Over the weekend, Senate Democrats found the 60 votes needed to press forward with the health care debate. I wasn’t surprised. As I have suggested in the past, I doubted that three or four moderates really wanted to be remembered as the Senators who let the conservatives talk health care reform to death.
This doesn’t tell us what will happen in the weeks ahead, but I remain hopeful that, in the end, we will wind up with a bill that closely resembles the current Senate and House proposals (which are not that far apart)—one that includes a public option.
My confidence is buoyed by the opposition’s growing virulence. Fear has turned to rage as they realize that the liberals may win.
Today, for instance, Robert Laszewski lashed out on The Health Care Blog (THCB) where he insisted that reform is about to implode:
“The latest polls are an unmitigated disaster for Democratic efforts to get their health care bills passed. This from Rasmussen this morning:
“Just 38% of voters now favor the health care plan proposed by President Obama and congressional Democrats. That’s the lowest level of support measured for the plan in nearly two dozen tracking polls conducted since June.
“The latest Rasmussen Reports national telephone survey finds that 56% now oppose the plan.”
Indeed, Laszewski was in such a lather that he omitted this sentence from the Rasmussen report: “Rasmussen Reports is continuing to track public opinion on the health care plan on a weekly basis. Next week’s Monday morning update will give an indication of whether these numbers reflect a trend of growing opposition or are merely statistical noise.”
Laszewski is a long-time health care consultant, and he understands the business of health care. In the past, I’ve agreed with many of his assessments of the health insurance industry. But on the question of reform, he has argued, from the beginning that only “bi-partisan reform” would work. Ignoring the fact that conservatives prefer the status quo and are essentially opposed to reform of any kind, Laszewski at first sounded moderate, but as liberal legislation wended its way through Congress, he became increasingly vehement. By the time the public option was added to the Senate plan, he seemed beside himself. The closer liberals come to victory, the greater his denial. In this way, Laszewski is becoming a sort of human contrary indicator.
So today, on his own blog, he describes the “Democratic Heath Reform Effort” as a “Political Charge of the Light Brigade.”
Determined to convince us (or himself) that the liberals are about to face a “disastrous” defeat, he insists that “it is not just Rasmussen that is measuring a dramatic slip in approval ratings for the Democrats on health care. Here are the last five consecutive polls released in the last week:
- Fox – Favor 35% Oppose 51%
- Quinnipiac – Favor 35% Oppose 51%
- CBS News – Favor 40% Oppose 45%
- CNN Favor – 46% Oppose 49
- PPP Favor – 40% Oppose 52%”
Source : http://www.pollster.com/polls/us/healthplan.php.
Meanwhile, he ignores polls that suggest that in the end, the country is simply split on this issue.
For example, a
- Washington/ABC poll shows 48% support; 49% opposed
- While an AP poll reveals– 41% support; 43% opposed
On the CNN poll, Laszewski is correct that 46% favor the legislation, 49% oppose it, but he failed to report on CNN's follow-up question: "If you oppose that bill is it because you think its approach toward health care reform is too liberal, or is it because you think it is not liberal enough?"
- 34 percent said they opposed the bill because it was too liberal.
- 10 percent said they opposed the bill because it was not liberal enough
- 3 percent said they opposed the bill for other reasons."
As Texas Tech University professor Alan Reifman points out, those results mean 56 percent of Americans ‘favor either the House-passed version of health care reform or something further to the left,’” The National Journal observes.
“A check of the Nexis news search shows that CNN broadcast results of the follow-up question as part of their poll stories several times on the day they were released. And the story that ran on CNN's online Political Ticker featured the same numbers prominently, including this characterization from CNN Polling Director Keating Holland: 'That may indicate that a majority opposes the details in the bill, but also that a majority may approve of the overall approach taken by House Democrats and President Obama.'"
I find Laszewski’s omissions heartening. They reveal just how desperate those who oppose the reform legislation have become. Such desperation suggests that they know that they are losing.
Many of us can—and will—squabble over details of the plans, but when it comes down to it, the majority of Americans understand that without health care reform, we are doomed to runaway health care inflation. If health care costs continue to rise as steeply as they have for the past ten years, in nine years, the cost of care will double.
The naysayers will continue to pretend that the liberal legislation offers no real savings. Often, this is because they don’t like the ways that reformers would pare the cost of care. For example, under the Obama administration, reformers would: slash fees for diagnostic testing, and trim reimbursements for some specialists while hiking payments for primary care doctors ( Medicare already has proposed making these three changes, beginning next year); refuse to reward hospitals for inefficiencies that lead to an excessive number of readmissions (another Medicare proposal); let Medicare negotiate for discounts on drugs (as the House legislation recommends); appoint an independent panel of medical experts that is insulated from Congress to oversee changes in Medicare payments (as both the Senate bill and the Obama administration have proposed) and use financial carrots and sticks to move health care providers away from fee-for-service and toward payment systems that reward value, not volume. Both the House and the Senate legislation call for reforms that define “value” as better outcomes at a lower price.
Why are so many of these proposals tied to Medicare? Because over the next three years, Medicare reform will pave the way for system-wide health care reform. The legislation makes it clear that a public plan will incorporate changes in what Medicare pays for and how it pays, changes that are designed to overhaul and streamline the way health care is delivered. Today, we have a horribly fragmented, highly competitive health care system. The legislation would move us toward a system where providers co-operate, sharing knowledge and equipment, while putting the welfare of the patient at the center of the system.
Opponents of reform ignore the reality that, in this nation, we already have working examples of health care systems that manage to deliver collaborative care for less—just the type of care that the legislation calls for. I have written about these medical centers here (Intermountain), here (the Mayo Clinic), here (Group Health Cooperative) and here (10 U.S. communities that have lowered the cost of care while lifting quality).
Let the cynics who say it “can’t,” “won’t,” “will never, ever, ever” happen read these posts. It will happen, and when we finally get around to doing it, I suspect that, in the end, we will do it rather well. We certainly have some strong models.
Maggie – You misunderstand Bob Laszewski’s comments. He is not an ‘opponent’ of reform per se; Bob is a realist. He is on the Hill often, knows of what he speaks, and although I haven’t discussed this with him recently, has been a strong supporter of intelligent reform – which the current legislation is most certainly not.
I’d note that of the measures you highlight above, several are not in the House bill, or are not part of either bill. In fact, neither bill does much at all to reduce health care spending. Both are much more likely to dramatically incresae spending overall, sticking us with yet another unfunded liability.
I’d hoped we had learned from Part D – that Republican sop to seniors that added $8 trillion to our ultimate unfunded liability. Alas, no. I’ve been, and will continue to be, a strong advocate for reform. Too bad there isn’t the stomach in Congress to address cost – because without cost control we have no reform.
Joe Paduda
at this point the polls are totally irrelevant. only 100 people count, those who will vote on the Senate bill and they’re not about to change their votes because of such polls. insofar as the polls have even tangential impact, they are state polls of interest to a specific member. national numbers simply don’t matter.
no one thinks enactment of any health bill will increase Democratic majorities in the next election and no one is right. ultimately, the economy will trump. but failure to pass a bill will mark the Dems as powerless and defensive, which is not a good place for an incumbent to be.
Who among you will be the first to step up and tell me face to fact that because I can’t afford health care or insurance or because my employer can’t afford it for me,,that because of that, I , or my children or loved ones should be denied the same level of care that any congressman, senator, nor even president is now afforded at the taxpayers expence,,,,I should in essence be told to go home, live as best as you can and die quietly.
Joe
Joe–
Bob may be in favor of reform, but he’s not in favor of the reform the Democrats are discussing.
From the beginning he said reform would have to be bi-partisan–that Republicans will have to help shape the bill.
That didn’t happen in any major way because Republicans don’t want much—if any–reform.
See the “reform bill” they finally came up with.
Bob also has ignored the cost-saving provisions in teh bill.
Regarding the cost-savings reforms that I talk about in this post, they are all in the legislation.
(I’ve read both bills more than once.)
You have to read carefully because the language is so tangled, but it’s all there.
For example, beginning on page 249, the House bill calls for changes in the physicians’ fee schedule, looking at individual serviceds to see where we may be overpaying or underpaying:
” For purposes
of identifying potentially misvalued services . . .” the legislation cals for looking at codes (or particular services)
“for which there has
been the fastest growth; codes (and fami1
lies of codes as appropriate) that have exp
perienced substantial changes in practice
expenses; codes for new technologies or
services within an appropriate period (such
as three years) . . .multiple
tiple codes that are frequently billed in
conjunction with furnishing a single serv
ice; codes with low relative values,larly those that are often billed multiple
times for a single treatment , . . ”
This is exactlly what MedPAC has recommended: look at the services where you have seen the greatest volume growth, and services that are performed more than once during a single episode of care.
MedPac suggsted that this is where you are likely to find very lucrative services–so lucrative that they tempt overtreatment.
The legislation calls for lowering fees for those services.
This is why Medicare is targeting diagnostic testing– volume of CT-scans has doubled in 7 years with no improvement in outcomes.
Cariologists fees are being cut becaue volume of angioplasties and by-passes is very high, with little benefit to many patients. These are what the legislation calls “misvalued services.”)
There is also a section on pay for physicains in accountable care organizations.
And the legislation is specfific that Medicare reforms will be incorporated in the public plan.
Jim–
I agree– at this point, polls are irrelevant.
But some who oppose the current reform bills seem to be hoping for a last minute popular uprising that will knock these bills out of Congress.
That’s not going to happen.
And, if you look at a wide variety of polls, it seems that the public is pretty split on the health care legislation. The number who favor it and the number who are opposed are usually pretty close.
Much depends on how the quetions are worded.And peole have different, often surprsiing reasons for supporting or opposing–as the CNN follow-up question shows.
This post seems to reproesent a last-ditch effort to declare the legislation a total disaster. A week or so ago, a similar post delcared that Democrats should “go back to the drawing board” and begin over.
This, of course, is not going to happen. At this point, there is no turning back.
Opponents of the legislation know this.
And they know that it establishes a few principles: society has a responsiblity to do its very best to provide high quality healthcare for all;
in order to participate, low-income people will need subsidies; we are over-paying for some services and products and underpaying for others.
Adjustments will have to be made.
Also, I agree that, for the Obama administration there is no turning back.
Failure to pass this legislation would suggest that this administration is not able to govern.
Finally, yes, I think the economy will be the big issue in 2010 and in 2012.
I’m hoping that begining in Jan. of 2010, the Obama administration focuses on creating jobs.
I think they will.
To me it boils down to two very important,seemingly disparate stars,FINALLY aligning- namely the imperative stars of morality and economics.
Reform will happen very soon. We really have no choice.
Dr. Rick Lippin
Southampton,Pa
Ruth–
I don’t think Robert L. would say you shouldn’t be insured.
But he doesn’t think we should raise taxes to increase coverage. (I think we should raise taxes on the wealthiest Americans who have seen their incomes soar– both in the last 8 year and since 1972.)
He also thinks that the current legislation doesn’t reduce waste and thus we as a country cannot afford it. I disagree.
But I think that at this point, the vast majoirty of Americans think you should have coverage.
Should you have coverage that is equal to the coverage that affluent famlies enjoy?
On that point, there is disagreement. There is also disagreement on what is “medically necessary” care.
For my part, I would say that all Americans should have access to all effective, medically needed care–and that includes mental care, treatment for addictions,
fertility treatments,tc.
The coverage in both the Senate bill and the House bill is as comprehensive as the coverage you would get if you were employed by a large corporation. And it includes dental and vision care for children– an element that I like very much.
It won’t be free (except for very low-income households.) And we still have work to do to make it “affordable” for those at the upper edge of the middle class as well as the upper middle class.
But we have three years to do that.
Dr. Rick–
Yes, and well put.
The vast majority of Americans realize that everyone should have access to heatlh care.
And our current broken system is well on its way to becoming unaffordable for all but the wealthiest.
As you say, we have no choice. This is why I am pretty confident that this legislation will pass.
There will be amendments, but I think it will pass pretty much intact.
That said, it will be a bloody battle.
I think that ignoring the non-supporters who say the bill is not liberal enough is tantamount to reporting malpractice.
Even a single payor fan would find the current bill wanting, but do you think they would think the current bill is better than no reform at all? Of course!
I hear a lot of discussion on cost issues, but I’m not too worried. In 1984 I remember while at Travenol (now Baxter) working with hospitals trying to understand how to operate more efficiently after revenue was slashed with the new DRG and MDC reimbursements.
We pioneered a focus on total treatment costs, average length of stay and re-admissions. Most of that work has been forgotten. But after studying current data for thousands of cases, it is possible to get those types of efficiencies again. And as you pointed out, there is language in these bills to do just that.
I had an interesting discussion with a very major medical device manufacturer a couple of weeks ago. While they were very good at using the most effective suppliers and processes to produce those devices, they stammered and stuttered about using those same techniques to produce better patient outcomes using those devices. Bottom line, they support the ideals of health care reform, as long as they keep their same profit margins and keep their oligarchies. On a positive note, the plant manager and his team believed so much in what they were doing they supported patient outcomes efficiencies, contrary to the views of senior management.
I’m not surprised about the volume being cranked up right now.
Bruce Fryer Protohit
I’m sorry, but I do not think opponents are that desperate.
See here what they’ve inserted in the Senate bill about comparative research.
http://hcrenewal.blogspot.com/2009/11/no-free-speech-for-comparative.html
I’m sure we will find other “pearls of that nature soon enough!
For the first time in DECADES I’m hearing tiny good news for primary care providers. Lot is needed to make a dent but at least it started with medicare putting out some sensible suggestions recently. Doctors pay maybe only 10% but they generate 90% of costs. currently we have the worst incentives. For a benign condition, one can currenly get away with few hundred thousand dollars of work up, all because provider can get away with it. The provider has no incentive to be prudent and sensible, in fact no incentive to get good history or do good clinical exam. why should they bother spending longer time to get answers when they can order more ct, mri even if they expose patients to more radiations and harnful effects.
Maggie:
Why should we even suggest about how desperate one side is versus another?
What does that have to do with the legislation’s value?
Why spend time fantasizing about how others feel, and spend more time on whether the legislation is worth passing?
Don Levit
Maggie,
Laszewski implies that health care reform is doomed because polls show more voters oppose the proposed legislation than support it. (“How can the Democrats ram anything so big and complex through as these health care bills with approval ratings–now in the 35% to 40% range–so low?”)
As Nate Silver at fivethirtyeight.com points out in his recent post “Democrats Damned If They Do; Damnder If They Don’t,” Congressional Democrats currently lead Republicans when voters are polled on a “generic [Democrat vs. Republican] ballot” 46-38 (46-41 if a health care bill passes with a public option). If Democrats fail to pass a health care bill, the poll shows a 40-40 tie would result.
Nate Silver: “Both polling and common sense would seem to dictate that the best way for Democrats to cut their losses would be to pass a health care bill — particularly one with a public option — and then move on to debating financial regulation and a jobs program, where public sentiment should be more on their side. They should probably not expect to gain ground if they pass health care — but they’re likely to lose more if they don’t.”
It’s safe to say that Congressional Dems would give more credence to Silver’s prognostications than to Laszewski’s. Fasten your seatbelt.
Dr. Frankie, Don, Ray, Bruce Fryer, Gary O.
Dr. Frankie–
The Institute of Medicine (IOM) has alreay set up a Comparative Effectiveness Panel.The members are seated. They do not include anyone from industry.
When the president funded Comparative Effectiveness at the beginning of this year (in the fiscal stimulus package) he charged IOM with doing this.
I suspect that the administration purposefully set up CER (comparative effectiveness reserach) before turning its attention to health reform legistlaton.
It did not want CER to become part of the debate/battle.
Everything does Not have to be in the reform legsilation.
There are many things that Medicare and the administration can do iapart from the legislation.
And there are many amendments that will be added to the legislation–and many removed as this process unfolds.
What matters is what happens in the final conference when House and Senate bills are merged.
Don–
Many liberals are disappointed that the reform legislation is not more radical.
Many fear the public option won’t pass.
All the way through this process, I’ve been more optimistic than many.
I thought we would get the public option in the House bill. I thought we would get it in the Senate bill.
I thought the Senate would scrape together the 60 votes to go forward.
I thought that the more liberal House bill would have at least as much influence as the more conservative Senate finance bill. Now, the Senate bill resembles the House bill in many important ways.
By taking a look at how conservatives are reacting, I’m trying to encourage progressives: we are winning this thing.
In politics, one always takes a look at how the other side is reacting.
If they sound very scared and very angry, this is a good sign.
My goal here is to enourage liberals: this legislation repersents a major step forward, and we are going to win.
We need to think positively.The Congressmen who have, in some cases, been risking their political careers for the sake of progressive health care reform need and deserve our support.
As for writing about the merits of the legislation–as you know I have written tens of thousands of words about the bils.
Ray–
Yes the legislatoin is good news for primary care docs.
A 5% incrase in 2010. A 5% to 10% increase in 2013 (in the House legislation). And, I would bet another increase between now and 2013. Compounded , that close to a 20% to 25% increase.
Plus, much larger scholarships and loan forgivenes for med students wh decide to go into primamry care.
Refomres understand that we need to shift the emphasis from agressive specialty care to chronic disease managemnt and prventive care. To do this, we must imporoven compensation for prmary care physicans, paying them to tlisten to and talk to patients.
bruce fryer–
Welcome– a very interesting comment.
Yes, we do already know quite a bit about how to make hospitals more efficient.
It’s a matter of having the will to implement what we know. This means getting hospital CEO’s to reassess their priorities.
I think the financial carrots and sticks in the legislation can do just that.
I hope you might be involved in the current effort, consulting with hospitals.
As for device-makers–as you note, they are not excactly patient-centered. This is another area where someone (Medicare? hospitals? ) needs to begin to negotiate aggressively for discounts. Many medical devices are shamelessly overpriced.
Many new medical devices are no better than the older devices they are replacing. They’ve added some bells and whistles, but nothing that helps most patients.
Gary O.
I agree. The Democrats will/must press ahead.
Fasten your seatbelts indeed!
Thanks Maggie,
Right now I’m focusing on workers’ compensation clinics and self-insured employers. We’ve got a lot of CER (12,000 cases) which indicate we can cut the total cost by 15% in this area. Since there are about 4M cases a year, seemed like a good place to start. We figure we can shave about $4B a year and improve patient outcomes.
Stay tuned.
Bruce Fryer–
Sounds like you are doing good work.
We really don’t need to reinvent the CER we already have.
We need to use it! (And monitor the use, to see if it’s working to lift (or at the very least maintain) quality while reducing costs.