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Tag: Policy/Politics

Plan B, Mr. President?

Robert LaszewskiAs the State of the Union approaches Democrats are considering their health care policy options. There are lots of reports about “Plan B”—pushing through the Senate bill with a parallel corrections bill that could be passed in the Senate using reconciliation rules.

That’s as dead as the original House and Senate health care bills. Moderate Democrats have no stomach for such a legislative stunt in the face of Massachusetts and bad health care polls. Many liberals even question that strategy.

Everyone is awaiting this week’s State of the Union speech. Will the President:

  1. Embrace the call by many on the left to Democrat-up and just ram it through?
  2. Call for a scaled back bill built around modest and popular first steps that could attract bipartisan support?
  3. Just jabber in a way no one can figure out which course he really supports?

My bet is on number three.

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The Filibuster, Supermajority and the Constitution

Ezra Klein has published an engaging series of interviews regarding the filibuster, and the prospects and shape of reform for the Senate’s much maligned rule of procedure. The prospects for reform don’t look particularly bright. And as we come to reckon with one of the final products of the filibuster floor, the Senate’s health reform bill, we may want to take a moment to consider the filibuster itself– this need for 60 votes.

Klein writes:

According to UCLA political scientist Barbara Sinclair, about 8 percent of major bills faced a filibuster in the 1960s. This decade, that jumped to 70 percent. The problem with the minority party continually making the majority party fail, of course, is that it means neither party can ever successfully govern the country.

It should also be noted that unlike today, a filibuster in the early 60’s required the arduous (and, it would seem, daunting physical task of continued speech and an inability to consider other legislation during the pendency of the filibuster. A set of circumstances which at times brought sleeping cots onto the Senate floor and may have served to limit the filibuster’s use.

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The Coming Clash over “Cadillac” Plans

GooznerNow that the Senate has passed its version of health care reform along partisan lines, let’s look ahead to  the single biggest issue that will draw the most heat in conference: The tax on so-called “Cadillac plans,” the largest revenue raiser in the Senate legislation.

As regular readers of this blog know, I consider it ill-considered and unfair, a tax on people stuck in expensive plans because they belong to groups with older and sicker beneficiaries who use more health services; small groups generally; or who live in areas with expensive delivery systems. The idea that taxing those plans will somehow encourage people to reduce their utilization is wishful thinking that ignores who actually makes health care decisions — doctors, hospitals,  drug companies, and other providers.

It also ignores why most people use health care — it’s because they are sick. The latest research shows less than 4% of the higher cost of some plans is due to extra benefits. Most of the rest is due to the higher claims of people in those more expensive plans, or the fact that the plans cover people in areas with expensive medicine.

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Voters Want Abortion-Neutral Health Care Reform

Mark-Mellman-resized A few months ago, I warned that some folks were attempting to misuse healthcare reform to restrict access to abortion. They have come a long way since then, endangering the vital struggle for healthcare — indeed, torpedoing reform is a key goal for many involved in this effort.

Americans oppose using abortion as a means of derailing health care reform and oppose using health care reform as a means of restricting abortion. The more voters find out about what is happening on Capitol Hill with respect to this issue, the angrier they are getting, because language inserted in the House bill will take away coverage for abortion that tens of millions of women already have.

Taking away existing coverage not only violates the public will, but also does fundamental violence to Democrats’ explicit promise that if you like what you have, you will be able to keep it.

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Senate passes bill, more to come

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.

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Why Health Care Reform Is So Difficult in the United States

Humphrey_Taylor_HIWhy is it so hard to change the American health care system? And so much easier to change other countries’ systems?

I pondered this question recently while attending the Commonwealth Fund’s International Symposium on Health in Washington where our latest survey comparing primary care in eleven countries was discussed. I heard presentations describing changes that have been, or are being, implemented in England, France, Germany, Norway, Sweden, Switzerland, the Netherlands, Canada, Australia and New Zealand. In some cases, these are fundamental reforms in how medical care is delivered and how providers are reimbursed. Many of these countries can demonstrate real improvements in the quality of care and efficiency in their systems.

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Enthoven beats up Gawande

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.

Senate Deal on Health Care Bill Done

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.

MedEncentive’s Five Year Report

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!

Joe is kicking them when they’re down

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.

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