Saturday, February 28, 2009

A national healthcare reform primer - Los Angeles Times

A national healthcare reform primer - Los Angeles Times

The cost of covering the uninsured ultimately will depend on the number of people included, the specific benefits they receive, and the amount of financial help the taxpayers would provide. The only agreement among economists who study the issue is that the tab would be a big one:* $200 billion to $250 billion a year, says Joe Antos of the conservative American Enterprise Institute.* $150 billion to $175 billion a year, says Len M. Nichols of the liberal New America Foundation.

According to CMS, we spent $2.1 Trillion on all of health care with costs rising rapidly. So even using AEI’s numbers, this only represents a 10% increase to cover all Americans.

Regardless of what happens, will I be able to keep the insurance I have now?

LA Times answers: “Almost certainly” and “Further, most people get their coverage at work, and this would continue.”

Which is too bad. Given the choice between keeping my $15 K a year policy and buying into a public policy (Medicare – like, if not Medicare) at lower cost, with less red tape, no pre-approvals, fighting for benefits and on and on, I believe most would choose the public option after it has shown its stuff. But if a public option is put out there, it allows the transition to begin away from bloated private insurers as they will have to compete with public policies.

If I don't have health insurance, would I have to buy it if an agreement on reform is reached?

This is the tricky mandate issue. Advocates say you can't cover everyone unless you make everyone buy a policy.Although nobody from the administration is using the "M" word these days -- a mandate would represent a big expansion of government authority -- many believe it is the logical way to go. So do Democratic leaders in Congress.Before such a mandate could become law, however, Congress would have to decide the amount of financial subsidies to help people pay for their coverage. Most people without health insurance work full-time and earn less than $30,000 a year. Meanwhile, the average policy for a family of four under job-based coverage cost $12,680 last year, with the employer paying $9,325, according to figures compiled by the Kaiser Family Foundation. Coverage for an individual through work cost $4,704, with the employer paying $3,983.A decision on a mandate would also involve intense negotiations between the government and the insurance industry over the terms and details of coverage.

The industry has indicated it's willing to deliver "guaranteed issue" (nobody gets turned down) in return for a law requiring mandatory purchase of insurance.The National Assn of Insurance Commissioners has proposed a model act for the states as a way to control costs. It says that the highest rates for any age group should be no more than 400% of the lowest rate charged to any group.

This would be reduced to 300% two years after the law is passed, then to 200% after five years. That would mean a 63-year-old living in San Diego, for example, could not be charged more than double the rate paid by a 25-year-old in Santa Monica.Price differences and subsidies are crucial. It would be meaningless to have the guaranteed right to buy health insurance if you make $30,000 a year, have high blood pressure and diabetes, and a policy would cost you $10,000.

Well explained. I don’t think it is “tricky,” as there must be guaranteed insurance for all and none can be left out or much savings gained by easy access to primary care is lost.

If I have a business, would I have to buy coverage for my workers?

The answer to this question may determine the success or failure of health reform efforts.

I’m a de-linker in the sense I don’t think insurance should be linked to income and, if you like the deep economics of it, ALL benefits are from wages anyway, so if you want to do like Germny and others,you could use a payroll tax specifically for this purpose. This will cause lots of sturm and drang, however.

Would there be some help for older workers who don't have coverage on the job and can't afford an individual policy?


Again, if we don’t get everyone in, it is not very “universal”, is it? I don’t know enough about the mind set of Congress to make a prediction, but how would the people who are just beginnning to enter their health care using years not be central to the solution?

Might there be a public health insurance plan?

This idea, backed by the president, would create for the first time a public insurance plan to compete with the myriad plans offered by private-industry insurers. The plan would be designed to provide a benchmark for quality coverage, with a basic package of comprehensive benefits. The Obama health plan issued during the presidential election campaign envisioned that millions of the 47 million uninsured would move into a public plan.

To quote Helen Hunt in, “As Good As It Gets,” “I hope, I hope, I hope, I hope.”

How can the country pay for a reworking of its health insurance system?

A nice discussion of some potential savings. This will cause a lots of discussion, but I would go back to the top of the article and point out that even the AEI’s estimates (which I admittedly have not read) which I expect are all worst case scenarios, estimates only a 10% or so increase in costs. I happen to be one who believes that the waste in our system is at least 30% and that in perhaps 5 years we will begin to see those savings. But, even if it costs more, it is the right thing to do.

Their bottom line:

If Obama can figure out a way to persuade Congress to expand coverage to millions of uninsured people, while keeping those with coverage happy, it will be a feat of political magic that has eluded presidents for decades.
I agree. It is up to us to make not doing the right thing a very unattractive option.


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Friday, February 27, 2009

A Public Health Insurance Plan |

A Public Health Insurance Plan

As the ball rolls along in our debate, one thing that keeps coming up is the idea that everyone must have insurance. Being forced to buy insurance from a private insurer ($15K a year at our house - from a "not-for-profit" !) is obviously not an option for most, especially considering the median family income is only about $60K. Medicare spends anywhere from $6K to $14K per enrollee (65 and over, mind you). So can a public option be the solution?

Here are the key findings of the report, but you can click the link above to get the full report, an executive summary and a PowerPoint show.

The report contains these findings:
• Medicare has controlled health care costs much better than have private health insurers over the last 25 years.
• The private insurance market is highly consolidated and needs competition from a public health insurance plan to lower skyrocketing premiums.
• Administrative costs are dramatically lower under public health insurance plans,
resulting in enormous savings to the system.
• The bargaining power of public health insurance plans significantly reduces provider costs.
• In a head-to-head competition, the public Medicare plan is much better at containing costs than private Medicare Advantage plans.
• Independent analyses show substantial savings can be achieved from a public health insurance plan that competes with private insurance plans.
• Quality and effectiveness innovations occurring under the public Medicare plan show that public health insurance plans have greater potential to drive the quality revolution than do private plans.
• Public health insurance plans increase choice, competition and accountability.

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Thursday, February 26, 2009

Overview Physician Fee Schedule Look-up

Overview Physician Fee Schedule Look-up

I didn't know this existed!

This allows you to look up reimbursement schedules by region and state for Medicare.

Have fun!

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Wednesday, February 25, 2009

Dartmouth Atlas of Health Care: Regional Disparity in Medicare Spending - Interactives - Quality/Equality newsroom - Quality/Equality - RWJF

Dartmouth Atlas of Health Care: Regional Disparity in Medicare Spending - Interactives - Quality/Equality newsroom - Quality/Equality - RWJF

The above link takes youto the interactive map that is kind of cool to look at and comare a few regions to see where yours falls.

The actual NEJM article is here. And here is the substantive part of the article (for me, anyway):

What's going on? It is highly unlikely that these differences in growth could be explained by differences in health. Marked regional differences in spending remain after careful adjustment for health, and there is no evidence that health is decaying more rapidly in Miami than in Salem.

The variations allow us to rule out two overly simplistic explanations for spending growth. First, "technology" is clearly an insufficient explanation: residents of all U.S. regions have access to the same technology, and it is implausible that physicians in the regions with slower spending growth are consciously denying their patients needed care. Indeed, evidence suggests that the quality of care and health outcomes are better in lower-spending regions and that there have been no greater gains in survival in regions with greater spending growth.1 Second, it is difficult to blame regional differences entirely on the current payment system, since all our evidence on regional growth comes from populations in the fee-for-service system. Other research has emphasized the role of managed care in moderating the growth of costs,2 but this story cannot explain the rapid growth in Miami, where roughly half of Medicare enrollees are covered by Medicare Advantage plans.

The causes must therefore lie in how physicians and others respond to the vailability of technology, capital, and other resources in the context of the fee-for-service payment system. A recent study by researchers in our group provides further insight.3 Using clinical vignettes to present standardized patient care scenarios to physicians throughout the country, the researchers found that physicians in high- and low-spending regions were about equally likely to recommend specific clinical
interventions when the supporting evidence was strong. Those in higher-spending
regions, however, were much more likely than those in lower-spending regions to
recommend discretionary services, such as referral to a subspecialist for typical gastroesophageal reflux or stable angina or, in another vignette, hospital admission for an 85-year-old patient with an exacerbation of end-stage congestive heart failure. And they were three times as likely to admit the latter patient directly to an intensive care unit and 30% less likely to discuss palliative care with the patient and family. Differences in the propensity to intervene in such gray areas of decision making were highly correlated with regional differences in per capita spending.

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Tuesday, February 24, 2009


EzraKlein Archive The American Prospect:

"Administration officials have been very clear on what the inclusion of 'universality' is meant to communicate to Congress. As one senior member of the health team said to me, '[The plan] will cover everybody. And I don't see how you cover everybody without an individual mandate.' That language almost precisely echoes what Senate Finance Chairman Max Baucus said in an interview last summer. 'I don’t see how you can get meaningful universal coverage without a mandate,' he told me. Last fall, he included an individual mandate in the first draft of his health care plan.

"The administration's strategy brings them into alignment with senators like Max Baucus. Though they're not proposing an individual mandate in the budget, they are asking Congress to fulfill an objective that they expect will result in Congress proposing an individual mandate. And despite the controversy over the individual mandate in the campaign, they will support it. That, after all, is how you cover everybody."

While I favor a single payer system as the best solution, it doesn't take a rocket scientist (or Ezra Klein) to see where the winds are blowing.

I have become comfortable with this approach. Although mandates have not worked out as well as we'd like in Massachusetts, it is hard to argue that they have not worked in Switzerland, Germany, Japan and other countries. I would argue that the chief differences are two:
1.) Spending enough money to actually give everyone a comprehensive benefits package (think Medicare, not Medicaid)
2.) Serious regulation of private insurers so that they cannot cherry-pick, deny, drop, obfuscate, etc

If we spend enough money in some private-public mix and if we regulate the insurers so they function more like the contractors who cut the checks for Medicare (the regional "carriers") and we subsidize those who cannot afford health care or insurance, we may not have single payer, but we will at least have a truly universal, fair, system.

AND THEN, if we still think we need to, we can work on transitioning to a true single payer system.

OK, let me have it.


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Tuesday, February 17, 2009

America's Agenda Health Care Summit Conversations

America's Agenda Health Care Summit Conversations

A collection of videos, that I have not yet reviewed, but put here for now as a bookmark.

Good line up of speakers, at least.

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Saturday, February 14, 2009

Poll Shows Strong Support for Obama Health Care Reforms - US News and World Report

Poll Shows Strong Support for Obama Health Care Reforms - US News and World Report:

"The poll shows that as Americans learn more about Obama's anticipated reforms, they seem better able to make up their mind about them -- either pro or con. For example, 62 percent of those surveyed who said they knew 'a lot' about the new president's ideas expressed support for the initiatives, with 36 percent opposed and only 2 percent saying they were 'not sure.' Among those who said they knew nothing about the Obama proposals, 66 percent remained unsure, 23 percent were supportive, and 11 percent opposed.

"Some other key findings:

"A majority of respondents said the reforms, if carried out, would improve the health care system. Sixty-one percent felt reforms would deliver adequate health insurance to more people, and 54 percent thought health care would be made more cost effective. But a fifth of respondents thought the changes would make the quality of medical care worse, not better.

"Support for the proposals did not vary significantly based on income. Fifty percent of people making between $15,000 and $25,000 annually approved of the Obama plan, compared to 51 percent of those making $50,000 or more. But the gap widened as respondents looked at specific issues, such as the plan's ability to boost the quality of care or strengthen the economy.

"Predictably, support split along party lines, with three-quarters of Democrats supporting Obama's overall plan, compared to 26 percent of Republicans. Many Republicans appeared to favor specific elements of the plan, however. For example, 70 percent supported the notion of having Medicare negotiate drug prices, and more than half (53 percent) agreed with offering subsidies to low-income families to ensure universal health coverage"

The full report is here.

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Thursday, February 12, 2009

Tire rims and Anthrax from "Balloon Juice "

Balloon Juice » Blog Archive » You’ll Never Get This 21 Minutes Of Your Life Back:

"I really don’t understand how bipartisanship is ever going to work when one of the parties is insane. Imagine trying to negotiate an agreement on dinner plans with your date, and you suggest Italian and she states her preference would be a meal of tire rims and anthrax. If you can figure out a way to split the difference there and find a meal you will both enjoy, you can probably figure out how bipartisanship is going to work the next few years."

Sorry, but I had to post this, because I'm using it as mental shorthand all the time, and I just heard it last week.

Someone also posted this adjustment, which I also like:

"Imagine trying to negotiate an agreement on dinner plans with your date, and you suggest Italian and she states her preference [would be a meal of tire rims and anthrax] to give the rich guy at the next table a tax break, hoping he buys your dinner."

I am more than a little concerned we'll have the same feeling as we break out the Chianti for the health care reform debate...

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Monday, February 9, 2009

Fraser Institute still allowed space in WSJ

A friend sent me this piece from the WSJ from the seriously delusional Fraser Institute (whom I may have to give their own subject tag at this point, but I'll stick them in with the Right Wing Noise Machine for now). My reply:

I love how these people love to site anecdotes. I note they never site the horrible anecdotes from the US.

I have some collected here:

The first entry on my blog in my "anecdote-off" section is from a BBC documentary on US healthcare from January.

Have fun. See how many anecdotes you can count in this brief half hour program. I think there are at least a thousand if you count all those poor people at the RAM Medical program. But there are stories every bit, actually worse, than any Canadian anecdote I've ever seen.

Keep scrolling down, you'll get the idea. If you are uninsured in America, you may as well be in Cambodia until you're sick enough for the ER.

Oh, and hip replacements in the US do have a short waiting time, thanks to OUR single payer system, Medicare, which is funded well enough to make it so,

And finally, the Fraser Institute is full of poopy-heads, and dishonest ones at that. ;-)

I love you, but aren't you seriously tired of being systematically manipulated by Fraser, Heritage, Club for Growth and the rest of the noise machine?


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Thursday, February 5, 2009

Annals of Public Policy: Getting There from Here: Reporting & Essays: The New Yorker

Annals of Public Policy: Getting There from Here: Reporting & Essays: The New Yorker:

"Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” In the battles between Betamax and VHS video recorders, Mac and P.C. computers, the QWERTY typewriter keyboard and alternative designs, they found that small, early events played a far more critical role in the market outcome than did the question of which design was better. Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area—even if prices, taxes, and competition are stiffer. “The long shadow cast by history over location is apparent at all scales, from the smallest to the largest—from the cluster of costume jewelry firms in Providence to the concentration of 60 million people in the Northeast Corridor,” Krugman wrote in 1991.
With path-dependent processes, the outcome is unpredictable at the start. Small, often random events early in the process are “remembered,” continuing to have influence later. And, as you go along, the range of future possibilities gets narrower. It becomes more and more unlikely that you can simply shift from one path to another, even if you are locked in on a path that has a lower payoff than an alternate one."

It's actually hard to get a representative paragraph out of this article. It is definitely worthwhile reading, as is everything Gawande writes, and begins with an overview of how universal healthcare took hold in England, France and Switzerland, and then makes the case for "path dependence", which starts the section I've quoted above.

Because I haven't written it in a while, Ill repeat a story. At a debate among single payer advocates and antagonists at
Duquesne University last year, I asked the representative of the very right wing Fraser institute of Canada, which of the world's nations systems he could live with us modeling ourselves after. Switzerland was the answer, and he conceded that the hybrid of using competing insurers and providers while requiring universal coverage with subsidies may be the second best solution for America. After laissez-faire capitalism, of course.

But it does make the point that the combination of path dependence and bits of common ground could lead us to real change.

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Art Caplan Lecture - Society of Critical Care Medicine

SCCM - Society of Critical Care Medicine:
"Max Weil Honorary Lecture
Arthur Caplan, MD
University of Pennsylvania
Philadelphia, Pennsylvania, USA
Beyond Band-Aids: How to Cure America's Ailing Healthcare System
Arthur Caplan, MD, argued that the United States healthcare system is broken, and it is important to evaluate the various healthcare reform proposals and their political feasibility. Healthcare professionals should have a prominent place in the discussion to ensure ethical and meaningful reforms."

Dr. Caplan spent the bulk of his time making the ethical case for healthcare reform. He based his argument on the right to opportunity, or equal opportunity, of all citizens to be free from the encumbrances of illnesses untreated due to lack of personal resources or lack of resources from our social safety net.

Fair enough, but I think this argument will fall flat, of course, to those who oppose health care reform of any stripe, but I think it rings peculiarly hollow to most others as well, including the most fevered advocates for reform.

I will be flagging my ignorance of formal ethics and bioethics here, as I am, like most, simply an amateur (but nonetheless opinionated) ethicist. (But, I am an intensivist, so maybe I am semi-pro?)

I think in addressing health care professionals, it is reasonable to appeal to their professionalism. In the Charter on Medical Professionalism, we are called to advocate for Social Justice:

"Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category. "

And this argument does need to be made to specialty physician organizations. Repeatedly. Many of our organizations have devolved into glorified trade organizations, only springing into action when income or clinical territory are threatened. We need to call ourselves and our colleagues to the better angels of our nature.

But this is really only the tip of the iceberg required to make the ethical case for universal healthcare. The real case rests on our common humanity, our common respect for the dignity of man, The Golden Rule.

A recent program aired on Bill Moyers Journal called "Beyond Our Differences", which explored the common themes of all world religions. It is a terrific program and I advise everyone to watch it, preferably with your family.

Is there a moral philosophy on the planet that does not require us to care for the least among us? Is there one which does not require us to care for the poor, the sick, the hungry to the best of our ability? Is there one that does not require us to respect the dignity of our fellow humans?

I like to joke that there is such a philosophy, Ayn Rand's Objectivism. Maybe there are other philisophical schools of thought that also reject these tenets, I will let the real philosophers out there correct me. But all religions, east and west, and secular humanism all carry forward this strong ethical mandate. As I look through my "Social Justice" subject tag, quite a lot are covered: Catholics and the Jesuits, Charles Dickens (and Protestants and humanists), physicians, Jews, and even the self-intersted. The "Beyond Our Differences" program covers these and more.

So, how to make the ethical argument? I think we must rely on our common humanity, our common philosphy of honoring the dignity of our fellow humans and doing our duty as citizens of a great country to "promote the general Welfare".

But better yet, let me sum it up as Uwe Reinhardt would, "Go explain to your God why you cannot do this, and he will laugh at you."

Sphere: Related Content - Zeke Emanuel: Scrapping the Health Care System - Zeke Emanuel: Scrapping the Health Care System (Audio only here- You may have to register.)

A lecture done for the Commonwealth Club of California on January 8, 2009.

As in his book, "Healthcare Guaranteed", he lays out his case for Health Care reform, which is for a social health insurance program. I actually agree with him, and he makes his case well. I think he gets a couple things wrong, in a way that is not helpful.

First, he spends some time being very dismissive of the single payer option. His arguments are two-fold. First, making a system work for 300 million people is impossible. Second, that continuing a fee for service system makes cost control impossible.

I happen to agree that working for a social insurance model is the best way to go, for a variety of reasons, that he covers well.

However, he is almost patronizing of those who advocate for single payer. This wouldn't be so bad if he hit the mark on his criticisms, but he does not. And it irritates and antagonizes those who would naturally on his side, if he persuaded instead of ridiculed.

Regarding managing 300 million accounts/people/policies: Our current Medicare system does not attempt to manage all of its members within a single entity. Medicare functions as the central agency, but regional carriers handle the day to day operations. And in Canada, the single payer system is broken into manageable chunks by province. There is no reason we could not implement our system in such manageable chunks.

His second argument is that fee for service is the real problem, not insurance company waste, and that we will get the most bang for our buck with payment reform rather than cracking down on insurers.

Maybe there are single payer advocates who advocate for the current reimbursement system, but I don't know any of them. So, in that sense, it is a straw man, but he really loses me when he he argues that we cannot have high performing, efficient organizations like the Cleveland Clinic or the Mayo Clinic under fee for service. I'm sorry, but those systems operate in a fee for service payment system. They have done some unique things within that system, but they are a model of how to make a fee for service system work properly. So, attacking single payer because it mandates no reform in payment models is silly and it antagonizes people who should be engaged, not belittled.

He additionally makes the case that insurance companies are not to blame for our problems and indicates that most of us would behave as these execs and employees would if placed in the same circumstances. Fine, I'll concede that, but the problem, single payer advocates point out is that the circumstances are the problem, not the employees. A system that rewards denial of care leads to massive bureaucracies designed to deny care. So, sorry, they are a big part of the problem.

And, while I'm in a critical mood, I do have a problem with suggesting VAT as a method of payment. We already have the most byzantine taxation system in the world. Why add another layer of complexity that will surely be more regressive into the mix. If you want to fund via taxes, fund via taxes. At least the income tax is somewhat progressive. And people are not completely stupid: if you tell them their taxes will go up $8000 but they won't have to pay $12,000 in health insurance premiums and another $1000 or two or three out of pocket, they'll get it.

This is intended in a spirit of constructive criticism so that we can advance the debate together.

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Wednesday, February 4, 2009

Blog Name Change


I don't know how many people check in to the blog here, but you will notice a name change today. And it's my 300th post, to boot.

Reflecting my own modifications of my opinions on health care reform, I felt that "Single Payer Blog" was no longer reflective of the content of the blog nor of my own primary position. My primary concern now is major, transformative health care reform and whether that takes the form of a social health insurance model or a single payer model or a hybrid of some kind, I can deal.

But I think changing the Blog name to "The Health Care Reform Debate Blog" reflects what I am trying to accomplish: Gather together my thoughts and resources that will make for a better informed, more rational debate.

I just got back from a busy week traveling and attending meetings and conferences, I hope to have some good posts up over the next few days, partly based upon my travels.


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Annals of Medicine: The Bell Curve: The New Yorker

Annals of Medicine: The Bell Curve: The New Yorker

Atul Gawande - Bell Curve

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JAMA -- Medical Acceptance of Quality Assurance in Health Care: The French Experience, December 10, 2008, Giraud-Roufast and Chabot 300 (22): 2663

JAMA -- Medical Acceptance of Quality Assurance in Health Care: The French Experience, December 10, 2008, Giraud-Roufast and Chabot 300 (22): 2663

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