200 would have simultaneously diminished corporate cash flow and increased the cost of hiring new workers for firms that did not presently offer health coverage- a recipe for no recovery.

HR 3200 created new health insurance premium subsidy for workers covering and estimated 20 million new people, but without any meaningful brake on future federal subsidies. To enroll these new folk, however, health insurers would have to comply with provisions of a new federal health insurance exchange, whose rules would have effectively ended medical underwriting.

The health coverage gated through the exchange was no longer be “insurance”, but a federally defined health care entitlement financed largely by employers. The bill also created a public health insurance option, which had the effect simultaneously of competing with and financially undermining private health insurers. All of this was to be overseen by a politically appointed Health Choices Commissioner, in effect, a commissar for the health insurance system. This nominally private-sector approach had a distinctly Soviet flavor.

Almost immediately upon HR3200’s release and for the following seven months, the Democrats have been playing defense on health reform and losing. Democrats elected from Red or Purple states ran from the bill as fast as their legs would carry them. They rebelled against the “public option”, the employer mandates, as well as the tax increases required to fund the premium subsidies.

Moderate Democrats also objected to subsidizing private coverage of abortions and to any enrollment of people in the US illegally (roughly 7-8 million of the uninsured). It might have been possible to address these concerns “privately”, e.g. in the initial drafting process, but by the time HR 3200 was released, many After almost four months of contentious negotiations, a revised version of the House bill passed by only five votes, one of which came from a stray Republican.

By the time Democratic moderate concerns had been clumsily and publicly accommodated (in the late fall), the resulting House bill had gravely offended three core constituencies of the Democratic party- women, Hispanics and the single-payer advocates, without materially addressing the critics of a huge expansion of federal power (and spending). The Democratic base lost enthusiasm for the bill while Democratic moderates continued to struggle with the “government takeover” label. By late fall, the legislation had acquired the odor and toxic sheen of a rotten side of tuna.

In the court of public opinion, the ensuing seven months (with a brief blip after Labor Day after a well- crafted Obama defense of health reform), were all down hill for health reform. Opposition to the process, as much as the substance, of health reform hardened, aided materially by a flurry of dealing making around the Senate bill (Medicare or Medicaid carve outs for Florida, Louisiana and Nebraska most visibly).

The late January loss of Ted Kennedy’s seat to an insurgent “Tea Party” Republican, Scott Brown, was an unmistakable warning sign that even formerly unassailable Blue State Democrats were now at risk. Political pundit Charlie Cook, who follows the Congressional races at a microscopic level, wrote recently that the Democrats have been in free fall since August. They lost gubernatorial races in New Jersey and Virginia, county executive races in solidly Democratic Fairfax County (VA) and Westchester and Nassau Counties (NY). A surge of inconvenient scandals- David Paterson, Charles Rangel and Eric Massa- all in New York- have further tarnished Democratic credibility. Cook placed the odds on the Democrats losing the House this November at 50-50 and sliding.

On the eve of the Presidential health reform “summit”, a Newsweek poll revealed that independent voters, crucial to re-election of Democratic moderates, opposed passage of health reform by a stunning 62-29% margin. Despite the White House’s feeling that the President could paint the Republicans into a corner and blame them for halting health reform, a Politico.com reader poll after the summit suggested the Republicans decisively outpointed the President (52%-19%) by stressing the fiscal and economic risks of the bill. There aren’t a lot of undecided voters left on the health reform issue- and strongly “anti-” sentiment outruns strongly “pro-” sentiment by almost two to one.

Now the White House and Democratic leaders are in the final scramble to find votes to send the President something he can sign and declare this endless and divisive process over. Speaker Pelosi suggested last week that, regardless of the damage they may suffer at the polls in November, House Democrats owe her and the President a reaffirmation of their support. Pelosi basically ordered her troops to swallow their reservations about this bill and fall on their swords.

Gloria Borger of CNN reported late last week that a “senior White House aide” characterized the coming vote on health reform as “the last helicopter out of Saigon”, the most unfortunate political metaphor of the Obama era thusfar. (For younger people, that helicopter was ferrying South Vietnamese collaborators with the United States off the roof of the CIA compound before the North Vietnamese Army flooded into Saigon). What did the “senior White House aide” mean? That the Communists are coming and congressional Democrats need to save themselves and run for the hills? It sure doesn’t sound like a clarion call to do the right legislative thing.

It isn’t the Communists that are coming. It’s a lynch mob. And the angry horde is going to discriminate between “progressives” and moderates. They are simply going to find and hang as many public officials as they can get their hands on – incumbent Congresspeople, Senators, Governors, state legislators, county executives. Unfortunately for the Democrats, the majority of those incumbents are Democrats. I’ve not seen such a toxic electoral atmosphere in my lifetime.

If she cannot find the votes to pass health reform, Speaker Pelosi will be deflecting blame and knifing her White House colleagues in the back all the way to the guillotine. If it passes, it will be in spite of, rather than because of, her advocacy. By maliciously complying with the President’s mandate, Speaker Pelosi and her arrogant, tone-deaf management of the legislative process badly damaged the prospect for lasting health reform. She should scramble for a seat on that last helicopter herself.