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Health Care and the 2010 Midterms

Nov 8, 2010• 15

By ROBERT LASZEWSKI

The election has given us a Republican House and a still Democratic controlled Senate. But, instead of Democrats having the 60 Senators they had when health care was passed in December, they will have a slim majority in the new Congress of 53 seats when the two Independents who caucus with them are counted.

Exit polls clearly show an anti-health care law sentiment. Exit polls done for the AP found 48% of Tuesday’s voters want the new health care law repealed, 31% want it expanded, and 16% want it left as is.

Remember those swing Democratic House votes that were on the fence over the health care bill last March? Most who voted for it are out of work this morning—and all but 11 of the 34 of them who voted against it also went down to defeat. Why did even those who voted against the new health care law lose their jobs? Because of one vote they all had in common–they voted for Pelosi as Speaker.

An issue, guaranteed

Nov 8, 2010• 16

By PAUL LEVY

I don’t mean this in a partisan way, but it is really distressing to read this New York Times article about Republican plans to dismantle parts of the recent health care bill by using the appropriation powers of the House of Representatives. I say this because of the unintended consequences that will result if they are successful in this approach. Let me give an example.

I think one of the most important aspects of the law is “guaranteed issue” of health insurance: Insurance companies will no longer be permitted to use pre-existing medical conditions as a bar to coverage. A concomitant of guaranteed issue is the individual mandate, the requirement that all people purchase health insurance. Why?

Left to their own, insurers will impose pre-exisiting conditions types of restrictions because they understand the moral hazard aspect of insurance. Healthy people provide an actuarial balance to sick people. If people only buy insurance when they need care, the risk profile of the insured population rapidly swings, upsetting the actuarial calculations used to establish premiums. So, if these restrictions are outlawed, everybody needs to be in the risk pool. Accordingly, you have to ban optional insurance.

But look at this quote from the article cited above:

Republican lawmakers said, for example, that they would propose limiting the money and personnel available to the Internal Revenue Service, so the agency could not aggressively enforce provisions that require people to obtain health insurance and employers to help pay for it.

I think the Republicans know that guaranteed issue is popular with Americans, and so they do not directly want to repeal that provision of the new law. But what will happen if healthy people start to opt out of getting insurance, only to return when they get sick? The system will quickly get out of balance. Ironically, this will only cause premiums to rise. I don’t understand why the Republicans would want that to happen, and I fail to see a strategic political advantage arising from that result.

This makes me wonder if they have thought this through completely and whether they understand the unintended consequences of their proposed actions.

Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

The $6-an-Hour Health Minimum Wage

Nov 8, 2010• 7

By JOHN GOODMAN, PhD

The stunning election results will put even more pressure on Congress to deal with the economy and jobs when it reconvenes in mid-November. But as it turns out, one way to boost the economy is to reconsider the health reform bill.

Most people intuitively know that the worst thing government can do in the middle of the deepest recession in 70 years is enact policies that increase the expected cost of labor. Yet that is exactly what happened last spring, with the passage of the Affordable Care Act (ACA).

How bad is it? As I explained at my own blog the other day, right now we’re estimating the cost of the minimum benefit package that everyone will be required to have at $4,750 for individuals and $12,250 for families. That translates into a minimum health benefit of $2.28 an hour for full time workers (individual coverage) and $5.89 an hour (family coverage) for fulltime employees.

Granted, the law does not specify how much of the premium must be paid by the employer versus the employee — other than a government requirement that the employee’s share cannot exceed 9.5% of family income for low- and moderate-income workers and an industry rule of thumb that employers must pick up at least 50% of the tab. But the economic effects are the same, regardless of who writes the checks.

In four years’ time, the minimum cost of labor will be a $7.25 cash minimum wage and a $5.89 health minimum wage (family), for a total of $13.14 an hour or about $27,331 a year. (I think you can see already that no one is going to want to hire low-wage workers with families.)Continue reading…

Wachter: Three Stories

Nov 8, 2010• 5

By ROBERT WACHTER, MD

In my travels, I frequently hear short stories that help illuminate my work and world. Here are three recent examples; think of them as little health policy tapas.

I recently spoke in a session with Peter Pronovost, the Johns Hopkins intensivist who is the world’s top researcher in safety and quality. We were talking about why engaging physicians in this work – so called “adaptive change” – is sometimes so difficult. Peter recalled a story about his son, who at age 6 came home and told his parents that he was terrified to enter the school bathroom. “There are monsters in there,” he said. His parents reassured him that there weren’t, but the next day he returned, wide-eyed and still panicked. Peter called the school to see if they had any explanation for his son’s sudden bathroom phobia. “Oh, we put in automatic flush toilets last week, and I guess we didn’t explain it to the kids,” said the teacher.

Peter’s point was that we often ask physicians (and others in healthcare) to absorb a tremendous amount of change without giving them the background and tools they need to understand these “monsters.” It’s a lesson worth remembering.

At the same conference, I went to a terrific session given by one of my UCSF colleagues, Adams Dudley, another critical care physician and one of the nation’s experts on the impact of transparency and pay-for-performance strategies on quality. Adams was discussing his observation that physicians often feel that they – unlike every other soul on the planet – are not influenced by monetary incentives. He told this story:

Sharing the Burden

Nov 8, 2010

By RICHARD SLOAN, PhD

Jessie has written about her perspective as the patient in an extremely stressful situation. I can add a different one: that of the husband of my seriously ill wife.

As a public person, Jessie not only has a great many friends and loved ones but also many colleagues and professional acquaintances around the country and the world. She had time to tell only a handful of people about her new diagnosis and that surgery was imminent. We discussed at length about how open she wanted to be about her condition and she decided that being completely open was “walking the walk” of a patient advocate. So I gathered a list of e-mail addresses to alert a wide network of friends and with the assistance of another friend, set up a website where I would periodically post updates on Jessie’s condition, and got a Google Voice phone number for people to leave messages for her.

Because the website was publicly accessible, I was concerned about just how much to share. Since Jessie’s major interest is in the role that people play in their health care, she has been exceptionally open about her own medical history and it is no secret that she has had multiple cancer diagnoses and a serious heart condition. Accordingly, disclosure of the nature of her stomach cancer and the surgical realities seemed in order. So I provided some details in the blog, most especially the significant surgical result: that the tumor was successfully removed and that Jessie retained about one-fourth of her stomach. The rest of the blog consisted of “color commentary,” like how many laps she had walked around the floor and whether she was bored.

A Prevention Revolution

Nov 8, 2010• 9

By SUSAN BLUMENTHAL, MD

“I will prevent disease whenever I can, for prevention is preferable to cure.” These are the words of the Hippocratic Oath, an ancient vow that has been recited by physicians for centuries. However, with seven out of 10 deaths in America attributable to largely preventable chronic illnesses, including heart disease, stroke, chronic lung disease, diabetes and some types of cancer, we have yet to see these words put into practice. Such is the history of our nation’s health care — or, perhaps more appropriately, “sick care” — system, where 75 percent of today’s U.S. health care dollars are spent on chronic illness and only three to five percent to prevent these diseases. Until now. As implementation of the recent health-reform legislation begins, our nation is finally putting prevention into practice. By providing significant financial support for preventive services and programs, the Patient Protection and Affordable Care Act (ACA) builds the foundation for a prevention revolution and moves our country closer to making Hippocrates’ vision a reality today.

Thanks to the new law, patients now will receive free preventive services at the doctor’s office. The ACA mandates that private health insurance plans established since March 23, 2010, must cover, without cost sharing, the services recommended by the U.S. Preventive Services Task Force. Additionally, as of September 23, 2010, all insurance plans must include these preventive services with their annual enrollment cycle except for those plans that have been grandfathered. This requirement will also apply to Medicare by the year 2011 and to Medicaid on a state-by-state basis. Recent research has shown that providing just five of these services — colorectal and breast-cancer screenings, flu vaccines, counseling on smoking cessation and regular aspirin use — could avert as many as 100,000 deaths every year. As a result of these new provisions, millions of Americans will now have free access to these preventive services and others, including additional cancer screenings, routine check-ups, vaccinations, prenatal care, and counseling regarding smoking, alcohol use, nutrition and obesity. This expansion of coverage represents a leap forward in our nation’s shift towards a prevention-oriented health-care system, to the benefit of millions of people. However, what happens in the clinic is only one element of a comprehensive public health approach that is needed to make this transformation a reality.

Friends, Fatigue and the Slow Slog Back

Nov 6, 2010

By JESSIE GRUMAN, PhD

I have much experience with serious illness. And so I am a connoisseur of fatigue: the sleepless edginess of post-radiation fatigue; the heavy constancy of cardiac fatigue; the blur and blues of chemotherapy-related fatigue.

I am learning again about post-surgical fatigue, which this time is characterized by short bursts of energy randomly emerging from an otherwise constant whacked-upside-the-head-with-a-golf-club sleeping/waking fog.

Regardless of the flavor, it is the force of fatigue that exacerbates the discomforts and symptoms of an illness. It is fatigue that makes each sip of water an action to be carefully planned, each trip to the refrigerator an accomplishment. It is fatigue that exhausts my hands holding a book and my mind when reading more than a few sentences. It is fatigue that shrinks my world to the size of my living room, leaching the meaning from family news, work developments and the impending election.

Fatigue diminishes me: I consist only of this disease, this body.

Into this gray desolation drop brief messages of support, of encouragement, of good wishes. These words are not sent to the thin figure lying on the couch staring at the sky. Rather, they are addressed to a friend, acquaintance, colleague, daughter, or sister – a person who stands up straight, is passionately engaged in her life and has a lot of work to do.

These messages remind me of the parts of myself that are eclipsed by my illness. And they reassure me that I will be able to find those parts again.

I am grateful for each one.

Jessie Gruman, PhD, is the founder and president of the Washington, DC -based Center for Advancing Health. She is the author of Aftershock: What to Do When You or Someone you Love is Diagnosed with a Devastating Diagnosis. She blogs regularly on the Prepared Patient Forum.

The Swing to the Right: The Election and Its Effects On Health Reform

Nov 6, 2010• 31

By DAVID HARLOW

Like Tom Friedman, who lampooned some of this year’s unreasonable campaign rhetoric in a recent column, I too would be in favor of reality-based political campaigns … but that seemed to be too much to ask for this year. Instead of truth, we now have truthiness. The joke news shows (and their joke political rallies) seemed to be more popular than the evening news. (I wish Jon Stewart and his 200,000 fans on the Washington Mall last weekend had stayed home, canvassing for their candidates of choice.) Fact-checkers told us that many political ads this season were in the “barely true” or “pants on fire” zones according to the Truth-O-Meter. But in the end, the buzzwords seem to have worked their magic, and many “insiders” are out, and “outsiders” are in. The angry and the impatient on the campaign trail have, in some cases, adopted the line from the movie Network: “I’m mad as hell, and I’m not going to take this any more,” perhaps forgetting that while that line garnered the Howard Beale character strong ratings, network bosses arranged for his on-air assassination when his ratings fell.

The Utopia tune at the top of this post, “Swing to the Right,” comes to you from the Ronald Reagan era, and perhaps we are seeing the generational swing of the pendulum back to the right. It does seem to happen every 30 years or so … but don’t blame me — I’m from Massachusetts (home to a Democratic sweep this Election Night).

The last two years have seen a tremendous amount of change in Washington. The question of the moment, of course, is: How will the election results affect implementation of health care reform?

The short answer is that even having sustained the losses that they have, the Democrats in Congress will be able to sustain a Presidential veto of any GOP anti-health reform initiative. The 2012 election may well determine the ultimate course of health reform. If the GOP gains further ground in two years, then implementation may be that much more difficult to accomplish.

Money and Healthcare Reform

Nov 5, 2010• 24

By JANE ORIENT, MD

Congress handed the Congressional Budget Office (CBO) some assumptions, the computers came up with the mix of adjustments needed to give a magic number under $1 trillion in 10 years, and the “Affordable Care Act” (ACA) emerged.

The “affordable” trillion apparently means net additional federal government expenditures, with the Treasury envisioned as one big pot of liquid gold. All the revenue gets mixed in, and the financial engineers turn the valves to direct the outgo. Less will go into some channels (“savings”), and more into others.

Numbers are thrown about—but where’s a spreadsheet of the money flows? The President couldn’t exercise a line-item veto even if he had one because there aren’t any line items. For example, how can you budget for each of the new bureaucracies if you don’t even know exactly how many there are (159—more or less)? And are they counted in the $1 trillion cost?

Swamp Creature

Nov 5, 2010• 10

By JEFF GOLDSMITH

Many people forget that before Washington DC was our nation’s capital, it was a pestilential swamp, whose few hardy residents regularly succumbed to tropical diseases like malaria. It was virtually uninhabitable in the summer (some say it still is), and like Houston and New Orleans, really began to boom only after the advent of affordable air conditioning. It is also a political swamp, infested with lobbyists and special interests, and Washington “lifers” – commentators, political operatives, consultants, intellectuals and bureaucrats who outlive increasingly fragile Presidential administrations. The electorate despises Washington, and sends waves of “outsiders” (e.g. ordinary Americans) to drain the swamp.

Though President Obama signed it into law in March, the new Affordable Care Act of 2010 is a swamp creature. Written by an exhausted Congress, half beast, half plant, the ACA is a seething, octopus-like tangle of well meaning but opaque government projects intended to expand health coverage and fix the health system’s numerous problems. Far more than “insurance reform”, it sprawls over and touches virtually every corner of our $2.5 trillion health system, bringing change, uncertainty and a ton of taxpayer dollars. It also has sunk its taproots deep into the national treasury and extends its feeding tentacles to an obese and hungry industry that already claims 17% of the national wealth.

A new wave of Republicans are about to hit town, fired up by their stunning mid-term election victory and control over the House of Representatives. One of their campaign pledges is to kill the swamp creature. They will shortly charge off into the swamp to try and kill it, like the British army tried to kill Francis Marion. In doing so, they expose themselves to a whole bunch of hidden hazards, including the beast itself. Handled thoughtlessly, the Republican campaign against health reform could damage the party’s prospects in 2012, even if the economy continues to sputter.