"Hey, Wait a Second -- This Bill Sucks"

by Tim Foley

categories: Enemies of Reform, Obama and Congress, Public Plan

Published July 08, 2009 @ 10:05PM PT

Someone once referred to it as the Bugs Bunny “What am I doing?!?” moment.  It’s that classic scene when everyone’s favorite wiseacre realizes what he's doing just stopped making sense – politely agreeing that Marvin the Martian should blow up Earth, for example – and literally stops himself in his tracks.  Congressional Democrats seem to be having this moment right now.  The House has produced a bill that largely tracks to achieving the health care reform platform the presidential candidates ran on;  the Senate Health, Education, Labor and Pensions Committee does so in a somewhat weaker way.  The Senate Finance Committee and Sen. Max Baucus, on the other hand, was poised to deliver a negotiated, watered-down bill, with quite a number of unproven and cockamamie gimmicks specifically designed to appeal to Chuck Grassley and in an attempt to be bipartisan.

It’s time to look at the end products and say, “If what bipartisanship nets us is a sucky bill… it’s probably no longer worth it.”

First into the fray was Senate Majority Leader Harry Reid, with a wake-up call that got people talking.  As first reported in Roll Call, “Reid told Baucus that taxing health benefits and failing to include a strong government-run insurance option of some sort in his bill would cost 10 to 15 Democratic votes; Reid told Baucus it wasn’t worth securing the support of Grassley and at best a few additional Republicans.” Jon Cohn on The Treatment quickly established what might be called the progressive blogger consensus:  “Bipartisanship is good but a sound health reform bill is better. If winning over just one or even a handful of Republicans means gutting the bill, it's not worth it.”  This same “trade 2 Republican votes for 15 Democratic ones” cost benefit analysis is doubtlessly what prompted Chuck Schumer to prophesy that the public health insurance option – which is as popular as taxing health benefits is unpopular with the general public – would be included in the bill one way or the other.

Reid’s was the loudest voice, but far from the only one. Sen. Bernie Sanders who has been supporting the public plan as a backup to his own single-payer bill, declared, “I think that it is fair to say that there are a number of us who would not be voting for anything resembling a Baucus-type plan as we understand it right now.”  Rep. Raúl Grijalva, co-chair of the Congressional Progressive Caucus, sounded the alarm over a perceived openness on the part of White House Chief of Staff Rahm Emmanuel to the trigger option, whereby a public plan would be kicked down a road for a few years and only come into play if private insurance hadn’t proven capable of bringing down the costs of health care by themselves:  “I want to be crystal clear that any such trigger for a strong public plan option is a non-starter with a majority of the Members of the Progressive Caucus.”  Translation:  good luck getting such a thing passed through the House.  Granted, the progressive caucus has been sending out releases regularly against the trigger, the health co-op, and anything that waters down the subsidies to make health insurance affordable to low- and middle-class families. Rep. Henry Waxman, one of the chairs of the “Tri-Committee” which is wrote the draft health care bill in the house and is guiding it in for a landing, hasn’t ventured into the fray on these debates in the Senate… until today, when an interview with him was entitled, “House Dems Won’t Budge on Public Option.”

Here’s the political reality – it was always a good idea to try for bipartisanship on a bill that would so dramatically change the lives of Americans across the country, both those with and without insurance.  But, and this is an important but, only if the process somehow led to a better bill or, at least, an air of legitimacy.  From the “Washington takeover” rhetoric in the House, to John McCain’s snotty but factually correct tweet, “peeling off an R or 2 is not real negotiation”, to Tom Coburn’s war on jungle gyms, that whiff of bipartisan legitimacy just ain’t coming.

Everyone keeps looking to the bipartisanship of the Senate Finance Bill as a test of its success.  This is fundamentally misguided, dangerous and flat-out wrong.  The ONLY test of its success is whether it gives every American a chance at quality, affordable health care. If we’re rushing an ineffective and half-baked co-op proposal, or leaving families making between $60,000 and $80,000 a year with no affordable health care options, or creating an unpopular and easy to demonize new tax on health benefits just to peel of “an R or 2”, that’s the equivalent of Marvin the Martian holding the Illudium Q-36 Explosive Space Modulator in his hands.

(Photo credit:  Hey Paul on Flickr.)

Why Is the AP So Pessimistic on Health Care?

by Tim Foley

category: Obama and Congress

Published July 08, 2009 @ 11:11AM PT

I try not to play media critic because, frankly, a lot of people do it much better and with more panache than I do.  But after reading through an AP article on health care which seemed to treat the proverbial molehill as a mountain – and a mountain that could potentially squash reform efforts at that – I’m compelled to ask, “What’s wrong, AP?  Do you need a hug today?”

Let’s take today’s AP report on the newly-announced deal with hospitals.  It has the headline, “White House, hospitals reach deal on health care,” but you could be forgiven for thinking the article isn’t really about the deal.  After a killer quote from Joe Biden about the inevitability of reform, the actual discussion of the deal is saved for paragraph 13.  That’s not a typo, folks.  You can have to go to paragraph 13, where the deal is discussed as, “the one bright spot right now for Obama.”

I’m sorry, what?

I can think of a number of bright-spots just in the past week:  the fact that all committees with jurisdiction are working within the same broad parameters, which track rather closely with the health care plan that Obama ran on;  the most excellent score from the Congressional Budget Office on the Senate Health, Education, Labor and Pensions Committee which helps make the argument that health care reform needs both the controversial employer mandate and public health insurance option to work effectively;  Wal-Mart stepping up and becoming an advocate for the employer mandate;  an analysis from the same CBO that the House bill would save $500 billion in Medicare alone;  and, of course, Al Franken being seated giving the Democrats the magic number of 60 – enough to pass health care with zero Republican votes, if needs be and if they can keep the more moderate Democrats from straying.

“The one bright spot,” AP?  And what are these dark spots that you fill 9 of the first 12 paragraphs with?    That the tax on employer-provided benefits – which Obama never supported, which he ran quite effectively against during the campaign, and which he continues to publicly say is not the way he would like to go – is proving unpopular.  This is the same tax increase that was only ever popular with those who supported the Wyden-Bennett Healthy Americans Act (note:  not currently under consideration), with Republican Sen. Grassley, and with Sen. Max Baucus, who seemed semi-obsessed with it.  This is the same tax increase that many leaders in the House, including Rep. Charles Rangel, Chair of Ways and Means and one of the representatives writing the bill, adamantly opposes -- and has for months.

So the fact that a payment model that Obama never embraced may also not be embraced by the only people who wanted it means the sky is falling?  And, moreover, overshadows a deal with hospitals to fund $155 billion of health care reform that Obama did want to have help pay for health care?

So says the AP -- which means it should solidified conventional wisdom by dinnertime and worked into Rep. John Boehner's talking points by morning.  Nice one, guys.

(Photo credit:  wai.ti on Flickr.)

How Impressed Should We Be with the Hospital Deal?

by Tim Foley

categories: Medicare and Medicaid, Obama and Congress

Published July 08, 2009 @ 07:06AM PT

In what has been the world’s worst secret for the past two days, Vice President Biden will be announcing a deal with the American Hospital Association, Catholic Health Association and the Federation of American Hospitals.  The tradeoff:  $155 billion in cuts to hospitals in Medicare and Medicaid for a more favorable timeline for when those cuts take place than what was originally pitched by the president.  This comes on the heels of the deal with Big Pharma to close the doughnut hole, and the NY Times teases this morning that a deal with various doctors groups may be next on the horizon.  The symbolic effect of these deals is perfectly obvious.  As Rahm Emmanuel said, “The very groups we have been talking to have been the most vocal opponents of health care reform; they are now becoming the vocal proponents for health care reform.”

But symbolism aside, how impressed should we be?

The proof will be in the pudding when Biden announces the terms today, but on first glance, pretty impressed.  Big Pharma’s deal was to spend $80 billion per year to partially close the doughnut hole in Medicare Part D, but it’s unclear how this helps fund the non-Medicare push for universal health care since it’s mainly defraying costs that were paid by individuals, not the government.  In contrast, this deal with hospitals, if it’s as good as advertised, directly supports the financing of health care.

President Obama had specifically targeted some cuts to Medicare reimbursements to hospitals as part of his 2/3 savings, 1/3 new revenue mix for funding the health care reform legislation being proposed in Congress.  Like his proposal to limit charitable deductions for those making more than $250,000 a year, it’s a good idea.  But also like that proposal, Congress wasn’t falling over themselves to adopt it.  The why, was obvious – hospitals were going to hate it.  Only now they don’t.

Instead of $200 billion over 10 years, these hospitals are agreeing to $155 billion or so.  It’s also on a timeframe favorable to them.  One of the particular cuts was what’s called the “Disproportionate Share” payments – money hospitals get when they provide a disproportionate amount of uncompensated care to the uninsured.  In theory, if we get to 95%, 97% or 100% insured in this country, we should pay less for that than in our current state of 84% (or less) insured.  Of course, there were problems – although Obama’s original proposal would have phased in these cuts over a number of years, that timeline always felt artificial.  It also presumes that those now with insurance will be less expensive to treat because they’ll start receiving regular primary care, paid for at good compensation rates, rather than receiving expensive emergency care that’s uncompensated.  But it will take years for those savings to kick in.  Probably the biggest concession the hospitals got from playing ball is the recognition that these cuts will be added slowly, and only “after a significant number of people have enrolled in the new insurance programs.”  They also got a pledge that the public health insurance option won’t pay straight-up Medicare reimbursement rates – a pledge that effectively cost the Administration nothing, as none of the plans on the table for the public plan would have done that.

Think of this more as a non-aggression pact.  At the end of the day, the Obama Administration gets most of the cuts they wanted and pledge not to more aggressively pursue them.  The hospitals (who don’t represent all hospitals, but are a sizeable chunk of the industry, taken together) pledge not to fight them.  Those savings go right into paying for the expansion of health care programs without a gun-shy Congress reluctant to take on an entrenched special interest.
It’s only a fraction of the money we need, but it’s still pretty impressive.

Health Co-Ops Yield Modest Improvements... After 60 Years or So

by Tim Foley

categories: Obama and Congress, Public Plan

Published July 06, 2009 @ 10:46PM PT

Somehow, the Senate Finance Committee is still talking about Sen. Kent Conrad’s largely useless “compromise” of creating a health co-op with federal seed money instead of creating a Medicare-like public health insurance option to compete with private insurers.  It’s not clear who they’re talking to.  The Republicans on the committee have been underwhelming in their faint praise of the idea, and the more progressive Democrats on the committee say straight up that it’s no substitute.  But it’s clear the focus is on compromise, and not the effectiveness of the policy to actually address the problems of rising costs, mediocre quality and a system that leaves too many – both with and without insurance – behind.

Clue number one, of course, is that we already have co-ops.  Almost by definition, if your solution is something we already have, then it won’t change the game.

Kaiser Health News summarizes the recent Bloomberg article on how the most effective health co-ops have developed:  “Washington State's insurance commissioner, Michael Kreidler, praised Washington's existing co-op, Group Health Cooperative, a 600,000 member plan that employs 922 doctors and 1,700 nurses, but noted that it took 60 years to develop, the paper says, adding: ‘While Group Health's premiums are generally no cheaper than competitors', the plan has been less aggressive than private companies at trying to purge sicker, costlier patients.’”

So the Senate Finance Committee is prepared to punt on expanding public coverage and breaking the monopoly of for-profit insurance that, as Wendell Potter said, “has proven itself an untrustworthy partner to its customers, to the doctors and hospitals who deliver care, and to the state and federal governments that attempt to regulate it.”  They’re willing to ignore the 72% of Americans who say they favor giving people the choice between public and private coverage (including 50% of Republicans).  In its place, they want to give us a “compromise” ill-defined co-op that won’t provide any more affordable coverage than regular insurance, will still seek to cherry-pick healthy patients and avoid sicker ones, but will just be nicer about it?  Gosh, that sounds empowering.

Oh, and it will take at least a generation – maybe up to 60 years – to yield that level of unspectacular results?

Would that we had that long to wait.  But America isn't Rip Van Winkle.  Our families, our businesses and your state and federal budgets need help now.

They need more prodding – tell the Senate Finance Committee a health co-op is no subsitute for a public health insurance option.

(Photo credit:  Archie McPhee on Flickr).

Who's In the News Today?

by Tim Foley

categories: For Profit Insurance, Obama and Congress, Public Plan

Published July 06, 2009 @ 07:27PM PT

It's the calm before the storm.  With the July 4 recess over, Congress will once again be taking up comprehensive health care in both chambers.  There are a lot of balls still up in the air with regards to timing, and even more for policy.  The House bill is still more or less on track for a full vote by the end of July, but the Senate bill may be pushed back to August 7 or later.  Given the likely difficulty in reconciling a progressive Senate Health, Education, Labor and Pensions bill with a "bipartisan" Senate Finance bill, I wouldn't write that date in pen.

So before we return to our regularly scheduled debates about affordability, circus-like amendment process, and largely-ignored speeches from the House floor about rationing, socialism, and other Frank Luntz greatest hits, here's a quick roundup of who managed to make news over the holiday weekend:

1.)  Chuck Schumer will not be denied

Say this for the senior Senator from New York - once he owns an issue, he's not letting go.  Months ago, Schumer was designated the point man on getting the public health insurance option into the Senate Finance Committee bill.  Since then, he has blasted away at how non-competitive insurance companies are during a committee hearing, make himself the go-to guy for negative quotes about the "trigger", joined Sherrod Brown of Ohio and the president as the most frequent public defenders of the public plan, and even seemed to begin to wear down Kent "Co-Op" Conrad's resistance to the idea.

He raised quite a few eyebrows on "Face the Nation" on Sunday when he boldly declared, "Make no mistake about it, the president is for this strongly. There will be a public option in the final bill."  But he made the calculus behind his thinking even more clear in an interview with the Huffington Post that could basically be summarized as, "Democrats have 60 votes - what the hell are we waiting for?"  (His actual quote was, "If you did a consensus within the Democratic Party, you would find the level-playing-field public option to be the answer.  And now that we have 60 votes, it seems to me like we don't have to turn it inside out for something we don't like.")

Spoken like a man who, as head of the DSCC for the last two cycles, knows what he's talking about.

2.)  Wendell Potter will not be silent

Potter is the former Cigna and Humana executive who two weeks ago delivered dramatic testimony pulling back the curtain on the business practices of the for-profit insurance industry.  It's hard to forget his description of health insurance as "a Wall Street-run system that has proven itself an untrustworthy partner to its customers, to the doctors and hospitals who deliver care, and to the state and federal governments that attempt to regulate it."

AHIP and others in the industry may have hoped that would be the last they'd hear from him.  No chance.  Potter is now a blogger with the Center for Media and Democracy, and he's already hard at work "call[ing] out misleading statements and statistics, outright lies and illogical assertions by opponents of meaningful health care reform-and to rat out the front groups that insurers and other special interests are funding to kill reform or, failing that, shape it to their benefit."

You can bet I just added him to my "must read" list.

3.)  The revolving door for lobbyists is alive and well, and working on health care

A frightening graphic in the Washington Post today details just how frequently the Congressional bodies who are now working on reform legislation are being lobbied by people who use to work for them.  As the caption reads, "at least 50 former employees of the Senate Finance Committee or its members now lobby on behalf of the health-care industry, in many cases for more than one client."  The graphic tells a tale all by itself, particularly for Max Baucus and Chuck Grassley, who are now being lobbied by their former chief of staff and former health policy advisors, who represent many, many, many clients among Big Pharma, Big Insurance and hospitals or nursing homes:

We all knew that the forces of the status quo were well-funded, well-researched, and well-connected.  But I don't think any of us quite realized that in addition to their money, their influence and their access, they had one advantage that those of us at the grassroots just don't have:  the buddies of those who are calling the shots.

(Photo credit:  Atomische on Flickr.)

Government’s Involvement in Health Care Around the World

by Tim Foley

category: Health Care Around the World

Published July 05, 2009 @ 09:21PM PT

The world is a very small place, if you’re going by the health care debate in this country.  You have the U.S., you have Canada, you have the U.K., and you have “All Others,” where they may or may not have medical care.  It’s preposterous, of course, and usually only done to make a specific point about “the evils of government involvement in health care.”  The plain truth is we’re never going to swap out our health care system for that of another country’s wholesale.  But if we really want to argue whether government intervention is necessary to reform our broken system, we need to look at the world around us.

Jonathan Cohn has a lengthy and highly-recommended article in today’s Boston Globe talking about, among other things, how poorly France and the Netherlands fit the stereotypes and talking points about what happens when government gets involved in health care.  The two countries are on opposite ends of the spectrum.  The Netherlands provides universal health care largely through private insurance companies;  France has universal basic medical care through a single-payer, with 98% of the population also opting to buy supplemental coverage through a private company.  (Yes, that means France has nearly covered its entire population twice over, and still spends less than we do as a percentage of GDP).  But both feature strong government involvement in terms of much heavier regulation of private insurers than anything we’re proposing today.  Yet they make terrible talking points for those who want to warn against the ills of government involvement.  Health care in those countries is more affordable, better quality, and doesn’t lead to the “inevitable” rationing that so many fear here at home:

In both the Netherlands and France, most people have long-standing relationships with their primary care doctors. And when they need to see these doctors, they do so without delay or hassle. In a 2008 survey of adults with chronic disease conducted by the Commonwealth Fund - a foundation which financed my own research abroad - 60 percent of Dutch patients and 42 percent of French patients could get same-day appointments. The figure in the US was just 26 percent.

The contrast with after-hours care is even more striking. If you live in either Amsterdam or Paris, and get sick after your family physician has gone home, a phone call will typically get you an immediate medical consultation - or even, if necessary, a house call. And if you need the sort of attention available only at a formal medical facility, you can get that, too - without the long waits typical in US emergency rooms.

This is particularly true in the Netherlands, thanks to a nationwide network of urgent care centers the government and medical societies have put in place. Not only do these centers provide easily accessible care for people who use them; they leave hospital emergency rooms free to concentrate on the truly serious cases. Tellingly, a Dutch physician I met complained to me that waiting times in her emergency room had been getting “too long” lately. “Too long,” she went on to tell me, meant two or three hours. When I told her about documented cases of people waiting a day, or even days, for treatment in some American emergency rooms, she thought I was joking. (In a 2007 Commonwealth Fund survey, just 9 percent of Dutch patients reported waiting more than two hours for care in an ER, compared to 31 percent of Americans.)

No one has created a perfect health care system.  There are problems with every one and strengths with every one – even ours.  But there’s one simple fact that we can’t escape:  whether it’s the Netherlands or Switzerland, whose reliance on private insurance makes it the favorite model of conservative economists as well as the model for Gov. Mitt Romney’s legislation, or the single-payer exemplars of Taiwan, Scandinavia and our neighbor to the north, no one has been able to control costs, expand access to all citizens and dramatically improve care without greater government involvement.  Not a single one.

I’m all for American exceptionalism, but this is ridiculous.

For more on health care around the world, check out these earlier posts:

• "Everybody Knows" Is Not a Credible Source on Canadian Health Care
• 5 Questions About French Health Care
• Swiping Ideas from the Swiss
• Turning Japanese? We Could Do a Lot Worse
• In Defense of English-Speaking Health Care

(Photo credit:  woodleywonderworks on Flickr.)

Medicare Payments: A Second Front on Health Reform

by Tim Foley

categories: Doctors and Nurses, Medicare and Medicaid

Published July 05, 2009 @ 02:01PM PT

The health care reform bills in Congress aren’t the only game in town.  The Wall Street Journal reported on Thursday that payment reform in Medicare is also underway, through the Centers for Medicare and Medicaid Services, the agency that sets rates for Medicare Physician Fee Schedule.  Primary care reimbursements will go up – a step long overdue.  Given the fact that Medicare is the Big Dog of payors, and any reforms they adapt tend to get quickly implemented by private insurance, there’s hope that primary care will soon be better compensated across the board.  But it will do so by reducing the total reimbursements for some specialties.  This could be a positive step for medicine, or it could unleash a flurry of lobbying, hand wringing and destructive rhetoric.  CMS may be opening a second front on the fight for health reform.

The details are not for the technically squeamish.  CMS sets the payment rates for over 7,000 services and procedures, so tracking who is likely to get paid what is beyond confusing.  It’s not like the release comes out and says, “We expect radiologists to get a 10% pay cut.”  I’m relying heavily on the analysis of blogger and ER attending Shadowfax to help me make sense of it all.  The short version is that some of the most lucrative scans, tests and consultations are being reduced in rate to something closer to what a primary care doctor would get charged for a similar consultation.  As you can imagine, this hits those specialists who utilize scanning technology the most.  Shadowfax explains:

Hardest hit among specialists are Radiation Oncology, Nuclear Medicine, Interventional Radiology, Cardiology, and Radiology, all of which see >10% decreases in direct compensation.  This may in fact be understating the impact, in that the compensation will also be cut for certain diagnostic procedures such as echocardiography (-42%), coronary angiography (-24%), as well as the payments for CT, MRI and PET scans, and radiologists often (though certainly not always) own the equipment being used to perform the scans.

The cuts aren’t coming willy-nilly.  Rather one of the arguments for limiting these payments is based on the cost of keeping up the equipment and how often it’s in use.  The old payment scale presumed many of these scanners are only in use 50% of the time, so they should be compensated higher in order to break even.  The reality is many of them are in use 90% of the time, and have become cash cows for providers and hospitals, leading to a perverse incentive to order still more tests and procedures, often “just in case.”  Whether the decision is conscious or unconscious, the fact that such procedures are so lucrative unquestionably leads to overtreatment, and increased health care costs that don’t lead to better health.

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