For a round-up of the most provocative posts that have appeared on health care blogs during the past two weeks, turn to Worker’s Comp Insider  where  Julie Ferguson has done a splendid job of hosting  the “Heat Wave Edition” of Health Wonk Review (HWR). As Ferguson observes, while it is “sizzling outside,” D.C.is “on fire” as “the budget battle heats up.”

 Below, I discuss and elaborate on two posts that seem particularly relevant to the war over the debt ceiling that is roiling Washington this week-end.

But I urge everyone to read the full “Health Wave Edition,” where they will find posts that focus on: a recent congressional hearing on Independent Payment Advisory Boards   (complete with video clips); an excellent primer on Health Exchanges, by Timothy Jost; The Fast Food Model for Corporate Medicine,” (a piece by Roy Poses’ that features Florida governor Rick Scott); why doctors offer credit cards in order to avoid discounting (from the Health Business Blog);  why less is more when it comes to angiograms (by Shannon Brownlee);  the effectiveness of Robotic Surgery (Gary Schwitzer); and whether OSHA's Voluntary Protection Program (VPP) is broken (Worker’s Comp Insider)

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Demagogues, Deficits and HealthCare: Are Drug-makers Untouchable?

Over at Managed Care Matters, Joe Paduda makes it clear that he is fed up with political demagoguery. 

In this timely post, Paduda reminds us that Medicare Part D, the prescription drug program passed as part of the Medicare Modernization Act (MMA) in 2003, represents “the largest expansion of entitlement programs since the Great Society." This was “a Republican program," he observes, that was “completely unfunded; short term, long term, any term. The GOP decided to NOT set aside funds, or raise taxes, or cut other programs; they just passed Part D, committed to paying for it out of 'general funds' and to hell with the future.”

 Democrats opposed the bill; nevertheless, it squeaked through Congress.  As a result, Medicare’s Actuaries recently reported, “the Part D program has contributed $9.4 trillion to the ultimate Federal deficit.”

Wait a minute. I thought conservatives wanted to slash “entitlement” programs. Why would they pass such an enormous program without worrying about how to pay for it?  

“Part D was a  political masterstroke,” Paduda explains, that  “undoubtedly helped George W Bush get re-elected along with many GOP legislators, as seniors loved the new program.”  (Part D also represented a windfall for drug-makers, and they, too, were pretty happy.)

“I bring this up not to anger my conservative readers,” adds Paduda, whose forthright and even-handed blog appeals both to conservatives and to progressives.  “But rather to educate some who aren't aware that Part D, and the costs of Part D, are the handiwork of Eric Cantor, John Boehner, Mitch McConnell et al. [his emphasis here and throughout]

“Yep,” he adds, “the strident voices screaming for cost control [today] were single-handedly responsible for a program that's added [trillions] to the ultimate deficit.” Paduda quotes “one libertarian”: “Every single one of these folks, without exception, is in no position to criticize Obamacare or claim to want to beat back the tide of socialism that supposedly began only two years ago when Obama rose to power. Every single one of them voted to shovel tax dollars to the pharmaceutical industry and the wealthiest age demographic — the elderly . . . “

 “How'd the GOP get away with this? Simple,” Paduda explained earlier this month: 

“The Republicans suspended Congress' PAYGO rules, the requirement that any bill that spent more money had to be offset by more revenue or cuts elsewhere.

“The Dems reinstated them.

“From all the caterwauling from the GOP side of the aisle, you'd think that Mitch McConnell, John Boehner, Newt Gingrich et al were well practiced in the art of controlling spending . . .

“And you'd be wrong.”

Not only did conservatives pass Part D, “the Republican Congress and Administration was responsible for preventing Medicare from considering any cost-benefit criteria in determining whether and what Medicare would pay for procedures, drugs, treatments, devices, etc. . . . these deficit hawks thought it was just fine for we taxpayers to be forced to pay for procedures with very little efficacy.”

“What makes me, and should make you, really angry,” Paduda concludes, “is the demagoguing by elected officials who've done exponentially more to damage our fiscal future than even the most pessimistic assessment of the health reform bill.”

Throughout the debt-ceiling debate, conservatives have argued that we must pare Medicare. If that is what they believe, then why not take a look at Medicare Part D?  President Obama has suggested that Medicare could cut spending by negotiating with drug-makers for lower prices. At the very least, as I have reported on Health Beat, Medicare could  insist that “dual-eligible’s” (seniors eligible both for Medicare and Medicaid) enjoy the same discounts that Medicaid recipients receive.

 But somehow, McConnell, Boehner and Cantor don’t seem to be picking up on the idea. They would rather slash Medicaid. And, based on what we are hearing this week-end, I fear that President Obama may let them do just that.

The Storm Over Medicaid –“Worse Than No Insurance?” 

On California Healthline, contributing editor Dan Diamond defends Medicaid against those who would cut tens of billions from the program. Today, many states refuse to offer Medicaid coverage to able-bodied adults living below the poverty level–unless they have children. These are the people that Oregon Governor John Kitzhaber has referred to (ironically) as “the worthy poor.”  But under the  Affordable Care Act, Diamond observes, “more than 16 million uninsured Americans are slated to be added to Medicaid’s rolls by 2019.”

Conservatives are not happy about this. Earlier this month, the Wall Street Journal reported that officials familiar debate over the debt ceiling “expect Medicaid to be the biggest source of cuts in federal entitlement programs in whatever compromise emerges.”  

After all, the poor don’t have a lobby.  Moreover, conservatives argue, Medicaid it is not doing the poor that much good anyway. As Diamond observes, some go so far as to claim that having Medicare “is worse than having no insurance at all.” He quotes Douglas Holtz-Eakin, president of the American Action Forum: “Medicaid coverage looks much better on paper than it does in reality.” Citing low reimbursement rates, barriers to patient access and the rising financial burden on the states, Holtz-Eakin warns that "without substantial Medicaid reform, Obamacare will result in a human and fiscal disaster.”

Granted, Medicaid is seriously flawed. And for some time, it has become popular, at least in certain circles, to argue that Medicaid provides worse care than the care the poor could find on their own.

 But now, Diamond points out, “a singular study” has “appear[ed] like a gift from the gods” which disproves the naysayers, “slicing through hardened opposition like a knife through butter,” by offering proof that Medicaid can improve the lives of millions of impoverished Americans.  Diamond is referring to a landmark working paper published by the National Bureau of Economic Research (NBER)  that researchers and physicians such as the Incidental Economist’s Aaron Carroll say “will be cited for decades.” 

Naomi wrote about NBER’s report on HealthBeat when it was first published, earlier this month, explaining that the research demonstrates that Medicaid offers health benefits that can be measured. The “findings were irrefutable,” she observes.  “Expanding low income adults' access to Medicaid substantially increases health care use, reduces financial strain on covered individuals, and improves their self-reported health and well-being. Specifically, adults with insurance coverage were 55 percent more likely to visit a doctor, 30 percent more likely to be admitted to the hospital and 15 percent more likely to take prescription drugs, according to the NBER paper. There were also measurable gains in use of preventive services; with a 60% increase in women over 40 having a mammogram, a 45% greater likelihood of having a pap test and a 20% greater chance of having blood pressure checked.

“Having insurance also had a real impact on the financial health of the low-income adults newly covered by Medicaid,” Naomi added. “They experienced a 25 percent decline in having unpaid medical bills sent to a collection agency and a 35 percent decline in out-of-pocket medical expenditures. For individuals whose income is below $11,000/year, these financial impacts are substantial and helped reduce stress.”

 The NBER report is hard to refute because, in contrast to the “observational” studies that conservatives have relied on to make their case that  Medicaid patients fare no better than the uninsured, this working paper is based on a randomized controlled trial– generally considered the gold standard for medical research. Normally it would be impossible to set up such a trial. To create a control group one would have to tell a group of citizens who qualified for Medicaid: “Sorry, we’re not going to give you insurance. We want see how you fare when compared to other, equally needy citizens, who do get coverage, so we’re going to ask you to draw straws.” Needless to say, this would be considered unethical.

But in the real world, Oregon had already done just that. Diamond explains: “Three years ago, lawmakers in Oregon announced they would expand Medicaid coverage. Ninety thousand uninsured residents applied, but the state could only afford to enroll 10,000. As a result, Oregon set up a lottery to determine who would be added to the program.

“A pair of prominent health policy researchers — Harvard University's Katherine Baicker and the Massachusetts Institute of Technology's Amy Finkelstein — stumbled across the lottery and realized it was ‘an unbelievable opportunity’ to test the benefits of expanding public health insurance. . .  . While the lottery was sure to frustrate 80,000 Oregonians, it also created the perfect structure for a randomized controlled trial, perhaps the most rigorous of academic studies, where one group of individuals receive certain benefits and a nearly identical group is denied them.

“The results of Baicker and Finkelstein's research–published by the National Bureau of Economic Research — revealed . . . that  health insurance offers tangible health and financial benefits.”

Now, Diamond writes, the question becomes: “Will this new Medicaid study change the course of [the political] conversation?”  He quotes Chicago University professor and Century Foundation fellow Harold Pollack; "Studies have influence, but they never speak for themselves … they have to line up with a particular moment in the political debate.”  Let me suggest that the time is ripe for someone to take this study, read it into the Congressional Record, and make the argument that Medicare’s benefits are real, and essential to our neediest citizens. It would be cruel to make them the easy target in the political follies that we call “deficit reduction.  

That said, a legislator who wants to defend Medicaid should concede that conservatives may be right when they argue that Medicaid beneficiaries live no longer than the uninsured. After all, we know that the poor die sooner than the rest of us, not so much because they receive less medical attention, but because the stress that comes with being poor, combined with an unhealthy environment, public schools that are failing the children who need them most, poor nutrition, few opportunities to exercise, unemployment and the self-medication that goes hand in hand with depression, frustration and anger can be lethal. Medicaid cannot repair all of the damage caused by poverty.

But while Medicaid may not lengthen an individual’s life, it can soften the blows that fortune deals out to those who have the bad luck to be born poor in a society where upward mobility has slowed.  At the end of her post on Medicaid’s benefits, Naomi quotes Kevin Drum from Mother Jones: “You may not live much longer if you have health insurance, but guess what? Your life is going to be a lot better. You're less likely to lose your teeth, less likely to be in pain, less likely to be incapacitated with chronic illness, and more likely to receive treatments that demonstrably improve your quality of life. . . . “

He continues, “And the economic peace of mind that even a modest program like Medicaid provides? That's yet another bonus. It's the least — literally the least — that a rich country can provide for its poorest residents.”

President Obama has made it clear that in the debt negotiations, Medicaid is on the table. But as of late this afternoon, he has refused to be at all specific about just how and where he would be willing to slice program. This gives me some hope.

Perhaps the president and his advisers at the Centers for Medicare and Medicaid (CMS) will find a way to cut Medicaid spending without cutting benefits, or reducing eligibility. They might start by taking a hard look at for-profit hospices and nursing homes where, we are told, patients are not receiving the care they deserve. The same profiteers who neglect patients also are prone to padding the bills that they send to the government. Then, CMS could consider letting Medicaid negotiate, not just for discounts on drugs, but for discounts on medical devices and durable medical equipment. Finally, CMS could cut costs by setting up systems to triage Medicaid patients out of ERs and to community health centers (CHCs) where they will find chronic disease management that is both less expensive–and better.  Under the Affordable Care Act we are expanding CHC capacity by 50 percent. If necessary, workers from Community Health Centers might visit crowded ERs, and shepherd appropriate patients, via public transportation, to a CHC that is open after-hours.