The ACP Advocate Blog

by Bob Doherty

Thursday, January 28, 2010

Did Obama's SOTU address give enough of a lift to health reform?

In my mind, President Obama's State of the Union speech settled, at least for now, the question of whether he remains committed to health reform:

"So, as temperatures cool, I want everyone to take another look at the plan we've proposed. There's a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo. But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. Let me know. Let me know. I'm eager to see it. Here's what I ask Congress, though: Don't walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people. Let's get it done. Let's get it done."

But will Obama back up his words by putting the full weight of his office behind the effort? Roll Call reports that Democrats are looking to the President to help them find a "clear path" to break the gridlock, and some remain doubtful about its chances.

Perhaps the most important development, other than Obama's speech, is a declaration today by Speaker Nancy Pelosi (D-CA) that she has the votes to pass health reform if the Senate agrees to adjust the bill through the budget reconciliation process, which requires only a simple majority. Channeling Winston Churchill, Pelosi is quoted as saying, "We'll go through the gate. If the gate is closed, we'll go over the fence. If the fence is too high, we'll pole vault in. If that doesn't work, we'll parachute in. But we're going to get health care reform passed for the American people." Senator Majority Leader Harry Reid (D-NV) also is "looking very closely" at the reconciliation option, according to Roll Call.

There are big differences between the House and Senate bills, though, so it will require President Obama's direct involvement and leadership to get agreement on the changes to be made through reconciliation and persuade a majority of Democrats to go along.

What about the GOP? I would like to believe that there could be agreement on an approach that would attract bipartisan support, but I doubt it. Republicans uniformly will oppose use of reconciliation to "force" enactment of health care. The Democrats will counter that reconciliation is justified to overcome Republican "obstructionism" in the Senate, which prevents legislation from being passed by a simple majority vote, and they will remind people that reconciliation was used to pass the Medicare Part D prescription drug program and the Bush tax cuts when the GOP controlled Congress.

The one area that could have been a fertile ground for bipartisanship is medical liability reform, but it is probably too late for that. The President asked for "better approaches" from either party to reduce the deficit and lower premiums. The CBO estimates that tort reform would "lower costs for health care both directly, by reducing medical malpractice costs - which consist of malpractice insurance premiums and settlements, awards, and legal and administrative costs not covered by insurance - and indirectly, by reducing the use of health care services through changes in the practice patterns of providers" and "reduce federal budget deficits by about $54 billion during the 2010-2019 period." Unfortunately, I don't see the President doing the heavy lifting within his own party to enact tort reform, and I don't see Republicans agreeing to support the broader health reform bill even if he did.

Finally, the wild card in all of this is whether the President's speech and subsequent actions will slow the erosion of public support. Last night, the President acknowledged the problem:

"Still, this is a complex issue, and the longer it was debated, the more skeptical people became. I take my share of the blame for not explaining it more clearly to the American people. And I know that with all the lobbying and horse-trading, the process left most Americans wondering, What's in it for me?"

The Kaiser Family Foundation's latest health tracking poll, fielded earlier this month but before the Massachusetts special election, found the public evenly divided overall about the health reform bills, but that, "Majorities reported feeling more favorable toward the proposed legislation after learning about many of the key elements, with the notable exceptions of the individual mandate and the overall price tag."

President Obama's speech provided a lift to health reform, but he will need to do more to persuade a skeptical public about what's in it for them.

Today's question: Do you think Obama's the State of the Union address lifted the prospects for health reform?

Wednesday, January 27, 2010

Which countries have the longest waits for medical care?

Yesterday, I borrowed liberally from Dr. Seuss' "Oh, the Places You Will Go" to describe the "weirdish, wild space" - The Waiting Place - in which we now find health reform.

This got me thinking about The Waiting Place in a different context: the time it takes to get an appointment with a physician. Anyone one of us who has had to wait weeks, or even months, for an appointment would agree that The Waiting Place is, as Dr. Seuss described it, a "most useless place" to be.

Critics of the pending health reform bills, like Conservatives for Patient Rights argue that they will lead to longer wait times for appointments. Their argument being that "government-run" health care, as exists in Canada or the United Kingdom, has been demonstrated to result in long waits for medical appointments.

I would dispute the premise that the reforms being considered by Congress are akin to the systems in place in Canada or the United Kingdom. Like it or not, the House and Senate bills would maintain private, employer-based health coverage as the principal source of insurance coverage. Still, I began to wonder about what the data show about wait times in different countries.

In 2007, the Commonwealth Fund released a report that compared U.S. health care against several other countries based on a variety of benchmarks. The data were principally derived from statistically random surveys of adult residents and primary care physicians from 2004 to 2006, in the following countries: United States, Canada, New Zealand, United Kingdom, Germany, and the Netherlands. This is what the researchers found:

* Canada had the highest percentage of patients (36%) who had to wait six days or more for an appointment with a doctor, but the United States had the second highest percentage (23%) who reported that they had to wait at least this long. New Zealand, Australia, Germany, and the U.K. all had substantially smaller numbers of people reporting waits of 6 days or longer. Canada and the United States, in that order, also had the lowest percentage of persons who said they could get an appointment with a doctor the same or next day.
* The United States had the largest percentage of persons (61%) who said that getting care on nights, weekends, or holidays, without going to the emergency room, was "very" or "somewhat" difficult. In Canada, it was 54%, and in the U.K, 38%. Germany did the best, with only 22% saying that it was difficult to get after-hours care.
* The United States, though, scored well on physicians' perceptions of how many patients experience long waits for diagnostic tests. 57% of physicians in the U.K, and 51% of Canadian physicians reported that their patients experienced long waits for diagnostic tests, compared to only 9% of U.S. physicians who reported the same.
* The U.K (60%) and Canada (57%) had the highest numbers of persons who had to wait four weeks or more to get to see a specialist physician. In the U.S., only 23% reported a wait of four weeks or more for specialty care.
* The U.S. also did very well on measures of wait times for non-emergency or elective surgery. Only 8% of surveyed patients in the United States reported a wait time of four months or more for elective surgery, compared to 33% in Canada and 41% in the U.K. Germany scored the best, with only 6% reporting a long wait for elective surgery.

The take-away message is that both the United States and Canada do pretty poorly, compared to most other industrialized countries, on how long patients have to wait to get a regular appointment with a primary care physician or after-hours care, but the U.S. does better than most on having shorter wait times for diagnostic procedures, elective surgery, and specialty care. Each of these countries, though, with the exception of the United States, has universal health insurance coverage, funded and regulated in large part by the government, so it doesn't seem likely that government-subsidized health care, in itself, is the sole factor in determining how long patients are stuck in The Waiting Place. Other factors, like the numbers of primary care physicians and specialists in each country, may be more important.

Today's question: What is your reaction to the data on each country's experience with wait times for medical care?

Tuesday, January 26, 2010

Dr. Seuss' Rx for Obama's health reform slump

"Oh!
The places you'll go!

You'll be on your way up!
You'll be seeing great sights!
You'll join the high fliers
Who soar to high heights.

You won't lag behind, because you'll have the speed.
You'll pass the whole gang and you'll soon take the lead.
Wherever you fly, you'll be the best of the best.
Wherever you go, you will top all the rest.

Except when you don't.
Because sometimes you won't.

You can get all hung up
In a prickle-ly perch.
And your gang will fly on.
You'll be left in a Lurch.

You'll come down from the Lurch
With an unpleasant bump.
And the chances are, then,
that you'll be in a Slump.
And when you are in a Slump,
You're not in for much fun.
Un-slumping yourself
Is not easily done.

You can get so confused
that you'll start in to race
down long wiggled roads at a break-necking pace
and grind for miles across weirdish wild space,
headed, I fear, toward a most useless place.

The Waiting Place ...
... for people just waiting.
Waiting for a bus to come, or a plane to go
or the mail to come, or the rain to go
or the phone to ring, or the snow to snow
or waiting around for a Yes or NO
or waiting for their hair to grow.
Everyone is just waiting."

The above excerpts come from Dr. Seuss' final, masterful book, "Oh, The Places You'll Go!," a motivational tale of overcoming life's challenges to arrive at great places.

I can't think of a better description of the present health reform slump, and of the weirdish, wild, space - the Waiting Place - in which members of Congress now find themselves. Waiting for President Obama to signal his intentions. Waiting for Speaker Pelosi and Majority Leader Reid to come up with a plan. Waiting for another chance to get health reform done, right.

(Meanwhile. Kristen Gerencher blogs in Market Watch about efforts by various stakeholders to ramp up pressure on Congress and the president to move forward on reform, including a joint letter sent yesterday to Congress and President Obama by the American Academy of Family Physicians, American College of Physicians, and American Osteopathic Association, advocating that a pathway be found to move forward on "essential" reforms to expand coverage, ensure a sufficient primary care workforce, reform payment and delivery systems, and support alternatives to the medical liability tort system.)

Dr. Suess wraps up by saying:

"On and on you will hike.
And I know you'll hike far
And face up to your problems
Whatever they are ...

And will you succeed?
Yes, You will, indeed!
(98 and 3/4 percent guaranteed)

KID, YOU'LL MOVE MOUNTAINS!"

President Obama's State of the Union address tomorrow will tell us much about whether he can face up to his problems, regain the initiative, and move mountains to achieve comprehensive health care reform for all Americans.

Today's question: What do you think President Obama should say about health reform in his State of the Union address?

P.S. The ACP Advocate Blog is a finalist in the sixth annual Medical Weblog Awards for the Best Health Policies/Ethics Weblog. Voting begins on January 27 and will close at 12 midnight on February 14. Please take a moment to vote for the ACP Advocate Blog.

Monday, January 25, 2010

Will Congress throw the uninsured under the bus?

The Wall Street Journal reports that the Democrats may put aside the party's goal of providing health insurance coverage to (almost all) legal residents. Instead, they might push for more scaled-back reforms including, "modest coverage for the uninsured, perhaps aid for small businesses, new rules for insurance companies and some policy changes to control federal health spending." To be clear, as the WSJ points out, no decisions have been made, and likely won't be, until after President Obama's state of the union address Wednesday.

I understand the political reasons why some members of Congress may want to put aside the goal of achieving near-universal coverage. Most voters have health insurance, and polls show that voters with health insurance increasingly are concerned that the health reform bills will increase their costs and reduce the quality of care they receive. So the political calculation appears to be: why pass something that is disfavored by a good proportion of the 85% of your constituents that have health insurance, so as to provide coverage to the 15% who don't, many of whom don't vote? Especially since most of the almost trillion dollar cost of the proposed bills is to fund programs to expand coverage.

We've seen this before. In 1995, when President Bill Clinton's efforts to reform health care collapsed, 40.6 million people in the United States, or 15.4% of the population, were without health insurance coverage during the entire year, according to the Census Bureau. In 2008, the exact same proportion of the population -15.4% - went without health insurance, but because of population growth, the total number of uninsured persons reached 46.3 million. The uninsured rate would be much higher, if it were not for enactment and reauthorization of the State Children's Health Insurance Program, which in 2008 provided coverage to 7.4 million low-income kids. The best one can say is 15 years after Clinton's health reform initiative collapsed, we have made absolutely no progress in reducing the percentage of the population without health insurance.

One big difference now is that both the House of Representatives and the Senate have passed bills that would cover between 94-96% of legal U.S. residents - the farthest this has ever advanced in the legislative process. Yet Congress and maybe President Obama may be on verge of deciding that the politics make it too hard to get the bills over the finish line.

I understand that the bills are controversial, and that people are troubled by the deal-making that went into getting the necessary votes. I appreciate that people are concerned that the U.S. can't afford to take this on now, even though the CBO says that the legislation will reduce the federal budget deficit. I "get it" that many people don't trust the government to deliver on the promise of better care at lower cost. I know that changes will need to be made in the bills to increase public support, such as elimination of some of the special deals made in the Senate. What I don't get is the apparent willingness of politicians to again throw the uninsured under the bus.

I don't know if providing everyone access to health coverage is a right, but I do believe that it is the right thing to do. I continue to have some hope that President Obama and Congress will find a way to ensure that "the U.S. health care delivery system provides access, best quality care and health insurance coverage for 100%" of Americans, as called for by ACP's vision of a desired future for U.S. health care. Tomorrow's state of the union address should at least tell us where the President stands.

Today's question: Do you think Congress and the President should throw in the towel in providing affordable health insurance coverage to all?

Thursday, January 21, 2010

"Dazed and Confused"

... is how Chris Frate aptly characterizes the Democrats' state of mind on how to proceed with health care reform. It doesn't help that President Obama and his White House staff are sending mixed signals.

It seems as if there are only a few options left:

- The House passes the Senate bill "as is" but with a commitment to modify parts of it through a separate budget reconciliation bill. This has the advantage of not requiring 60 votes because a filibuster is not in order in the Senate for a bill that has already passed and is awaiting action by the other chamber. Any changes made through budget reconciliation can also be passed by a simple majority. But as the Washington Post reports today Speaker Pelosi has rejected this option, at least for now.

- The House and Senate could drop the current bills and start anew with drafting a new bill to be passed strictly through budget reconciliation on a strict majority vote. This though creates all kinds of political and procedural hurdles - including the need for the committees of authorization to have to "mark up" a new bill. The reconciliation bill could only include provisions with a direct effect on federal spending and revenue, so popular regulatory provisions, like banning pre-existing conditions exclusions, likely would have to be left out. And, with the Democrats eager to get health reform behind them, I don't see them wanting to start anew.

- Reid and the White House could reach out to a small handful of Republicans, like Olympia Snowe (R-ME) and Susan Collins (R-ME), to get them to support a compromise that gets them to 60 votes. Not impossible, but difficult, because the Democratic leadership may have burned bridges with them, and the few Republicans who might be "in play" will be under tremendous pressure from their party not to play ball. Compromises to get GOP votes will run the risk of losing votes from Democrats, and I would not be surprised to see some of the Senators who voted for the current bill having second thoughts. The back-and-forth negotiations that would be required would drag the process out longer and lead to more deal-making, the last thing the Democrats want.

- Or the Democrats could themselves break the bills up into individual parts and force Republicans to vote for or against provisions that may be popular. The likely result would be a far less expensive bill that would make modest changes (like banning pre-existing conditions and voluntary pooling arrangements, maybe with Medicaid expansion and some limited subsidies targeted to the poor). This too, though, would require new committee "mark up" and drag the process out for months, with no certainty of success. And disaggregating the bills could lead to an unworkable result: for instance, requiring that insurance companies accept people with pre-existing conditions (popular with voters) likely will require a mandate that individuals buy insurance (less popular) and subsidies (very expensive) to make coverage affordable.

- The White House and Congressional leadership could just walk away from the process of trying to get health reform passed and try to blame it on Republican obstructionism, making the midterms a referendum where both sides would point figures on why health reform failed.

Where does this leave ACP and its public policy agenda? We don't control the politics, process or procedures of health care reform. Our agenda is determined by our own policies - not the politics of the moment. As such, we will continue to advocate that Congress enact legislation to advance our four priority areas: coverage for all, workforce and primary care, payment and delivery system reform, and medical liability reform. We have been pushing this agenda long before the latest political developments, and will continue to do so until progress is achieved.

There is no easy way forward. But if health reform fails, the best opportunity we've had to advance fundamental reforms to achieve key policy objectives - like reforming Medicare payments to support primary care, training more primary care internists, funding research on comparative effectiveness, and of course, affordable coverage for all - will be set back. And if health reform fails, health care spending will rise at a rate that that the country simply can't afford.

Kevin Pho, MD, may have said it best, in his admonition to his colleagues on the Right:

"With the potential defeat of ObamaCare, you may have won the battle, but will lose the war. The current health reform efforts, in the grand scheme of things, were very incremental in nature. Without it, the number of uninsured will rise, and health costs will continue to spiral upwards. That will eventually bring America's economy to its knees, and, as I said a few months ago, 'once that happens, more draconian measures will be forced upon us. Measures that assuredly will not be friendly to doctors.'"

Today's question: Do you agree with Kevin Pho that defeat of Obama's health care reform will lead to more draconian measures being forced upon physicians?

P.S. - The ACP Advocate Blog with Bob Doherty has been nominated for consideration in the Best Health Policy/Ethics category in the 2009 Medical Webblogs Award Program sponsored by epocrates. (It may not yet show up yet in the list of nominees, since it usually takes a day or so for the latest nominees to show up.) If you would like to support the nomination, you can do so by following the instructions "to place a nomination." The editors ask that when nominating, you indicate the blog's name and URL, as well as your thoughts why this particular blog deserves recognition.

Wednesday, January 20, 2010

"I'm not dead ... yet"

One of my favorite movie scenes is from "Monty Python and the Holy Grail," when an unfortunate soul pleads with the designated collector of corpses (this being after the plague, mind you) that "I'm not dead ... yet." The collector responds by whacking him on the head ... until he is, in fact, quite dead.

This scene comes to mind as I blog about yesterday's stunning GOP upset of the seat-that-used-to-be-held-by Ted Kennedy. If the election of Republican Scott Brown didn't quite kill off health care reform, some Democrats are quite willing to complete the task.

Ezra Klein blogs for the Washington Post that, "a Democratic Party that would abandon their central initiative this quickly isn't a Democratic Party that deserves to hold power. If they don't believe in the importance of their policies, why should anyone who's skeptical change their mind? If they're not interested in actually passing their agenda, why should voters who agree with Democrats on the issues work to elect them? A commitment provisional on Ted Kennedy not dying and Martha Coakley not running a terrible campaign is not much of a commitment at all." Steve Pearlstein, also writing in the Post, argues that the Massachusetts vote was not a referendum on health reform: "There are lots of reasons other than derailing health reform why normally liberal Massachusetts voters may have wanted to send an angry signal to the state's political establishment. For Democrats in Washington, the danger now is not that they will ignore the election returns, but that they will misread them and sound a premature retreat from a historic and game-changing opportunity."

Yet there is no denying that even if the Massachusetts outcome didn't kill health care reform, it has put it on a death watch. Many of Brown's supporters came from independents who, according to pre-election polls, were highly motivated by their opposition to the health care reform bills. But Massachusetts already has near-universal coverage - broadly supported by its voters - so it is hard to view the election as a flat-out rejection of reforms that they themselves enjoy. And, as I wrote in yesterday's blog, there is no denying that the public lacks confidence in the government's ability to deliver on the promises of better care at lower cost to them.

Politico reports on several options available to Democrats to continue to move forward on health care reform, but there is a clear divide among rank and file members in both chambers on how or if to proceed. And, as I write this, CNN is reporting that President Obama may offer a scaled down version of health care reform - bans on pre-existing conditions exclusions and expanding Medicaid to cover all of the poor and near-poor - as a potential fallback.

I understand all of the focus on the politics of health reform, and I suppose that if I were a Democratic member of Congress, that is the main thing I'd be thinking about. But I am reminded that the reasons for health care reform are just as valid today as they were yesterday: tens of millions of Americans lack access to affordable health insurance coverage, many more have difficulty paying their bills, quality is uneven, and costs are rising faster than we as a country can afford. These were true when Obama took office one year ago today - when, by the way, there were only 58 Democratic Senators (Specter of Pennsylvania hadn't yet switched parties, and Franken's win over Coleman in Minnesota was being contested in the courts) - when the popular refrain was "Yes, we can." Now, with 59 Senate votes, some Democrats are saying "no we can't" to health care reform?

In September of last year, I blogged about the plight of a Missouri bartender I met at an ACP chapter meeting:

"She said she has some serious health problems that require expensive medications, which are only partly covered by the health insurance plan offered by her employer. Her company plan also covers her 19 year old dependent daughter with a serious mental health condition. Her husband, an independent contractor who can't find coverage on his own, also relies on his wife's plan for coverage. She said that even with the insurance, her premiums and out-of-pocket health care bills are so high that 'I don't know how we'll make it.' She was planning to take a day off from work to plead with state Medicaid office to cover her daughter, even though she had already been advised over the phone that her daughter wouldn't qualify."

I wrote that, "I hope we don't lose sight of this Missouri bartender, and the millions of working American families, who can't afford health care and are looking to Washington for help. None of the bills making their way through Congress are perfect - far from it. But I believe the litmus test of whether the results are worth it is whether our Missouri bartender and her family can get good coverage at a price that they can afford."

I still believe this. The voters in Massachusetts elected Mr. Brown, knowing that he promised to be the 41st vote against health care reform, and their choice needs to be respected. But Massachusetts has near-universal coverage, is it too much to ask that a Missouri bartender - and the tens of millions like her - have the same? The current Congress and President can still bring home the Holy Grail of health care reform, but only if they - and we the voters - want it bad enough.

Today's questions: What advice would you give to President Obama and Congress? Give up on health reform? Move forward with the basic framework that has been passed by both chambers? Or pass as scaled down version?

Tuesday, January 19, 2010

Losing and winning the battle for public opinion

I am not going to speculate - yet - about the meaning of the Massachusetts' special election to fill the vacancy created by Ted Kennedy's passing, mainly because I'd rather wait until the votes are cast. I'll have something to say about it, tomorrow.

But I don't think anyone can reasonably dispute the fact that public opinion, in general, has swung against the pending health reform bills. And the reasons for this require some thoughtful analysis by the health reform advocates if they hold out any hope of turning opinion around. Blaming the polls on "scare tactics" gives too much credence to the worst of the opposition's arguments, while suggesting that the public doesn't "understand" the benefits of reform is condescending, and even more to the point, ineffective. You are not going to win over the public by calling them dupes (to the health care lies) or ignoramuses (because they aren't smart or informed enough to see the benefits to them). At the same time, though, the critics of the health reform bills should think twice before prematurely concluding that the public has decisively bought into their view they will lead to "government-run" health care.

Real Clear Politics reports that when the results of nine different polls, conducted since the first of the year, are averaged together, 51.1% of respondents oppose the health reform legislation while 40.9% support it. But it isn't that simple.

Gallup finds that Americans narrowly favor passage of the bill, by a margin of 49% to 46%. The CNN/Opinion Research poll "finds that 57% generally oppose" the bill while only 40% "generally support" it. But the CNN poll shows that solid majorities favor two of the most "liberal" proposals in the House-passed version: taxing high income people (with 61% support) and the public plan option (with 55% support).

The Kaiser Family Foundation's December tracking poll (not included in the Real Clear Politics poll averages) finds that, "Overall, 54 percent say the economic challenges facing the country make it more important than ever to tackle reform, while 41 percent say we cannot afford to take on reform now." In this poll, "45 percent say the country would be better off if health care reform passes, down 9 percentage points from November, compared to 31 percent who say the country will be worse off and 17 percent who see no impact." At the same time, however, Kaiser reports that "the percentage of Americans who believe they will be personally better off if Congress passes health care reform is down seven percentage points from last month to 35 percent, making for a much more divided public on this measure, with roughly three in ten saying they think they will be worse off (27 percent) and another three in ten not expecting to see much change (32 percent)." In other words, more people believe that the bills will be better for the country than will personally benefit them.

The Washington Post/ABC poll similarly shows that most Americans are not persuaded that they will be better off if health reform passes. 53% say that it will cost them more if health reform passes than if the current system were maintained, and only 38% say the quality of care will be better if health reform passes compared to 50% who say it will be better under the current system. 56% believe that the overall cost of health care to the country will be higher if reform passes compared to 37% who say it will be higher if the current system is left as it is. The Washington Post poll, like CNN's, also shows that more Americans favor a tax on high income persons and the public option than oppose them.

In my mind, the polls show that opponents have been most effective in raising doubts among Americans on two of the core claims for health care reform: that the bills will lower their costs while improving (or at least not hurting) the quality of care they receive. But I don't think that the polls show that there has been a wholesale rejection of the need for health care reform, or that most Americans buy into the view it is too liberal and will lead to government-run health care. Instead, they don't trust that the bills being debated will deliver on the promises of better care at lower cost, and that is why a majority now oppose them. The proponents of health reform have not yet figured out how to make them feel otherwise.

Oh, and one thing about Massachusetts, no matter who wins today's election, the polls show that most of the Commonwealth's residents like their state's universal health insurance program, which consists of individually mandated insurance with subsidies to buy coverage and health exchanges to make it more affordable - just like the bills being debated in Congress.

Today's question: Who do you think is winning the battle for public opinion, and why?

Thursday, January 14, 2010

Why do red states gain the most under health reform?

With news that a tentative deal may have been reached on the contentious issue of a tax on high cost health plans, the negotiations on the health reform bill may be on the verge of overcoming one of the biggest obstacles to reconciling the House and Senate bills. It looks increasingly likely that the House and Senate may strike a deal to allow a revised bill to be sent, as early as tomorrow, to the Congressional Budget Office, for a revised estimate of its impact on the federal budget. This would set the stage for possible passage of the legislation by the end of this month or early February.

Without assuming anything, it isn't too soon to begin talking about who gains and who loses under the likely compromise legislation. Writing in the Health Affairs blog, Claudia Schur and Marc Berk estimate that "the states most likely to 'win' as a result of health care reform are Arkansas, Idaho, Kentucky, North Carolina, Oklahoma, Tennessee, and Utah. All of these states have a relatively high number of uninsured and all are in the bottom half of states in terms of cost under both financing mechanisms." They used a simple metric - "benefits were measured in terms of the state's current proportion of uninsured residents, and costs were assessed by ranking the states to see which would be hardest hit by each of two financing mechanisms, a tax on high earners and a tax on high health insurance premiums" - to determine which states would get more benefit than their contribution to the cost.

"Among the states most likely to 'lose'" they write, "are Delaware, Nebraska, and New Hampshire as well as the District of Columbia. Each of these states has a relatively lower-than-average proportion of uninsured residents, and each would fall in the "High Cost" category under either of the financing options." Other states would do better or worse depending on which financing mechanism - tax on high income residents or tax on high cost insurance plans - is used. Many other states fall somewhere in between.

What do the "winning" states have in common? They have more uninsured persons, fewer unionized workers, lower average insurance premiums (meaning fewer "Cadillac" plans to be taxed), and fewer high income persons (meaning fewer people who fall in the income brackets that may have to pay higher taxes). "The overall pattern therefore shows a curious alignment" they write since, "states with the most to gain under health care reform are overwhelmingly represented by Republicans, while those states likely to do worse are much more likely to have Democratic senators."

This dissonance between a state's partisan voting pattern and how much they will gain is dramatic: "When we examine the seven states most likely to be winners under reform, we see a combined split in their Senate delegations of twelve Republicans versus two Democrats. The three states most likely to lose under health care reform are collectively represented by four Democrats and two Republicans. When we add in the group that would be losers under the income-tax option, the split becomes even stronger, with these states being represented by eighteen Democrats and four Republicans."

If politics was all about bringing home the goods, then one might expect that the states that will gain the most from health reform would be the most in favor of it. But the "red" states that will gain economically from health reform are also the ones whose electorate tends to be most distrustful of government. Because these voters don't particularly like government, they have been willing to tolerate high number of uninsured persons. Now, though they will gain the most if the federal government ends up picking up the tab to cover more people - even though their own Senators (and most of their residents) were against it. Meanwhile, many of the Democratic "blue" states will see more of their tax dollars go to paying for health care coverage in the states that didn't want it in the first place.

The best hope the Democrats have is that once health reform is signed into law, red state voters will eventually discover that they have gained the most from the programs, and may even give the Democrats some of the credit.

Today's question: What do you take away from the dissonance between how much a state will gain from health reform and how little support it has in the state?

Wednesday, January 13, 2010

What do the health reform bills do ... to increase Medicaid pay for primary care?

Beyond the "big" issues - like the tax on high cost health plans, employer mandates, and national versus state health exchanges - being negotiated by the House and Senate leadership, there are a myriad of other issues that have to be resolved before Congress votes on a final bill. In some cases, the differences are narrow, but for others, the bills take a very different approach to the policies, priorities and funding issues involved.

Take primary care. The House and Senate alike agree that primary care needs to be supported, and both bills have provisions to increase primary care workforce. But below the surface there is a big difference on how much money the federal government should spend on primary care, particularly when it come to increasing payments to physicians.

Both the House and Senate bills will increase Medicare payments to primary care physicians. But the House would also spend $57 billion over five years to increase Medicaid payments for primary care services so that they are on par with applicable Medicare rates. More than just primary care physicians would benefit under the House Medicaid pay parity proposal, since any physician - regardless of their specialty - who bills for the specified primary care services (mainly, office visits and other evaluation and management codes) would get the fee increase. The Senate bill does nothing to increase Medicaid pay rates.

Yesterday, the American College of Physicians joined with 118 organizations to urge House and Senate negotiators to include the Medicaid pay parity provision. The letter explains that, "Medicaid rates average just 66% of Medicare rates for primary care services and are woefully inadequate to cover the cost of providing care ... The inadequacy of Medicaid reimbursement levels must be addressed in conjunction with the Medicaid expansion or we risk leaving our poorest and most medically-vulnerable residents behind despite the remarkable promise offered by health reform." As reported in MSNBC several months ago, low Medicaid payment rates are the principal reason why few physicians accept large number of Medicaid recipients.

Both the House and Senate bills would add about 15 million more persons (mainly, adults without kids) to Medicaid, but unless the House pay parity provision is accepted, most of them will have a hard time finding a doctor who is accepting Medicaid. Jonathan Cohn writes in the New Republic that, "increasing the reimbursements in an existing public insurance program that already underpays doctors and hospitals would seem like a no-brainer--which, as it happens, it is, for a great many reasons." Also read Jacob Goldstein's Wall Street Journal blog on the same topic.

The House of Representatives is pushing for the Medicaid pay parity provision to be accepted in the final bill, but the $57 billion price tag is making it a hard sell for fiscally-minded conservative Democrats, who want to keep the total costs of the final bill below $900 billion. Still, expanding Medicaid to cover tens of millions more people won't give them access to care, unless Medicaid pay rates are increased to make it possible for doctors to take care of them.

Today's question: Do you accept Medicaid patients? Would you accept more if the Medicaid reimbursement was increased to no less than the Medicare rates?

Wednesday, January 6, 2010

Keep government out of health care? It's already there.

As I wrote in yesterday's blog, the federal government is now responsible for about 35% of total national health expenditures. But the public sector's contribution is actually much larger: today, almost one out of every two dollars spent on health care comes from federal, state and local governments. In 2008, combined spending by the public sector (federal, state and local governments) represented 47.3% of the total national expenditures (all sources, public and private, combined). Governments' share has grown over the years: in 2000, 44% of the total national health care bill was paid by public funds, up from 42% in 1980 and 37.6% in 1970.

Another way to look at this is how many people are covered by government or private sources. The Census Bureau reports that in 2008, 84.6% of U.S. residents had health insurance coverage. Of these, 66.7% had private insurance and 29% government insurance. In 1999, 72.5% were covered by private insurance and 24.5% by government programs.

(I wonder if those who argue that the U.S. has the best health care in the world realize that they are talking about a system where more than 87 million people already depend on the government for coverage, and where one out of every two dollars spent on health care already comes from government funds.)

How much would the House and Senate bills expand the government's role?

The Congressional Budget Office estimates that over the next 10 years, the Senate bill would add 15 million more people to the Medicaid and SCHIP programs compared to current law. Four million fewer people would be covered by employers, and five million fewer by the individual insurance market. Twenty-six million people would get coverage through insurance plans offered by a state health exchange, and most of these people would get subsidies from the federal government to help them afford the plans. The House bill too would add 15 million more to Medicaid/SCHIP, but it would actually increase by 6 million the number of persons covered by private insurance offered by an employer. Twenty-one million would get coverage through a national health exchange, which would include private health insurers as well as a public option. (The public option is not expected to be in the final House-Senate bill.) Under the House bill, the number of people who buy individual insurance would decline by 6 million people.

Under both the House and Senate bills, the vast majority of Americans - in excess of 160 million - would get their coverage from employer-sponsored private health plans.

I understand that there is a serious case to be made from the right against the further expansion of the government, just as there is a serious argument to be made from the left that the proposed reforms should do more to expand government's role.

But an honest debate would at least start by acknowledging the fact that the government already is involved in health care, big-time, and its role will continue to expand, with or without health reform, just as it has for more than forty years now. (No politician that I know of - other than maybe Ron Paul - is proposing to keep government out of health care, since this would mean eliminating or at least rolling back Medicare, Medicaid, the Children's Health Insurance Program, the VA, military medicine, and Tri-Care - not to mention eliminating NIH research, funding for graduate medical education, and a whole host of other popular programs.)

An honest debate would also begin by acknowledging that the House and Senate bills would further increase the government's role in health care by enrolling more people in government programs, subsidizing the purchase of private insurance, and regulating insurance companies, but most people would still get coverage from private insurance offered by their employer. You may believe that this is a good or bad thing, but let's not pretend that the current debate is really about keeping government out of health care (it is already there) or creating of a government-run health system (the bills don't).

Today's questions: What do you think the role of government will be in health care, without or without health care reform? What do you think its role should be?

Tuesday, January 5, 2010

Government spending on health outpaces private sources

Much of the debate about the health reform has been on whether or not it will lead to government-run health care. But the fact is that the government's share of health care spending already is growing at a faster rate than private spending, a trend accelerated by the recent economic recession.

A new report from Medicare's actuaries, published in the journal Health Affairs, found that "Federal government spending for health services and supplies increased 10.4 percent in 2008 . . . and accounted for almost 36 percent of federal receipts, up considerably from 28 percent in 2007. By comparison, spending for health care by private businesses grew just 1.2 percent in 2008, in part because of a drop in the proportion of employer-sponsored insurance premiums paid for by employers" while "health care spending by households grew 4.3 percent in 2008, a deceleration from 5.9 percent growth in 2007" but still more than the adjusted personal income growth of 2.7%.

The current economic recession, the authors say, had two major impacts on health spending:

* "The economic stimulus bill shifted more federal dollars to Medicaid, causing total Medicaid spending to rise to 58.5 percent in 2008, compared with 56.5 percent in 2007, and there was slower growth in personal health care paid for by private sources of funds, which increased just 2.8 percent in 2008, the lowest rate since the mid-1990s" and
* "The low rate of private spending growth in 2008 occurred as personal income growth slowed, employment fell, and enrollment in private health insurance plans declined."

Overall, U.S. health care spending growth slowed to 4.4% in 2008, "the slowest rate of growth over the past forty-eight years." Yet despite the slow-down, health spending increases "continue to outpace growth in the resources available to pay for it" as the share of gross domestic product (GDP) devoted to health care increased from 15.9 percent in 2007 to 16.2 percent in 2008.

Other study highlights: In 2008 total Medicare spending grew 8.6 percent, reaching $469.2 billion, accelerating from 7.1 percent growth in 2007 mainly attributable to "increased fee-for-service (FFS) spending for hospitals and a further shift in enrollment to Medicare Advantage plans, which have higher average Medicare payments per beneficiary than FFS." National health expenditures, public and private combined, on physician services alone "increased 4.7 percent in 2008, a deceleration from 5.5 percent growth in 2007" and "retail prescription drug spending growth decelerated to 3.2 percent, reflecting the continuation of a slowing trend that began in 2000."

Critics of the current health reform effort often say that they are fighting to keep the federal government out of health care. But the fact is that the government's role in paying for health care has been growing for decades. In 1970, the federal government's share of total national health expenditures (all sources, public and private combined) was approximately 23.6%. The federal share was 28.2% in 1980; 30.8% in 2000, 33.7% in 2007, and 35% in 2008. (See this table for a detailed breakdown of annual spending on health by source of funds.) During much of this time Republicans controlled the White House and/or one or both chambers of Congress.

Enactment of health reform will surely expand the government's role in financing health care even more, but the notion that this fight is over "keeping government out of health care" is, well, out-of-touch with the simple reality that government's role in paying for health care has been steadily increasing over the past forty years, with the support of both political parties and, it seems, the American public.

Today's question: What do these estimates say to you?

Monday, January 4, 2010

Meet the New Year, same as the old year

Congress returns to Washington tomorrow to begin the difficult process of bridging the differences between the health reform bills passed by the Senate and House. Usually, this would involve creation of a conference committee - consisting of members appointed by the House and Senate leadership and from the committees of jurisdiction - to lead the negotiations on producing a common bill - called a conference agreement - which would then be voted on as a substitute to the original bills as approved earlier by the respective chambers.

But as Jonathan Cohn reports today in the New Republic, Democrats are "almost certain" to substitute informal negotiations for a formal conference process to "avoid a series of procedural steps--not least among them, a series of special motions in the Senate, each requiring a vote with full debate - that Republicans could use to stall deliberations" as they did in November and December. Read Paul Blumental's Sunlight Foundation blog for a good explanation of how the decision to bypass the conference process will allow for speedier consideration of the bill while "potentially limiting both the public's and many of their elected official's ability to consider the changes to the bill."

The decision to forgo the conference process is not that unusual. Both political parties have muscled legislation through, without a conference report, when they have had the majority, and even when a conference committee has been convened, it often has been more of a showcase than the open and transparent process described by House and Senate rules.

But this time, a decision to forgo a conference agreement creates political risks for President Obama, since he ran on a promise of transparency. Politifact, an independent fact-checking web site, reported earlier this year that President Obama promised during the campaign to bring "all parties together, not negotiating behind closed doors, but bringing all parties together, and broadcasting those negotiations on C-SPAN so that the American people can see what the choices are, because part of what we have to do is enlist the American people in this process."

I am sure that administration and its Democratic allies will argue that it is Republican obstructionism that has forced them to bypass the conference process, but my gut tells me that this will play into the hands of critics. They will argue that it is more evidence that the legislation is the product of secret backroom deals, and this will make it harder for President Obama and his Democratic congressional allies to persuade a public that already is distrustful of Washington that the final bill is good for them. At the same time, I also have no doubt that the GOP would use a formal conference process to delay a vote as long as possible, during which they would work to intensify public opposition to its passage.

It would have been nice to think that both parties might have resolved to play nicer in the New Year, but 2010 is starting off the same way as last year, with both parties locked into a take-no-prisoners conflict that leaves no room for bipartisanship.

Today's question: What is your opinion of the Democrats' decision to bypass a conference agreement?

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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