Reform Rodeo

1. Sen. Baucus, releases the Finance Committee’s public option-less, co-op-based draft bill that will be marked up later in the month (full draft in PDF here, Baucus’ interpretation of it in today’s WSJ op-ed) .

1(a). Ezra Klein opines about how “BaucusCare” should be improved, and in doing so provides a good overview of some of the draft’s key provisions.

2. The New York Times has a nice primer on one of the most discussed possibilities reforming health care: health insurance exchanges. It is definitely worth following the link the Times provides to the FEHB online comparison tool to see how easy it is for federal employees to shop for health insurance.

3. The Kaiser Family Foundation has released their annual report (summary in PDF format here, full report in PDF format here) the shows the changes in employer health benefits.

4. The Robert Wood Johnson Foundation summarizes a New England Journal of Medicine poll which finds that a majority of physicians support a public option.

5. The Health Care Blog has a nice run-down of HHS’s effort to retake control of EHR certification from CCHIT–and what the not-for-profit CCHIT is doing in response.

6. In Case You Missed It: Professor Nathan Cortez in The Health Care Blog on “Immigrants, Health Reform, & Lies” — originally posted here on HRW.

If You Give a Republican a Cookie…

Senator Charles Grassley (R-Ia), who is seeking re-election next year and is said to have wrested key concessions from his Democratic counterparts in the Senate– including, according to AP, “an agreement to back away from a government plan to compete with private insurers” –dipped his beak in the ignominious trough of the demagogue over the weekend. AP reports that Sen. Grassley

told an Iowa crowd he would not support a plan that “determines when you’re going to pull the plug on Grandma.” The remark echoed conservative activists who wrongly claim a House health care bill would require Medicare recipients to discuss their end-of-life plans with doctors.

In addition, with recent (perhaps hasty) speculation regarding the demise of a Public Option in Health Care Reform, The Wall Street Journal reports that “The number two Senate Republican said Tuesday replacing a public health care option with a nonprofit private cooperative wouldn’t win any more Republican support, saying they are essentially the same thing. Sen. Jon Kyl (R., Ariz.), said Republican objections were more fundamental than simply changing the name of a new national entity to compete with private medical insurers.”

Senator Kyle, who as Whip is said to speak for the Republican Party,  favors a more private market based approach to health care reform–utilizing such means as medical malpractice reform, allowing small businesses to join together to give them more negotiating clout with health insurers, and allowing health insurance to be permitted to be sold across state lines like other forms of insurance. In addition, Sen. Kyle is reported to support federal government encouragement of “individuals to save more for potential health care needs through tax-friendly accounts, which would reduce their reliance on costly insurance.”

Notably, in a 2006 report on the affect of the minimum wage on families in Sen. Kyl’s home state,  the Children’s Access Alliance of Arizona stated that “Arizona has the widest income gap in the nation. The average income of the top 5% of Arizona families is 14 times greater than the average income for the bottom 20% of families.” Also worth noting is that Senator Kyl voted against increasing the minimum wage in 1997, 2005 and 2007.

On Health Care Legislation, according to On the Issues.org, Sen. Kyle voted as follows:

• Voted YES on means-testing to determine Medicare Part D premium. (Mar 2008)
• Voted YES on allowing tribal Indians to opt out of federal healthcare. (Feb 2008)
• Voted NO on adding 2 to 4 million children to SCHIP eligibility. (Nov 2007)
• Voted NO on requiring negotiated Rx prices for Medicare part D. (Apr 2007)
• Voted YES on limiting medical liability lawsuits to $250,000. (May 2006)
• Voted NO on expanding enrollment period for Medicare Part D. (Feb 2006)
• Voted NO on increasing Medicaid rebate for producing generics. (Nov 2005)
• Voted NO on negotiating bulk purchases for Medicare prescription drug. (Mar 2005)
• Voted YES on $40 billion per year for limited Medicare prescription drug benefit. (Jun 2003)
• Voted NO on allowing reimportation of Rx drugs from Canada. (Jul 2002)
• Voted NO on allowing patients to sue HMOs & collect punitive damages. (Jun 2001)
• Voted YES on funding GOP version of Medicare prescription drug benefit. (Apr 2001)
• Voted NO on including prescription drugs under Medicare. (Jun 2000)
• Voted YES on limiting self-employment health deduction. (Jul 1999)
• Voted NO on increasing tobacco restrictions. (Jun 1998)
• Voted YES on Medicare means-testing. (Jun 1997)
• Voted NO on blocking medical savings accounts. (Apr 1996)
• Rated 0% by APHA, indicating a anti-public health voting record. (Dec 2003)

More extensive analysis of the votes may be found at On the Issues’ 18 full quotes on Health Care.

In a statement on Senator Kyl’s own website regarding Health Care, he notes that “The shortage of health care professionals is due, in part, to Medicare’s efforts to control costs.”

Senator Kyl has repeatedly opposed what he terms “government intervention” in the health care and health care insurance market, stating that it will invariably lead to bureaucrats standing in between patients and their doctors and what will ultimately amount to the rationing of health care.

Interestingly enough, on his website Sen. Kyl notes that in his home state of Arizona, “The average wait for a consultation with a gastroenterologist in the Phoenix area is now two to three months. Mesa hospital administrators report acute shortages of both orthopedic surgeons and neurologists, resulting in emergency room and inpatient consult delays.”

Senator Kyl does not seem to equate such waits or shortages with any form of market based “rationing” and states that the long waits for care at present are “partly due to exorbitant medical liability premiums and the lack of physicians willing to practice under the threat of lawsuits,” and, presumably,the above mentioned “Medicare’s efforts to control costs.”

Regarding Medical Malpractice as a means of Health Care Reform, Senator Kyl, as we’ve reported before, according to Bloomberg.com might be be best to look elsewhere. Regarding real Health Care Reform, for those who had entertained the notion of Bipartisan dialogue as a means to passing comprehensive legislation, they too might be best to look elsewhere. I would suggest, for now, while there are still cookies to be had, the House–where a substantial number of Democratic Representatives have insisted that they will not vote for any reform measure which does not include a Public Option.

Schumer v. Grassley, Face the Nation

On Face the Nation, Senator Chuck Grassley reaffirmed his opposition to a public option, stating that “the power of government is an unfair competitor.” He also, however, expressed an openness to health care cooperatives, if they are “in the area of what we have known in cooperatives in America– and there’s even a few insurance cooperatives already operating in America– if they’re within what we have known of cooperatives and the concept of cooperation for the last 150 years, I think we can reach a favorable compromise.”

This may be too much to ask, but Senator Grassley (or at least his staff) follows this blog on Twitter– or at least did before this post. But as regards the failed history of health insurance cooperatives in America, the essentially moribund state of those cooperatives which do still exist, and the difficulty of implementing an effective cooperative plan, he might be well served to read these posts by Professors Timothy S. Jost, “Jost on Cooperatives,” and Tim Greaney, “Market Entry by Health Care Cooperatives: Neither Quick nor Easy. ” Might I also suggest that as we look to reform healthcare in America, the spectre of legislating anew “what we have known” and functioned under is not particularly reassuring. The prospect of “overhauling” health care is appealing simply because “what we have known” doesn’t work.

And I guess the question is, with a filibuster-proof majority in the Senate, a proposal which includes a Public Option making its way out of the Senate’s HELP committee, and a similar proposal emanating from out of the House, ultimately how essential to the issue is what Chuck Grassley thinks ? Yes, he can wrangle and tie up a bill in the Finance Committee– but he and his Republican comrades in private insurance arms can’t tie up all the bills– nor do they have enough votes to quash, or even do more than delay a vote on a bill before the Senate for a mere 30 hours post-cloture. With the advent of the Democrat’s filibuster-proof majority, as long as those Democrats can muster the political will, might I suggest that Senator Grassley’s position has been relegated to being nothing more than a day plus 6 hours of inconvenience? But sure it would be nice to have the benefit of Senator Grassley’s expertise in health care.  Just as it would also be nice to have the entirety of Congress along for the ride instead of kicking an screaming and casting blame and aspersions along the way– but the American Public has seen fit to no longer grant the Republicans more than a “suggesting” seat at the table: their vote no longer essential, their power diminished accordingly– their views relegated to their own merit or lack thereof, void of the political power derived from a substantial bargaining position. Under these circumstances a compromise which leaves us with “reform” void of substantive change in the form of a public option is both unnecessary and, might I say, the result of a failure of will and command.

However, faced with strident opposition to the Public Option from Senator Grassley, the realization of Democratic Party power was evident in Senator Schumer’s response.  Schumer cited the “strong public option” contained within the current proposals from both the House and the Senate’s HELP Committee and stated that in “the Finance Committee, we’re trying to come to some form of compromise. But make no mistake about it, the President’s for this strongly and there will be a public option in the final bill.”

Spoken like a man with all the votes he needs.

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Public plans and chronic care

 

The public plan question continues to permeate health reform discussions.   Last week, surprising analysis from the CBO seemed to be leading some Democrats to support stripped-down reform.  On Sunday, polling data was published showing overwhelming support for a public plan that could compete with private plans in a reformed marketplace.  Senator Conrad has proposed a “health cooperative” as a “compromise” between those for and against public plans, suggesting that a plan operated by and for its members could serve many of the functions of a public plan, without presenting the political problems presented by public plans - which he regarded as insurmountable.

Tim Jost and Tim Greaney in previous posts here and here have raised important concerns about cooperatives.  Cooperatives, as they point out, are not new; in the form of mutual insurers, non-profits, and Blues, things very like what Senator Conrad describes existed for decades.  Unfortunately, they have mostly wandered from their community mission to mimic the business practices of for-profit insurers.  Senator Conrad may be agreeing on forms of oversight and organization of a “cooperative” that may lessen the gulf between his original proposal and those of public plan proponents.

What does this have to do with chronic care?  Reform 2009 has focused on access and the uninsured, although cost is certainly another driver.  It is now well-known that health costs are not homogeneously spread; instead, a small number of people need most of the expensive care each year.  Many of these people need expensive care because they are living with multiple chronic illnesses.   Care for chronic conditions is often poorly coordinated, and the costs of care are increasingly shifted to the patient in the form of copayments, coinsurance, and deductibles.

Current draft reform bills gesture to the need to coordinate chronic care.  The House June 19^th House version, at section 1178, would create “fully integrated dual eligible special needs plans” to “optimize” the health and well-being of people eligible for both Medicare and Medicaid, with serious chronic illnesses, and at section 1302, would create a Medicare medical home pilot program for people with chronic illness.  What about those covered in the private marketplace?  Section 1441 would add as a “consideration” in the Secretary’s setting of health priorities “health care provided to patients with prevalent, high-cost chronic diseases.”        The Senate version would directly address the chronically ill in private insurance.  Section 101 would amend the National Health Service Act to require health coverage to contain  ”care coordination and chronic disease management” activities, as well as “medical home” provisions which, as described further in section 212 of the draft bill, would require the plans to provide for medical teams to coordinate chronic  care.

Adding chronic care management provisions to Medicare and Medicaid is a good step.  Nudging private plans to provide appropriate chronic care is also a good thing.  As Robert Kane (University of Minnesota), Edward Wagner (MacColl Institute), Thomas Bodenheimer (UCSF), and others have increasingly demonstrated, patient-centered, clinically-based chronic care coordination has the potential to greatly improve care and patients’ quality of life.  There is increasing evidence that chronic care management can save money, as well.

Private plans - for-profit and non-profit - are aware of advances in chronic care, and to varying degrees have adopted innovative care coordination methods.  But they don’t do enough, for two entirely rational reasons.  First, employers and individuals switch health insurers frequently, for a variety of reasons, leading insurers to regard members as “theirs” for only a few years.  Paying for expensive care (e.g., bariatric surgery for obesity) that pays dividends over a longer time frame, then, pays dividends for their competitors.  Second, insurers who do an excellent job maintaining panels of chronic care specialists, and coordinating care among them, risk becoming “sick people magnets,” attracting exactly those people their actuaries tell them will hurt their bottom line.  Risk adjustment is a partial corrective, but clearly does not level the playing field enough in a market where marginal profits spell success or failure.  Mandating that insurers act against their interests is the right thing to do in this case, but we should not be surprised if they react with less than dizzying zeal.

We all have a chronically ill parent, child, grandparent, or friend whose health has spiraled down because our current delivery and finance systems have failed them.  There are many barriers to reversing the trend away from patient-centered, humane, chronic care.  One barrier that must be addressed is the structural failure of our competitive health insurance market in this regard.  It doesn’t pay to be good at chronic care, and things that don’t pay are, for perfectly understandable reasons, problematic in that marketplace.

President Obama said yesterday that competition from public plans can be “an important tool to discipline insurance companies.”  Others have argued that the public plans can serve as a benchmark, or a compass setting, for private plans.  In chronic care management, here’s what that might get us.  A public plan can be charged with doing an excellent job coordinating chronic care.  Private plans can be similarly charged, but, for the reasons described above, they will have strong market interests to avoid that charge.  The public plan in this area (as in others) can allow us to recognize, by comparison, how well private insurers are doing at the task we most need them to do: provide care for the ill — for those who really need health coverage and care.