Tuesday, February 9, 2010

Washington, D.C. (noun): a place where nothing can move, advance or happen

Tom Toles' editorial cartoon in todays Washington Post says it all.

Washington has become a place where nothing can move, advance or happen. Having been paralyzed by a huge snowstorm over the weekend, the federal government has been closed since Monday, our roads are clogged with unplowed snow, our Metrorail system won't run above-ground trains, the schools are closed (until June, it seems)--and to top it off, another 10-20 inches of snowfall is expected in the next 24 hours. (Yes, our trains really don't run when we get more than a few inches of snow. You Chicagoans can stop laughing now.)

Of course, the snow and ice will eventually melt, and Washington will get back to normal. Not so the partisan gridlock that apparently will prevent anything from getting done even when the government reopens for business.

In an effort to break the health care reform stalemate, President Obama invited Republicans to participate in a televised, bipartisan summit, scheduled for February 25. But the House GOP leadership has threatened to boycott the event, writes the Washington Post's Chris Cillizza, unless Obama meets their many demands--including pulling the plug on the current bills and starting over. The Washington Post's Shalaigh Murphy reports that President Obama today told House GOP minority leader John Boehner (R-OH) today that that his core goals -- lowering health-care costs for businesses and individuals and expanding coverage to the uninsured -- remained non-negotiable. But Obama said he would consider GOP alternatives that accomplish the same results. He also said he would sign what he considered to be a "less-than-perfect bill."

Here's the rub. The White House and most Democrats believe a fundamental purpose of health reform must be to provide affordable coverage to all Americans--including the more than 30 million legal U.S. residents who have no health insurance. It is this core belief that caused the House and Senate to produce complex--and costly legislation--designed to ensure that 94-96% of all legal residents would have access to affordable health insurance. By contrast, Laura Meckler writes in the Wall Street Journal that House Republicans reject Obama's standard that the final bill must cover large numbers of uninsured people, quoting Rep. Dave Camp (R., Mich.) as saying: "We didn't portray our bill as being universal coverage . . . We never attempted to do that."

Instead, the House GOP alternative would lower premiums in the small and individual insurance market, with a negligible impact on reducing the numbers of uninsured Americans. According to the Congressional Budget Office, it would "reduce the number of nonelderly people without health insurance by about 3 million in 2019 and leaving about 52 million nonelderly residents uninsured. The share of legal nonelderly residents with insurance coverage in 2019--83 percent--would be roughly in line with the current share." The GOP alternative "would reduce average private health insurance premiums per enrollee in the United States, relative to what they would be under current law-by 7 percent to 10 percent in the small group market, by 5 percent to 8 percent for individually purchased insurance, and by zero to 3 percent in the large group market."

Meanwhile, most voters "want the two sides to keep working to pass comprehensive health-care reform" according to the Washington Post's latest poll. "Nearly two-thirds of Americans say they want Congress to keep working to pass comprehensive health-care reform. Democrats overwhelmingly support continued action on this front, as do 56 percent of independents and 42 percent of Republicans."

The voters may want both parties to work together, but that Democrats and Republicans can't even agree on the ground rules to meet to discuss if they can reach an agreement doesn't bode well for bipartisan progress. Digging Washington out of two blizzards may turn out to be a lot easier than advancing the political prospects for health reform.

Today's questions: Do you believe that covering the uninsured should, or should not, be a principal purpose of health reform? What issues, if any, do you think would be ripe for bipartisan support?


Arvind said...

Covering the uninsured is more appealing politically than practically. Once insurance premiums are affordable, and individuals/families are afforded the same tax credits as employers to purchase medical coverage, and the playing field for consumers and providers are evened out, more people will be able purchase coverage that best meets their needs and budgets, rather than being forced to accept what their employer or Medicaid forces them to take.

There are several more practical ways to provide access to those that cannot afford to buy coverage, which can be discussed. For this to happen, Congress and the President must involve the community physicians in the discussions. Of course that is too much to ask of this administration.

Rich Neubauer MD said...

I think covering all or nearly all needs to be a primary end point of the current reform efforts. I feel this way for several reasons:

1) I think efforts at cost control will be difficult or impossible otherwise. In our current system of haves and have-nots, it is too easy to just look the other way when some group doesn't have the great coverage that you have and to have interest groups therefore just looking out to protect what they have against others that want a piece of the action.

2) The growing ranks of the uninsured is a moral outrage and a blight on the country.

3) The current employer supplied insurance system paralyzes workers into jobs they would otherwise like to move out of. It stifles vibrant economic activity

4) The current situation invites class warfare

5) the cost of supplying emergency (expensive!) care to the uninsured is re-distributed to everyone else, so it is not "free" to society

It is very painful to see the current paralysis in Washington. It is hard to predict what will happen if no reform emerges from this ordeal, but one thing is absolutely for sure. If the uninsured remain as such and their ranks grow with the current jobless recovery, that group will suffer greatly from health care disparities and the effects of that could be far reaching.

Steve Lucas said...

I personally distinguish between insurance, cost and access. Insurance cannot control cost; it can only reduce payments to service providers. When reimbursement reaches a point where there is no profit for the provider, they will discontinue providing the service and you will have an access issue.

Expanding Medicaid to those without insurance may not provide them with access to medical services since they may not find a service provider. Mandating service means the government will take control of all aspects of our medical industry.

My personal goal would be to provide access through dramatically reduced pricing. I personally feel the retainer or cash business model reduces out of pocket cost for many without insurance while providing a more sustainable business model for the front line practitioner.

This model needs to be supported at the federal level through the enactment of tort reform and a national insurance market. Doctors need to practice without looking over their shoulder. Patients need to have a definitive cost structure regarding their medical expenditures.

Today states have mandates, that while conceptually wonderful, add to the cost of basic coverage. The addition of this coverage promotes additional testing, thus becoming a vicious circle of cost escalation.

I feel we have a responsibility to create an environment where those with medical needs can feel financially secure in seeking treatment. I just do not know that expanding a broken insurance system accomplishes this goal.

Steve Lucas

Jay Larson MD said...

Having health insurance coverage just for the sake of having health insurance coverage will not be of benefit to people unless there is associated assess to outpatient providers.
Patients with Medicaid, Medicare, and Tricare are already having access issues to outpatient providers due to low provider reimbursement for office visits.

If the goal of health care reform is to increase access and lower costs, the “value” system will have to change also.

In regards to the Democrats and Republicans working on any part of health care reform in a bipartisan way… well let me put it this way, North Dakota has a better chance of having a balmy winter in the 80’s with no snow.

tomcsmt said...

It seems that our greatest difficulty is defining our questions before we seek answers. To ask " Do you believe that covering the uninsured should, or should not, be a principal purpose of health reform?" invites no serious answer. It depends on who the uninsured are, why they are uninsured, what covering them means, and how you would accomplish the coverage. We will make no progress until we learn to see both the forest and the trees simultaneously.