Wednesday, April 29, 2009

Groups strategize for single-payer plan - Print View

Groups strategize for single-payer plan - Print View:

"President Barack Obama and Senate Finance Committee Chairman Max Baucus (D-Mont.) rarely pass up a chance to snub single-payer health care — a term that means a government-run system. So opponents on the left who want their voices heard in the debate over health care reform are planning to yell a little bit louder as Congress considers creating a public insurance plan to compete with private insurers.

"Their strategy is simple: By pushing hard for single-payer health care, a robust public insurance option ends up looking like a compromise Democrats could accept.

"“The best way to get half the pie is ask for the whole pie,” said Katie Robbins, assistant national coordinator of Healthcare-Now, which will not endorse the public plan but acknowledges the strategy. “It is like horse trading.”"

"And here is a hint about why proponents and opponents of the public plan talk so frequently about “choice”: It polls really, really well. Support for the public plan jumped to 78 percent when people were told it would give consumers more options. "

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EzraKlein Archive | The American Prospect

EzraKlein Archive The American Prospect

This is just too fun. Fraser Institute puts on prominent Canadian physician to dis Canadian health care, which he does, mildly IMHO, but then proceeds to dis the American system even more!

And Dr. Day (former CMA President) makes some great points:

1. Waiting times are a function of the way Canada funds hospitals, by bloc grants to hospitals rather than having money follow the patients as in the rest of the world.

2. Waiting times cost more, particualarly in terms of patients illness progression and economic costs of lost work, wages, productivity, etc.

3. Britain has essentially fixed its waiting time issues by dispensing with the bloc system.

4. “I think this is what people tend to forget. They equate alternatives to the Canadian health care system with ‘Americanization,’ which is not what we’re talking about. We’re talking about countries like Belgium, and Switzerland, and France, and Austria.”

5. One should be able to buy private health insurance (in Canada) to supplement the Candian Medicare system.

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Monday, April 27, 2009

Congressional Health Care Caucus

Congressional Health Care Caucus

I found this website, apparently the nexus of pushing back on Democratic attempts at halth care reform.

It is fairly lame, in my estimation, largely reminding readers how horrible the rest of the world has it and how the free market and charity care can still fix it all, in spite of a half-century of evidence to the contrary. You know, let private health insurance CEOs and bureaucrats do whatever they choose so that we can be protected from government bureaucrats.

Anyway, one of the things that I always hear from conservatives, and is found in a primer written by Congressman Michael Burgess, MD, is that medical innovation will come to a screeching halt if we get universal health care. He points out that 22 of the past 25 Nobel Laureates in Medicine were Americans.

So, I checked it out on Wikipedia, and I will admit I only checked out the most recent 10 or so, but would you be shocked to learn they all worked at Universities or large, well-funded, non-profit foundations (like the Howard Hughes Insitute)? Me neither.

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Paperwork, profits clog health care's efficiencies

Paperwork, profits clog health care's efficiencies:
DEAN CALBREATH, San Diego Union Tribune

"Jim G. Kahn, health economist at the Institute for Health Policy Studies at the University of California San Francisco, found a similar pattern during a study of California hospitals, clinics and doctors' groups. He found the doctors' groups were spending an average of 14 cents per dollar related to legal, accounting and processing costs involved with health insurance.

"“You have to have teams of lawyers and accountants to negotiate contracts and to figure out who pays for what,” Kahn said. “You have to have whole teams in place to figure out what errors there are (in the paperwork) and how to fix them.”

"Kahn said that in a single-payer system like Canada's, the data are centralized, resulting in less time, money and effort being spent on administrative tasks. “And then you could apply that savings to provide better health coverage,” he said.

"Critics of a single-payer concept worry that a government-run system would end up being too costly and too bureaucratic, without providing the benefits of innovation and cost-cutting that competition is supposed to bring. But if that were true, why does our system cost more than those abroad?

"The entities that seem to benefit most from the current system are the major pharmaceuticals, which are among the nation's most profitable companies, and the life insurers, which have also done well.

"Donald Cohen, executive director of San Diego's Center for Policy Initiatives, a liberal think tank, said the top seven for-profit health insurers made a combined $12.6 billion in 2007, an increase of more than 170 percent from 2003. Part of those profits go toward paying high salaries for the top executives. The seven chief executives received an average compensation of $14.3 million in 2007, with pay packages ranging from $3.7 million to $25.8 million.

"Cohen suggested that one way of lowering costs would be to create more competition, by having a government health plan competing with the private insurers. Government-run programs, he said, typically run with low administrative expenses, often with overhead running at 1 percent to 3 percent of their expenses. In contrast, the privately run insurance firms have overhead costs as high as 20 percent, partly because of their high salaries.

"As Cohen noted, conservative think tanks like the Reason Foundation, Heritage Foundation and others have argued that allowing the private sector to compete with the public sector can benefit the taxpayer. Why shouldn't the reverse be true?

"“Public-private competition in health insurance will squeeze overhead and profits from the middlemen in the system so we can put more money into actual health care,” Cohen said. "

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Reforming Health Care -

Reforming Health Care -

The WaPo decides a public option is a bizarre fixation...

"Of the many possible issues that could snarl health-care reform, one of the biggest is whether the measure should include a government-run health plan to compete with private insurers. The public plan has become an unfortunate litmus test for both sides. The opposition to a public plan option is understandable; conservatives, health insurers, health-care providers and others see it as a slippery step down the slope to a single-payer system because, they contend, the government's built-in advantages will allow it to unfairly squash competitors.

"For liberals, labor unions and others pushing to make health care available to all Americans, however, the fixation on a public plan is bizarre and counterproductive. Their position elevates the public plan way out of proportion to its importance in fixing health care. It is entirely possible to imagine effective health-care reform -- changes that would expand coverage and help control costs -- without a public option."

The comments excoriate them, for the most part.

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AMNews: April 27, 2009. AMA letter backs Obama's broad principles for health system reform ... American Medical News

AMNews: April 27, 2009. AMA letter backs Obama's broad principles for health system reform ... American Medical News:

"But embracing the eight principles does not mean the AMA necessarily backs every idea on health reform that Obama has revealed so far. For instance, the president has called for creating a public health plan option linked with a national health insurance exchange to serve as competition for private plans. In its letter to the White House, the AMA says it supports a health insurance exchange to ensure coverage choice and portability, but it does not weigh in on the public plan option. To move toward universal coverage, Congress should build on the employer-based system and strengthen the safety net provided by publicly financed programs such as Medicare, Medicaid and the Children's Health Insurance Program, Dr. Nielsen and Dr. Rohack wrote.

"Dr. Nielsen stressed that the organization is mindful of the need to watch the dollar signs as policymakers work toward the goal of universal coverage. 'It's very important for us that all Americans have health care coverage that's affordable. But we do understand that we can't afford everything for everybody, so we need to have fiscally responsible conversations.'

"The letter proposes expanding on Obama's principles in a number of ways, including:

  • Reforming and improving the insurance market through the use of modified community rating, guaranteed renewability and fewer benefit mandates.
  • Assisting low-income individuals through premium subsidies and cost-sharing assistance.
  • Promoting medical home models to reduce system fragmentation and improve care coordination.
  • Establishing antitrust reforms that would allow groups of physicians to contract jointly with payers as long as the doctors certify they are collaborating on health information technology and quality improvement initiatives.
  • Easing the effect of liability pressure on the practice of defensive medicine through innovative approaches, such as health courts, early disclosure and compensation programs, and expert witness qualification standards"

The "8 Principles" of Obama are at the end of the article.

I do wonder why the AMA is pushing back on the public option. It seems to me the only chance physicians have of keeping reimbursement rates reasonable because private insurers will do their darndest to NOT wring savings out of the system (except on the provider side!), and so all that money is money not available to providers. One man's waste is another man's revenue.

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Shortage of Doctors Proves Obstacle to Obama Goals -

Shortage of Doctors Proves Obstacle to Obama Goals -

"Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors — the very ones needed to coordinate the care of older people with chronic conditions like congestive heart failure, diabetes and Alzheimer’s disease.

"“Primary care physicians are grossly underpaid compared with many specialists,” said Mr. Baucus, who vowed to increase primary care payments as part of legislation to overhaul the health care system.

"The Medicare Payment Advisory Commission, an independent federal panel, has recommended an increase of up to 10 percent in the payment for many primary care services, including office visits. To offset the cost, it said, Congress should reduce payments for other services, an idea that riles many specialists.

"Dr. Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, said: “We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way.

"“If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.”"

So, do we have the beginnings of class war in medicine? Our spending is unsutainable, we spend it in the wrong places quite often, and the specialties with something to lose ( high reimbursement rates) are not going to take this lying down.

The article also goes on to point out that as we bring more people into the ranks of the insured, waiting times will go up. Gee, where have I heard that before?

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Saturday, April 25, 2009

Conservatives Live in a Different Moral Universe -- And Here's Why It Matters | | AlterNet

Conservatives Live in a Different Moral Universe -- And Here's Why It Matters AlterNet:

With all that in mind, Haidt identified five foundational moral impulses. As succinctly defined by Northwestern University's McAdams, they are:

• Harm/care. It is wrong to hurt people; it is good to relieve suffering.
• Fairness/reciprocity. Justice and fairness are good; people have certain rights
that need to be upheld in social interactions.
• In-group loyalty. People should be true to their group and be wary of threats from the outside. Allegiance, loyalty and patriotism are virtues; betrayal is bad.
• Authority/respect. People should respect social hierarchy; social order is
necessary for human life.
• Purity/sanctity. The body and certain aspects of life are sacred. Cleanliness and health, as well as their derivatives of chastity and piety, are all good. Pollution, contamination and the associated character traits of lust and greed are all bad.

Haidt's research reveals that liberals feel strongly about the first two dimensions -- preventing harm and ensuring fairness -- but often feel little, or even feel negatively, about the other three. Conservatives, on the other hand, are drawn to loyalty, authority and purity, which liberals tend to think of as backward or outdated.
People on the right acknowledge the importance of harm prevention and fairness
but not with quite the same energy or passion as those on the left.

Libertarian essayist Will Wilkinson of the Cato Institute -- one of many self-reflective political thinkers who are intrigued by Haidt's hypothesis -- puts it this way: 'While the five foundations are universal, cultures build upon each to varying degrees. Imagine five adjustable slides on a stereo equalizer that can be turned up or down to produce different balances of sound. An equalizer preset like 'Show Tunes' will turn down the bass and 'Hip Hop' will turn it up, but neither turns it off.

A fascinating piece. I post it here because I think it would be wise to run through these five principles as we write letters, engage in debate, etc.

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Friday, April 24, 2009

Charles Krauthammer - Obama: The Grand Strategy

Charles Krauthammer - Obama: The Grand Strategy:

"It is estimated that a third to a half of one's lifetime health costs are consumed in the last six months of life. Accordingly, Britain's National Health Service can deny treatments it deems not cost-effective -- and if you're old and infirm, the cost-effectiveness of treating you plummets. In Canada, they ration by queuing. You can wait forever for so-called elective procedures like hip replacements."

And we ration by income, employment circumstances, insurance company whim, or genetic lottery (i.e., pre-existing conditions).

Imagine if Canada or Britain pulled 1/6 to 1/3 of their population out of the queues for these reasons. Do you expect their waiting times would be as long?

And it is also worth pointing out that the OECD has looked at waiting times and we are not alone among countries in having no significant waiting times. We are the only one of them that rations as I've pointed out.

So, just say it straight up: If we let the less fortunate into the system it'll ruin things for the "good people."

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Helping the Bottom Line - an Online Report

Helping the Bottom Line - an Online Report

From HHS, the email summary is as follows:

Today, the Department of Health and Human Services released The Bottom Line: Health Reform and Small Business. The new report highlights key facts about the impact of high health care costs on small businesses including:

Nearly one-third of the uninsured – 13 million people – are employees of firms with less than 100 workers.

In the past two years, more than half of small businesses that offered coverage reported switching to plans with higher out-of-pocket costs in response to rising premiums. Another third switched to a plan that covered fewer services, and 12% dropped coverage entirely.

Among small businesses that offer coverage, 40% report spending more than 10% of their payroll on health care costs.

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Tuesday, April 21, 2009

Millennial [Generation] Physicians

Listening to a talk recently, the speaker indicated that the Millenial generation has distinct views of work/life balance compared to us older docs. They value time off and independence. They value work and the marginal benefits of longer hours to achieve higher income as simply not really worth it.
I hope this portends some good for the profession, though the trend towards not viewing medicine as a calling may alarm some. I tend towards the Millenial view, however, seeing my profession more as a way of contributing to the world than as a true calling. And it looks like that is the majority view of my generation, the Boomers.

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With Son in Remission, a Family Struggles to Find Coverage -

With Son in Remission, a Family Struggles to Find Coverage -

"Now the Walkers face the possibility that Jake will no longer be seen at Houston’s renowned M.D. Anderson Cancer Center, which they credit for his remission.

“You realize how vulnerable you really are,” said Ms. Walker, who exhibits the maternal ferocity of a black bear. “You just — not give up — but you just feel that you’re at a loss, that you’re at your wits’ end. I ask myself, ‘Do I really have to lose my home to save my son’s life?’ ”

Neither of the Walkers has been able to land a job with the kind of large group coverage that would disregard Jake’s health status. His cancer history effectively makes him uninsurable on the individual market. He is too old to qualify for Medicaid as a child, and it is virtually impossible in Texas to qualify as an able-bodied adult.

Because the Walkers own their modest house, they have been told they do not merit other government assistance. With little predictable income beyond Ms. Walker’s $688 unemployment check every two weeks, the family cannot afford the state’s high-risk insurance pool or continuation coverage through the federal Cobra law.

To date, Jake’s treatment has cost nearly $2 million. Almost all of it has been paid by Cigna under a preferred-provider family policy that Ms. Walker paid $426.28 a month for through DHL, the troubled shipping company where she worked as a billing agent.

Until last fall, Mr. Walker was the co-owner of a business that supplied DHL with trucks and drivers, but it too fell victim to downsizing. The feed store, the last in an area where suburbs are swallowing ranchland, has been losing money.

What has made the Walkers feel most helpless, though, is that their son has been left so exposed, after all he has endured.

“Your job as a parent is to protect your children at any cost,” Ms. Walker said. “I really felt like I had let him down.”"

At the beginning of the article, Mrs. Walker's salary was noted to be $37,000. She paid, out of that, $426 a month for her health insurance (admittedly, pretty darn good insurance given the expense of Jake's treatment). $426 x 12 = $5112 per year bringing her salary down almost 14%, not counting the subsidy on the employer side, probably close to another $5K.

The economic costs are brutal enough, but the fear, uncertainty, and skimping on care (prescriptions, skipping office visits, etc.) are just not acceptable in the richest country in the world.

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Monday, April 13, 2009

National Journal Online -- Health Care Experts -- Paying (Or Not) For Reform

National Journal Online -- Health Care Experts -- Paying (Or Not) For Reform - Uwe Reinhardt Response:

It didn't take long before one of several howitzers got dug in to shoot at the idea of universal health insurance. The one out now is the familiar 'we need to control health care costs in our bloated, inefficient health system first before we can bring yet other Americans under the umbrella of health insurance and into the system.' That cannon has served us well for over three decades now. I can imagine its roar already, even before the cannon is fully cocked.

To shoot this cannon, you must have a license, and the requirement for that license is that you must be well insured and, indeed, be one of the folks who have helped bloat the system and made in inefficient. And because we, the well insured bloaters, have come to love that system so, we’ll do everything in our power not to change the status quo, won't we?

The other cannon, still being readied, is the 'crowd out' or 'crowd in' cannon. It gets deployed whenever someone in Congress or in the White House identifies the year's 'objects of compassion' (OCs). For example, the OC's may be uninsured children, or unemployed adults over 50, or whatever. The compassionate originator of the idea to do something for the OCs may calculate that it will take, say, $2,700 per OC to practice compassion upon them. No sooner uttered than the computers at the AEI or NBER or RAND or wherever start to whirr, figuring out how many OC-look-alikes now privately insured will be crowded into the new public program intended mainly for the original OCs. And before you know it, the federal budget cost calculated as (federal cost per original OC plus federal cost per crowded in OC) divided per original OC is staggering. Bullet hits on the mark, OC plan is destroyed. Mission accomplished.

This is how America has always successfully warded off any impending threat of universal coverage. Maybe it'll work again this time.
There's more...

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Wanted: A Clearly Articulated Social Ethic for American Health Care

Classic Uwe Reinhardt piece: "Wanted: A Clearly Articulated Social Ethic for American Health Care."

From JAMA. 1997;278:1446-1447

Throughout the past 3 decades, Americans have been locked in a tenacious ideological debate whose essence can be distilled into the following pointed question: As a matter of national policy, and to the extent that a nation's health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?

The 'yeas' in all other industrialized nations had won that debate hands down decades ago, and these nations have worked hard to put in place health insurance and health care systems to match that predominant sentiment. In the United States, on the other hand, the 'nays' so far have carried the day. As a matter of conscious national policy, the United States always has and still does openly countenance the practice of rationing health care for millions of American children by their parents' ability to procure health insurance for the family or, if the family is uninsured, by their parents' willingness and ability to pay for health care out of their own pocket or, if the family is unable to pay, by the parents' willingness and ability to procure charity care in their role as health care beggars.

I think this is a great piece and I can't add anything to it and it is well worth the read. The responses in the letters section that followed are, sadly, very revealing about the debate then and now.

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Saturday, April 11, 2009

How health care costs contribute to income disparity in US - The McKinsey Quarterly - health care costs income disparity US - Economic Studies - Country Reports

How health care costs contribute to income disparity in US - The McKinsey Quarterly - health care costs income disparity US - Economic Studies - Country Reports

The top-income category (earning on average $210,100 annually1) has enjoyed rising incomes and growing employer-paid health care benefits, which have made their out-of-pocket spending on health care a relatively small and affordable portion of total spending. The higher-middle-income category (earning an average of $84,800 annually) and the lower-middle-income group (earning on average $41,500), have also seen increasing benefits and incomes—but at a much slower rate, making the uncovered portion of their health care costs ever-more expensive. In the bottom-income category (earning an average of $14,800 a year), incomes have been stagnant, and their employers are less likely to pay for their health insurance. This group is finding any health care difficult, if not impossible, to afford.

As part of a study of widening income gaps between US households, we found that rising employer-paid health insurance premiums constitute a growing share of the
combined income of lower-paid employees—a much larger share than for those who
are higher paid. For those workers within the bottom-income group who are insured (22 percent), the ratio of employer-paid premiums to household income is 20 percent. That compares with 3.3 percent for the top-income group, in which nine out of ten workers are insured.

This is in line with New America's estimate of 17% of household compensation now going to health care, which, really, is a prohibitive amount for lower and middle income families.

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