Win-Win: Obama’s Student Loan Reform Decreases Student Loan Premiums and Works towards Health Reform Passage

Student loan legislation is being twinned with the health care reform legislation proposed by the House for reconciliation.  The language contained in the House “fix it” bill would stop federal subsidies to private lenders like Sallie Mae and would instead originate all federal student loans in the Department of Education.  Such reform is estimated to save taxpayers $67 billion over ten years according to the Congressional Budget Office.  The savings would be used to fund more need-based Pell grants, which are provided to low-income students to promote access to higher education.  In the past year alone, applications for Pell grants have skyrocketed due to the fact that many people are returning to school given the difficult economy.

Because only one reconciliation bill may be passed per year, the student loan reform legislation has been included in the health care reform bill.  President Obama wants to include the loan language in the bill because of its estimated savings as well as the benefits it will offer need-based students, and he finds the inclusion a “no brainer.”  The Democrats will need at least 51 votes in the Senate to pass the bill, however, and several members from their own party, including Ben Nelson of Nebraska and Blanche Lincoln of Arkansas, have already voiced concerns about the negative impact these changes will have on the loan companies and their employees.

The House Education and Labor Committee has already tried to discredit the claims of those who want to keep the loans with private lending companies. Rachel Racusen, communications director for the Committee was quoted as saying:

Lenders’ claims about job losses have already been debunked as another scare tactic to save their sweetheart deal.  While this legislation will trim the profits of banks, it will not lead to enormous jobs losses.

Democrats in favor of the bill add that the private lending companies will still be utilized for other loan services.  Some point to the alliances created in the Senate between loan companies and Senators.

Dissenters of the loan reform are missing the bigger picture concern: the benefits reaped by society through the intellectual development and financial security for America’s students.  Senator Patty Murray of Washington said:

My own personal perception is, when we have thousands of kids on the street marching because they can’t get into our universities and don’t have the capability of pay for college, this is the best time for us to act.

Betting on Health Care Reform

At least investors think health care reform will be happening some time soon.  The Wall Street Journal reported that managed care stocks fell after Obama asked Congress to take an up or down vote Wednesday afternoon.  It might be wishful thinking (or dreadful, depending on which way you look at it) for the investors who are moving their investments from managed care plans.  With Congress members still treating health care reform as a game of cat and mouse, whether a vote will happen and whether the vote will be for reform is yet to be determined.

Take for instance Nathan Deal, a Republican from Georgia, who is purposely postponing his resignation from the House until a vote on health care happens so that he can get his nay vote in.  Then, there is the promise from Senate Republican leader Mitch McConnell to repeal health care reform before it has even been passed.  And despite Wall St. estimations to the contrary,  with the complications of reconciliation, the prospect of getting a bill that actually creates a mass exodus out of managed care seems at least somewhat iffy.

Interestingly, as the Washington Post revealed on Wednesday, private insurance companies, such as the infamous WellPoint, will be the primary beneficiaries of a failed health care reform attempt.  As Ezra Klien stated:

The argument is simple: Wellpoint’s business model is uncommonly concentrated in the individual and small-group markets. Those are the exact markets that health-care reform will drastically change. Those are the markets where people get rejected for preexisting conditions, where insurers spend 30 cents of every premium dollar on administration and where rate hikes are volatile and constant. Health-care reform wants to change all of that, and if it does, Wellpoint’s business model will be changed, too.

It would seem, then, that health care reform would not be difficult to carry through in considering who stands to win and who stands to lose if reform is not passed.  One of the major barriers is the Republicans’ animosity towards using reconciliation to pass a final health care bill, an idea they consider foreign to the democratic process.  However, as NPR just reported this past week, reconciliation is not “unprecedented,” and in fact, it has been used many times in the course of our country’s history to pass similar bills.  COBRA, Children’s Health Insurance Program (CHIP), and changes to Medicare have all happened through reconciliation.  Moreover, between 1981 and 2008, 16 out of 21 reconciliation bills were Republican initiatives.

Without a final vote on health care soon, many worry that the momentum will be lost.  Many members of Congress, steadfast in their platform promises, are not helping the process move any quicker.  In the meantime, insurance companies continue to prosper; Americans continue to pay the price.

While Medicaid Enrollment Rates Increase, States Face Financial Pressure to Decrease State Medicaid Spending

Last week, the Kaiser Family Foundation released a report indicating a large jump in state Medicaid enrollment from June 2008 to June 2009.  The report said that the 7.5 percent increase was the greatest one-year jump in enrollment rates ever, with over 3 million people joining the public health program funded jointly by the federal government and individual state governments.  The reason for the increase  is thought to be that because more people became unemployed due to the economic crash, more individuals turned to Medicaid for health coverage.  However, because the economic downturn meant less revenue entering into state budgets, state Medicaid programs have not been able to keep up with the rise in new enrollees.

During a convening of state governors at the White House this week, state officials will likely raise the issue of Medicaid spending. The issue is pressing in light of the impending funding cut when stimulus money from the American Recovery and Reinvestment Act of 2009 will expire in December of this year.  The governors will likely ask that the stimulus funding be continued until states can somehow make up for their large current budget deficits.  In addition to asking for more money, the governors will also likely discuss the feasibility of health care reform efforts.  With both House and Senate versions of health care reform proposing increases to state Medicaid programs to ensure the coverage of more uninsured individuals, the state governors would, understandably, like to know where the money for such expansion would come from.

The National Association of State Medicaid Directors estimates that states’ budgets will fall  short  $140 billion in the next fiscal year.  This means even less money for the likely further increase in Medicaid enrollment to come this year, as Medicaid enrollment generally lags behind unemployment.  To account for the deficit, many states are planning to reduce their Medicaid programs. USA Today finds that three categories of such reductions exist:

• California, Arizona and Virginia propose reducing who’s eligible. In Arizona, 310,000 people would lose coverage. California also wants to increase premiums.
• Michigan, Tennessee, Massachusetts and others propose eliminating benefits. Masachusetts’ elimination of restorative dental services would save $56 million, says Medicaid director Terry Dougherty.
• Texas, Pennsylvania, Louisiana and others propose cutting payments to hospitals, doctors or nursing homes. Several states are considering new taxes on hospitals as a way to avoid cutting these payments.

States that accepted stimulus money to expand their Medicaid programs in 2009 are restricted from any such cuts that would affect low-income enrollment.  However, if the stimulus funding is not extended, some states are planning on heightening eligibility requirements.  For other states, while decreasing hospital and doctor reimbursement seems like the worst possible option– given that many doctors have already stopped accepting  Medicaid patients due to what they deem to be an insufficient rate of reimbursement– many states’ officials find that the only other viable option they have is raising taxes.  Many state leaders refuse to increase taxes in fear of the political backlash come November.

Realizing the need for health care reform to help manage the burden of paying for health care, state governors have stated a desire to be part of the health care reform conversation.  Many have already expressed their dislike for individual mandates, which they believe will drive more individuals to state Medicaid programs.  For the most part, however, the governors want reform and they want it now, finding that they simply can’t afford to wait another year.

It is also worth noting that an underlying issue from these new numbers is whether the Medicaid program is actually a good prototype for expanding health care coverage.  Drew Altman, President and CEO of Kaiser, put in perspective Kaiser’s report as well as the concerns of public spending that were sparked by the Centers for Medicare and Medicaid Services’ projections for 2009-2019– which forecast that public spending on health care will surpass private spending.  He noted that while spending in public health insurance programs would increase, the cost-benefit would be better, since per capita costs on health care were lower in government-run programs than in private insurance programs.  According to Altman, such numbers did not undermine health reform efforts, but instead denoted “the need to control health care costs in the public and the private sectors alike.”

Obama’s Plan for a Health Care Summit and the Unenthusiastic Response

Last week, President Obama announced plans to hold a bipartisan health care summit to push forward on health care reform and to give both sides an opportunity to discuss ideas for health reform legislation that will be able to garner enough votes for passage.  While President Obama and Democratic Congressional leaders want to use the health care proposals that have already passed in the House and in the Senate, Republicans say that they are unlikely to vote for a bill unless the current proposals are scrapped and the process is started afresh.  It seems like Americans, once again, may be left watching the theatrics of the health care reform debate without actually being the focal point of it.

Some conservative Congress members have already responded to the President’s invitation publicly to make their steadfast positions known.  Representative Eric Cantor (R-Va.) said this past week that he was not willing to discuss a “health reform package that spends money we don’t have.”  He added that “House Republicans have offered the only plan that will lower health care costs.”  If that is true, it is likely attributable to the fact that the House Republican bill would cover only 3 million uninsured Americans, compared to the Democratic House bill which would  insure an additional 36 million Americans.

On Monday night, House Minority Leader John A. Boehner (R-Oh.) joined Cantor in submitting a letter to White House Chief of Staff, Rahm Emanuel, which said that the Republicans were not willing to come to the table unless certain prerequisite questions were answered.  You can see the whole letter here.  In the letter, Cantor and Boehner express their non-support for reform that the American people themselves are not supporting; the basis for such being the recent Republican Senate win in Massachusetts.

Exactly what are the citizens of American thinking about health care reform anyway?  CNN reported on Tuesday that nearly two-thirds of Americans want Congress to persist in passing health care reform legislation.  The poll, an ABC News/Washington Post survey, also indicates that Americans blame both Democrats and Republicans on their unwillingness to compromise.  HHS Secretary Kathleen Sebelius herself is quoted as saying, “When people look up close at the personal activities of Congress they are confused and disgusted with the whole process and too afraid that whatever is going on can’t possibly be good for them or their families.”

Many believe that the idea for the health care summit was to address the back-door processes that led to American distrust and to make it all more transparent.  Still, there appear to be more differences between the conservative version of reform and the liberal version than points of reconciliation.  Though the prolonged tug-of-war between both sides does not seem like one that might be resolved in a day of convening, the summit is, perhaps, at least a start.

And, while the political contenders decide what to do about the summit, the health reform stalemate has presently-occurring repercussions. Many hospitals, which were holding on to the hope of reform, are now at the point where downsizing their health systems is thought to be the only step left.  Hospitals all around the country have been seeing more and more uninsured patients, and with no one to cover the full cost of services, the hospitals providing unreimbursed care are said to be further sinking into debt– and must therefore cut staff as well as services.  On the individual level, Americans are also finding it difficult to  keep up with the costs of health care, and while many forgo insurance, those that cannot due to chronic illness or necessity of care are finding the cost further prohibitive.

It would make sense, then, that Americans do want reform.  Andrew Rubin, Vice President for Medical Center Clinical Affairs for NYU Langone Medical Center and radio show host for HealthCare Connect, says that one of the underlying reasons why Americans are reluctant to give support for legislation is their lack of understanding of what is happening, not because they do not want to see change.  Let’s hope that the proposed health care summit will be used to clarify issues for Americans who do need and want health care, instead of for just another political brouhaha.

Medical Care for Haitians: US Announces Funding

This past Sunday, the White House resumed military airlift of injured Haitians into the United States.  The halt on incoming Haitian patients had happened just days earlier, springing from the economic and logistic fears of many state officials of Florida, where the majority of patients from Haiti were being sent for care.  After finding a solution to the hospital capacity issue in Florida,  and fully knowing that they could not keep certain patients in the medically hazardous environment which is Haiti, White House officials reopened U.S. hospital doors to  badly injured patients.  Yet, the resounding question “who is going to pay for this emergency care?” remains.

The costs are not insignificant.  One Florida hospital executive estimates costs to her hospital alone to be in the millions, and while she hopes some of this cost will be lessened through federal government assistance, other hospitals have already started to initiate reimbursement for the costs themselves through private donations.  In addition, many doctors and nurses are volunteering their services to help reduce the high cost of the care.

The U.S. Department of Health and Human Services announced on Monday that they would supply funding for the emergency care through the National Disaster Medical System, which is usually accessed only in times of domestic emergencies. As described in the announcement, “activation will allow U.S. hospitals that treat Haitian patients evacuated with life-threatening injuries due to the earthquake, to receive federal reimbursement for the costs they incur.”  The reimbursement for the care to Haitians is equal to 110% of Medicare rates.

Since the announcement of aid through the National Disaster Medical System, hospitals in other areas, such as Atlanta, are agreeing to treat patients.  Hospitals in the Atlanta and Florida area are able to provide assistance due to their proximity to Haiti and their “extensive medical resources.”  Other hospitals in the New York, New Jersey, Philadelphia, and Boston areas have been notified that their medical centers may also be tapped  for help in treating the Haitian patients.

Because some of the patients that are being treated at American hospitals are American citizens who were in Haiti when the earthquake hit, some of the medical care can be reimbursed through the insurance coverage that those patients may already have or be eligible to receive.  Interestingly, Haitians who are not legal residents of the United States might also qualify for insurance through Medicaid, but to qualify, the patients would have to be granted “Humanitarian Parole” by U.S. Citizenship and Immigration Services.  Up until this point, Humanitarian Parole visas, which last for a year, have mostly been granted to orphans who were already in the process of being adopted before January 12^th.  Only 50 Humanitarian Parole visas have been granted to those who were sent to the United States for health care; due to the difficulty in tracking patients after their care is complete, the Immigration Services is hesitant to grant more such visas.

While the federal government appears to have systems in place to aid Haitians who are in dire need of medical care for now, questions about long term help still linger.  International aid experts want to see systems of sustainability put into place so that Haiti can once again stand on its own after the foreign aid ends.  Maybe our nation’s leaders will be able to give to Haiti the health care reform it needs, even if they can’t give it to America itself.

Medical Experts Say Haitians Will Need Health Care Help for Years to Come

The BBC recently reported that medical organizations with members serving the Haitian communities affected by the earthquake on January 12^th warn that one of the larger issues for Haitians will likely be the need for increased medical supplies, such as prosthetic devices and rehabilitation services.

Concerned about infection, doctors in Haiti have had to amputate the limbs of a great many injured patients.  In addition to the need for such resources as medical devices and prosthetic equipment, doctors are also still in need of simple medications.  Antibiotics are needed to prevent the spread of infections and painkillers to help damaged patients simply make it through the day.

Because many of the country’s hospitals were also destroyed by the earthquake, doctors in Haiti are performing most care in makeshift open areas.  And in such environments, infection spreads fast.  Though the few hospitals that are running are reported to be in relatively well-organized condition, many of the patients in those hospitals are not leaving as they have nowhere else to go, except perhaps the streets– where infections await their open wounds. So they stay,  Doctors are left with fewer and fewer areas to treat, and the number of patients increases. To remedy the situation, there are plans at present to quickly build a convalescent center.

The present medical needs are only the beginning.  The concerns of some medical experts extend to the years after the media eye has turned away from Haiti, after the NGOs have left the country, and after foreign doctors have returned to their home-countries.  These experts worry about how the Haitians that are being treated today will be able to continue with one less leg or one less arm in the future.  Without proper rehabilitation services or necessary follow-up medical care, many Haitians will lack the physical capabilities to rebuild their lives.  Mark Hyman, a doctor and volunteer with Partners In Health, calls these future medical needs of the injured Haitian community the “third wave,” and he finds that such aid is not yet realized:

Soon, very soon, there is the need for rehabilitation, helping the thousands with lost or broken limbs get back on their feet or foot again. There are no physical therapists, no facilities, and no place for them to go for care. As the immediate surgical needs are slowly addressed, the psychological needs explode magnified by each minor aftershock.

Some medical device companies have already donated supplies to aid the doctors’ efforts as well as money to support the other necessary aid efforts in Haiti.  While such donations are helping address an urgent need, they are being outpaced by the number of amputations being performed.  Hope lies in the idea that health care systems will be put in place before the external help exits; that prosthetic devices will ultimately be made available to the patients that need them; and that Haitian medical workers are trained to be able to properly care for those who cannot care for themselves.

The needs of the Haitian people are great, and the impact of this disaster will be felt for years to come.  Please give to help those who are working hard towards rebuilding Haiti.  Click here to find a list of the different organizations through which you can donate. And if you happen to be a part of a prosthetic device company which wants to do something amazing, we’d love to write the story.

Intersecting Issues: Immigration Reform and Health Care Reform

The LA Times reported this past week that the pending health care reform would negatively affect rather than improve the health of California’s citizens.  Why would this be the case?  Nearly thirty percent of the state’s population consists of immigrants.  In L.A. County itself, there are more uninsured residents than any other U.S. county; as the L.A. Times calculates, the majority of that uninsured population are likely immigrants:

It’s a safe bet that the majority of those people are immigrants, because health officials say that 40% of all the patients treated at county hospitals are undocumented. In recognition of that fact and of the hospitals’ legal and ethical responsibilities to treat the uninsured ill and injured — regardless of their immigration status — Washington currently subsidizes their care at facilities, like L.A. County’s, with “disproportionate” numbers of such patients.

The House bill for health care reform would reduce the funding for such subsidies modestly, while the Senate bill would significantly decrease payments towards the subsidies.  Whatever the outcome of the compromise bill, L.A. County will be left worse off.

As we know, neither the House nor the Senate bill would cover undocumented immigrants, or allow them to receive subsidies or tax credits for purchasing insurance.  However, even if the country will not be paying for the health coverage of such immigrants, it will be and already is paying for the high costs of having immigrants treated in emergency rooms, since many hospitals, such as those mentioned in the L.A. Times piece above, treat patients regardless of their immigration status.  Hospitals that provide emergency services and participate in Medicare are required to treat all who come to them for emergency services by the Emergency Medical Treatment and Active Labor Act; some of the costs for the emergency care are covered through Medicaid, while others result in expenditures that the hospitals incur as debt.  The effects of the debt can result in higher hospital fees for other patients.  But greater hospital charge rates for the uninsured are a matter of contention, and tend to obscure the actual value of services rendered and unpaid for. Having said that, it is not unimaginable to think that provisions in the health care bills may actually drive up medical expenses for some segments of the population–and that such increased expenses will have significant adverse affect upon the whole.

Again, the House bill does a better job than the Senate version does at addressing the issue of immigrant health, as the House would allow for undocumented immigrants to participate in the health insurance exchange by permitting them to purchase insurance policies. While the House bill would require immigrants to pay for the policies entirely, the Senate bill does not allow for immigrants to participate whatsoever.  It is worth considering that the immigrant community consists largely of young, healthy individuals; the impact upon the risk pool of their inclusion is no small thing.

Some health care advocates believe that resolution lies in immigration reform, so that immigrants can become citizens of the United States.  An LA Times story about a UCLA study released this last week is also worth considering:

The report said that legalization, along with a program that allows for future immigration based on the labor market, would create jobs, increase wages and generate more tax revenue. Comprehensive immigration reform would add an estimated $1.5 trillion to the U.S. gross domestic product over 10 years, according to the report.

Though many Americans seem to feel that immigrants are taking jobs away from unemployed American citizens, CNN writer Ruben Navarrette, Jr. points out that much of the labor immigrants participate in is in areas of work that Americans themselves have shunned.

Behind the politics of both health and immigration reforms lies the compelling stories of immigrants who have labored in our county and who are in desperate need of health care.  While data and numbers can show the cost-benefits of allowing immigrants to participate in health care, the issue of treating ill humans seems an ethical one– not something to be justified by statistics alone.  But at the heart of this is the simple question, is healthcare a  human right? Or is it a luxury–a “treat,” if you will,  to be dispensed according to the rules of carrots and sticks? and not just a luxury.

What about the Kids? Health Care Reform and Children

During the reconciliation process of the House and Senate bills, one of the issues likely to be raised is what to do with the Children’s Health Insurance Program, commonly known as CHIP.  Under the Senate bill, federal financing for CHIP would be extended for another 2 years past the current expiration date of 2013.  The House bill, on the other hand, would allow CHIP to come to a close in 2013 since the bill plans to expand coverage for children through Medicaid and through the health insurance exchange– where subsidized health insurance would be available.  Whether or not these health reform initiatives will be able to meet the medical needs of children is a matter of debate.

CHIP is a “state-federal partnership” that was created in 1997 under the Balanced Budget Act to help insure those children who are from families that earned too much to qualify for Medicaid.  Similar to Medicaid, the federal government matches state dollars spent on CHIP (average of 57% federal responsibility for Medicaid spending, 70% for CHIP), but unlike Medicaid, the allocations to states for CHIP is capped.  CHIP also places greater discretion in  individual state’s hands regarding eligibility requirements.

One of the first bills Obama signed as President was the Children’s Health Insurance Program Reauthorization Act, or CHIPRA, in February 2009.  CHIPRA added $33 billion in federal funds to use towards providing coverage to 4.1 million children via Medicaid and CHIP through the year 2013.

In 2007, over 80% of eligible children nationwide participated in Medicaid or CHIP. Currently, 29 million children are enrolled in Medicaid, 7 million in CHIP. If CHIP were to be allowed to expire and absorbed (at least partially) by an expansion of Medicaid, however, the lower reimbursement rates for Medicaid could mean that those children transferred would not have access to as many health care providers as they would have had under CHIP.  While Medicaid might seem to be a sufficient substitute, it would still leave gaps that CHIP had filled if the reform does not include higher reimbursement rates for Medicaid and automatic enrollment provisions, as proposed by the House. In addition, as it stands, because of the relatively low reimbursement rates from Medicaid, many doctors have ceased to accept either new or all Medicaid patients.

The alternate option of funneling children to the insurance exchange does not seem promising either.  Many children currently enrolled in CHIP could become uninsured if their families cannot afford the plans offered in the exchange, which is a concern– as many families will still have a hard time meeting the premiums– even after the proposed subsidies from the government.  Senators Jay Rockefeller of West Virginia and Bob Casey of Pennsylvania have proposed to avoid some of these issues by expanding CHIP until 2019, a move that they say would benefit our country’s children by ensuring their access to health coverage.

In considering the options, it would behoove us to remember that “a stitch in time saves nine,” and that the regular health maintenance of children– much more likely for those children who have insurance– will pay dividends in the form of less of those costly visits to the emergency room and hospital stays. We would also be advised to remember that uninsured children in the hospital have bbeen shown to face a 60% greater risk of death than those children who have either private or government health insurance.

Dollars and Sense & Health Care Reform

With health care reform approaching its culmination point, like all things most memorable of the past year, the overarching question remains, “How much will this cost us?”  As it currently stands, the House version of health reform will cost an estimated $1 trillion over a decade, while the Senate version comes in at $871 billion.  Next, comes the obvious second question, “How will the government pay for it?”  As Kaiser Health News summarizes in its recently released guide to health reform:

Both bills hit up the wealthy, but in different ways. The House would impose a 5.4 percent income tax surtax on individuals who earn more than $500,000 a year and couples that earn more than $1 million. The Senate would increase the Medicare payroll tax rate from 1.45 percent to 2.35 percent for people who earn more than $200,000 a year and families that earn more than $250,000.

To raise money to pay for the legislation, the Senate would impose a 40 percent tax on the portion of most employer-sponsored health coverage that exceeds $8,500 a year for individuals and $23,000 for families. The Senate also would raise the threshold for deducting medical expenses to 10 percent of income, up from 7.5 percent.

Overall, the financing provisions could spur a pitched battle; the House hates the Senate tax on high-cost policies, while the Senate opposes the House’s income-tax surcharge.

In addition, many Americans worry that efforts to contain costs within the bills will lead to decreased standards of care.  As a New York Times piece reveals, however, this may not be the case.  The article examines the health system in Richmond, Virginia, where there are stringent state infrastructural expansion guidelines placed on health care practices and hospitals to contain costs.  The state requires large medical infrastructural expenditures by health care providing institutions– in the form of hospital expansion or even major equipment purchases– to be approved by the state through a “certificate of need.”  Neither of the House or Senate bills  includes such a provision, but there is a great deal of speculation that the oversight and cost-cutting measures in both will have a deleterious impact on the quality of health care.

While Richmond spends less than average per capita on Medicare than other metropolitan areas, patient outcomes are better than average. The Times reports

The quality of care in Richmond is better than in most American metropolitan areas, according to various measures, and it continues to improve. Medicare data, for example, shows that Richmond hospitals do a better-than-average job of treating heart attacks, heart failure and pneumonia.

But perhaps the most interesting aspect of the Times’ analysis relates to those states that do not police their health care infrastructure expenditures– or, as in South Dakota, had done so formerly, but ceased to do so.  When South Dakota “scrapped” its certificate of need program, one chief operating officer reported going on an expansion binge. In such cases, the number of patients that providers treat is said to correspond proportionally to the level of health care resources available.  One medical officer found this “supply-sensitive” phenomenon to mean that the more hospital beds a hospital has, the more patients it is likely to see.  Build it and they will come– or perhaps more to the point– they will be sent. At our expense.

Holiday Shopping for Health Care

With Black Friday done and out of the way, one cannot help but wonder if any Americans were bargain hunting for health coverage.  After all, barring exigent circumstances, in the current health care market, shopping around to compare prices seems like an economically sensible thing to do.  Individual health care plans have been charging higher and higher premiums; the rate of uninsured Americans is increasing, and those who are insured increasingly face greater deductibles and out-of-pocket expenses. Price can make a real difference.

One uninsured women in Seattle used PriceDoc.com to comparison shop to see which health care providers in her area provided the cheapest gynecological exam.  She said that the only real comparisons she made while searching for health care was price.  In the end, the Seattle woman was able to access what she considered to be quality care at a price she could afford.  But there is that old joke about the perils of looking for bargains in parachutes and brain surgeons to consider. A sheer price comparison implies fungible service.

Congress members are currently in the process of doing their own bargain hunting for health care that won’t break the country’s bank.  While Republicans are said to fear that insurance premiums will increase under the proposed health reform models– partly due to increased taxes on insurers, Democrats counter that the strict regulations to be imposed on insurance companies will drive costs down.  Democrats further talk about the benefits of the health care exchange model, in which the individual market will not be able to deny coverage or charge higher premiums based on preexisting conditions, age rating, or gender rating.  The Center for Studying Health System Change says that these rules, if set in place, will directly lower the premiums that people with medical problems and women will pay.

The Obama Administration has commended the House and Senate bills for incorporating cost-cutting tools.  As a guideline for measuring the cost-effectiveness of the health reform proposals, the Obama Administration has identified four pillars– as found in Ronald Brownstein’s “A Milestone In the Health Care Journey.” Those pillars are:

1.      Taxes on high-end health insurance plans;

2.      Payment reforms that focus on incentivizing doctors to provide quality, coordinated care;

3.      An independent Medicare commission to contain costs; and

4.      A bill that is at least deficit-neutral over the next ten years.

The House and Senate bills incorporate each of the pillars to varying degrees, with the Senate bill thus far the most inclusive.  Congress members say that such principles–and specifics– will be heavily discussed in the coming weeks of debate.

While Americans wait for reform to ring in easier times, they may, however, be left to fend for themselves.  In case you were hoping to give the gift of better health care to a loved one, check here to compare plans, and use these helpful tips to save money on health care.  And don’t forget to schedule necessary appointments to  use what’s left of your current health care allowances before benefits get taken away by the start of a new year!

Taking the Fraud Out of Medicare Expansion

One of the ways the Obama administration hopes to pay for health care reform is through policing Medicare fraud.  It is estimated that the Centers for Medicaid and Medicare Services (CMS) spends $60 billion a year on fraudulent claims.  According to Senator Grassley of Iowa, the federal agency received warnings of fraud by watchdog organizations, but did not respond to most of them; these warnings fell upon the CMS’s shoulders under the Bush Administration.

A report by the Department of Health and Human Services finds that much of the fraud in the Medicare Prescription Benefit program could have been avoided through better management of the companies that were hired by the federal government in 2006 to investigate and monitor the fraud.  Grassley notes that the companies, called Medicare drug integrity contractors or Medics, were essentially a waste of money because they were never given the proper information to perform the audits.  The New York Times reports that the Bush Administration did not allow for the audits by Medics to proceed until its final few months in office.

Under the current model, scams to get Medicare reimbursement for non-existent services are easier than one might think.  Just this past July, a couple who owned a medical business was indicted for submitting false reimbursement bills to the CMS for power wheelchairs that they claimed had been lost or destroyed during Hurricane Katrina.  Other scams include medical suppliers billing Medicare for equipment that was never given to patients, creation of fake medical supply companies, and acceptance of illegal kickbacks for referring Medicare patients to unneeded services.

Solutions to fraud, however, are not as clear-cut as one might wish.  For example, there is a worry that over-policing the CMS will lead to valid claims being denied at greater rates. Also, enforcement and punishment are issues.  Some health care companies have been able to escape criminal prosecution by paying restitution amounts for the fraudulent claims.  Finding restitution to be an insufficient deterrent to would-be fraudsters,  Senator Arlen Specter of Pennsylvania wants to see scammers put behind bars. But there is also something to be said for the realization that the “Arthur Anderson solution” is really no solution at all.

Another interesting aspect to consider here is that the CMS finds that provisions of the House bill intended to reduce Medicare fraud will not save all that much money.  In spite of this (or perhaps because of it) many of our leaders have demanded that some action be taken to reduce Medicare fraud– even Sarah Palin says fraud is an issue.  One hopes that the Obama administration will learn from its predecessor’s mistakes (if in fact they be such) when it comes to creating watchdogs such as Medics, but then muzzling and not feeding them.

Here’s an Idea: Asking Doctors about Health Care Reform

The New York Times just published a very interesting article that ties the efforts of the medical community to bring about change in the American health care system with Congress’s attempts to reform health care through legislation.  The article, which details the research of a team of health care providers in the Intermountain Healthcare system in Utah and Idaho, offers insight into what doctors are doing on their own to effect change while waiting for our nation’s leaders to implement the means to better health care for Americans.

As can be seen by American Medical Association’s recent endorsement of the Democratic House bill, and the long time call of the National Physician’s Alliance for reform, there is a consensus among  health care providers for health care reform.

Of course, essential in that reform is delivery system reform. Part of delivery reform is likely to emphasize not only preventive care, a cornerstone of Obama’s plan, but also a careful monitoring and consideration of the outcomes of health care practices.  Although there is debate about the best way to monitor and measure such practices, and some bridle at the prospect of being “confined” to protocols derived from large studies,  the evidence-based medicine model is emerging  as a favored tool with which to analyze how health care providers themselves can produce more cost-effective, life-preserving results. Evidence-based medicine puts protocols in place (which may be overridden at a doctor’s discretion) and relies heavily on the statistical analyses of a health care system’s performance (i.e., patient outcomes from particular practices).  Such is the model executed by the Intermountain Healthcare system highlighted in the Times article.

The protocols ultimately implemented sometimes differ from the usual course of treatment offered by some doctors. The physicians at Intermountain Healthcare admit that it is often hard for doctors to hear that they are doing something wrong– or perhaps “not optimally” would be a better choice of words.  The Executive Director of Intermountain Healthcare Institute for Healthcare Delivery and Research, Brent James, relates that some doctors do not believe the results of the statistical research because doctors are reluctant to change their ways, but that oftentimes when presented with clear statistical evidence doctors change their practices.  He gives the example of obstetricians who were performing elective inductions prior to 39 weeks for pregnant women for the sake of convenience, as the inductions save hours of labor for the mothers and therefore hours of hospital time.  However, an analysis showed that babies born prior to the 39th week of gestation were far more likely to wind up in intensive care. After doctors saw the data, and protocols were put in place, James found that the rate of elective inductions fell dramatically. A similar protocol developed for the treatment of one form of pneumonia was said to have cut the rate of death for that condition by 40% over several years.

Some doctors contend, however, that the medical metrics of evidence-based models are not the best way to bring change in health care practice, both because doctors will feel pressured to follow set protocols without considering other possible treatments and because humans are not statistical data that can be remedied through calculations and formulas. The danger, of course, is in negating the healing art– in throwing the proverbial baby– independent critical thought– out with the bathwater.  Doctors of this school of thought often espouse  revamped medical education as a better way to reform health care practices; after all, the basis of how health care providers develop their practices is the way in which they were/are taught.

And one wonders if there isn’t room for both approaches. If the education of medical students can be changed to incorporate better and cost effective practices based on studied outcomes (perhaps in part culled from the Health IT initiatives), and changed to incorporate greater emphasis on preventive care (coupled of course with a pay system which rewards patient wellness), while still respecting doctor autonomy so as not to prepare a generation of medical robots. It doesn’t sound “un-doable.”

Interestingly enough, medical schools have seen an increase in students applying to their programs.  In response, four new American medical schools have opened.  With the older generation of health care practitioners on its way to retirement, the need for more doctors is imminent.  But, we need doctors that are able to help carry the new ideals and practices of a reformed health care system; reaching into the med school curriculum would seem to make a lot of sense.

The House Democrats’ Health Care Plan Unveiled, Questions on Women’s Access to Health Care Remain

Last Thursday, October 29^th, House Democrats announced their bill for health care reform, the Affordable Health Care for America Act.  The House bill includes provisions such as a public option and employer mandates.  For women, the House bill has been a controversial issue; though the bill contains provisions that will expand women’s access to certain areas of health care, other areas have been neglected.

On the plus side is the bill’s prohibition of domestic violence being categorized as a pre-existing condition for health insurance purposes.  Ms. Pelosi was able to follow through on her promise to women that such a discriminative practice would be ended through the House bill.  Meanwhile, U.S. News attributes the inclusion of women’s health needs in the bill to the widespread women-led activism for health care reform.  Still, as significant aspects of women’s access to health are yet left unaddressed, some advocates wonder if we should have asked for more.

One issue of contention is that an amendment to the the bill allows for 12 years of exlcusivity for biologic drugs– some of which have been found particularly efficacious in the treatment of breast cancer. In addition to the 12 year exculsivity period, manufacturers will also be able still to engage in the process known as “evergreening,” the practice of changing a drug slightly–such as altering the time release mechanism– and thereby garnering additional periods of exclusivity. These periods of exclusivity prohibit cheaper generic versions of the drug– known as “follow-on biologics” or “biosimilars” from entering the marketplace. (To read more about the biologic exclusivity debate read here and here.) The end result would seem to point– if money matters (and when does it not?),  to a decrease in the availability of breast cancer biosimilars and thus a decrease in available efficacious treatment.  One of the bill’s sponsors, Anna Eschew of California, defends the proposal on the grounds that it does not interfere with women’s access to breast cancer treatment, and that it only curbs the ability of bio-pharmaceutical generic competitors to freely utilize the costly, extensive research and development of the original bio-pharmaceutical innovators.  Eschew believes that lesser periods of exclusivity will have a chilling effect on biologic research and development– as lesser exclusivity would make it more difficult for the original developers of the drugs to recoup the large expenses associated with such development.

Reproductive health care issues have also come to the forefront of the debate, but with a clear consensus yet to have emerged on what the bill does or does not cover within the various exchanges, options and subsidies within the bill.

While political groups are preparing to battle out these issues, one thing remains constant, women are a force that both democrats and republicans want on their side.  The House Democrats were paying attention when drafting their health plan, but the holes still left in women’s health care access might mean that women need to make themselves heard again–and this time, maybe a little louder.

Another Call for Women’s Action on Health Care Reform

Just a little over a month ago, Michelle Obama called upon women to take action to make sure their representatives would vote for health care reform.  This past week, Michelle made another request for women to respond to the national health reform debate during a breast cancer event at the White House.  As the debate seemingly winds towards a conclusion of reform, still, women are unsure that health care reform will actually accomplish that which really needs to be done to help women access better, more comprehensive health care.  While mom’s of America are saying the current health care reform proposals do not include their needs, the National Women’s Law Center exclaims “I am not a preexisting condition.”

The National Women’s Law Center released a second report this month on the affect of gender bias and discrimination in health insurance on women’s lives.  Their report includes an analysis of the discrepancies in health care access between men and women as well as an updated state-by-state comparative chart of states that still allow gender-rating and pre-existing condition discrimination in their health care plans.  Another interesting aspect of the report is the information on states that have, as of late,  reformed their health care systems to be more inclusive of women’s access to health care. One might wonder if the reformation was spurred or enabled in part as a result of the initial report’s publicity.

If you’re wondering about how your state fares in relation to women’s health care issues, be sure to check the most recent NWLC Report as well as Kaiser’s www.statehealthfacts.org.  Also, the Commonwealth Fund has just released a new report comparing the various Congressional health reform bills of 2009.  The report shows that the proposals which seem to pay most (though not enough) attention to women’s health care needs are that of the Senate Health, Labor, and Pensions Committee and the House of Representatives Tri-Committee, which both hope to establish an Office of Women’s Health.  All of these online resources are a great way to get more information and find out where holes in the health reform bills still need to be filled.

To be able to voice direct concerns, the organization Women of Color United for Health Care Reform is hosting a call-in day on Tuesday, October 27^th that will directly connect women to their respective Senators and Representatives.  The calls will be a chance for women to tell their Congress members what they want from health care reform and why allowance of pre-existing conditions denials and gender-rating are not acceptable.  Such calls worked well earlier this month in an event organized by Organizing for America, which enabled callers to tell Congress that they wanted health care reform– with many saying they that really wanted a public option.

Action needs to be taken– and the Obama Administration is asking for exactly that from women.  Though women are most often the health care decision makers in the family unit, men are also needed to voice their concerns:  why their mothers, daughters, wives, and sisters deserve a health care plan that serves their needs.  Call in on Tuesday, the 27^th and let Congress know what’s on your mind.

Opportunities at the Intersection of Health Law and Public Interest (If You Seize Them)

I was given the honor of moderating a panel on Non-Profit Organizations and Health Law at the ASLME Conference at Seton Hall Law last Friday.  After listening to the panelists speak about the benefits and detriments of working in non-profit health law, I was left pondering the potential job opportunities in the field.  The speakers, Keri Logosso of Wynona’s House and Bryn Whittle of the Community Health Law Project, both discussed their journeys toward their respective careers as health lawyers.  One of the women characterized herself as a “non-practicing” attorney, whose original career goal was to become a doctor; the other said she was had never expected to be a trial advocate, but through the eventual twists and turns of her career history found herself representing low-income, disabled New Jersey residents.  Through the narratives of their personal success stories, Ms. Logosso and Ms. Whittle imparted helpful advice for the future health lawyers in the audience.

When did you know you wanted to be a health lawyer? Both of the panelists spoke of the moments in their lives when they realized that combining their passion for serving and healing others with their interest in legal issues was what they wanted from their careers.  Though this was not an epiphany they had early on, both women found that their career choices had come full circle in that each of their prior work experiences led to the eventual goal of practicing health law.  That sort of incremental realization certainly gives hope to those of us who are still unsure as to career paths.

How do I get hired in the field of non-profit health law? Both speakers addressed the characteristics of ideal candidates for jobs in the field of non-profit health law.  While those characteristics included such traditional requirements as past experience in the field, willingness to learn, and strength in knowledge of health law issues– some non-traditional factors also came up:

1.       An aspiring health lawyer needs to have the tenacity that will take him past the initial crush of being turned down from fellowship opportunities or legal work at an advocacy organization. Other opportunities will arise which will ultimately allow one to work towards the goal– but you have to remain open to them.

2.      The recent health law graduate should be willing to take not only that work that ideally interests him but any work that could potentially be of use later on in his career.  Jobs you originally think might not interest you greatly could be career changers as was the case for both of these panelists.

3.      The trained health lawyer must build connections at every step of his career.  Ms. Whittle stressed the importance of getting your name out and building contacts for when you might need references or recommendations.

4.      Finally, the health law student must be tenacious.  The best way to get a job is by making that extra call or writing that additional letter.  Also, the health law graduate should not be afraid to reach out to government leaders.  Ms. Logosso stated that students should call their local elected officials to inquire about available work.  Such techniques helped her once secure the position of Governor Corzine’s Health Policy Advisor.

5.      The health law graduate should not shy away from trying out private law opportunities.  Ms. Logosso said that in such private sector work there are often opportunities to perform high-level pro-bono work and to gain the necessary experiences to develop your strengths as a lawyer.

What’s the competition like? With all that has been happening in the field of health law, it is certainly an opportune time to be looking for a job in the field.  The health law world is experiencing change on a unparalleled level. Such changes will require regulatory, compliance, and litigation advocates in unprecedented numbers as the dust settles on pending reform legislation. Lawyers, at all levels, will help define the fine print. As we posted a few months ago, according to American Lawyer magazine, Health Law jobs are already on the rise.

Having said that, it was also said that competition in the public sector can be stiff– and one needs to prepare oneself fully in order to successfully compete.  The inspiring stories of Ms. Logosso and Ms. Whittle demonstrated, however,  that it is certainly not impossible to get a job as a public interest health lawyer, and that one may work towards the dream job over a period of time– gaining at each turn the skills and experience requisite for that job of all jobs.  It all brought to mind for me that famous quote from Warren Buffet: “I don’t look to jump over 7-foot bars: I look around for 1-foot bars that I can step over.”

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