Thursday, January 26, 2012

How Bad Budgets and Broken Politics Undermine Health (and what can be done about it)

Earlier today, the American College of Physicians released a report on the State of the Nation’s Health Care in 2012. The report makes the case that unwise budget choices and broken politics are undermining progress in reducing health care costs, improving health and expanding access. It calls on Congress to reverse across-the-board budget cuts (sequestration) that will have a devastating impact on programs to ensure public health and safety, conduct medical research, provide access to care for vulnerable populations, and address a growing shortage of physicians.

This was NOT a case, though, of ACP being another “special interest” complaining about budget cuts to favored programs. For one thing, we don’t believe that government programs to protect the public from natural and manmade health disasters and pandemics, ensure their food and drugs are safe, and help find cures for cancer and diabetes qualify as special interest “pork.” For another, ACP proposed an alternative plan to achieve hundreds of billions in budget savings that focus on the real cost-drivers: fixing a dysfunctional physician payment system, reducing the costs of defensive medicine, enacting structural reforms in Medicare and Medicaid, and reforming the tax system to encourage people to consider costs when choosing health benefits.

Many of ACP’s recommendations to reduce costs in a fiscally and socially responsible way have been endorsed by bipartisan commissions that have come up with plans to reduce the federal budget deficit. But the report notes that a broken political system that favors confrontation over compromise has made it nearly impossible to move forward on such common-ground solutions.

Rather than allowing politicians to continue to hide behind divisive rhetoric while ducking the real issues, ACP challenges them to answer three questions each about how they would improve health care quality and access and reduce costs. For Republican candidates, the questions focus on the unanswered “replace” part of “repeal and replace.” For President Obama and Democrats, the questions focus on possible changes to the ACA and their views on entitlement reform.

(You can find the report and all of its supporting materials here, including a slide deck that summarizes the key findings and recommendations.)

Realistically, ACP’s report is not going to lead to a “Hallelujah” moment when the politicians decide to deal responsibly with health and to seek bipartisan agreement of common-ground reforms. But through today’s report, ACP at least hopes to show them that there is a way forward.

Today’s question: What do you think of ACP’s assessment of the state of the nation’s health care, our proposals for a better way to reduce costs, and our challenge to the candidates?

Wednesday, January 25, 2012

Health Care Reform Barely Mentioned in SOTU???

Last night’s State of the Union address was many things, but one thing it wasn’t was a clarion call by the President for the public to support his health care reform law. Instead, he confined his comments to a pledge “not go back to the days when health insurance companies had unchecked power to cancel your policy, deny your coverage, or charge women differently than men.”

You would think that the President would have spoken out more passionately on what he clearly considers to be his signature domestic accomplishment. Just as surprising, the Republican response by Governor Mitch Daniels (R-IN) didn’t even mention the party’s promise to repeal “ObamaCare.” His only implicit reference was in the context of distinguishing the GOP’s approach from his characterization of the President’s:

“In word and deed, the president and his allies tell us that we just cannot handle ourselves in this complex, perilous world without their benevolent protection. Left to ourselves, we might pick the wrong health insurance, the wrong mortgage, the wrong school for our kids; why, unless they stop us, we might pick the wrong light bulb.”

And that’s too bad. I would have liked to see President Obama make a clear case as to why the country is better off under the Affordable Care Act—and especially, I would have liked him to make the moral argument that it is simply wrong to deny millions of people access to health insurance simply because they can’t afford it, or work for an employer that doesn’t offer coverage, or live in an area where coverage is not accessible, or have a pre-existing health condition. I would have liked to have heard Governor Daniels explain what the GOP would offer instead of the ACA—and for that matter, whether the party even believes, as it has for almost its entire history, that a goal of public policy should be for everyone to have access to affordable health insurance coverage. After all, universal health insurance coverage was first proposed by a Republican president, Teddy Roosevelt, almost 100 years ago!

Just because the President and Governor Daniels didn’t have much to say about health care reform, though, doesn’t mean that there isn’t much to say. Tomorrow, ACP will be releasing its annual State of the Nation’s Health Care report. The report will provide an assessment of progress and challenges in U.S. health care, discuss the danger to health created by unwise budget cuts, offer an alternative framework to achieve hundreds of billions in savings by addressing the real cost drivers in health care, discuss the obstacles to achieving bipartisan common ground consensus created by the country's broken politics, and conclude with a challenge to the candidates, Republicans and Democrats alike, to provide clear answers about their plans for health care. (I will have more to say about ACP’s report in my next blog.) Last night, neither President Obama nor Governor Daniels were willing to reveal much, which is too bad, because voters have a right to know.

Today’s question: What did you think of health care reform getting only a passing reference in the President’s remarks and the GOP response?

Thursday, January 19, 2012

Politicians won’t admit it, but repeal means taking real benefits away from real people

Politicians who favor repeal of the ACA like to talk in general terms about getting rid of the two thousand pages of law (“monstrosity” is their preferred description) that it created, ignoring the fact that those same pieces of paper extend or improve benefits for hundreds of millions. It is easier to make rhetorical points about “government-run” health care than to explain what you are willing to take away, and from whom, or what you would offer to replace it.

The reason for this, I think, is mainly political: if the politicians really leveled with the people about what they and their families will lose if the ACA is taken away—and without a realistic alternative—many voters would think twice about repeal.

Consider this. Imagine that it is a week from now, and Mitt Romney is in St. Petersburg, Florida, campaigning to wrap up the GOP nomination. Imagine if he gave the following speech to a group of mostly senior citizens:

“Dear friends. As you know, I am opposed to ObamaCare. I am opposed to government-run health care, and my first item of business when I am President will be to repeal it. But you have a right to know what this might mean for you.

Say you are a senior citizen who is receiving a 50% discount on brand-name drugs filled through Medicare’s donut hole—I see there are quite a few of you in the room! After repeal, the discount will disappear. So if you are now paying $100 a month for a prescription, you will pay $200 monthly after ObamaCare is repealed. This means that after repeal, a typical senior enrolled in traditional Medicare will pay $3500 more for their drugs over the next decade.

Also, if you are a senior on Medicare, you now get routine preventive exams, like screening tests for cancer and an annual wellness exam at no cost to you. But after repeal, you will have to pay out of your own pocket for the deductible and co-payments. Yes, the 1,348,087 Florida seniors who now get these services for free will have to start paying for them.

Your internist will get paid less to take care of you. Right now, primary care doctors get a 10 percent Medicare bonus on their office and nursing home visits. After repeal, they won’t get the bonus. What this means is that a typical internist will end up being paid $8000 less from Medicare after repeal. Also, starting in 2013, primary care doctors were supposed to get a big raise from Medicaid, so that the program would pay no less than Medicare. In Florida, this would have meant that Medicaid payments to your primary care doctor would have gone up about 45 percent. But after repeal, Florida Medicaid will go back to paying primary care doctors only a little over half of what Medicare pays them.

Some of you may have granddaughters and grandsons who just graduated from college—congratulations!—and are out looking for a job. In the past, they probably would have lost their health insurance after graduation and until they got employed. Not now, though: the health reform law allows them to be covered under their parents’ plans—some 2.5 million young adults nationwide in 2011 got health insurance as a result. But after repeal, their parents’ plans no longer will have to offer them coverage, and they probably will have to find an affordable plan on their own, if they can.

Some of you may have a grandchild with a pre-existing condition, like asthma. Today, insurance companies can’t turn them away. After repeal, though, nothing will stop an insurance company from turning away or dropping kids who are unfortunate enough to be sick and need health insurance.

Right now, insurance companies must spend at least 80 percent of the premiums they collect from working people on patient care, not profit and administration. After repeal, there are no limits on how much they would be allowed to take out of premiums to pay their CEOs eight-figure salaries and hand out big profits to their shareholders.

Finally, starting in 2014, most of the nearly 4 million people in Florida who don’t have health insurance will get coverage, either through Medicaid or a private health insurance plan that the government will help pay for. After repeal, most of them likely will still be without coverage.

These are the facts, folks. I want to be honest with you, repeal means taking real benefits away from real people. But I favor repeal, because I don’t think the federal government should be involved in your health care. I don’t think we can afford it. I don’t think people should be required to buy health insurance. I don’t think we should tell insurance companies how to run their businesses. And if you need help from the government, I think you should ask Governor Rick Scott for help, because the states can always do it better than the federal government, right? Don’t you agree?”

Mr. Romney saw that the room was strangely silent, many in the audience seemed visibly upset, and few even had their calculators out. Funny, he thought to himself, the polls say that a majority of Americans favor the ACA’s repeal. I guess they weren’t really ready for straight talk about what is really in the law and what they could lose. Next time, I think, I will stick to the tried-and-true railing about government-run health care, and leave out the details about what benefits the voters will lose. They can always find that out after I get ObamaCare repealed.

Obviously, no politician in his right mind would give a speech like this. And I understand that Republicans like Mr. Romney have strong philosophical and pragmatic reasons for opposing the Affordable Care Act, notwithstanding the benefits that it offers to millions. I also understand that President Obama and the Democrats aren’t leveling either with the American people on the fact that Medicare and Medicaid can’t be sustained as they currently exist, and that pretending otherwise and demagoguing solutions does a disservice to the public. But I do think the public has a right to know that “repeal ObamaCare” means that they and their families will get less in benefits and pay more for their health care, and if the politicians won’t tell them, then someone else must.

Today’s question: Do you think politicians who favor repeal should level with the American people about the benefits they will lose if the law goes away?

Friday, January 13, 2012

Historic declines in health spending growth? Healthier people? Who knew?

Blogging about health care can be a downer. Exploding health care costs, too many uninsured, Medicare pay cuts, a dysfunctional political culture . . . and so it goes. But I came across a couple of new reports that suggest that there may be some rays of sunshine among all of the clouds.

For one thing, did you know that health care cost increases have hit a 50-year low? That’s right: health care costs in 2009 and 2010, the most recent years for which data are available, had the smallest increase since the days when Elvis Presley was topping the charts. According to the government’s most recent analysis:

“In 2010 extraordinarily slow growth in the use and intensity of services led to slower growth in spending for personal health care. The rates of growth in overall US gross domestic product (GDP) and in health spending began to converge in 2010. As a result, the health spending share of GDP stabilized at 17.9 percent. . . Continued slow growth in private health insurance and out-of-pocket spending (which grew just 2.4 percent and 1.8 percent, respectively) and decelerations in Medicare and Medicaid spending growth (which slowed to 5.0 percent and 7.2 percent, respectively) contributed to overall low growth in 2010.”

Oh, and another piece of good news in the report. You know the allegation that “ObamaCare” has caused a big spike in health care spending? Not so . . . the Affordable Care Act added a statistically insignificant amount to the nation’s health care bill, even as millions of seniors got discounts on their brand name drugs and no-cost preventive services, 2.5 million young adults were able to keep their coverage through their parents’ plans, and children with pre-existing conditions could no longer be dropped from coverage.

It is true that the last two years’ decline in health spending growth might not be entirely good news, since the researchers suggest that some of it may be because people put off needed care during the recession. Some might be luck, like the fact that we had a relatively uneventful flu season.

But another analysis found that annual health care cost increases have been slowing for the past eight years, so neither bad luck (the recession) nor good luck (not a lot of flu) can explain it all.

This doesn’t mean we are out of the woods on health care spending: even though it is increasing at a historically low rate, it is still growing faster than the overall economy. The Congressional Budget Office (CBO) still projects that “spending on the major mandatory health care programs alone would grow from less than 6 percent of GDP today to about 9 percent in 2035 and would continue to increase thereafter. Altogether, the aging of the population and the rising cost of health care would cause spending on the major mandatory health care programs and Social Security to grow from roughly 10 percent of GDP today to about 15 percent of GDP twenty-five years from now. (By comparison, spending on all of the federal government's programs and activities, excluding interest payments on debt, has averaged about 18.5 percent of GDP over the past 40 years.)”

Still, the fact that health care spending growth has been slowing for almost a decade now is good news. Maybe we are starting to figure out a way to deliver care more effectively and efficiently.

People also are healthier, according to another new government report. In 2010, life expectancy increased, the death rates fell for all five leading causes of death, and the death rate from homicide was as low as it’s been in half a century, according to the National Center for Health Statistics.

Policymakers frankly aren’t sure why homicides and health spending growth have dropped so much. As Buffalo Springfield sang in the 1960s, “There's something happening here, What it is ain't exactly clear.” But still, it is good to reflect that despite all of the challenges facing American health care, it isn’t all gloom and doom.

Today’s question: Why do you think health care spending growth has reached historic lows, even as the population is healthier?

Monday, January 9, 2012

Emptying the Cost Control Tool Kit (Revisited)

“Imagine that it is 2013, and a new President is sitting in the Oval Office... Imagine that he (or she) was elected on a platform of cutting taxes, rolling back the Obama administration's increased spending, and reforming the Medicaid and Medicare entitlement programs... To make things even more interesting, let's imagine that [although]... expansion of health insurance coverage [was] enacted into law... most of the cost controls were stripped out or weakened as a result of political opposition. Health care spending has continued to rise at breakneck rates, and the Medicare trust fund is about to run out of money.

What is a new President to do?

Because the most promising approaches to gradually ‘bend the cost curve’ - comparative effectiveness research, coverage of evidence-based preventive services, advance care planning, reductions in regional variations in the quality and cost of care, and the public option - were left out of the health reform law... the only cost-cutters left are hugely unpopular ones. Increase the age of eligibility and slash Medicare benefits? Means-test Medicare to exclude the rich? Slash payments to doctors and hospitals? Go back on your campaign promise and raise Medicare payroll taxes? Or let Medicare go broke?”

The above comes from a post I wrote in November, 2009, four months prior to the Affordable Care Act becoming law. I bring it up again because here we are, less than a year from the presidential election, and in my view, things are turning out just as I had feared. Critics of the ACA, mostly from the right, are doing everything they can to discredit even the most modest programs to lower health care costs, while at the same time deriding “ObamaCare” for not controlling costs! The result may be that a new President—are you listening, President Romney, Santorum, Gingrich, Huntsman or Perry?—may have nothing left in the tool kit to tackle health care spending, other than shifting costs onto patients and cutting their benefits. Let’s say that President Obama is re-elected; he too may find that the most effective tools to lower health care spending have been damaged by the political effort to turn the public against them.

Case in point: Grace-Marie Turner’s breathtaking distortion that Washington is funding research on the effectiveness of different medical treatments for the purpose of “setting up the systems to direct doctors to practice Washington-approved medicine.” (Turner is the Executive Director of the Galen Institute, which describes itself as “a non-profit public policy research organization devoted exclusively to advancing free-market ideas in health policy.”)

Independent fact-check organizations long ago discredited the idea that CER “is being used to build a ‘scientific’ case for government rationing of health care” as Turner claims. In August 2009, the Pulitzer Prize winning “PolitiFact” said that a similar claim by [now Speaker of the House] Rep. John Boehner was false, pointing out that “it's a stretch to call giving patients better information about which treatments and drugs are most effective ‘rationing.’ In fact, given specific language in the bill to the contrary, we think it’s outright wrong... to claim the research findings would be used by the government to ration care.” (The law says that “Nothing in this section shall be construed to permit the Commission or the Center to mandate coverage, reimbursement, or other policies for any public or private payer.”), a project of the Annenberg Public Policy Center, also said that it is “false” to say that CER will allow government to “decide what care I get (a.k.a. they won’t give grandma a hip replacement).” Yet this doesn’t stop the Grace-Marie Turners of the world from repeating this discredited claim over and over again, probably because they know that scaring people into believing that the government will ration their care is the most effective way to undermine support for health reform, facts be damned.

It is this type of shamelessly cynical attack that former CMS administrator Don Berwick decried in uncensored remarks delivered a few days after leaving government:

Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys. Let me give you an example: the outrageous rhetoric about “death panels”– the claim, nonsense, fabricated out of nothing but fear and lies, that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. It is purveyed by cynics; it employs deception; and it destroys hope. It is beyond cruelty to have subjected our elders, especially, to groundless fear in the pure service of political agendas…

And, while we are at it, what about “rationing?” The distorted and demagogic use of that term is another travesty in our public debate. In some way, the whole idea of improvement – the whole, wonderful idea that brings us –thousands – together this very afternoon – is that rationing – denying care to anyone who needs it is not necessary. That is, it is not necessary if, and only if, we work tirelessly and always to improve the way we try to meet that need.

The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry “foul” about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people – elders, the poor, the disabled – who are least able to bear them.

The fact is that the next president, whether it is in 2013 or 2017, will have to deal with the fact that health care costs are rising at an unsustainable rate—and this will be true, regardless of whether the Affordable Care Act survives or not. Empowering doctors and patients by giving them information about what treatments work well, and what doesn’t, is the kind of program that conservatives should embrace, because “markets” don’t work if people do not have the information needed to make a comparative choice. Helping patients make their own decisions about how they want to be treated when their life is coming to an end is good and compassionate care, not a government death panel. But the unrelentingly cynical attacks on such common sense ideas to help improve care and reduce costs may actually work in persuading the public to reject them, leaving the new president with nothing in the tool box other than cutting benefits and raising taxes.

Today’s questions: What is your take on the continuing claims that comparative effectiveness research equals government rationing? And what will this mean for the ability of the next president to lead a discussion on controlling health care costs?

Friday, January 6, 2012

Physician strikes can’t be justified to make a political point, ever.

With Congress’ continued failure to enact a solution to the Medicare SGR problem, more and more physicians may decide that it is time organize a strike or boycott to send a message to Congress. Or something akin to a strike, like a single day when doctors collectively close their offices except for emergency care.

Earlier this year, the ACP Internist published a letter from a member who argued exactly that. He wrote that “it is time for the ACP, AMA, AAFP, and other groups to call for and lead a Medicare strike, whereby physicians refuse to see Medicare patients, except for urgent/emergent problems, for a period of, say, three days. By the way, don’t call Grandma by phone and tell her that her appointment is cancelled. Let her struggle across town and up to the office with her walker, then tell her why she won’t be seen that day, then hand her a piece of paper with the office phone numbers of her senators and representative on it. Maybe then we will see real change. If that doesn’t work, strike for a week. Then two weeks. Then a month. It is obvious that only such action will get rid of the SGR.”

There is precedence for a physician strike to put pressure on legislators. In 2003, the New York Times reported that almost all of the 30,000 physicians in New Jersey “canceled routine checkups and rescheduled elective surgery during the week of Feb. 4 in one of the nation's largest walkouts ever by doctors” to protest the state legislature’s unwillingness to curb malpractice premiums.

It is refreshing, then, that the brand new version of ACP’s code of ethics, published in the current issue of the Annals of Internal Medicine, reaffirms the College's position that strikes, boycotts, and other collective actions to deny care to patients or to inconvenience them are flat out unethical:

“Changes in the practice environment sometimes adversely affect the ability of physicians to provide patients with high-quality care and can challenge the physician's autonomy to exercise independent clinical judgment and even the ability to sustain a practice. However, physician efforts to advocate for system change should not include participation in joint actions that adversely affect access to health care or that result in anticompetitive behavior. Physicians should not engage in strikes, work stoppages, slowdowns, boycotts, or other organized actions that are designed, implicitly or explicitly, to limit or deny services to patients that would otherwise be available. In general, physicians should individually and collectively find advocacy alternatives, such as lobbying lawmakers and working to educate the public, patient groups, and policymakers about their concerns. Protests and marches that constitute protected free speech and political activity can be a legitimate means to seek redress, provided that they do not involve joint decisions to engage in actions that may harm patients.”

Yes, it is frustrating that Congress hasn’t ended the endless cycle of scheduled Medicare payment cuts. Physicians have a right to be angry. Traditional lobbying—persuading our democratically elected lawmakers to do the right thing—is a slog, difficult, time-consuming, and doesn’t always deliver the desired results, especially in today’s broken political system. But professionalism says that “the physician's primary commitment must always be to the patient's welfare and best interests.” [ACP Ethics Manual]. Accordingly, Congress’ failure to do its job cannot be an excuse for physicians not to do theirs. Collective actions to deny care to patients, in order to make a political point, can never be justified.

Today’s question: Do you agree with ACP that physician strikes or boycotts can never be ethically justified?

Tuesday, January 3, 2012

Beyond repeal, what would the GOP do about health care? And Obama about entitlements?

Hard to tell . . . and maybe not much, judging from what the presidential candidates have put forward so far. Last Friday—just in time for the first votes taking place today in the Republican nominating process—the American College of Physicians posted a comparison of how the major candidates propose to deal with health care access, workforce capacity, and costs of care. There isn’t much for a voter to go on.

The Republican candidates uniformly say that they want to repeal “ObamaCare” but aren’t saying much beyond that, which is too bad. The 2012 election may very well determine the ACA’s immediate political future—will the law stay or go? President Obama, of course, favors continued implementation of the law, the Republicans want to it to go away. But what else do we really know about the candidates’ plans?

If the Supreme Court overturns the individual insurance mandate, the Republican candidates will applaud the decision, but what do they propose should replace it? Will they also want to get rid of the popular prohibition against insurance companies discriminating against people with pre-existing conditions? If not, how would they make the pre-existing condition provisions work without the mandate? When they say they favor the ACA’s repeal, does this meant they want to repeal some of the ACA’s other popular provisions, like discounts on prescription drugs offered through Medicare, and coverage of preventive services at no cost to the patient? Or do they want to repeal only parts of the ACA, and if so, which ones?

If the ACA is repealed, what will they do about the 51 million who lack health insurance, and the 30 million who would get coverage under the ACA? Do they think it is okay for millions of Americans to go without health insurance? Do they have a plan to cover them? Or have some other way to ensure that they have access to needed care?

What will they do about rising health care costs, the number one contributor to the federal budget crisis? A mainstay of GOP criticism of the ACA is that it doesn’t do enough to control costs, but at the same time, the candidates are critical of the programs in the ACA that are supposed to help lower costs and have been vague about their own cost control plans. Would they repeal the ACA’s funding for comparative effectiveness research? For designing and implementing new payment and delivery models like Accountable Care Organizations? If IPAB goes, how would they save the same amount of money? What are their alternatives to lower health care costs?

What about the growing shortage of primary care physicians, expected to reach more than 40,000 by the end of the decade? Would they repeal or cut off funding for the programs in the ACA that are supposed to help, like increased funding for the National Health Service Corps, the redistribution of unused residency slots to primary care, and grants for primary care training, education and practice improvement? If they feel the market will solve the primary care shortage problem, how—since the market has consistently undervalued primary care?

Speaking of free markets, would the GOP candidates break up insurance company dominance of certain markets? Lift price controls on doctors and hospitals? Go after drug company practices that limit competition and drive up costs?

Hard to tell . . . and maybe not much, because the GOP candidates aren’t saying.

What have the GOP candidates proposed, other than getting rid of the ACA? Most seem to agree on selling insurance across state lines, enrolling more people in health savings accounts, giving states more options, and reforming the medical liability system, but that’s about it. Such reforms, though, would only insure about 3 million more people and have only a nominal impact on cost, according to the Congressional Budget Office. And we already know that many states, left to their own devices, have done an abysmally poor job in providing access to poorer residents.

Now, on most of these issues, it is easier to tell where President Obama stands—like it or loath it, his Affordable Care Act lays out a specific set of policies that the president has pledged to uphold. But he won’t say what should be done if the Supreme Court overturns the individual insurance mandate later this year.

And on entitlement reform, the Republicans have been far more specific on their plans than President Obama: most of them would convert Medicare to a defined contribution program and Medicaid to block grants. President Obama has been critical of both, but unclear on what he would do to reduce the growing costs of both. Increase the retirement age to 67, or make higher income people pay more? Offer a voucher system along with traditional Medicare?

Hard to tell . . . and maybe not much, because President Obama isn’t saying.

ACP believes that physicians have a professional responsibility to be informed advocates for patients, but the candidates have a responsibility to inform the public on what they would do if elected to the country’s highest office. Being against the health reform law isn’t enough—the GOP candidates need to tell us where they would take us. Being against Medicare vouchers and block grants isn’t enough—President Obama needs to tell us where he would take us on entitlement reforms. If they don’t, and they end up in (or in the case of Obama, return to) the Oval Office, they hardly will have a mandate to make the difficult decisions needed to ensure access, control costs, and have enough doctors to take care of patients.

Today’s questions: Do you think the presidential candidates are saying enough about what they would do about health care? What do you think about ACP’s comparison tool?