At the moment, the Senate health-care compromise would replace the public option with a menu of private sector non-profit insurance plans overseen by the Office of Personnel Managment (OPM), the goup that oversees Federal Employees’ Health Benefit Plan (FEHBP).

 I say “at the moment” because I’m not at all certain that this compromise will hold. As one pundit observed over the week-end: “It’s bad enough to witness how the legislative sausage is made; it’s worse to see it being made on the fly.”

But let’s assume for a moment that the Gang of Ten Solution holds. What will it mean for unemployed and self-employed Americans under the age of 55?    Those who support this proposal talk about how much federal employees like FEHBP, and how successful it has been, as if it were a single plan, like Medicare, that offers the same benefits to everyone. 

The truth is the FEHBP is make up of a menu of private plans—some pretty good, some not so good. Many carry very high deductibles. Senators and postmen typically have very different plans.

Over at Kaiser Health News, Gail Wilensky, an economist and a senior fellow at Project HOPE, an international health education foundation, and a former administrator of the Health Care Financing Administration (now the Center For Medicare & Medicaid Services) asks a key question about the private sector plans OPM would oversee:

“One of the real questions . . . .  how much variation in the benefit structure will actually be allowed? When you look at FEHBP, you've got the $5,000 a year Mail Handler plan, and you have standard Blue Cross Blue Shield, which is $12,000 – $13,000 a year. Those are pretty big differences. The issue is what are you going to set up: a skinnied down plan with a tight network that would allow it to be low cost, or whether you insist on a very expansive plan in terms of benefits with few exclusions. The question is going to be the nature of what these plans are supposed to look like.” http://www.kaiserhealthnews.org/Stories/2009/December/14/FEHBP-health-insurance-public-option-OPM.aspx

Today, some observers have been aruging that we must pass some form of health care reform because if we don’t, tens of thousands of Americans will die prematuely 00 because they don’t have health insurance.

But having health insurance doesn’t necesssary mean access to the health care that might save lives: good chronic disease management; smoking cessation clinics with no co-pay; Pap smears with no co-pay; pre-natal care and nutrititional counseling; mental health care; primary care with no co-pay;  chemotheray  that can acually give a cancer patient extra years; very expensive drugs that can slow down MS; access to specialists (who may or may not agree to join the network of a less expensive plan that pays lower fees. )

Finally, experience shows that if the insurance carries a high deductible, patients are just as likely to defer needed care as they are to put off less vital care.

The alternative is  to require that all of the plans that the OPM oversees provide a full package of comprehensive benefits. This means that they will be more likely to cost $12,000 to $13,000. Like any private sector plan, they will have high administrative costs to cover lobbying, marketing, advertising and executive salaries. Unlike the public option , they will have no vested interest in reducing costs and lifting the quality of care.

Probablly we’ll wind up with a mixed bag: pretty-good plans for those who can afford the  highest premium;s and  poor plans for the middle-class and the  poor. Supporerts will call this “giving Americans choices” and ignore the fact that we are still rationing care by ability to pay.

Will  the least expensive plans save tens of thousands of lives?  Probably not.   They should save some lives, but as Marilyn Moon, vice president and director of the health program at the American Institutes for Research points out on Kaiser Health News: 
“These private plans aren't necessarily [going to be] doing what is best for the population. They're doing what they think is best for their own competitive environment and other criteria. So the question is, how are you holding the plans accountable?”

OPM doesn’t hold the federal employee plans accountable. It’s not a regulatory agency and it doesn’t have the size or the clout to insist that insurers meet certain standards in terms of providing value for health care dollars. Without a public plan in the marketplace, no one will be setting a benchmark that puts patients first.

Boston surgeon Atul Gawnde and Don Berwick, the president of the Institute for Health Care Improvement, understand that we can create a sustainable, universal U.S. healthcare system only if we reduce costs. And they recognize that by spending less, we can, in turn, lift the quality of care. As Berwick puts it: “The best health care is the very, very least healthcare that we need to gain the long and full and joyous lives that we really want.”

Talk to virtually anyone who has studied the problem in depth, and they agree. While many uninsured and underinsured patients receive too little care, a great many well-insured patients—including Medicare patients—receive too much of the wrong kind of care. Gawande explains: “Our system neglects low-profit services like mental-health care, geriatrics, and primary care, and [is] almost giddy in its overuse of high-cost technologies such as radiology imaging, brand-name drugs, and many elective procedures.”

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“Where is the plan to make health care affordable?”

“I want to see the savings.”

“Show me the money: Lay it out in simple language– on one page.”

Critics of health care reform legislation have become increasingly adamant on one point: They want to know how reformers are going to rein in the skyrocketing cost of care. And they want to know now. They’re not interested in “pilot projects,” or proposals that they refer to as “reform lite.” They want a proposal that the Congressional Budget Office can “score,” tallying up the savings the way one might add up the points in a tennis match, neatly, definitively, without argument.

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Kaiser has just posted a report which suggests that the Medicare Buy-In will be even more expensive than I thought. It turns out that median family income for Americans 55 to 64 who don’t have insurance is just $22,510. By contrast, as I reported yesterday, median income for all Americans in that age group is substantially higher–$58,000. Many have jobs—and employer-based insurance.

This means that the Medicare Buy-In will be attracting seniors who are much poorer than average. In this country, there is a high correlation between poverty and poor health. The group most likely to opt into Medicare will be sicker—and need more care—than the average middle-aged American.

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There is much to be hammered out before a final health reform bill emerges from Congress. Disputes over the public plan, abortion, financing and when reforms will actually take effect continue to delay progress. But on one thing, apparently, there is broad consensus: Nearly everyone supports prevention. In fact, a recent poll found that 71% of Americans favor increased investment in disease prevention and believe it will save money in the long run.

Prevention is a broad concept, encompassing everything from flu shots to prostate screening to smoking bans to confronting racism. And just because Americans say they favor increasing funding for “prevention” does not mean they all envision the same approach. Some personal-responsibility advocates, for example, throw their support behind pay-to-play prevention efforts—like increasing insurance premiums for people who smoke or are overweight. Others, like Senator Barbara Mikulski, believe the most important investment in prevention is to guarantee access to routine screening tests—mammography, Pap smears and colonoscopies—even if evidence suggests this may not always be the case.

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Last night, the news broke that the “Gang of Ten” (the Senators who have been trying to break the deadlock between moderates and liberals) had come up with a two-part alternative to the public option.  Under their proposal, Americans 55 to 65 could buy in to Medicare if they choose—and if they could afford it. Meanwhile, for Americans under 55, the public option would be replaced with non-profit private insurance plans overseen by The Office of Personnel Management, the group that now administers the Federal Employees’ Plan.

Begin with expanding Medicare to people 55 to 65. This is an idea that I wrote about in Money-Driven Medicine. Bruce Vladeck, who ran Medicare during the Clinton administration, was convinced that Medicare could compete successfully with private insurers, in large part because its administrative expenses are so much lower. I agree that in the late 1990s, it would have been a good idea.

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A family illness has kept me away from the blog for much of the past week.

But today, I plan to post–about the  Senate compromise, and other matters.

Tomorrow, I'll begin catching up with responses to comments.

Maggie

Senate liberals and moderates have closed ranks, defeating many who hoped to use seniors’ fears of Medicare cuts to bury health care reform.

As the Assocociated Press (AP) reported: “Unflinching on a critical first test, Senate Democrats closed ranks Thursday behind $460 billion in politically risky Medicare cuts at the heart of health care legislation, thwarting a Republican attempt to doom President Barack Obama's sweeping overhaul.

“The bid by the bill's critics to reverse cuts to the popular Medicare program failed on a vote of 58-42, drawing the support of two Democratic defectors. Approval would have stripped out money needed to pay for expanding coverage to tens of millions of uninsured Americans. .  ..”

Tuesday, I appeared on GRITtv with Laura Flanders and explained why conservatives who oppose health care reform were objecting to Medicare cuts—not because they wanted to protect Medicare patients, but because they wanted to protect the for-profit insurance industry.

You’ll find the roundtable discussion, which included TNR’s Jon Cohn, The Nation’s John Nichols and Pro Publica’s Olga Pierce here: Laura Flanders – http://lauraflanders.firedoglake.com/

This vote reinforces my belief that, in the end, we will wind up with legislation that resembles  the House bill, and includes a strong public option.

Those who oppose reform have been using the recent CBO report to claim that, under the Senate bill, many Americans will pay more for health care.

That’s not what CBO said. A careful reading of the report suggests that even people in the individual market will wind up paying less because under reform, insurance is likely to cover more of their health care costs.

First, here’s what CBO actually said: For most Americans who have group insurance (usually through an employer) there will be little change in their premiums. Those who purchase their own insurance in the individual market (usually the self-employed and early retirees) could see their premiums rise by 10 percent to 13 percent in 2016.   But, “that extra cost would buy better coverage, the CBO said, and hefty federal subsidies would drive down payments by nearly 60 percent on average for low- and middle-income families.”

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Part 1 of this post described how the US Preventive Services Task Force’s (USPSTF’s) message about mammograms has been distorted by the press. Despite what you may have read, the Task Force did not recommend that women in their 40’s skip mammograms; it advised them to discuss the risks as well as the benefits with their doctors. And the USPSTF was not trying to save money; it is not charged with cutting the cost of care. Its only goal is to give women full information about the benefits and the limits–of mammography screening.

Below, I explain that what the task force just explained about the risks of mammography is something that it tried to tell us years ago. But Congress stood up and said “No—we don’t want women to know that.” Why? Because lobbyists for those companies who make mammography equipment did not want women to know that mammograms can lead to unnecessary surgery.

Below, I also note that some patient advocates as well as many disinterested physicians applaud the Task Force’s message. It’s just not as controversial as the media pretends. Indeed just one month ago the chief medical officer of the American Cancer Society was questioning the advantages of mammography in the pages of the New York Times.

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