What if in 2012, unemployment remains relatively high, the recession continues, and voters blame President Obama, voting him and his Congressional supporters out of office?
Consider how that would affect health care reform. If the House bill prevails on the timing of reform, the the Exchanges will open in 2013, subsidies will be available, private insurers will be regulated, and the Public Plan will be available to tens of millions of Americans. Conservatives elected in November of 2012 would have only two months to try figure out how to derail the roll-out scheduled for January 1, 2013.
By contrast, the Senate legislation now under consideration would push reform forward to 2014. The Exchange, the public plan, the subsidies –none of the above would be scheduled to become a reality until one year after Conservatives took control of both the White House and Congress. In a year, determined politicians could repeal and dismantle most if not all of the reform plan.
Could they do such a thing? Yes, particularly if, during the 2012 election they continued to fuel voters’ fears about the upcoming overhaul of the U.S. health care system.
I haven’t had time to think this through. I may be missing something. But on the face of it, I have to say that I'm opposed to delaying reform until 2014.
I understand that this gives reformers more time to bring down the cost of care, and find the funds needed to fund the overhaul. But, much as I hate to say it, we can’t afford to ignore the possibility that the conservatives return in 2012—even if only for one term. In a single term, they could undo everything that reformers had achieved.
With regard to your comment, ‘In a single term, they could undo everything that reformers had achieved.’, I might frame the issue differently. Perhaps, the conservatives or moderates might implement aspects of health care reform that were omitted by the Dems.
Some examples:
(1) Tort reform
(2) Real cost control, not present thusfar in either branch of congress
(3)Comparative effectiveness research with some teeth. Shame how Secretary Sebelius caved this week in Mammogate genuflecting to politics instead of to evidence-based medicine.
(4)Giving individual states latitude to perform reform. One federal size may not fit all. In addition, if several states pursued different reform avenues, we might discover at lower cost what strategies actually work.
(5) Personal responsbility. When patients have some financial stake in the game, they ask more questions of their physicians and costs will go down.
(5)Medical quality initiatives that actually work. The ones that the government has issued thusfar are effective for employing beancounters, but do nothing to enhance true medical quality.
http://www.MDWhistleblower.blogspot.com
Dr Kirsch raises some interesting points, though he ignored the fact that decades of state experimentation has yielded few lessons to date. I’m reallyinterested, tho, on point five and any data he has that supports it.
I personally don’t think delaying reform would benefit the public.
The foxes are running the hen house now. All of this is set up to benefit the very few people in charge of insurance, pharma, hospitals, device makers, software suppliers etc.
This whole thing is no reform, its the creation of a hog trough of money.
I’m sick of it all, do they have a test for that and a treatment for healthcarereformititis?
Maybe we should all be screened and then prophelatically treated!!!
Maggie
On Countdown with Keith Olbermann on thursday night Senator Sheldon Whitehouse said that in the Senate bill there is an opt-in provision where states can come online earlier by waiving certain start dates. When Keith told this to Wendell Potter, while he was interviewing him, Wendell was surprised by this. Thought it was a pretty good idea, if the final bill doesn’t have the public option coming on board for four years.
Michael–
I’m afraid I have to disagree on all counts.
1)I’m sorry to see that your put “tort reform” on the top of your list–a reform that would (supposedly) benefit doctors rather that focuses on patients.
Patient advocates are wary of tort reform because it could make it difficult for middle-class patients who have been harmed by medical care to sue.
I attended a Consumers’ Union conference on patient safety last week, and there physicians made the points that the first, best way to attack the malpractice problem would be to lower the number of errors in our health care system.
Since the IOM report “To Err is Human” was released 10 years ago, caling for reduction of medical errors, there has been no improvement. Indeed the numbers of errors seems to have increaed.
I am all in favor of addressing the malpractice problem. I’ve written about it many times on this blog.
But the fact is that we know that the current version of “tort reform” (capping malpractice awards, as in Texas) does not reduce overtreatment.
This is why the administration has recommended funding of studies that might find an approach that does work.
2) Apparently you have ignored my posts explaning how these bills would control costs. You also apparently ignore IOM’s assessment of how they will control costs.
Already, Medicare has annouced that it plans to slash fees for diagnostic testing by as much as 38%–beginning Jan. 1.
It also plans to cut fees for cardiologists by 6% while raising fees for primary care docs by 4%.
And Medicare will cease paying hospitals for an excessive number of preventable readmissions. Finally, the House bill would give Medicare the power to negotiate for discounts on drugs. Since Pharma enjoys 16% profit margins, and current takes in 16% of the $2.6 trillion we spend on heathcare, there is a huge amount of money to be saved there.
3) Comparative Effetiveness Reserach:
Again, apparently you don’t read the posts, The funding for a comparative effectivenss panel in the fiscal stimulus package shows that this is something that the administration is seroius about. And the panel IOM has appointed is very good (I have written about it).
Comparative Effectiveness reserach also stands behind Medicare’s decisions to cut fees for tests and for cardiologists.
AS for mammograms, perhaps you think that the adminisration should have annouced that under reform, we will no longer cover mammograms for women under 50? Or maybe just said, no more mammograms starting next week?
For three decades the medical establishment has told women that they must have mammograms or they risk dying of breast cancer.
Let me ask a question: have you ever told your wife and daughter (if you have a daughter) to avoid mammograms? The research has been out there for years. Some years ago, the NCI presented it to Congress, and it was all over the news. . . .
But probably you didn’t tell the women you know to steer away from mammograms because they would have thought you were crazy.
The fact is that we cannot suddenly tell women “What we have told you for three decades was wrong. ” Or , put it this way: We could try telling them that, but they wouldnt’ believe us. They would think the government was just trying to save money.
Even people on this thread, who have read the posts. don’t seem to understand that this is about heatlh, not money.
Sebelius ultimately said every woman should talk to her doctor and make her own decision. We can only hope that doctors will begin to educate their patients.
Education is a process, and in this case, it will take time.
You can’t educate people by simpliy pulling the rug out from under them.
If you were a woman, you might have a better understanding of the complexity of the problem. See Naomi’s most recent post. .
Or, think of it this way: have you told your male patients, relatives and friends that they shouldn’t have a PSA test because we have no evidence it does anyone any good and much evidence it does harm? Have you told anyone who has been diagnosed with early-stage prostate cancer that they shoudl just wait and see what happens because we have no evidence that any treatment works?
This is all true, but men are reluctant to believe it.
Prostate cancer, like breast cancer, is a very charged subject.
4) Where exactly would states get the money to cover everyone in their state?
Massachusetts, one of the wealthiest states in the nation, is having a very hard time trying to do it.
Or perhaps, by reform ,you don’t mean, universal coverage, but instaed mean tort reform, and higher co-pays and deductibles for patient?
5) Personal Responsibility–the conservatives’ rallying care. Translated, it means: I don’t want to pay for anyone but myself. You’re on your own.
The medical reserach shows that when patients have “more skin in the game” (i.e. higher co-pays and deductibles) they are just as likely to defer Necessary care as they are to put off unncessary care. Again, your idea of refrom does not seem very patient-centered.
5) Medical quality initiatives that actually work. Such AS??????
We have hard evidence tha the quality intiatives now in use at places like Intermoutnain do work–and these are the ones reformers plan to adopt. See piece on INtermountain in NYT magazine, 8 days ago.) Specifically, having doctors work collaboratively, on salary, paying for quality, not volune of care, emphasis on primary care and chronic disease management, etc.
Gregory–
Where would the states get the money to set up a public option,and provide subsidies so that everyone could afford it?
How would the states make the public option affordable for those who don’t qualify for subsidies?
Right now, most states are close to broke.
Also, the states don’t have the authority to do the things that we need to do to make healthcare affordable: reducing some doctors’ fees, reducing over-payments to inefficient hospitals; find a way to bring down drug costs (either by importing drugs or negotatiing discounts with Pharma) pay bonsues to docs who join accountable care organizations where they are on salary and collaborate with each other rather than competing. . .
I don’t know what Whitehouse was talking about.
Perhpas he was saying that states could trying setting up the community co-ops that the Senate bill talks about. But historically, the vast majority of health co-ops have failed–and again, they would need seed money from the state.
bottom line: we do need three more years to begin to bring down health care costs (through Medicare reform, with insurers following Medicare’s example in many cases) before either taxpayers or individuals can afford universal care.
Right now, a family plan costs an average of $13,500–and that’s if you (or you and your employer) are getting group rates.
Under universal care, a family earning $90,000 joint, that doesn’t have an employer who helps to pay the premium is going to have to foot the bill for a family plan by itself. (Famlies earning $90,000 won’t qualify for subsidies–tax-payers can’t afford to give subsidies to famlies on the top two steps of a 5-step income ladder–helping those on the 1st 3 steps will be hard enough.)
I figure that to make the family plan affordable for that family earning $90,000, we need to bring premiums down to $9,000–if not lower. Lower administrative costs in a public plan will save $2,000. That means we have to save another $2,500 by lowering the prices we pay for some drugs and treatments, and by learning that often, better care means less care–fewer tests, fewer surgeries, more preventive care.
This means changing the culture–changing both patients’ and doctors’ expectations. In three years, we can make some inroads, but it will take time.
Maggie;
I think you can see that when the $90,000 income family has trouble affording health insurance, we have a real problem.
We have a necessity priced as a luxury.
While trying to figure out ways to chop the premiums down is a worthwhile exercise, why work with the already unsustainable?
Let’s design programs that more people can afford without subsidies.
The only way to drive down costs is to demonstrate to the providers that they are offering services which are too expensive.
Once enough people are unwilling to play the game, either the prices come down, or the services are simply not provided.
Don Levit
Don Levit with this excellent response shows the circular nature and difficulty in reform with these two opposite statements:
“We have a necessity priced as a luxury.”
“The only way to drive down costs is to demonstrate to the providers that they are offering services which are too expensive. Once enough people are unwilling to play the game, either the prices come down, or the services are simply not provided.”
———
I guess we must first define that which is a necessity because if it is a necessity, those who need it cannot go without it. Uninformed and scared patients in a caveat emptor environment will never define this necessity. So the real question for the reform minded, who need to get control of costs, is to FIRST define the necessary care for all. How to do that??
Don & NG
Don– I agree. We pay more –far more–than every other developed country for virtually every medical service and product.
How do we bring prices down?
First, I think we have to do what other developed countries do: subsidize medical education for doctors and nurses.
When med students graudate with $200,0000 in loans– at age 33, just at a point when one might be thinking of marrying, starting a famil— it’s little wonder that they are very concerned about how much they earn.
By creating this situation, we have programmed them to be extraordinarily worried about money, and making as much money as they possibly can.
Other developed countries pay for med school education, and pay docs significantly less once they begin working.
This means that their med
schools attract students who are primarily interested in the science of medicine–and/or helping patients. They don’t go into medicine for the money.
At the same time, these countries draw med school applicants from a much largeer pool. In this country, students coming from poor and many middle-class families consider med school just too expensive for them. They can’t imagine having $200,0000 in debt. And they don’t have families that can help them out during the long years that they are in med school.
The way other countries do it makes more sense to me.
The good news: the reform legislation is moving in that direction, doubling the amount of money available for med school scholarships and increasing loan forgiveness.
NG–
My take is that any care that is effective is necessary care.
In other words, all Americans should have access to all effective care.
Of course I’m not talking about purely cosmetic care (Botox). And in most cases, I’m not talking about a very expensive drug that gives a patient 2 or 3 months.
When I describe a treatmetn as “effective” I’m thinking in terms of benefit for the patient.
Two or three extra months of very poor quality life (prolonging hte process of dying) does not usually provide a benefit for the patient.
On the other hand, I can imagine a patient and her palliative care specialist talking it over and deciding she wants those three months becuase in two months, her daughter is going to give birth to the patinet’s first grandchild.
She wants to see her daughter after that happens.
This is why these decisoins need to be made by patients (not their relatives) consulting with palliative care specialsts who have been trained to talk to patients about dying, trained to let patients know that it’s okay to die, it’s okay to decide you want to fight to the end. It’s probably the most personal decision any of us will ever make.
But ideally, it’s not made by our relatives or our doctors. The patient himself/herself, who is going throug the process, the suffering, to decide whether or not he or she wants extraordinary treatment to prolong his or her life.
When I think of “effective care” I am talking about care that addresses mental illness, addiction, infertility.
These are expensive treatments. Can we really afford to cover all effective care for all Americans?
Yes.
We now waste 1/3 of our heatlh care dollars on ineffective care–redundant, unncessary tests, ineffective procedures and sugeries, treating the cmplications that follow those unncessary surgeries, end-of-life care that provides neither comfort nor cure (while not paying palliative care specialists adequately–so we have too few of them.)
We Do know waht effective care is.
Witness the fact that, for a number of years, we have known that mammograms pose more risk than benefit for most women.
We just don’t get the information out there, for reasons that have to do with politics and money.
Now, I think that this will change.
Yes, there is much ambiguity in medicine.
But there is also much that we know about what is and isn’t effective for patients who fit a particular profile that has been suppressed.
Maggie,
With respect to offering effective care to all in need of it, do you see cost benefit analysis entering this picture in what is offered to everyone as oppose to what may work but you have to pay separately for it or have a special insurance rider to cover some less cost/benefit effective processes?? Take dental care of example. There are effective procedures that will easily bankrupt the system if offered to everyone (full mouth implants), but then there are procedures to stop infection and restore comfort which are justified for all.
More clarity will be needed for me to see the way forward!
Maggie, I’m starting to believe that you are sponsored in some way by certain members of the healthcare system.
Am I right or wrong?
Do you have a full disclosure somewhere you can direct me to?
“Personal Responsibility–the conservatives’ rallying care. Translated, it means: I don’t want to pay for anyone but myself. You’re on your own.”
Maggie,
This is cheap.
When you engage in cheap rhetorical tactics like this you show that you’re not in any sense a “journalist”. You’re a political activist. You’re a class-warrior. This is simply one of the ways you demonize those who disagree with you, as you must do before you take their wealth away from them.
The reason you’re talking about health care today is because that is where the money happens to be that you want to re-distribute. In some other generation you’d be ranting about robber barons or the bourgesie.
Oh, you object to others translating your own words for you, to show the real meaning? Then don’t do it yourself.
I’m one of those conservatives, and I’ll tell you what I mean by my own words, thank you: I mean we don’t trust you or people like you to decide what health care or whose health care to pay for.
I have a wife, a son, an aging father. I want to use my money to take care of these people. I don’t want to send any money to Washington DC so Rahm Emmanual can decide how to use it to pay for health care — or whatever the left decides will buy votes next year — for people I don’t know.
Selfish? Make that case if you like, but you’re preaching a sermon, not engaging in “journalism”.
That you want to depict those who don’t agree with your politics or moral judgments — and don’t trust you to distribute the country’s wealth — — as selfish doesn’t make you Mother Teresa.
It just makes you narcissistic, like all social engineers.
Maggie:
Doubling medical school scholarships and increasing loan forgiveness
are great short-term solutions for physicians, but at what ultimate cost?
Let’s see, you are proposing to subsidize overpriced tuition, simlarly to overpriced health insurance premiums.
This is supposed to bring costs down?
When loans are forgiven, does that mean the taxpayers pony up the difference?
Costs are merely shifted to the taxpayers, increasing our debt, and strangling our children’s financial options.
We must start thinking long-term Maggie.
How will your recommendations work beyond the next 10 years?
Don Levit
NG, Ed,
Ed–
I work for a non-profit and make approximately half of what I made 12 years ago when working in the for-profit sector for Barron’s.
(IF you factored in inflation, I’m probably making one-third of what I made then).
During much of the time that I was at Barron’s, I had great freedom to write whatever was true.
But gradually, journalism changed. It became harder to tell the truth. Editors wouldn’t approve your story ideas.
I’m very happy in my current job because , once again, I can write anything that is true.
No one edits or censors what I write. They don’t even ask to look at it before it is posted.
And no one pays me extra to promote their agenda. (What a cheesey idea. But too often, people who would consider taking money to do something wrong assume that others would too..
NG & Don
Thank to you both for your comments.
I would suggest that you both overestimate what certain things cost (full mouth implants and scholariships for med students) while underestimating the big ticket items that drive health care spending (80 percent of our healthcare dollars are spent on patinets suffering from 7 chronic diseases including : congestive heart failure, diabetes, depression, heart diseases cancer. . ”
And often the treatments are totally ineffective, providnig no benefit for the patients (many bypasses and angioplasties, much chemo for late stage cancer, etc. (
NG– The bottom line is this: We now squander such a large share of our healthcare dollars that, if we reduced the waste, we can easily afford full mouth implants for anyone who needs them.
Treatments for chronic diseases are so expensive because they are chronic– patients suffer from these diseases for a long time. Often they are hsopitalized multiple times.
A ful-mouth implant, by contrast, is a one-time procedure, and not that expensive.
It’s the big ticket items for chronically ill patients that have driven the nation’s health care bill skyward.
We do have the money to pay for the full-mouth implants.
One-third of the $2.6 trillion that we now spend on healthchare is squandered on redundant, often unncessary tests, unproven, ineffective treatments, and over-priced drugs and devices that are no better than the older products they are trying to replace.)
If we reduce the waste, we have plenty of money to cover high quality, effective care for all.
Full mouth implants are very, very cheap when compared to 10 days in the hospital– or care for a chronic disase.
A full mouth implant doesn’t require hospitalizaiton. It also probably heads off other problems.
The most expensive care is care for chronic diseases that bounce patients in and out of the hospital over a long period of time (diabetes, severe depression, some cancers that don’t kill quickly, congestive heart failure etc.)
Don–
Medical schlarships and loan foregiveness are, like full mouth implants, one-time expenses
By contrast, the billions that we spend on chronic diseases that are not well-managed go on and on. That’s why we call these diseases “chronic”. 80% of the $2.6 trillion that the nation spends on healthcare is spent on thise diseases.
Moreover, the loan forgiveness and scholarships for students who go into primary care in areas where they are needed would pay back many times over.
If we have more primary care docs, more Americans will have a chance to receive more of their care from primary care doctors.
We also need to pay those doctors more (which the legislation is doing)
This creates net savings. Primary care is less expensive than specailist care, and if primarh care docs are paid to spend time talkng to and listening to patients, they can solve many problems themselves, without referring to specialits.
Net, net: savings.
In the 1970s, we had excellent med school scholarships and loan foregiveness progrsms. (This all ended after President Reagan was elected in 1980)
My sister-in-law, who graduated first in her class at Yale Med school, had one of these scholarhips.
She was sent to a rural area in the state of Washington where she was a family doctor.
She met her husband there–also a primary care doc.
Today, they are still there
This is how these scholarships redistribute medicine, sending excellent docs to places where they are needed.
Maggie wrote:
“If we reduce the waste, we have plenty of money to cover high quality, effective care for all.”
————
Well I hope you are correct here. I think the idea is to bend the cost curve down because even now it is likely too high for sustainability. If everything that is effective is offered to potentially everyone without a cost-benefit analysis, how do we control costs, or induced demand really, from running that cost curve ever higher even if you get rid of ineffective care. You seem to be just substituting more effective care for ineffective care, and I don’t know if that is sustainable given our past history. I just have the suspicion that eventually cost-benefit is important in what is offered to all??
Thank you Maggie for answering my question. Your sometimes seems to me over-the-top defending of non-profit hospitals caused me to think that somehow you are compromised.
Have you found any non-profit hospitals who put money over medicine too much?
Maggie:
You still have not answered the question if whether loan forgiveness and subsidizing premiums simply encourages medical schools and insurers to keep raising their unsustainable prices?
You seem to place an inordinate amount of faith on the net savings, the back end, in which we’ll recoup these costs many times over.
Is there some point in which the up-front costs do not allow for back-end results?
We are at a point in which even the insurance premiums are too costly to protect the asset, our health.
Haven’t we already crossed the threshold on an up-front basis?
Don Levit
NG:
You comment abour substituting more effective care for ineffective care is very astute.
Wouldn’t it be in the providers’ and patients’ best interests to do so?
Once we set the standard for effective care, just think of all the wonderful treatments which will be invented to satisfy such a standard.
Don Levit
NG, Don
NG–
One-third of our healthcare dollars are wasted on ineffective and over-priced care.
If we squeeze the waste out of the system–and refuse to over-pay for some exorbitantly priced drugs and treatments–we have enough money to cover effective care for everyone.
Other countries do it.
For instance, they cover in vitro fertilization for everyone. (To some people that seems at the extreme edge of effective care, though as I’ve explained int’l studies show that covering IVF saves money. IF insurance doesn’t cover it and couples have to pya out of pocket, they will be tempted to implant 6 or 8 embryos (because they can’t afford to do it twice) and we wind up with more preemies and very comlicated births, all of which cost more than the IVF.
Read Dr. Don Berwick’s book, “Escape Fire” where he explains that the problem is not lack of money, the problem is how we spend it. (Berwick is the highly-respected president of the Institute for Health Care Improvement.)
The UK uses cost-benefit analysis because they have much less money to spend on healthcare (per person) than we do.
Their experience shows that cost-benefit analysis requires putting a price tag on a year of good quality life. (Should we be willing to pay $2,000, $3,000,, $4,000 for a treatment that will give the average patient an extra year?) Cost-benefit analysis also means asking what a year of life is worth at age 65 versus at age 18. Many medical ethicists wold argue that a year of quality life is worth more the younger you are. Or that those who haven’t had a chance to lead a full life should come first when using cost-benefit analysis when rationing care. This means cutting back on care for older Americans–something that few Americans over the age of 50 are willing to comtemplate.
Finally, cost-benefit analysis means making decisions about whether the benefit is great enough to justify the cost of keeping a premature baby who may live for only a few years–or who will always be severely handicapped–alive.
Luckily, we don’t have to face those questions. As Berwick explains, we have enough money to provide effective care (which means benefits outweigh risks to the patient) for everyone.
Going forward, one way that we will save enough money to provide effective care for everyone is to shift the empahsis from aggressive specialty care to preventive primary care and chronic diseaes managment.
The reform legislation would pay bonuses to doctors that create patient homes and keep their patients out of the hosptial. Those bonsues are far less expensive than hosptializations
We know that in parts of the U.S. where patients more primary care physicians–and fewer specialists, care and less expensive, and outcomes are just as good, sometimes better.
This is why Medicare is propoing raising fees for primary care next year while lowering reimbursements for cardiologists.
We’ll see a series of incrasess for primary care and cut for specialty care over the next few years, and ultimatley this will mean that more med students will choose primary care. (Loan foregiveness and scholarships for those who choose priamry care will help.)
We dont’ need more cardiologists; we know that a good half of the by-passes and angioplasties being done provide no benefit to the patient.
Don–
Medical school is expensive becaus education is labor intensive and because med schools need to make capital investments in advanced tehcnology so that they can train students. No doubt sometimes that technology is over-priced and/or no better than an older similar technology.
Perhaps some money could be saved there.
But education is always labor-intensive, and thus costly.
In other countires the government covers all or nearly all of the cost of medical education.
There is no reason why we can’t do that here.
As for insurance premiums, as I have explained in the past, they have been going up because a) we overpay for a great many products and services and b) every care Americans are exposed to more tests, treatments and medications. Many of us are overtreated, exposing us to unncessary risks and costs.
I see Paul Starr agrees with you about postponing implementation (in Sunday’s NYT).
http://www.nytimes.com/2009/11/29/opinion/29starr.html?th&emc=th
“Accelerating the timetable of reform ought to be a priority. Although the legislation calls for some important interim measures, the Senate bill defers opening the exchanges and extending coverage until 2014. By comparison, when Medicare was enacted in 1965, it went into effect the next year.
“For Congress to put off expanding coverage to 2014 would be asking for a lot of patience from voters. It would also give the opponents of reform two elections to undo it. President Obama would have to run for re-election in 2012 defending a program from which people would have seen little benefit.
“To speed the process, the legislation ought to give states financial incentives to adopt the reforms on their own as early as mid-2011. A state like Massachusetts, which already has a working exchange, could move expeditiously to qualify for federal money. The final deadline for the federal government’s expansion of coverage should be no later than Jan. 1, 2012.”