Posts Tagged ‘uninsurance’

I’m Fed Up with This

February 8, 2010

I used to follow the pundits and read the inside stories about the progress of health reform.  During the past year, I’ve avidly read and the NY Times, watched Washington Week in Review, and followed #hcr on Twitter to keep up with what’s happening.  But I’m fed up with the way that the Republican spin has become the conventional view of things.

Latest example — in today’s Politico Pulse lead, Chris Frates writes:

President Barack Obama announced Sunday that he will hold yet another meeting on health care reform. But this one comes with two twists – it will be televised and bipartisan. The move seems designed to help counter the public’s distaste for legislation that Democrats crafted behind closed doors and rammed through both chambers with little Republican support. [emphasis mine]

You gotta be kidding.  First, the legislation was not “crafted behind closed doors” any more than most bills in Congress.  On the contrary, the legislation has been available for public scrutiny since the original bills were introduced last spring in the House.  You could even go further back to Sen. Baucus’s white paper in November 2008, which laid out the basic framework for all the bills that followed.  When each subsequent bill was introduced, the Kaiser Family Foundation and many others produced “side-by-side” comparisons so that people could understand the key elements of the bills.  The details (the public option, the insurance exchange, the affordability credits, the excise tax, the Medicare Advantage reductions, the “doughnut hole”, and many more) were agonizingly dissected by the mainstream media, the bloggers, and interest groups.  As Jon Cohn said today,

The idea that Republicans haven’t had a chance to present their ideas on health care reform is a bit mind-boggling. Five separate congressional committees had hearings; each chamber had floor debates. That’s hundreds of hours the GOP had to talk about health care, all of it in public view and televised on C-SPAN.

And the Democrats “rammed it through both chambers”?  Anyone watching the process objectively would say that the Democrats did just about everything they could to accommodate Republican interests and wishes.  First, they wrote a bill that incorporates many Republican ideas in an attempt to get bipartisan support.  It’s built on the existing private insurance and medical care delivery system; it’s not the single-payer plan that many progressives wanted.  It uses market forces to control costs rather than regulation and government price setting.  And it includes pet Republican ideas such as tort reform and allowing people to buy insurance across state lines.  (Ezra Klein has summarized this nicely in a new article.)  Second, the Democrats included the Republicans in almost every step of the process.  The best example was the “Gang of Six” led by Sen. Baucus.  For weeks during the summer and early fall, we watched the Democrats’ attempt to accommodate the wishes of Grassley, Enzi, and Snowe.  But it became clear that the Republicans were only stringing the Democrats along.  They never intended to get on board; they only wanted to drag out the process.  And when the votes were finally taken, it was clear that the Republicans had decided – for purely political reasons – that they would oppose any bill.  For them, defeating the Democrats was more important than reforming health care and saving the lives of the uninsured. Their obstructionist tactics were appalling, and their hypocrisy was sickening.  The basic facts: this is a bipartisan bill that the Republicans chose to oppose, despite the best efforts of Democrats to accommodate them.

But most of the media seem to have been co-opted by the Republican spin machine.  I would have expected better from a so-called independent press.


House of Straw or House of Bricks?

January 24, 2010

A week ago, before the Massachusetts special election, health reformers felt that their house was almost finished.  The edifice of health reform had been built painstakingly using blueprints designed by policy and political experts during the past 10 years.  It wasn’t a perfect building — like many construction projects, there were concerns that it would cost too much and wouldn’t be aesthetically pleasing — but most agreed that it would provide shelter for those who had been excluded from health coverage: the uninsured and the medically uninsurable.  The imperfections could be fixed later.  As many said, this would be the foundation and framework on which an even better health system for the U.S. could be built.  And the wolves who had ruthlessly blown down health reform houses in the 1990s and before had been kept at bay.

As the reformers stood on the top floor last week, deciding on the final touch-ups and planning for the housewarming, someone pulled the rug out from under them. The upset election of Scott Brown to fill the late Sen. Kennedy’s seat changed the political calculus. It would not be possible for the Senate to pass a bill including the final modifications, since a unified Republican minority of 41 would be able to block consideration of the bill. It turned out that under the rug was a hole in the floor, and suddenly the reformers were on the next floor down.  The reformers might have to leave the top floor unfinished (the modifications that were needed to get House approval), but they could still have a pretty solid building if they could reach agreement.

But the Democrats haven’t been able to find a way to finish it off.  The idea for the Senate to quickly pass the modified bill before Brown was seated was rejected as politically unseemly.  The plan for the House to simply pass the Senate bill and send it to the President for signature has apparently been rejected by House members.  The idea of a two-step process – the House would pass the Senate bill in exchange for a promise that the desired modifications would be included in a separate budget reconciliation bill – seems like a pragmatic if inelegant solution, but it is apparently stalled for lack of clear direction.  Some have suggested that a “pared-down” bill – incorporating some insurance reforms, small business subsidies and Medicaid expansion – might be the only feasible option.  Others are skeptical that any reform could pass the Senate and said that the Democrats should “pivot” to other issues like job growth. Suddenly the reform effort seems to be in free fall.  The reformers have fallen through a hole in the top floor, and now it seems that every floor has a hole.  It’s a panicky, sickening feeling – not knowing where the bottom might be.  The memory the recent earthquake in Haiti is fresh in everyone’s mind, and we all know that the death and damage was immensely compounded by the poor construction standards in that impoverished country.  Is the health reform house built of bricks or straw? Is it so easy to tear down a house that was so carefully constructed?  And if the building were to totally collapse – surrounded by a new generation of gleeful howling wolves — how many decades would it be before a new house could be built?  How many more uninsured people would die because there was no shelter from the storms of catastrophic injuries and chronic disease?

I think the health reform proposal is much stronger than most people think.  The conceptual framework was built during decades of thoughtful policy analysis that incorporated the best of liberal and conservative thinking.  The legislative details have been carefully crafted to fix the most serious problems in the current system without creating a political backlash from the health industry’s economic interests.  The bill still has political momentum from the 2006 and 2008 elections, in which Democrats ran and were elected on a promise to reform our health system.  The problems of our current situation haven’t gone away, and anyone that can build a better health system will deserve a lot of credit.

In the last few days, there have been signs of hope.  Forty-seven distinguished health economists sent a strong letter of support for reform to Congress, and many political analysts pushed the Democrats to complete the bill.  The President reasserted his commitment to comprehensive reform at a town hall meeting in Ohio, and the Democratic leaders in Congress are reportedly working on a two-step process that could pass the House and Senate.  It may be that the health reform house will be completed with nearly all the floors intact.  What happens in the next few days will determine the life and death of hundreds of thousands of uninsured, and it will shape the political landscape for decades.

Vitality vs. Security? Not So

November 26, 2009

David Brooks gets it partly right in his recent column – the health reform debate is fundamentally about values – but he is wrong about the trade-offs.  His framing – “vitality or security” – sets up a straw man, a false choice.  How can anyone say that allowing 18-22,000 people to die each year due to lack of health insurance (according to the IOM and Urban Institute) represents “vitality”?  The tremendous loss of life as well as needless suffering and lost productivity in our current health system are surely a drag on our nation’s vitality.  And as Jon Cohn points out in his response to Brooks, the current employer-based system creates job lock for many people, stifling entrepreneurship and job mobility.

Of course, the Congressional health reform proposals could be stronger on cost containment, but they would be politically DOA.  The choice is simply between the status quo – with continued rising costs, rising uninsurance, inconsistent quality and more needless deaths – or an imperfect reform bill that expands coverage, reforms the insurance market, reduces mortality and suffering and establishes a framework for future cost containment initiatives.  It’s not about vitality vs. security – it’s slow death vs. possible cure.  Or in terms of values, it’s “we’re all in this together” vs. “you’re on your own”.

Saving Two Trillion Dollars – What’s Missing?

May 13, 2009

Can we bend the cost curve without covering the uninsured?  Slowing the growth of health care costs seems to be the focus of the current political debate; undoubtedly, this is an essential element of health reform.  If we don’t get costs under control, the strain on government budgets, employer benefit expenses, and individual budgets will be immense.  We also know that increasing costs have been driving the rise in uninsurance.  Zeke Emanuel made this point nicely in his 2008 article (“The Cost-Coverage Trade-off”, Ezekiel J. Emanuel, MD, PhD. JAMA, February 27, 2008 – Vol. 299, No. 8)).

Efforts to bend the cost trend downward – such as the May 11 announcement by health care industry leaders – are admirable, but the results will be limited until we fix the problem of the uninsured.  While rising costs are a primary cause of the rise in uninsurance, the reverse is also true:  the rise in uninsurance contributes to rising costs. Why?

It starts with the cost shift problem.  As the number of uninsured increases, the amount of uncompensated care costs increases.  In response, hospitals and providers shift costs to privately-insured patients, which causes insurance premiums to increase.  This cost shift adds to the problem caused by the underlying rise in health care costs.

There is one other important factor in the link between rising uninsurance and rising costs.  In the current environment, the easiest way for most insurers and providers to achieve their financial goals is not by being more efficient.  Managing expenses by improving efficiency is hard; insurers face provider backlash, and hospitals and physicians face internal management and political obstacles.  Managing revenues is an easier path.  For insurers, it is easier to “manage” their risk profile.  For hospitals and providers, it is easier to “manage” their payer mix.  Until we minimize the incentives for insurers to use risk selection strategies (e.g., by legislating guaranteed issue, rate pooling for individuals and small groups, and risk adjustment mechanisms), they are unlikely to pursue greater administrative efficiencies.  And until we minimize incentives for providers to use payer mix management strategies (e.g., by reducing the number of uninsured), they are unlikely to develop more efficient care delivery processes.

In summary:  Emanuel’s article stated, “without controlling costs, any attempt at universal coverage will be transient”.  I agree, and I would add: without universal coverage, any attempt at controlling costs will be unsuccessful.