Friday, October 31, 2008

The big issues the candidates are not addressing: The cost of health care

The cost of health care

Question to our readers:

What is the greatest fiscal challenge facing the United States?


Health care costs.

Many readers might be surprised by this answer, since a more obvious choice, given today's headlines, is the sub-prime mortgage and credit crisis. But rising health care costs are likely to have even more catastrophic consequences for the federal budget and the national economy.

Peter Orzag, the director of the Congressional Budget Office, a non-partisan agency that advises Congress on budget policies, had this to say:

"Rising health care costs and their consequences for Medicare and Medicaid constitute the nation's central fiscal challenge. Without changes in federal law, the government's spending on those two programs is on a path that cannot be sustained."

The CBO is concerned because the rising costs of Medicare and Medicaid will add to an explosion of federal debt and consume an ever growing share of the federal budget, leaving diminished budget resource available for other purposes. Medicare has a payroll tax structure that depends on more people paying in than taking money out, but there will be a continued decline in the number of taxpayers paying into the program and a huge increase in the number of people claiming benefits. (The Kaiser Family Foundation has an excellent chart the illustrates the problem.)

Dr. Orzag's slide presentation from a lecture he gave at Stanford University describes the problem and possible solutions. He observes that most discussions in the media misdiagnose the problem, attributing it to aging and demographics, when most of the fiscal problem is due to rising cost per beneficiary (not number or type of beneficiaries). His slides present some fascinating observations from behavioral science about the reasons for increased health care spending, including what can be learned by studies on how the size of containers affects consumption of fresh and stale popcorn (see slides 24-26)! (The popcorn slides refer to a study in the Journal of Nutrition Education and Behavior, which found that "container-size influence is so powerful that even when the popcorn was disliked, people still ate 33.6% more popcorn when eating from a large container than from a medium-size container.")

What have Senators Obama and McCain been saying about the costs of health care, and specifically, Medicare? Again, just as was the case with the primary care crisis discussed in yesterday's blog, not too much. As shown in ACP's web tool that compares the candidate's positions, they have some modest proposals to create incentives for prevention and wellness; to improve care coordination; increase transparency by reporting on quality and cost of care; to fund comparative effectiveness research; and to increase use of health information technologies. Few experts believe, though, that such measures alone will solve the problem.

Without serious policies to slow the growth in health care, the next President--particularly if he is fortunate (or unfortunate) enough to be elected to a second term--could face a "Medicare meltdown" that exceeds the challenges posed by today's economic crisis. Bailing out Wall Street is tough enough, but what will it take to bail out the almost 62 million people who will be on Medicare by 2020?

Today's questions to our readers: Do you agree with Dr. Orzag that health care spending is the greatest fiscal challenge facing the Unites States? If so, what would you recommend the new President and Congress do about it?

Thursday, October 30, 2008

The big issues the candidates are not addressing: Access to primary care

Access to primary care

Between now and Election Day, I will be inviting your comments about the big health care issues that neither Senator McCain nor Senator Obama are addressing--or at least not emphasizing in the campaign.

Today's topic: the impending collapse of primary care medicine in the United States.

In January 2006, the American College of Physicians warned that primary care was heading for collapse, citing the decline in the numbers of young physicians choosing primary care specialties like general internal medicine, and evidence that general internists were leaving the field in greater numbers than subspecialists. The paper received a lot of favorable comment, but also a fair amount of comment that the word collapse overstates the problem.

Now, few argue the point that the United States is facing a huge shortage of primary care physicians for adults. A study published in Health Affairs estimates a shortage of 35,000 to 44,000 primary care doctors for adults by 2025. The Journal of the American Medical Association reports that only two percent of fourth year medical students plan to go into general IM. The message is getting out to the broader public as well: the November Reader's Digest writes that "soaring office costs demanding insurance companies, low Medicare payments, staggering debt, and politicians who refuse to make hard choices are driving primary care physicians out of business." ACP President-elect Joe Stubbs, a general internist in Albany, Georgia, was quoted by Reader's Digest as calling the primary care issue "an evolving crisis of unprecedented proportion."

Yesterday's Washington Post reported that the experiences in the two states have guided the health care reform proposals of Senators McCain and Obama: Senator Obama has looked to the Massachusetts experience, and Senator McCain has looked to Minnesota. As the Post noted in its article, "the large number of people who have gotten insurance [under the Massachusetts plan] and are suddenly looking for care has aggravated a shortage of family physicians and other primary-care doctors" in the Commonwealth.

So what have the candidates said about primary care? Not too much. As ACP's comparison of the candidate's positions shows, Senator Obama's plan mentions the importance of primary care and the need to reduce medical education debt, but that is about it. Senator McCain's plan does not propose any policies to address the primary care shortage, although the GOP's convention platform mentions its belief "in the importance of primary care specialties and supporting the physician's role in the evaluation and management of disease."

The problem for the next President is in the absence of policies to reverse the collapse of primary care, access and outcomes will be poorer and costs higher. Even if the new President and Congress could agree on a plan to dramatically reduce the number of uninsured, they may find that there aren't enough primary care doctors left to take care of them, just as Massachusetts has found. Giving someone an insurance card doesn't give them access if they can't find a primary care doctor to take care of them.

Today's questions for our readers: Do you agree that primary care is nearing collapse? If so, what should the next President do about it?

Wednesday, October 29, 2008

Is health care a privilege, a right, or a responsibility?

One of the most provocative topics during this election year came in the form of a question posed by moderator Tom Brokaw during the October 8 presidential debate:

"Is health care in America a privilege, a right, or a responsibility?"
Senator Obama responded, yes, "It should be a right for every American." Senator McCain replied that "I think it's a responsibility, in this respect, in that we should have available and affordable health care to every American citizen, to every family member. . . But government mandates I -- I'm always a little nervous about."

The question of whether health care is a right or a responsibility--could it be both?--is explored in excellent commentary by Maggie Mahar. She writes in the The Health Care Blog that "The idea of health care as a 'right' is usually pitted against the idea of health care as a "privilege." Given that choice, I'll circle 'right' every time."

But she notes that defining health care as a right can come across as "shrill and demanding" and cites the views of a Dr. Shadowitz, an emergency physician and self-described "fellow traveler" of the "angry left" who writes in his "Moving Meat" blog that:

"When we use the language of 'rights,' we are generally discussing very fundamental liberties, which are conferred on us at birth, and which no government is permitted to take away: free speech; religion and conscience; property; assembly and petition; bodily self-determination; self-defense, and the like. Freedoms. Nowhere in that list is there anything which must be given to you by others."

Some conservatives are taking this view to create a legal bulwark against government-mandated coverage. George Will writes approvingly in The Washington Post of an Arizona resolution that, if approved by voters on November 4, would enshrine in the state's constitution the right of people to make their own health care choices without government interference. Resolution 101 reads:

"Because all people should have the right to make decisions about their health care, no law shall be passed that restricts a person's freedom of choice of private health care systems or private plans of any type. No law shall interfere with a person's or entity's right to pay directly for lawful medical services, nor shall any law impose a penalty or fine, of any type, for choosing to obtain or decline health care coverage or for participation in any particular health care system or plan." [Emphasis added]

Many doctors, fed up with government price controls that undervalue their services, may like the part about guaranteeing the individual's the right to pay for lawful services. Even so, physicians who believe, as ACP does, that the government must guarantee coverage should be concerned about Resolution 101. It turns the entire rights debate on its head, establishing rights that would limit the government's ability to require coverage instead of creating a right to coverage as health care rights advocates have long argued.

What do you think--is health care a right? A right to affordable coverage? Or a right to make health care decisions without government interference and mandates?


Welcome to the inaugural posting of the The ACP Advocate Blog by Bob Doherty!

Today's topic, Is health care in America a privilege, a right, or a responsibility?, is covered in a separate post.

First, I want to tell you a little bit about myself, the editor of this blog.

I have been advocating for internists and their patients for almost 30 years, first with the American Society of Internal Medicine, and then with the American College of Physicians, following the merger of ASIM and ACP in 1998. I am not a physician, but a lobbyist/policy guy who helps doctors influence health policy on behalf of their patients.

I am also a lifelong New York Mets fan and former vendor at the late (great?) Shea Stadium, making me well-prepared to accept disappointment (Especially required of Mets fans the past two seasons!) and deal with a cacophony of strong opinions--essential traits for advocacy in the nation's capitol!

This blog will reflect my work with ACP, but will not be a mouthpiece for ACP's positions. Instead, I hope to invite commentary on the most provocative and intriguing health policy discussions I come across in my daily work.