The Health Care Blog – Page 872 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Economist: “A huge step forward. With one exception …”

Sep 10, 2009• 39

A thumbs up:

“Cleverly borrowing good ideas from both sides of the party divide, his proposals at least look like a plausible basis for agreement. The plan obliges everyone to take out health insurance while creating a tapering subsidy for poorer families to help them afford it. It also requires insurance companies to end various nefarious practices, such as refusing to insure people with existing conditions or cancelling their coverage just when they need it most. To pay for these long-held liberal goals (the cost is put at $900 billion over ten years), the president has committed himself to several policies that Republicans, if only they could remove their partisan spectacles, should applaud.

Immigrants, Health Reform, and “Lies”

Sep 10, 2009• 47

By NATHAN CORTEZ

In a much-anticipated prime time address to Congress, President Obama made the case for health care reform. One ostensible goal of the speech was to correct misinformation about the bills proposed by Congress. As a scholar who studies both health care and immigration (and sometimes the intersection between the two), I’ve grown increasingly frustrated with the misconceptions surrounding this issue — and I very much hoped the President would deflate the myth that health reform would provide federal benefits to undocumented immigrants.

Of course, when President Obama made this very point (”The reforms I’m proposing would not apply to those who are here illegally”), he was greeted with a heckle from South Carolina Representative Joe Wilson, who shouted “You lie!” Although Rep. Wilson later apologized for his “lack of civility,” he didn’t recant the basic factual assertion, making clear that he still disagreed with the President’s statement that health reform doesn’t cover undocumented immigrants. Of course, the media has jumped on this story, but perhaps unsurprisingly, few bothered to clarify the underlying factual dispute.

Neither bill published by the House or Senate covers undocumented immigrants. In fact, both bills state in pretty plain terms that they don’t do it. The House bill, titled America’s Affordable Health Choices Act of 2009, states in Section 242 that those not lawfully present in the United States are not eligible for insurance subsidies or tax credits. To make it even more clear, Section 246 is titled “No Federal Payment for Undocumented Aliens,” and states “Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States.”

Likewise, the Senate Health, Education, Labor, and Pension Committee’s bill, titled the Affordable Health Choices Act, states in Section 3111(h) that “Nothing in this Act shall allow Federal payments for individuals who are not lawfully present in the United States.” The Senate Finance Committee has yet to release its bill, but it’s a good bet that undocumented immigrants similarly will be excluded.

Although nothing in the bills apparently would prohibit undocumented immigrants from purchasing health insurance in the new national marketplace (called an “exchange” and a “gateway” in the House and Senate bills), it’s not clear why anyone would take issue with immigrants purchasing insurance on their own, without federal subsidies. Moreover, although nothing in the bills seems to alter federal funding for emergency care provided to immigrants, nothing creates such a benefit either — thus undercutting Rep. Wilson’s contention with the President.

This controversy should remind us that immigrants remain in a sort of health care purgatory, caught in our two most dysfunctional systems — immigration and health care. In the mid-1990s, Congress severely limited immigrant access to programs like Medicaid as part of welfare reform, making it difficult for even lawful immigrants to enroll. In fact, even lawful immigrants aren’t eligible for Medicaid for five years after entering the United States — and various peculiarities of immigration law often push this waiting period to ten years. At the same time, immigrants do receive indirect federal funding for health care through the Emergency Medical Treatment and Active Labor Act (EMTALA), which requires hospitals with emergency departments to screen and at least stabilize patients presenting with emergent conditions. Thus, hospitals must provide emergency care regardless of the patient’s immigration status.

Unfortunately, most immigrants are ineligible for means-tested public insurance programs like Medicaid. This regulatory framework has led to “medical repatriation,” in which hospitals effectively deport immigrant patients to unload expensive long-term care burdens. Of course, hospitals — most of which are run by state and local governments — complain about unfunded federal mandates like EMTALA. Hospitals can be “stuck” treating immigrants whose medical needs have shifted from acute to long-term (as with the car accident victim who needs neurological rehabilitation and nursing care). As Prof. Boozang discussed, a growing number have begun “repatriating” immigrant patients by sending them back to their country of origin — without consulting immigration officials — sometimes by purchasing commercial plane tickets or even hiring air ambulances.

Certainly, there are more humane ways to handle health care for immigrants. California, for example, legalized cross-border health insurance, thus allowing immigrants living in the state to purchase insurance with lower premiums and deductibles that covers care provided in Mexico. Arizona and Texas have considered similar legislation, to no avail. Recently, UCLA researchers estimated that over 950,000 people travel from California to Mexico for medical care every year. For a population being left out of health care reform, traveling to Mexico for care may be the future — whether voluntary or not.

Professor Cortez teaches and writes in the areas of health law, FDA law, administrative law, and the legislative process at SMU School of Law. His scholarship focuses on international and comparative health law, particularly the regulation of emerging international markets in health care and biotechnology, such as cross-border health care, medical tourism, and clinical trials. He also writes about immigration federalism.

Before joining the SMU law faculty, Professor Cortez practiced with the Washington, D.C., law firm Arnold & Porter, where he represented medical technology clients in administrative, legislative, litigation, and transactional matters, with a special emphasis on health care fraud and abuse, FDA enforcement, health privacy, and the Medicare and Medicaid programs. Professor Cortez is a frequent contributor to Health Reform Watch, where this post first appeared.

Public Still Backs the Public Plan

Sep 10, 2009• 34

By MERRILL GOOZNER

The Wall Street Journal reports this morning that President Obama in his speech tonight will renew his support for including a public plan option in health care reform. He will also endorse an individual mandate, which could cost uncurrently uninsured families as much as $3,800 a year for health insurance.

Meanwhile, recent polling suggests the public is still in the president’s corner on the public plan. This from today’s New York Times:

After weeks filled with seemingly ominous portents for Mr. Obama’s ambitions, there is evidence that public opinion remains basically supportive of him. Despite intense controversy over the “public option,” a government-backed insurance plan that would compete with the private sector, a CBS poll at the end of August found that 60 percent of Americans still support the idea, down from 66 percent in July. And half the respondents to the poll said Mr. Obama had better ideas on health care than Republicans, down from 55 percent.

What Obama Must Demand from Congress on Health Care

Sep 8, 2009• 23

By ROBERT M. REICH

Congress returns this week to one of the fiercest and most important debates in recent memory — whether and to what extent the nation will provide health care to all Americans, and how we will reign in the soaring costs of health care overall. But do not expect unusual courage from this Congress in standing up to demagogic lies and money-toting lobbyists. An unusually large portion is facing close races in 2010, both in primaries and in the general election. Republicans have many primary challenges from the right. A record number of Democrats, who took over Congress in 2006, hail from traditionally Republican or swing states and districts.

In order to get anything meaningful through this session of Congress, then, the President will have to give congressional Democrats far more leadership and more cover. Doing so is harder now than before the recess, when he was still basking in the afterglow of a honeymoon and 60 percent favorabilities.Yet it’s not too late. Addressing a joint session of Congress next Wednesday is a good idea but Obama can’t rely solely on his exceptional rhetorical skills. He’ll need to twist arms, cajole, force recalcitrant members to join him, threaten retribution if they don’t come along.

Most importantly, he’ll need to be specific about what he wants — especially about three things. I hope says the following next Wednesday, and makes clear to individual members that he means business.

No Alternative: An Analysis of the GOP Plan

Sep 8, 2009• 38

By HARRIS MEYER

Congressional Republicans have been blasting away all summer at the Democrats’ health reform legislation. But they might face heavy blowback if more Americans took a close look at two ambitious health reform bills sponsored by GOP lawmakers.

While the GOP plans include some worthy ideas, they have fatal policy flaws at their heart, largely related to insurance risk selection. Plus, they’re vulnerable to many of the same big-government political attacks leveled against the Democratic proposals. That may be the reason Republican lawmakers aren’t talking up their plans at the stormy health care town hall meetings they’re hosting across the country.

The two bills – the Patients’ Choice Act (PCA), sponsored by Oklahoma Sen. Tom Coburn and several House Republicans, and the Health Care Freedom Act of 2009 (HCFA), sponsored by South Carolina Sen. Jim DeMint – have a fair amount in common, though DeMint’s bill is the more conservative and deregulatory of the two.

More surprisingly, each bill shares some features with the Democratic proposals – including health insurance exchanges, subsidies for the uninsured to buy coverage, insurance market reforms, accountable health organizations, and a national rulemaking commission. The sad part of the nasty, mendacious political debate this summer is how little Republicans and Democrats have focused on those big areas of agreement.

Happy Trails, Trigger

Sep 8, 2009• 3

By ROGER COLLIER

Okay, my apologies to Roy Rogers, but I was pleased to see in the New York Times that the idea of a public plan trigger is finally getting serious consideration by the White House and by Senate Finance Committee members.

I proposed the trigger concept in a piece that ran in THCB back in March. It was clear then that a nationwide public plan faced very considerable political obstacles, and I suggested that a more acceptable approach might be to establish a public plan option that would be implemented only where and when private plans failed to meet predetermined cost control targets.

Senator Olympia Snowe proposed the trigger approach to fellow members of Senate Finance some weeks ago, and the NYT reports that the White House—desperate for at least one Republican vote in the Senate—is now analyzing its political feasibility and practicality.

Senator Snowe’s approach, reflecting the situation in her home state of Maine, where the market is dominated by a single insurer, would tie the trigger to affordability, rather than to cost control. This approach has political advantages, but could be labeled as unfair, since it includes a factor that private plans cannot control—individual incomes—in the trigger comparison. It also has the disadvantage of focusing on individuals who are just above the Medicaid income threshold. To achieve affordability for this lower-income group could mean a public plan network virtually identical to that of Medicaid, raising the question: why not just allow this group to buy-in to Medicaid?

Healthcare Reform: Strangled In Its Bed

Sep 8, 2009• 3

By JOE FLOWER

Follow the bouncing ball here: Health care was a mess, cost way too much, sick people getting dropped by insurance companies and left to die and bankrupted and all that. The obvious solution: Go to a single-payer system, or at least to a universal, subsidized, heavily-regulated private system, like all those other countries who pay half as much or less for better results.

But that would never fly, because the health plans are way too big and employ a lot of people, including a zillion lobbyists, so politically, forget it. We’ll back off and cut a deal.

Here’s what the new deal was supposed to be: We’re not going to wipe out the insurance companies. What we’ll do is offer people an alternative insurance plan, a “public option.” It will be cheaper because it will only pay 5% over Medicare rates, but doctors and hospitals will be mandated to take it. And it will also be cheaper because it’s a government offering, so it takes out no profit, and it won’t have to compete with other insurance companies to pay out as little as possible.

Individuals will have to buy insurance, or they will pay a big fine to the IRS. But there will be these “insurance exchanges,” offering lots of plans that will actually compete for the public’s business (instead of the one or two now available in most markets), plus the “public option.” Employers will have to offer plans with “essential benefits,” meaning good coverage of hospitalization, drugs, outpatient care, mental health care, and so forth. Small employers will have to chip in, too, but they get help with the cost. If the employer doesn’t offer a good plan with “essential benefits,” the employee will be able to take the money the employer is chipping in, and buy a good health plan on the “exchange.”

Sounds like a plan. Health plans couldn’t turn anyone down for “pre-existing conditions,” they would have to take everybody. On the other hand, everybody would have to take them, unless the “public option” turns out to be both way cheaper and more reliable.

Of course, along the way, everybody else gets what they want, too, out of this deal. The drug companies, for instance, get told that, no, the government will not negotiate with them for lower prices; any government plan will just pay market prices. And we’ll make it harder, not easier, for generics to compete with brand-name drugs. And no organization, company, or government will be able to re-import drugs from overseas, where they cost much less.

Oh, and of course there will be nothing in the bill to make health plans actually honor their contracts, stop refusing to pay for stuff they agreed to pay for, or stop tossing out people who get really sick and spend too much.

Then the details start getting sliced up, and things start turning weird. The Blue Dogs in the House get the Commerce Committee to turn out a bill that says, well, actually, hospitals and doctors should not have to take the public option. It should be voluntary, and they should be paid market rates, that is, what they are paid now. So the savings go out the window. The public option, in this version, is not particularly cheaper than the private plans. And anyway, employers with a less than a $500,000 payroll (which is 87% of all the employers in the nation) would be exempt. They wouldn’t have to provide any health care insurance at all. The employees would still have to buy it for themselves, though, or pay a big fine. Of course, they could buy the no-longer-particularly-cheap public option.

Over in the Senate, the key Finance Committee lets it leak that it’s probably dropping not only the public option altogether, but employer mandates, too. Employers won’t have to offer health plans at all, but the employees have to buy them, whether anyone’s offering them a decent plan or not.

Democrat Kent Conrad, on the committee, says nobody will go for a public option plan; instead we’ll try co-ops. This idea would consist of trying to start new not-for-profit insurance companies in every market in the country. Doctors and hospitals would not have to sign up with them. The coops would not have their rates tied to Medicare; they would have to pay market rates. Actually, they would have to pay more than market rates, because the doctors and hospitals in those markets are already signed up with the existing insurers and have plenty of business already, thank you very much. So the new coops would have to bid premium rates to get providers to sign up, or they would have to “rent” them (again at a premium) from their competitors. No big deal, though: If it’s voluntary and paying market rates, the “public option” would have the same problem – high prices, not many providers, so not many customers.

And then Ted Kennedy’s committee turns out a bill that says, well, actually, employers are not really obliged to offer a minimum level of health care insurance – yet the bill keeps the requirement that employees must accept and pay for whatever health care plan their employer offers them, whether it seems an acceptable level of care at an acceptable price or not. So again, savings for the individual go out the window, and now choice of health plans does, too.

If a so-called “reform” bill comes up with these elements – no employer mandate, strong individual mandate, market rates for everything, no real insurance reform – there is no reason to vote for it. It is worse than no bill at all.

That is about what we are facing now.

With nearly 30 years’ experience, Joe Flower has emerged as a premier observer and thought leader on the deep forces changing healthcare in the United States and around the world. As a healthcare speaker, writer, and consultant, he has explored the future of healthcare with clients ranging from the World Health Organization, the Global Business Network, and the U.K. National Health Service, to the majority of state hospital associations in the U.S. He has written for a number of healthcare publications including, the Healthcare Forum Journal, Physician Executive, and Wired Magazine. You can find more of Joe’s work at his website, www.imaginewhatif.com, where this post first appeared.

More by the same author:

Fear and Loathing over the Stimulus Bill
Healthcare as a Complex Adaptive System

Interview: TR Reid on healthcare reform around the world

Sep 8, 2009• 12

By Matthew Holt

TR Reid is a former foreign correspondent with the Washington Post. He spent two years (partly funded by the Kaiser Family Foundation) looking at health care systems across the world and has been featured heavily in many media venues lately asking the simple question, if everywhere else can cover everyone at half the cost, how do they do it? I had a great and not too long interview with him last week.

His book is called The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care and here's an interview he did as part of Frontline's Sick Around The World.

Funnily enough I'm posting this from Barcelona, Spain where hopefully I won't have to use the healthcare system unless I get carried away with the late night Sangria…