Thursday, January 28, 2010

My notes for Testimony for GOP doctors caucus January 21, 2010

[I know, I know,State of the Union! I did want to get this up, however, for the record. My opening statement is here.]

As I do not have a transcript, and the video posted by the Caucus only contains the opening statements of the Congressman and not the panel (imagine that!), these comments reflect what I recall based on my note taking on the fly during the hearing.

The committee was co-chaired by Congressman Tim Murphy and Rep. Phil Gingrey.
Rep. Murphy started hearings and made some comments about the congressional process, the election in Massachusetts, and then outlined his specific ideas for healthcare reform: these included purchasing insurance across state lines; focus on cost, outcomes and transparency;health insurance should be personal portable and should not lose insurance with job. He also in passing mentioned that Medicare has not been overhauled since it was passed.

Gingrey also opened with observations about Massachusetts election. He then quoted Jefferson, "Whenever the people are well-informed, they can be trusted with their own government;... whenever things get so far wrong as to attract their notice, they may be relied on to set them to rights." He postulated that people don't like the House or Senate bills, and that deals or cut behind closed doors were bad, and finally that the GOP stands opposition to health care reform is currently constituted

Congressman Roe stated that the process should be open and transparent and that simple ideas will increase access. He is opposed to special interests deals that were made, and quoted a survey that said that 91% of people surveyed like what they had in regards to health insurance, and something along the lines of "when you take this much money out of the system..." bad things will happen.

Congressman Broun had a very simple message that can be summed up as the market will fix all. He has introduced HR 3889 along these lines . He referenced the original intent of the Constitution. He spent a few minutes complaining about CLIA regulations that shutdown labs and he thought this was inappropriate and was bad for healthcare.

Congressman Fleming said that we agree on the need for increased access and decrease costs.

Congressman Boozman: transparency is critical.

Before I move on to the testimony, I do want to say a few words about the opening statements. I do not doubt that all of the Congressman would like to achieve universal access to health care in some sense of the word. I do not believe that their sense of universal access to health care comes anywhere near my concept of universal access to health care. They are perfectly comfortable, I believe, with a multitiered system, with poor receiving charity care when it is available, the less poor receiving Medicaid rationed as it is by its fee structure, and then others with very poor insurance policies which limits their access to care, and so on. It is fairly striking to me, that Medicare really is the Cadillac plan in the United States. Private health insurers may pay more for procedures or office visits or what have you, but Medicare provides care to everyone in the level that ensures the basic dignity of every patient. Is dignity important? To some, it is not. But I think, as someone who advocates for a traditional view of social justice and basic dignity of human beings, that the ability to seek medical care and not beg for it is important not only to the individual, but to us as a society.

All of the Congressman at some point during the day reference how important they felt it was to have the ability to purchase insurance across state lines. My view, and the view of many economists and health policy experts, is that this will lead to a race to the bottom. In one of my meetings with Congressman Murphy, he expressed great skepticism in the ability of a government program to do anything properly. He argued that he'd seen some government programs go so wrong as to make him supremely cautious about allowing any new government programs to be enacted. I understand the skepticism. But my skepticism of the ability of state governments to avoid the corrupting influences of money and corporate power far, far outweigh any concern that I have about a federal government program going out of control. And I say this as someone who believes that the privatization of our defense efforts in the forms of Blackwater and other extra governmental agencies has become extremely dangerous for this country. But, looking out across states, and seeing how easy it is for corporations to drastically influence state elections including those for judges and Supreme Court justices, the ability to pressure insurance commissioners, the ability to influence elections for state representatives, and also seeing how poorly some states manage and fund their Medicaid programs, I worry about the states.

I certainly think all the sentiments expressed about transparency in the process and the avoidance of sweetheart deals and backroom deals are very true. However, to hear this from the party of Medicare Part D, and Billy Tauzin, energy policy by Exxon and Enron, the party that by and large believes the BS of Ayn Rand, I find this concern, well, inconsistent. But, I will echo all of those sentiments.. FDR would have gone out and challenged all those special interests that the Democrats made deals with. I, too, am disappointed in my party's leadership.

Regarding the comment about Medicare not been changed since its inception, I guess one could argue that the general concept of Medicare hasn't changed since its inception, but obviously, many parts of the program have changed. Some of the biggest changes included the massive increases in spending in the 60s and 70s allow for growth hospitals expansions of a residency programs in medical schools and so on. Other big changes have come in the forms of DRGs in order to contain costs, this remains a mainstay of financing of health care by both public and private insurers around the world. Payments to physicians and the structure of these payments has changed drastically since the inception of Medicare. Another interesting one is, the addition of the end-stage renal disease benefit program. Because of the sympathy engendered by patients who cannot afford dialysis and were driven to destitution and death, a benefit was added to pay for people with end-stage renal disease. This is now also an untouchable program. But consider that even this program with such good intentions has the same fatal flaw as much of the rest of American medicine, in that it focuses on taking care of the patient after the disease has progressed beyond retrieval. Very telling, indeed.

I was quite surprised by Congressman Roe's comment about the ill effects of taking large amounts of money out of the system. If American medicine were anything close to lean mean machine, there might be some validity to that comment. But the massive amounts of bureaucratic waste, the massive amounts of over testing, under testing, over treating, under treating, the perverse incentive system of rewarding procedures over prevention and high-tech healthcare often with marginal benefit, over coordinating the care of complex patients, the abysmal end-of-life care, the "sweetheart deal" of Medicare part D., the excess subsidies in Medicare advantage plans, and on and on make this comment ludicrous.

Briefly, regarding the Thomas Jefferson quote, all I could think at the time was, that's why the Democrats have overwhelming majorities in both houses and the White House. They'd finally had enough. I do not claim to be an expert in the Massachusetts election, but the only sound clip I saw of the victor was a short sound bite in which he made proclamations about health care reform that were, to be kind, misleading. This dovetails with Congressman Roe's notation that most Americans are happy with the insurance they have, if they have it. I think doctors and nurses will back me up on this: most of them are only happy because they haven't had to try using their insurance. It's that sticky part about when you actually have to use your benefits and become sick and miss work and possibly lose your job and so on and so on so many become unhappy with their insurance and stunned to find out how poorly it sometimes functions. Monty Python said it best with their "never pay" insurance companies sketch.
Panel testimony then followed. Besides myself, the panel concluded Paul Fronstin, Ph.D. of the Employee Benefit Research Institute testified on how the excise tax in the Senate bill will force companies to limit employee coverage, and The Lewin Group’s John Sheils told the Caucus that if these bills passed, wages will decrease as employers pay more in healthcare benefits. Other witnesses included Jim Martin of 60 Plus Association and Dr. Karen Nichols with the American Osteopathic Association.

Fronstin of the EBRI: I will admit that my mind wandered here and I did not critically analyze his testimony on excise tax. A couple of points he did make were that 20% of the population accounts for 80% of the cost of health care, and that chronic conditions are the bulk of the cost.

Jim Martin of the 60+ organization, the conservative alternative to the AARP and, he did not disappoint. It was, unfortunately, like listening to a mash up of Limbaugh/Hannity/Beck/Coulter/Malkin quotes. They believe in healthcare reform but incremental and he emphasized first do no harm. He argued to not take a wrecking ball to the current system, that cuts to Medicare will hurt seniors "whether you're for Medicare or against it" (an interesting quote, eh?), that seniors are scared, that they "paid their due" and expect their due, and he also perseverated on the size of the bill in pages, and also that that "bureaucrats are asking seniors to sacrifice more." You know, I'm not even going to bother.

Dr. Nichols of the AOA: one of five medical students is osteopathic; there is a physician work force shortage; graduate medical education funding needs to be expanded not just reapportioned; Medicare pays for graduate medical education the hospitals and so training incentivize to stay within the hospital and out of community areas and underserved outpatient settings; international medical graduates-the US imports doctors and this creates an international brain drain; primary care physicians are disincentive on by income; only 55% of the work of a primary care physician is actually taking care of patients; payment system values procedures and not coordination of care or cognitive services; emphasized the need to repeal the SGR; threefold difference in income in primary versus specialist; national health service Corps deferments need reinstated.

Shiels of the Lewin Group (he had lots of charts and graphs but we did not get copies, so I missed a lot): the House bill creates a $372 billion increase in employer costs; talked about the change in after-tax income which I didn't follow; changes in average family health spending; if under 50,000 they get a net savings, if over 100,000 there was a modest increase in cost and if greater than 150,000 there is a $443 increase in the House bill and hundred $47 and the Senate bill.

Question-and-answer period. I'm going to have to free flow this because i don't have many notes because - can you believe it- I was paying attention.

Medicare advantage, why is it being cut?
Mr. Martin said it's because the AARP wants market share
We disagree, as does the AMA, and other organizations, and the White House explanation is here.

Gingrey Massachusetts hates the Massachusetts health care reform plan. Except that 68% like their own plan. And 70% of physicians like it, too. And among Obama voters who voted for Brown, only 23% thought Health Reform went too far, with 41% not knowing why they opposed it and 36% didn't think it went far enough! He is worried about the work force adequacy
Nichols reiterated the need to fix the SGR.

Mr. Martin voiced his disgust at people at the Townhall meetings August being called un-American clearly did not get the point. I almost grabbed the microphone next to me to shout him down so he would get the point. Really. I almost did it.

Martin also mentioned that we should scrap all the bills and the Medicare is going bankrupt. I find this magical thinking by the Right about medicare truly amazing. Medicare is going bankrupt, but taking money out of Medicare, even overspending on Medicare Advantage, reducing practice variation, increasing preventive care and improving care coordination and all the things we talk about to improve quality and decrease cost, are off the table. It reflects the schizophrenia of having a popular government program that they would love to vilify and gut if they could, but they can't because seniors will have their heads. And seniors like Martin want it all and more in terms of spending on them, the rest of the economy and the country be damned.

Mr. Broun tried to get us all agree that market reforms that solve the system's problems
I was wondering if Medicare was unsustainable for Part D, as it is now...I will try to find out.

Broun reiterated his idea of four things he considered "critical:" 1. being able sell insurance across state lines is critical, 2. association pools were critical, 3. high risk pools were critical, and 4. health insurance costs be 100% deductible. Dr. Brown also made the amazing statement that he went to Canada and only found one Canadian happy with Canadian healthcare. Just one table for now, because this is just so terminally stupid: 34% of Americans think we need to completely rebuild our system compared to only 12% of Canadians. And only 28% of Republicans still believe that we have the best system in the world.

There was more, but this is enough for now.

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