What happens when you Stun Gun yourself?
Buried in this somewhat balanced article about HSAs which postulates that the healthy & wealthy may get most out of health-savings accounts, is this gem from a leading “free-marketer” and HSA advocate:
John Goodman, the president of the National Center for Policy Analysis in Dallas and an advocate of HSAs, said that the tax incentives are appropriate because the accounts serve two purposes. “This isn’t just a savings account,” he said. “It’s self-insurance for health care.”
Meanwhile, veteran Democratic Congressman Jim McDermott tells the other side of the coin. But it’s the same coin.
A bedrock principle of this nation is to pool our resources and share the risk, because it benefits us all. That’s why we collectively support police and fire departments, national defense and a host of other essential services. The alternative would turn back the clock to the early 20th century, when people were wiped out by one moment of misfortune.
Is HSA any different? No. HSAs would accelerate a trend that has seen the percentage of employers offering health insurance drop 15 percent during the Bush Administration. A HSA would be an incentive for employers to transfer more of the burden to the individual. The outcome is inevitable, even for forward thinking, employee-focused, responsible corporate citizens. How long can they last when the competition abandons providing health insurance?
So the left and the right agree—HSAs et al move us to self-insurance or self-pay for health care and away from the idea of pooling. Of course rational people think that for health care with its uneven distribution of risk and costs, that’s nuts. The right (or at least the honest right) just thinks that it’s all OK. But at least we’re all agreed on what it is.
Here’s my FierceHealthcare editorial today
Last year the most viewed article in Health Affairs was an article suggesting that 50% of bankruptcies in America were in some part related to medical costs. The article was written by a group led by two of the intellectual leaders of the single payer movement, Harvard professors David Himmelstein and Steffi Woolhandler. This week their findings were challenged by two Northwestern-affiliated researchers, David Dranove and Michael Millenson, who reviewed their data and claimed that the number was closer to 17%. They also suggested that the not as many of people declaring bankruptcy were as solidly middle class prior to their medical catastrophe as the Harvard group had suggested. Himmelstein et al shot back saying that the Dranove and Millenson had got their math wrong, and that they were lackeys for AHIP the health insurance industry group that sponsored their study — even though it was a peer reviewed article which AHIP funded but didn’t control. Some of their supporters accused Dranove and Millenson of "swift-boating".
Why is this obtuse academic dispute so important? Whatever the facts, and facts are very malleable in our political debates, the role of the middle class in health reform is vital. There is incontrovertible evidence that lower-income Americans have disproportionately higher health costs out of pocket than poorer people in other countries. But 100 years of history shows that politically this doesn’t matter too much. If it becomes accepted that middle-class, middle income Americans are equally vulnerable to financial catastrophe due simply to bad luck with their health, then the political discussion might shift. So this is one of those occasions where, as Keynes said, the scribblings of some (not-yet) defunct economist might actually matter in terms of politics and policy.
UPDATE: If you haven’t had a chance yet, you can listen to this week’s podcast of my converstation with Millenson on this very topic.
It wasn’t going to be too long before I took the issue of the DEA’s assault on physicians and patients over to the political masses in one of my Spot-on columns. Calvinists in the Medicine Cabinet is the result. Go there and enjoy, and feel free to come back here to add comments.
This is a fine way to waste your life. Escapa!
Over at Health Care Renewal, Tony Poses has done some excellent digging into the tale of how the University of Miami, best known for the close to criminal behavior of its football players over the years, is (by proxy of a middleman) stiffing the janitors at its hospital from getting health insurance. Meanwhile, university President and former Clinton HHS secretary — not that she did much while holding that hot seat other than make the camera pan way down when she walked in the room for the State of the Union — Donna Shalala was profiled in the New York Times for her luxury lifestyle. It’s all in the story: A Tale of Three Ironies: University of Miami’s Janitors Still Have No Health Insurance. And Roy digs up the fact that she gets a decent chunk of change for doing basically nothing by being on UnitedHealth Group’s board. ($750 for listening to a summary of a phone call? Nice work if you can get it).
Of course, compared to the average take home pay of UnitedHealth board members, that’s chicken feed. But the average is somewhat distorted by the CEO.
I’m too lazy, stupid, busy to post anything here today, (although I’ll have something up at Spot-on later) but the commenters on the piece about CDHP’s that Brian Klepper wrote a few days back are kicking up a storm, and it’s interesting stuff. So please go read them instead.
Roy Johnson is a Director of IS Applications at Children’s Hospital of Wisconsin in Milwaukee. He got a little hot under the collar after the piece I wrote on Monday about HISTalk’s post on how out of date technology was in health care IT. Here’s his take
Actually it’s worse than you think. Epic uses a Mumps back-end (the same technology IDX uses for the back-end) with a nice bright, shiny front-end and a spin-off of data to a SQL database for customer data queries (IDX is doing the same thing). So explain to me why GE acquired that three legged, one eyed, octogenarian dog called IDX and hailed it as a great advancement??? Despite Cerner using current technology, they have interoperability and context management issues between their own modules because they were all developed separately and they seem unable to resolve them (and they have a terrible record for support). So we’re down to Eclipsys. Given the run up in stock price lately they are the “real deal”, at least as far as Wall Street is concerned. But as soon as the next great software advance appears, I predict that they also will sink into the abyss of old technology because the cost of rewriting systems is too great for these companies (not just cost, time and migration issues, but also the inevitable “bugs” that they introduce and must expend efforts re-solving).Perhaps I am a bit cynical.
But we should also look in the mirror and realize that we in healthcare are also part of the cause for the lack of advancement. After all, it isn’t as if there isn’t innovation in the world of IS. But healthcare in general is reluctant (to put it mildly) to try and to actively support anything really new and innovative in automation. It costs too much and/or it takes too much time and/or they want someone else to lead the way. There is no shortage of reasons why not to do something new. For example I can’t get our finance people to seriously consider a different automated receivables system from the one they have been using for 18 years, because it works and they don’t want to risk having a new system cause a spike up in days receivable (though they would dearly love to have point and click features).
I am of the opinion that it will take a focused national effort to move healthcare out of the computing dark ages by mandate and financial support. Without this commitment (and the current political speak commitment is meaningless) we will not find a way to achieve the envisioned national health initiative nor find a way to effectively manage costs in healthcare.
This is a podcast that I’ve done with Michael Millenson who deigns to attack David Himmelstein’s hallowed article on medical bankruptcy. We had a good time in this interview, even though I think Michael’s picked the wrong target, and he’s ever the purist. The last couple of minutes had to be excised so that either of us might ever work in this town again….
Here it is: Michael Millenson interview
UPDATE. And here’s the Dranove Millenson article, and the reply from Himmelstein, and the retort to that reply. And the name calling from Don McCanne. They should have known that that Ignagni woman would be trouble!
Ken Melani, who was the medical director at Blue Cross of Pennsylvania when I presented to them back last century but is now the CEO of HighMark (since BC and BA merged), points out the rational logic for private (non-profit) health plans. And that of course is to try to stay alive as a regional power that will be used by the government as a utility after the eventual inevitable government take-over:
Government expenditures for health care have taken a bigger piece of total spending every year since the creation of Medicare and Medicaid in 1965. While Republicans in Congress viewed the new Medicare prescription drug program as a way to expand the role of private companies in the massive health insurance program, Dr. Melani said the end result is a further expansion of government spending. "History has been made," he said. "If you look year after year, decade after decade, the government has been growing in its role as the financier of medical services, both through Medicare and Medicaid. We’re not growing from the private sector standpoint; we’re shrinking as a proportionate share." The key for Highmark, the region’s dominant health insurer, is to maintain and enhance its position as a regional player so that it can work as a key government contractor, Dr. Melani said.
Of course, a government-regulated utility — which Melani sees as being Highmarks’ future — will have to be managed in a slightly more sensible way than the Republicans rolled over Part D.
If the government expansion continues, the ongoing experiment with the new Medicare Part D prescription drug program provides lessons in how it should — and shouldn’t — develop, Dr. Melani said. One is that consumers like choice, but too much choice is confusing. Consumers in Pittsburgh, for example, can buy Part D benefits in more than 60 shapes and sizes, but they can’t make apples-to-apples comparisons between plans, Dr. Melani said. Another lesson is that the transition of beneficiaries from one government program to another can be difficult. For example, many low-income patients whose pharmacy benefits shifted from state Medicaid programs to Medicare on Jan. 1 were unable to access benefits at the pharmacy because of glitches.
But then again, even if the government can’t manage its own programs, insurance companies have no hope of controlling costs:
But the other key driver is technological advances in medical care, whether in the form of advanced imaging equipment, improved medical devices or new pharmaceutical products. Noting the emergence of cancer treatments that cost tens of thousands of dollars per month, Dr. Melani said insurers were nearly powerless to stem the tide."How can we afford that new technology?" he asked. "First of all, is it worth it? We won’t even ask that question, because we don’t do that in the United States. But how many of these $100,000-per-year treatments can we continue to support and survive as a country, as an economy? "You take the unit price of professional services, the unit price of technology, and we’re out of control — totally out of control."
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