Reform Rodeo II

Photo by David Monniaux

1. On the Public Option Developments:

The New Republic has an optimistic assessment of the recent developments which are said to have forced the Obama administration to adopt a more centrist strategy.

2. On Exercise:

An interesting article in Time Magazine describing the counter-intuitive results that exercise–particularly strenuous exercise–may have on weight gain. However, see this article in the New York Times, describing a Finnish study which found that strenuous physical activity–and not moderate physical activity–reduced the risk of a suffering from a number of different types of cancer.

3. On Treatment Guidelines:

The New York Times also has an interesting discussion of the difficulties of implementing national treatment guidelines that aim to help health care providers utilize best practices. (Note: The article may require a free New York Times account).

4. On Payment Reform:

A recent piece in the New England Journal of Medicine explores the implementation of alternatives to the fee-for-service model.

5. On Taxing Health Benefits:

Merill Goozner frames the taxing of health benefits, arguing as others have, that taxing health benefits may in fact be regressive.

6. On the Best Health Care In the World:

Ezra Klein has a nice discussion of (and link to) an interesting post by the Urban Institute where they explore the (un)truthfulness of claiming that the U.S. has the best health care in the world.

7. In Case You Missed it:

Professor Tim Greaney  in The Health Care Blog: “Market Entry by Health Care Cooperatives: Neither Quick Nor Easy” (Originally posted here on Health Reform Watch, then picked up by THCB).

8. In Case You Missed it:

Professor Timothy S. Jost in The Health Care Blog ,”Are Cooperatives a Reasonable Alternative to a Public Plan?”  (Originally posted here on Health Reform Watch, then picked up by THCB).

9. Wild card Pick: If you haven’t heard about the astounding medical applications of a pooch’s powerful snout, this short video (with an accompanying transcript) from National Geographic is definitely worth watching.

If You Give a Republican a Cookie…

Photo by Clara

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.

Market Entry by Health Care Cooperatives: Neither Quick Nor Easy

[Ed. Note: Considering recent speculation that the Public Option may be "dropped" in favor of adoption of Health Care Cooperatives, this post, which originally appeared in Health Reform Watch back on June 15th seems particularly worthy of reiteration. For those of you unfamiliar with Professor Greaney's work, he is the Chester A. Myers Professor of Law and the Director, Center for Health Law Studies, St. Louis University School of Law. A frequent contributor to HRW, he is a nationally recognized expert on health care law; Thomas Greaney has spent the last two decades examining the evolution of the health care industry. His bio may be accessed here; his recent testimony to the Senate on "Competition in the Health Care Marketplace" may be found here.]

Tim Greaney, St. Louis University School of Law

The idea of establishing regional cooperatives, advanced as an alternative to President Obama’s public plan option, has attracted attention as a means of assuring that health reform legislation contains some means to improve competition among health plans around the nation. But the proposal, which may have superficial appeal as a “middle ground” between a public plan option and an unchecked private market, is ill-equipped to fix the key problems a public plan would address. In addition, recent experience teaches that timely and effective entry by such plans is unlikely.

The first issue is whether a cooperative, organized by consumers or other groups, can effectively deal with the shortcomings of the existing delivery system and insurance market. Thus far, the proposal advanced by Senator Conrad is pretty sketchy, but are grounds for skepticism. A central reason for having government sponsored plans is to allow the efficiencies of Medicare’s well-established administrative structure and innovative payment experiments to carry over to the private sector. Coops provide no such advantage. A second advantage of public plans is that they would likely achieve some bargaining leverage by virtue of their probable role as insurer for people representing higher risks whom private insurers find some methods to avoid. Hospitals and physicians will be hard pressed to bypass such a significant presence in the market and the public plan can thereby exert market-wide pressure to keep provider and pharmaceutical costs down. Whether co-ops will be willing to undertake the role of covering such individuals or able to sponsor innovative delivery systems to treat them is far from certain.

In any event, it is hard to envision numerous regional coops gathering the necessary data, experience and reputation to serve as a benchmark or counterweight to dominant hospitals and provider groups across the country. Further, there is a serious question regarding the independence and mission of coops. It is a mistake to assume that nonprofit entities will necessarily work to the advantage of the public. Unfortunately, our experience with nonprofit hospitals and HMOs suggest that they can easily be persuaded to play along with other providers and may not always vigorously pursue their charitable mission. Keeping cooperatives’ eye on the ball would require close attention to the control and governance of such entities.

The second objection is based on timing and practical considerations. There is ample evidence from our experience with health insurance markets that developing effective coop-sponsored plans will not come easily or quickly. It is clear that new entrants into health insurance markets face a host of obstacles. The prevalence and magnitude of entry barriers is evidenced by the dominance and profitability of existing insurance plans. One or a handful of companies dominate most health insurance markets around the country and these firms have enjoyed consistent and robust profits. Economic theory would suggest that such profit opportunities should have invited entry by rivals eager to capture some of the profits available in those markets.

Additional proof of the obstacles to entry are found in the investigations by insurance commissioners into proposed mergers in their states. In Pennsylvania for example, the proposed merger of Highmark and Independence Blue Cross would have combined the dominant insurers in two large distinct geographic regions of the state. Evidence provided to the State indicated that numerous attempts by regional and national firms such as Aetna and Coventry to enter both markets had proved unsuccessful over the years. Expert studies suggested that a variety of factors including brand loyalty, difficulties in securing physician and hospital network contracts, regulatory and information gathering costs, and obstacles created by the contracting practices of incumbent providers, thwarted entry. Newly formed coops needing to acquire expertise and develop networks will surely face enormous difficulties penetrating markets.