I’m now part of a Washington Post panel responding to a health-care reform question each week. Click here to find the panel.

This week’s question:  “Is the Individual Mandate Necessary?”

You’ll find my reply here.

Let me add that while I think we need an individual mandate, I am concerned that the House version of health care reform lets insurers charge older customers twice as much as younger customers. At this point, the Senate Finance Committee also allows insurers to discriminate by age. This could make it very hard for 50-somethings who don’t qualify for subsidies to afford a family plan. Under the House bill, a couple with joint income of $75,000, before taxes, would not receive a subsidy. And if they are self-employed, and receive no help from an employer, the premiums that they would be expected to pay could easily run as high as $13,000 a year. After taxes, if they live in a high-tax state, they might take home $65,000 a year—or less. This means that health care premiums would eat 20 percent of their income—or more.

I don’t think it makes sense to suggest that a young couple, earning $150,000, jointly, shouldn’t pool their resources with a 50-something couple earning $75,000.  Don’t younger Americans want to help pay for the health insurance that their parents need? These days, as more 50-somethings become unemployed, it’s not that unusual for college-educated 20-somethings and 30-somethings living in two-income households to earn  significantly more than their middle-class parents.

Both Social Security and Medicare ask all Americans to pay the same percentage of their paychecks into the system, regardless of  age. When they grow older, younger taxpayers will benefit from a system that expects all of us to pull together.  Universal health care should follow the same model: everyone in, no one out of the pool.

Today’s headlines tell us that last night the nation’s hospitals agreed to contribute $155 billion over 10 years toward the cost of insuring the 47 million Americans without health coverage.  According to the Washington Post  “the agreement that three hospital associations reached with White House officials and leaders of the Senate Finance Committee is the latest in a series of side deals that aim to reduce the cost of revamping the nation's health-care system and to neutralize influential industries that have historically opposed such reforms."

We’re told that “about $40 billion would be saved by slowly reducing what hospitals get to care for the uninsured . . . . The reductions would probably not begin for several years, after a significant number of people have enrolled in the new insurance programs.

“For their part, hospital officials have an understanding that, if the final legislation includes a new government-sponsored insurance program, it will not pay at Medicare or Medicaid reimbursement rates, which the industry has long argued do not cover the cost of services.”

What Does This Mean?

I have a few questions. First, how can anyone promise that a public sector plan “will not pay at Medicare or Medicaid reimbursement rates” when we don’t know what Medicare and Medicaid reimbursement rates will be in 2010 or 2011? 

We do know that there are plans to change the structure of reimbursements—bundling payments to doctors and hospitals, refusing to pay for preventable readmissions, paying bonuses to hospitals and doctors that approach benchmarks for efficiency set by hospitals like the Mayo Clinic.  Medicare has been experimenting with bundling payments to the doctors and hospital involved in a single episode of care for quite a while. All of this is part of a larger plan to begin to pay for quality, not quantity of care. Presumably, a public sector plan will follow suit.

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There’s powerful storytelling going on over at Obama’s grassroots website, Organizing for America,  and clearly the goal is to use gripping narrative to get Americans to stop thinking about health care reform and start feeling the need for change. The newest addition to this site is called “Health Care Stories for America” and it includes a neat, interactive map of the U.S. that is constantly updating with new stories of health care woe from real people across the country. Site visitors can click on a megaphone at the bottom of a story they like to help promote its status and increase the anecdote’s chance of being pegged on the interactive map.

Here is an excerpt from a highly rated story from “Barbara” in Wocester, MA who was faced with $65,000 in medical bills when her insurer denied coverage after her son was in a serious bicycle accident:

“It's the phone call in the middle of the night that no parent ever wants to receive. Your son, a student at George Washington University, has been taken by ambulance to the emergency room. The doctor on the other end of the line explains, as you desperately wake-up into the nightmare, that in a bicycle accident your child has landed on his jaw, has broken almost all the bones in his face and has lost many teeth. He's lucky; there was no spinal damage, no brain injury, no eye involvement, and he's alive. But even after 5 hours of surgery, and 8 titanium plates installed into his face, you are told that reconstruction and recovery will take a year. Somehow your son gets through the long hospitalization, and the trauma. But there is no preparation for the next phone call: all further medical treatment is being denied by your insurance company.”

The Obama campaign plans to use stories from this site as the President conducts his “listening tour” around America to garner local support for his health plan and other issues that include energy policy and his Supreme Court nominee. Tomorrow alone, there are public meetings scheduled for several cities in New Hampshire, South Carolina and North Carolina. They will continue throughout the month of July as Congress remains in recess.

The use of anecdotes to influence health policy is not new; both sides used the technique during the 1993 battle over Clinton’s health plan. (The main difference being that conservative opponents used a fictitious couple—Harry and Louise—to act out a fictitious dilemma to make their point.)

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Today’s Washington Post reports that “The nation's largest insurers, hospitals and medical groups have hired more than 350 former government staff members and retired members of Congress in hopes of influencing their old bosses and colleagues.”  And here’s the kicker:  “Nearly half of the insiders previously worked for the key committees and lawmakers, including Sens. Max Baucus (D-Mont.) and Charles E. Grassley (R-Iowa) debating whether to adopt a public insurance option opposed by major industry groups.” 

Indeed, at least 50 former employees of the Senate Finance Committee or its members now lobby on behalf of the health care industry. Here you’ll find a Washington Post “Sphere of Influence” graphic showing how 41 lobbyists are linked to specific members of the Finance Committee.  (Note Max Baucus at the center near the top of the circle.)

The health care industry has embarked on “a record-breaking influence campaign” the Post observes,  “spending more than $1.4 million a day on lobbying in the current fight, according to disclosure records. And even in a city where lobbying is a part of life, the scale of the effort has drawn attention. For example, the Pharmaceutical Research and Manufacturers of America (PhRMA) doubled its spending to nearly $7 million in the first quarter of 2009, followed by Pfizer, with more than $6 million.”

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“Plan To Slash U.S. Health Costs May Be Tough Pill To Swallow” blared a headline on Investors Business.com late last week. The story begins: “When someone takes out a scalpel, it's usually going to hurt — a lot. Yet Peter Orszag, President Obama's budget director, claims the U.S. could slash $700 billion in annual medical costs without affecting quality.”

The article quotes arguments on both side of the debate, but the headline has already signaled that the story has a point of view.  And this hard-hitting quote from Greg Scandlen, head of the conservative “Consumers for Health Care Choices” at the Heartland Institute, seemed to sum up the story’s thesis: "It is often impossible to know ahead of time what is going to work and what won't. The notion that a physician should only deliver services that he knows ahead of time will work ignores real-life conditions. "It's offensive that a bean counter like Orszag should Monday-morning-quarterback physician decisions."

The truth is that Scandlen simplifies “real-life conditions” by ignoring the fact that every medical treatment carries risks as well as hope of benefits. If there were only benefits then the old-fashioned “Oh what the heck, let’s just go in there—what harm can it do?” school of medicine would make sense.
But it doesn’t. This is why patients should ask questions about the downside.

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Politco.Com’s Mike Allen broke the story yesterday: “For $25,000 to $250,000, The Washington Post has offered lobbyists  . . . off-the-record, non-confrontational access to Obama administration officials, members of Congress, and the paper’s own reporters and editors. http://www.politico.com/news/stories/0709/24441.html

 “The astonishing offer was detailed in a flier circulated Wednesday to a health care lobbyist, who provided it to a reporter because the lobbyist said he felt it was a conflict for the paper to charge for access to, as the flier says, its “health care reporting and editorial staff."

The event was billed as a “Washington Post Salon,” an intimate" off-the-record dinner and discussion at the home of CEO and Publisher Katharine Weymouth.”

Before the news cycle ended yesterday, the planned series of dinners had been cancelled. Today, the Washington Post’s Howard Kurtz quoted Weymouth “This should never have happened. The fliers got out and weren't vetted. They didn't represent at all what we were attempting to do. We're not going to do any dinners that would impugn the integrity of the newsroom."

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One would think that insurers would want to do their own comparative effectiveness research to find out whether cutting edge drugs, devices and procedures really provide greater benefits. 

Past experience tells us that newer treatments are not always better for many patients. Often, they are effective for a small group that fits a particular profile, but not for most of us. And they are almost always more expensive. Wouldn’t it make sense for the insurers to invest in comparative clinical trials? They could save billions, and show their customers that they were watching out for them—protecting many of them from needlessly aggressive, potentially risky, care, while covering the treatment for those who would benefit.

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