Wednesday, October 28, 2009

The Public Plan Rorschach Test

The idea of offering people the option of enrolling in a public plan, similar to Medicare, has become the Rorschach test for health reform. Many conservatives see it as a foot-in-the-door that will lead to government-run, socialized medicine. Many liberals see it the same way, as the first step to achieving a single payer system, although fewer will admit to it.

If you distrust and dislike insurance companies, you like the public plan. If you distrust and dislike government, you despise it.

Then there are the deal-makers, the people in Congress who have to find a way to bridge these differences so that they can get a majority in the House and a 60 vote super-majority in the Senate. For them, the policy is less important than the votes they need to pass a bill. They are the ones who dream up things like "triggers", so the public plan would only go into effect if private insurers don't cover enough people and keep costs under control, or state opt-out or opt-ins, so each state could decide whether or not to participate. The deal-makers also have to decide if they will get more votes by having a "robust" public option (meaning that it would pay doctors or hospitals based on the Medicare rates), as the liberals insist, or whether it would use negotiated rates, as many of the "centrists" prefer.

The Hill newspaper is reporting that Speaker Nancy Pelosi (D-CA) will be unveiling an agreement tomorrow to have a public plan option that would use negotiated rates instead of Medicare. Last week Senator Majority Leader Harry Reid (D-NV) announced that the Senate bill will have a public plan with a state opt-out.

But one way or another, the public plan has come back from the dead, as captured in this Halloween illustration brought to us by The Washington Post cartoonist Tom Toles.

The scary thing about the public plan though, may be what it doesn't do, as Fred Hiatt, writes in The Washington Post. He argues that the public plan allows the politicians to pretend they are controlling health care costs while for the most part ducking the issue. Robert Samuelson, also writing for The Post, makes a similar argument, that the debate of the public plan allows Congress to "fake it" when it comes to controlling costs.

I see the public plan in the similar fashion as they do. Although the public plan has become the defining issue for many, I think there is a lot less to it than meets the eye. Depending on how it is structured, it could do some good in introducing some needed competition to the insurance industry, but I hardly believe that its inclusion or not is going to make or break health care reform. Especially since the deal-makers likely will water it down so much it won't have that much negotiating clout in the market.

Today's question: How important do you believe the public option is to health care reform?


Jay Larson MD said...

I agree. The importance of a public option is based on how it is set up. If the plan is robust and is able to keep administrative costs and subsequent premiums down, then there would be some competition in the insurance market.

If the public option uses Medicare rates + 5% to keep premiums down, then it will be detrimental to general internists and other cognitive specialties, which could lead to access issues.

If the public option is a way for Americans to get health insurance when they have no other option, then great.

In the big picture, the public option is probably not a big player in health care reform due to its contentious issues. The public option would not bend the cost curve significantly. Bending the cost curve should fall on physicians to practice responsibly.

Arvind said...

Contrary to your characterization, there is a third category of folks out there - those that don't trust either private insurers nor the government (this includes me and a majority of practicing doctors). It would behoove you as our spokesperson to keep this large group in mind.

Based on the premise of your question, Bob, it is obvious how sold you are on the idea that simply "covering" a few million people with some type of insurance plan will actually constitute "health reform". Nothing could be far from the truth.

Your friends, the "deal-makers" on the Hill, are experts at drafting legislation that never addresses the problem head-on, but rather makes them look good in public, i.e. the next election cycle.

Whatever, they do, it will create a long term divide in the form of a "class-divide" where those that believe in the "public option" will subscribe to it and have their own "health care system" and those that can afford private coverage will have their own.

All this nonsense will, in the end, neither control costs, nor improve access to care, and most dedicated professionals will eventually disappear - we will all be standing in lines at a local CVS or Walmart or the local affiliate of Geisinger or Kaiser Permanente to see the next Nurse Practitioner or Physician Assistant, who in turn will be on-line with a doctor somewhere in the world to "sign off" on the case. Welcome to the beginning of conversion to the Third World.

PCP said...

This whole debate has become more about ideology on administering it rather than health care delivery reform. The ideological divide is over the role of Gov't vs Insurers in it and who gets how much share of the market.
Very little is done to address the main issues of health care delivery and financing.
The monstrous administrative costs.
Lip service is being paid to Physician Generalist workforce issues. Almost no funding for GME expansion to deal with the 15% extra insured. A mere 5-10% extra for PCPs with a 200-300% pay differential compared to procedural specialists.
No discussion about misalocation of resources, and lack of value based purchasing of goods and services.
Nothing to address the "consumerism with a 3rd party payer" scam. Nothing but lip service to Tort reform.
Nothing to seriously regulate the insurers and turn them into utilities with fixed annually approved rate increases.
Nothing to educate the public about lifestyle issues, to encourage healthier lifestyles, and nothing to increase personal accountability(en contraire, reforms don't broach topics like premium adjustments based on riskier lifestyles etc)
We as a nation are on the precipice of bankruptcy, and i do not think many of us understand how close we are following the virtual blanket of money we have put over the financial system to prevent collapse, fewer consider what this new entitlement will do to get us there. Sans delivery system reform and some sensible method of regulating demand and instituting value based purchasing'
I hope this thing implodes as I said before. I want reform more than most, but this ain't it. Finally the not too surprising(for me) defeat of the SGR repeal, shows to me, we Doctors are being used/abused in this process. Our responsibility gene is being used against us. We are being taken for granted. If we were going to go out on a limb to support this, which was never a good idea IMHO, then surely we needed to get more respect than what we got last week. With so much waste in the system, why are we the ones that have to go cup in hand each year to beg for restitution of last years fees? I am sick of it. I am a professional and I should be able to set my fees. How did we let it evolve to this from "usual and customary"? We need to take a long hard look at that and consider our options in future lobbying efforts. Maybe one of these years letting the 25% cut happen will galvanize us to do something.
We will near certainly get all stick and no carrot out of this. Most PCPs are already getting more stick than they can handle.

Jay Larson MD said...

PCP makes excellent points. Health care reform should have an emphysis on delivery system and tort reform in addition to insurance reform. Current health care reform still does not deal with the difficult issues.

Primary care will continue to tank until one day someone notices that all the general internists and FP's are gone. Those few left fighting in the trenchs will answer with a resounding "Duh".

Rich Neubauer MD said...

I’ve started to think of the current efforts to reform health care delivery as phase one of something that will be going on for some time. In that sense, the success or failure of the current effort may depend on how well or poorly it sets the stage for future developments.

One aspect of this is that if we stay on the same trajectory that we are on now, we are on a collision course with disaster. There is every reason to believe that unless we set the stage for major change, we will consume an ever increasing portion of the GDP in health care. Along those lines, making a philosophical decision now that a key feature of our system should be covering all our citizenry would be a superb foundation for the future. Personally, I am skeptical that anything but a public plan can accomplish that.

A second aspect is cost control. Given the complexity of issues involved in cost control, and the dysfunctional underpinnings of our current system, it should surprise no one that we have not addressed this problem effectively. It will not be easy, but I think the need for comprehensive efforts to reduce cost will be starkly evident once we do move on from the current system. The current system essentially hides the human cost of “irrational rationing by denial” and gets away with it by punishing those who are generally the least effective advocates. Cost control will affect physicians, industry, individuals, but should be possible without decreasing quality. In my opinion the only way to accomplish it is first to get everyone in the tent. Otherwise, all players will just grind in their heels and advocate for narrow interests. Again, I think a public option is the only way to do that.

A third aspect is access. Adding supplicants to the system will uncover the not so hidden problems we already know are there in workforce. I recall the frustrating discussions I had just a few years ago with CMS representatives at our ACP national meeting where they noted that “we have no indications that there are serious access problems.” At the time my response back was “just keep doing what you are doing, and you will soon see serious access problems”. At some point, and it might as well happen sooner than later, our government will need to fully recognize that via the power of their programs, they actually do control the demographics of what health care workers do within our systems of care. Turning around the primary care collapse that threatens will be 2 parts wise choices in government, and 1 part needed changes “in the profession”. A path to the needed changes in the profession is already laid out in the advanced medical home.