Leavitt on the SGR -- A Simple Solution for a Complex Problem

I'll admit it, I'm embarrassed. It's been over a month since my last post, which, although for perfectly legitimate reasons, is still unacceptable. Since it's Sunday night and I'm not at work and have no inspiration, I've turned to Leavitt's blog for a topic.

Leavitt's last post, dated Dec. 3 (he is a much better blogger than I), discusses the SGR, or sustainable growth rate, update. This rate determines how much physicians are paid for specific procedures. Because of the way that it's formulated, SGR updates actually would have been negative updates in the costs of procedures over the last couple of years. Obviously, giving physicians less and less money for the same procedure has not gone over too well for an industry with a very well-organized lobby. So physicians have successfully lobbied over the last couple of years to overturn the negative update and get a small increase. Which in turn, increases the negative rate increase for the next year.

It's a pretty sick cycle, and this year physicians are stuck lobbying against a 10% cut to their payments. That's huge. According to Leavitt,

This is a lousy system and it hasn’t reduced Medicare costs. The total expenditures just keep going up. Why? When rates per procedure don’t go up, doctors have simply done more procedures.

I think this is slightly simplistic reasoning for why the rates have increased. Nevertheless, Leavitt makes an interesting suggestion for fixing this obviously screwed up system:

Long term, the solution to this problem is to change the way we pay doctors. At least some portion of their payment should be based on how successful they are in keeping people healthy, rather that just the volume of procedures they perform [pay for performance].... [W]e cannot make progress unless doctors adopt a system of electronic medical records. Such a system depends on being able to gather quality data electronically.

What struck me as most interesting was his shift from a pay-for-performance system to EHRs. I am a full supporter of the EHR, but I'm not really sure how its adoption will lead to us correct the $200 billion deficit Leavitt earlier in the post says that we have from not reducing reimbursements to physicians. His prescription:

It is the position of the Administration that any new bill overriding the SGR law should require physicians to implement health information technology that meets department standards for interoperability in order to be eligible for higher payments from Medicare.

The connection between EHRs and pay-for-performance systems is a little tenuous. It's one thing for HHS to tell doctors to stop charging the government for their screw ups -- it's a complete other to mandate that doctors adopt costly technology or they won't get a raise. It would be completely awful to implement such a mandate without some financial assistance, especially for Medicare beneficiaries in rural areas where it's already difficult to find doctors who accept Medicare.

I guess I was expecting Leavitt to argue for a more, um, comprehensive reform. EHRs are great, and if you need to tie them to the SGR in order to ensure that they are implemented, go for it. But don't act like the fix to the growing problem of physicians payments can be encapsulated in better technology.

On Leavitt

I found out yesterday Michael Leavitt has a blog. I feel like I should have known this sooner, but alas, I found out about it from an article in USA Today. I don't even like USA Today.

Nonetheless, it turns out Leavitt has used it recently to defend President Bush's veto of S-chip. Not a huge surprise, but I thought it'd be fun to see what exactly he's saying. Here's some clips of a post from Oct. 9:

Some months ago, the Democratic leadership in Congress made clear they were going to send the President an SCHIP bill he would have to veto.

Hmm. I find this argument interesting. "Congress sent something to the president they knew he would HAVE to veto." As if someone is forcing his hand to sign that veto.

During that period we will hear a lot of political rhetoric but in the end the veto will be sustained. When that occurs we can get down to the business of solving this problem. ... [Democrats] have chosen to proceed as though the President’s opinion isn’t important.

Here's my other problem with the administration's political tactic. Why didn't they attempt to compromise BEFORE the bill's signing? President Bush didn't have a reasonable opinion prior to the bill's passage. What makes his opinion important now? Is it really any wonder the Dems aren't open to additional compromise?

It's not really any surprise how Leavitt's blog reads. I mean, he's the White House mouthpiece, this is how it should go. Doesn't stop me from thinking he's wrong.

****

Despite his party line belief in the inherent evil-ness of S-chip, I don't actually dislike a lot of Leavitt's policy ideas. David Broder of the Washington Post wrote an opinion piece on Sunday about Leavitt, which I think highlights some of the good that he can do for the health care system. Leavitt last week at a conference of insurers and health care providers described what he sees as the "coming revolution in health care in this country," according to Broder, which "is a story that, while less publicized than the SCHIP fight, holds promise of a better day not just for children but for all Americans." Broder writes

What I learned about Leavitt in his years as governor is that he is blessed with vision that sees future policy challenges and developments more clearly than most politicians. In this case, he is visualizing a radically different kind of medical marketplace, in which families armed with specific information about the treatment success and prices of hospitals and doctors can shop at will for the best quality and most affordable care.

...

Leavitt's view is that the government should not own health care; instead, it should organize the health-care marketplace and then let competition based on full information proceed.

Broder notes ("do not faint," he says) that Leavitt's plan is consistent with Hillary's health care plan. Leavitt's view that the health care marketplace needs to be organized is an important one, one that I think is often ignored. Government has organized other fields -- technology is a great example of this. Radio and the switch to digital cable, for example. When the government doesn't set standards, innovation flounders a bit, i.e. electronic health records. It's important that they all work together, but no one has stepped up to say how exactly those systems should work. I have to add that a bit of regulation is necessary, and I would imagine that Leavitt would not agree with that.

That's all for now, but look forward to more clips from Leavitt's blog, now that I've discovered it exists.

An embarassment to bloggers everywhere

Yep, that's me. It's been almost a month since my past entry, which is so sad. I'm going to blame it on my work load, which has become out of control as S-chip has spiraled out of control (perhaps the increase in news is actually MORE reason to blog, but still) and has left completely exhausted and unable to write another sentence about anything related to health care. Today, though, I am feeling energetic. And plus, you may have heard that just two hours ago, the House failed to override President Bush's veto.

Surprise, surprise, I know. Doesn't mean I wasn't rooting for some rogue Republicans to heroically stand up when voting and say, "I vote for children!" ... alas, no luck there.

So what's next? Dems have a couple of options when it comes down to it.

Change the bill slightly, so it becomes more difficult for Republicans to lie to the American people about why they should hate the bill (but can't ... a recent CBS poll found that even 70% of Republicans wanted to reauthorize S-chip). If Dems put in language that prohibits states from enrolling children in families with annual incomes of over 300% of the federal poverty level -- which the vetoed bill does in essence anyway -- then Republicans will be unable to break out their "Familes earning $83,000 a year will be on the public dole!" line.

The small revisions will have the effect of either a) persuading enough Republicans to switch their vote and vote to override, or b) make Republicans look sooooo bad that they won't be able to get reelected. It's 10 million children or the president, as Rahm Emanuel, Pelosi and Reid are so fond of saying. Who are they going to choose?

Another alternative: actually work with the president and Republicans to craft a different bill. I don't personally think this will ever happen. There's a pretty big differences between $5 billion and $35 billion and they'll never be able to bridge that gap. I don't think the president seriously thinks they'll be able to compromise either. In my head, I envision Bush as a whiny little child throwing a tantrum over S-chip. He was invited to the party, but thought no one was going ... now that it turned out to be a big deal, he wants in -- and he'll cry, and cajole and veto until he gets his way.

Here's some preliminary coverage from the New York Times and CNN.

I heart Chuck Grassley.

I know, I know, I shouldn't say such things about a Republican, but really I can't help myself in this case. Grassley is just so into S-Chip, it makes my heart all aflutter.

Here's why: President Bush apparently got a little misinformation (probably was intentional, who knows) about what the compromise S-Chip bill would do. Someone told Bush the bill would cover children in families with annual incomes of $83,000 (400% of the federal poverty level). However, this is patently untrue. The compromise bill, finalized over the weekend with final text expected today, limits S-Chip enrollment to 300% of the poverty level (maybe 350%, I'm not sure). The $83,000 that Bush refers to in his little rant on Thursday was about New York. NY petitioned to cover children in families at 400% of the poverty level ... and was denied, as Bush should know since his right hand man, HHS Secretary Mike Leavitt, did it.

So Grassley comes out Friday and says flat out, Bush, you don't know what you're talking about. Some highlights of Grassley comments:

• From CongressDaily: Bush's comments indicate a "miserable lack of understanding of what we're doing and even what his own administration has done;"
• From LA Times: Bush's proposal for SCHIP is insufficient "to accomplish what he said he wants to do, and that's cover more kids;"
• From USA Today: "The White House must recognize that bipartisan compromise is necessary" to continue the program; and
• From NY Times: "Drawing lines in the sand at this stage isn't constructive. I wish he'd engage Congress in a bill that he could sign instead of threatening a veto, and I hope he'll still do that."

"Miserable lack of understanding" is my favorite. I think it's just so rare that a Republican comes out and says it. You're wrong, Bush, and you suck (okay, maybe the "you suck" part is just my own personal view).

Runner up for favorite Republican on S-Chip is Orrin Hatch. When asked if he would vote to overturn Bush's veto, Hatch said, "You bet your sweet bippy I will." Aw, shucks, Orrin, you're just too adorable.

I started this post originally on Friday, and obviously more things have happened than my expression of adoration for two senior Republican senators. No, indeed, you may have heard that the compromise bill has been released. Here's the details, ala a Senate Finance Committee press release.

Grassley and Baucus, 1, Stark, 0

To be honest, I almost can't even stand to blog about S-chip anymore, I am so sick of hearing about it. But since it is my life and I love it, and I am a mere 10 days away from seeing SOMETHING actually happen with it, here's yet another post about S-chip.

The House gave in. The "compromise" bill (hopefully) is being released tomorrow and word on the Hill is that Stark lost his oh-so-precious cuts to Medicare Advantage. Baucus and Grassley must be thrilled. Sure, it's not really much of a compromise (considering it is so closely worded to the Senate bill they might not even have to re-vote on it, depending on whether the House can force some concessions). But still. At least it's something. That can pass in the Senate at least -- all bets are off in the House. Today I read that 17 House GOPers have said they will vote in favor of the new bill. Another Republican member (I forget who, but he's working along with Rahm Emanuel) predicted 30. The question becomes: Will it be enough to override a veto? I've heard some mixed predictions -- some say that there's these limited number of Republicans volunteering to support it, while others have said (over and over, I would say), Republican or not, you simply cannot vote against children.

Only 10 days before we find out. I'm going to fucking go into S-Chip withdrawl when this is over.

Let's talk Mayo Clinic

and Hillary, for that matter.

But focusing on the Mayo Clinic for a sec ... The clinic on Friday released 19 recommendations for health care reform. One of their major proposals is to make health insurance more portable. I mentioned this topic in my last post. I simply cannot stress enough how much I support portable health insurance. It doesn't make any sense to have it tied to employers anymore. I mean, hello, people of my generation have extreme ADD when it comes to holding a job. How are we ever supposed to establish a connection with a doctor, which will help us receive better, more coordinated care, if we keep having to change insurance providers every year and a half? New York Times says that one and four change jobs every year ... and I think they might be referring to me, haha.

What really surprised me about the coverage on this was the employer response. According to the Times,

Executives of several large employers who took part in the Mayo discussions agreed that rising medical costs and the aging of the baby boomer generation were pushing the current system toward a crisis. But they said they were not ready to abandon their current health plans for employees.

“We do not believe in relinquishing the employer-sponsored health care system,” said Anthony C. Wisniewski, a Mayo panelist who is executive director of health care policy at the United States Chamber of Commerce.

That's basically all the article says about it, which is kind of annoying because I want to know WHY they don't want to give up health insurance. It would make them totally more profitable. God knows those car makers are itching to drop insurance coverage ... why not businesses in the Chamber of Commerce? Perhaps because a good insurance plan makes a job offer more attractive? Hard to say without a better background in business.

You can read the rest of the recommendations here. Overall, I felt like the recommendations were very thought out .. radical but not so radical it couldn't be done. I'm very hopeful that Hillary will implement some of their recommendations into her reform. The whole quality-cost debate I think is pretty standard, but portability is something I would really like to see implemented.

Now on to discussing my girl Hill's proposal. Since I didn't cover it at work (as I did the Mayo Clinic) this is news to me too. Looking a press release from today on her website, the final prong of her three prong plan includes none other than --- PORTABILITY. (Full disclosure: I love Hillary. I volunteer for her campaign. Which truly demonstrates my love because I hate making cold calls ... but for her, I do it.). She even throws in tax credits. Listen to her: "If you like the plan you have, you can keep it." It's genius. She has some other good things outlined in the press release, so I recommend reading it.

From a different press release (the mainstream media will have more detailed coverage tomorrow ... if I have time I'll post some the main pieces so I am not completely one-sided.):

If you’re one of the tens of million Americans without coverage or if you don’t like the coverage you have, you will have a choice of plans to pick from and that coverage will be affordable. Of course, if you like the plan you have, you can keep it.

• Affordable: Unlike the current health system where insurance premiums send people into bankruptcy, the plan provides tax credits for working families to help them cover their costs. The tax credits will ensure that working families never have to pay more than a limited percentage of their income for health care.
• Available: No discrimination. The insurance companies can’t deny you coverage if you have a pre-existing condition.
• Reliable: It’s portable. If you change or lose your job, you keep your health care.

...If you have a plan you like, you keep it. If you want to change plans or aren’t currently covered, you can choose from dozens of the same plans available to members of Congress, or you can opt into a public plan option like Medicare. And working families will get tax credits to help pay their premiums.

Reading this shit practically makes me giddy. Also, hopefully you caught last week's Newsweek, which had extensive coverage about Hillary and "what kind of decision maker she'd be." It has some good insight into the lessons she's learned from the failed health care reform attempt of 1993/4. Here's a different web exclusive article on health care and Hillary.

For once I'm not going to write about S-Chip

There was an interesting opinion piece by Michael Cannon, director of health policy studies at the Cato Institute, in today's USA Today. Cannon argues that so many of the uninsured have access to insurance ("As many as 20% of the "uninsured" are eligible for government health programs, so in effect they are insured. On top of that, economists Kate Bundorf of Stanford University and Mark Pauly estimate that as many as 75% of the uninsured can afford to buy insurance," he writes), increasing access to health care isn't really the problem we should be focusing on ... cost is.

He writes:

Simply expanding coverage would have little effect on the quality of care, health disparities, or how long we live, nor would it stop free-riders from shifting costs to others. In fact, expanding coverage through government regulation or tax-and-transfer programs would make our problem worse.

He makes a point about the rising cost of premiums, that they aren't

some inevitable result of market forces, but of government programs and tax preferences for employer-controlled insurance. By rewarding employer-controlled coverage — and penalizing plans that stay with you from job to job — the government strips people of their health insurance when they need it most.

He then goes on to support Bush's tax breaks. I'm not completely sure how I feel about that (I know very little about taxes, just that I seem to pay a large proportion of my very small paycheck), but I think Cannon makes a good point that plans that travel should not be penalized, especially since I do think they will be the new way of purchasing health care in the future. Regional purchasing pools are the wave of the future, I'm telling you.

Back to Cannnon ... he ends by saying

If we want to increase access to health care, our first priority must be to contain costs. Nothing would help more than 200 million cost-conscious consumers.

Letting Americans own their health care dollars is the right thing to do. And as it happens, it would also cover a lot of the uninsured.

Cannon makes some very valid points. Cost containment must happen. We as a nation cannot continue to spend as much on health care as we do. And obviously this ties into a couple other areas, such as increasing preventive care and overall health. High insurance and hospital fees are not completely to blame here ... so is obesity and not exercising and smoking and not getting regular check-ups. A change in tax policy is not going to lower costs on its own. We need to have a different view toward health altogether.

Who knew you could do this?

Reporting on S-chip has taught me so much about procedural tactics, it's kind of scary.

This week was no exception. Bush decided on Friday, after business hours, while Congress is in recess, that he is going to make it virtually impossible for any state to enroll children in S-chip if their families earn more than 250% of the federal poverty level. Under his news rules, if states want to insure children in families earning above 250%, they must:

• Enroll 95% of eligible children in families under 200% of the poverty level (This is impossible. No state does it.);
• Ensure that children in families over 250% are uninsured for a year before enrolling them;
• Charge kids in families over 250% premiums and copays at the same rates as private insurance;
• Ensure that the percentage of children enrolled in private insurance plans doesn't drop by more than 2% (to make sure that employees aren't dropping their private insurance left-and-right to run on over to public assistance, the Republicans' anti-Christ); and
• Create mechanisms to ensure that employers don't create policies that encourage employees to switch to public programs.

While it probably goes without saying, I think this new policy is stupid. Yes, I suppose Bush is technically within his rights to create it ... it just seems unnecessarily cruel to set states up for failure, and in turn, children. It really bugs me in its hypocrisies. Bush expects (or maybe he doesn't?) states to now strive for enrolling 95% of all eligible children at 200%, the law's "original intent" or whatever, but under Bush's SCHIP proposal, there wouldn't be enough money to pay for them long-term. What's the point of bringing children into the program, if two years down the line, you are going to have to kick them out when the program runs out of funding? In essence, he basically set up that rule to prevent states from covering children above 250%. Someone never told Bush "honesty is the best policy."

Obviously he can't tell the truth about what he's doing, though. He would sound like an asshole. Which I think perfectly describes what he just did, denying care to children and putting more burdens on states. He is being so incredibly inflexible about everything that is S-chip.

Real reporters' coverage available here and here and here.

Closure of King Harbor Hospital

Friday's announcement that Martin Luther King Jr. Harbor Hospital will close after losing $200 million of federal funding, after it failed a second CMS inspection, highlights yet another problem caused by having high numbers of uninsured residents.

King Harbor is one of the lowest-income areas of L.A., meaning most likely a large number of patients visiting the hospital for care would be uninsured or on Medicaid. Either way, the hospital was probably operating on larger debt than most other hospitals in higher income areas. While I'm sure all the hospital's problems cannot be blamed on funding (I really hate it when government entities blame all problems on inadequate funds -- **cough cough** -- FDA), I think it's safe to say that the hospital would have been able to hire more knowledgeable staff and run the place more efficiently with more funds from the very beginning.

In short, what I'm trying to say is that a vicious cycle exists within our current health care system:

• Uninsured/underinsured residents are less likely to receive care because they can't pay the bills;
• Hospitals that serve large numbers of uninsured/underinsured can't collect enough funds when they're patients can't pay, thus making it difficult to hire competent staff;
• Without competent staff, the hospital can't offer care worth paying for, and might end up the way of King Harbor, and the community loses access to care all over again.

I think that single-payer systems have a lot of problems, but I think in this situation they offer a benefit. When the government is paying for care, and the wealth of the patient is no longer a factor, all patients have a better shot at receiving high quality care. Our system simply reinforces an existing socioeconomic divide. Will there still be a divide under a single-payer system? Of course. There's no way of convincing a doctor to practice at a hospital if he or she is concerned about being shot driving to and from work. Same idea for rural areas. But at least wealth is taken out of the equation.

***

Last week, the Philadelphia Inquirer had a great opinion piece about health as a public good, as opposed to a private good, that I think relates to the problems with King Harbor. Columnist Chris Satullo writes,

Health care is a classic public good that should be supported by a social compact: The healthy should pay into the system to underwrite care for those who need it now, both as a matter of civic morality and self-interest. They need to support the system now so that it'll be there come the inevitable day when they'll need it.

...

The goal shouldn't be for government to supplant the private health-care market, but to tame it. States have tried, but only the feds can really do what's needed: Organize the market rationally so it covers all at a basic level, wastes less, and offers consumers intelligible, workable choices.

For more coverage about King Harbor, see here, here and here.

Now what?

With both the House and the Senate having passed substantially different versions of health care legislation, I'm intrigued to see how the conference committee is going to find some sort of viable solution. Both sides are saying, "here's this provision of our bill that can't change" and they seem completely at odds with each other.

In the House, both Dems and Republicans are saying that the tobacco tax increase can't go above 45 cents. Dems already lost 10 votes because of the tax in the first round, who knows how many more they'd lose if they increased the tax to the Senate level of 61 cents.

Meanwhile, Republican senators do not seem willing to even consider cuts to Medicare Advantage (complete bullshit if you ask me...). But the Senate already has the smaller expansion -- if you were to just collect funds from a 45 cent tax increase, it wouldn't even be enough to fund the $35 billion expansion. So basically senators have to find a completely different, non-controversial source of funding. I hope they're creative, because I'm not sure that exists.

My prediction: $35 billion expansion, with some of the House's Medicare provisions (definitely the reversal of scheduled physicians cuts, to be funded perhaps by the cuts to nursing and inpatient rehabilitation centers?), without the MA cuts. All to be funded with a 45-cent tax increase and "unidentified non-controversial tax" (I've heard that perhaps they could better collect back taxes, and that would get lawmakers the needed money).

What makes it even more tricky is the impending presidential veto. I wish Bush would get off his ideological high horse already. Leavitt is quoted in the NY Times as saying

Congress was jeopardizing health care for millions of needy children by passing bills that “the president will have no choice but to veto.”

Seriously, what an ass. So not only does the conference committee have to come up with something that most of the lawmakers can agree on, it also has to be veto-proof. That, or millions of children go without health insurance. No pressure Congress. No pressure at all.

On S-Chip ... and Medicare Advantage ... and Physician Reimbursements ...

Finally back from vacation, and almost caught up at work.

Dominating my work life these days is S-Chip, both the House and the Senate versions. I gotta say, the House version bugs me. It just seems so utterly unrealistic. The bill does so much ... from a major expansion of S-Chip, to a 45-cent tobacco tax, to major revisions in Medicare (i.e. physician reimbursement levels, nursing home and inpatient rehabilitation reimbursements ... and let's not forget everyone's favorite -- Medicare Advantage).

Reimbursed on average 12% higher than traditional Medicare, and sometimes as high as 19% more, Medicare Advantage is House Dems' favorite source of S-Chip funding to meet their own pay/go guidelines. And no wonder why, the latest CBO scoring finds equalizing the payments will save $50.4 billion over five years and $157.1 billion over the next decade. Dems argue that there's no reason these plans should get more, just because they're private. It's a big Republican scheme to make insurance companies richer, they say.

Republicans, along with AHIP, HATE the idea of equalizing the reimbursement rates. Some reasons they give why the rates shouldn't be equalized:

1. The lower reimbursement rates will make the plans unprofitable and cause the insurance companies to drop them, which could hurt seniors in rural areas, who have limited options to begin with.
2. If companies drop the MA plans, minorities will be adversely affected because they enroll in higher numbers in the private plans. (This is a contentious assertion. Rep. Pete Stark, and other supporters of an equalization, say this is simply not true -- that minorities are equally enrolled in both the traditional plans and private plans.)
3. Reducing the reimbursement will cause physicians to stop accepting patients enrolled in the plans, which would obviously be bad for everyone.

So who to believe?

MedPAC, which advises Medicare, issued recommendations (PDF) in June saying that MA rates should be equalized. It writes that

MedPAC has a long history of supporting private plans in the Medicare program. The Commission believes that Medicare beneficiaries should be able to choose between the [traditional] Medicare program and the alternative delivery systems that private plans can provide. Private plans may have greater flexibility in developing innovative approaches to care, and these plans can more readily use tools such as negotiated prices, provider networks, care coordination and other health care management techniques to improve the efficiency and quality of health care services.

However, the recommendations continue:

The Commission believes that payment policy in the MA program should be built on a foundation of financial neutrality between payments in the traditional ... program and payments to private plans. Financial neutrality means that the Medicare program should pay the same amount, adjusting for the risk status of each beneficiary, regardless of which Medicare option a beneficiary chooses.

I'm going with MedPAC. I think overall reimbursement rates are too low and the access to care for Medicare beneficiaries is a problem, but I don't think continuing to give private plans more money is the solution. I'm all about an overhaul of the reimbursement system.

So go ahead and equalize 'em, Stark, you've been waiting for this moment all session. (Now if only you could get enough support in the Senate to actually make it happen...).

More on S-Chip in the days to come.

Moore vs. Gupta, Round 2

As promised, here's the Larry King Live segment:



I gotta say, I really thought that Moore would rip Gupta to shreds, but Gupta makes some valid points AND comes off as much more sane than Moore. CNN really should have better fact-checkers, considering they are supposed to be a reputable news source (although I really lost respect for CNN several years ago when they posted a story about Barbie and Ken breaking up). $251 vs. $25 is a huge difference, and someone should have caught that on their end.

This is why Michael Moore seriously annoys me

Chill out, Michael.



While I think Moore is an absolutely ridiculous interviewer, he has a right to be angry, Gupta's criticisms of his movie are not accurate or fair (see Moore's website, which includes links to his citations). Gupta should have known better than to fuck with someone as angry as Michael Moore. His movie might have been incredibly one-sided, but not many people have challenged the truthfulness of any of his statements.

I hear that Gupta and Moore are going to battle it out on Larry King Live tonight. Unfortunately, I don't really have television, but I'm hoping it'll be on YouTube tomorrow and I can respond then.

As usual, women get screwed

As a women's studies minor in school, I did a lot of reading about how women are forced to succeed within a society built by men. A lot this concept has to do with the workforce: in order to get ahead, you have to put in a lot of hours and spend a lot of years, etc., which forces women to either choose not to have a family, or to not get ahead.

Of course, I am always really happy to read an article about how some companies have implemented a policy (such as telecommuting, flexible hours, daycare onsite, etc.) that provide all employees (not just women -- the policies also benefit men) greater flexibility that allows them to avoid being forced to choose between having a family and succeeding in a career.

So it really bugs me to see shit like the (slow) rise in popularity of high-deductible health plans . According to an article on Thursday in Dow Jones (I can't link), several studies show that women get fucked in out-of-pocket costs under HDHPs. It's not only bad enough women have to be pregnant, most likely be the primary caregiver once the kid is born, while working, now women also might have to pay more to be pregnant.

HDHPs are not women-friendly health plans. They are, as usual, a way for businesses to save money while leaving women behind.

The Commonwealth Fund in April released an issue brief written by Judy Waxman, vice president for health at the National Women's Law Center, and Elizabeth M. Patchias, a health policy analyst at NWLC. It writes,

Women are more likely than men to need health care throughout their lifetimes. Women’s reproductive health needs require them to get regular check-ups, whether or not they have children, and women of all ages are more likely than men -- 60 percent versus 44 percent -- to take prescription medications on a regular basis .... For younger women, this difference is even greater; women ages 19 to 29 use prescription drugs at almost three times the rate of men in that age group. Further, women are more likely than men to have a chronic condition requiring ongoing treatment (38% vs. 30%). Finally, certain mental health problems, including anxiety and depression, affect twice as many women as men.

It concludes,

Given these factors, policy proposals that provide comprehensive benefits at affordable cost would help more women obtain meaningful coverage. Conversely, reforms that result in higher out-of-pocket expenses and limited benefits will not significantly improve the health and financial security of women.

Exactly, ladies.

Sicko is Right.

I saw Sicko right after work on Friday (lest anyone ruin it for me before I saw it), and I left with a couple of impressions:

1. I must move to France ASAP.
2. The British have a really great sense of humor.
3. I didn't hate it as much as I thought I would.

It's just, I don't think I single-payer system is the right option for the U.S. Perhaps Moore's right, perhaps it works so well in France because the French government fears its residents. But if I've learned one thing in the last 7 years of the Bush administration, it's that the U.S. government has absolutely no fear of its citizens. We are the government's apathetic pawns. I do not trust the government to run my health care, and I certainly do not trust the government to contract out my health care. And to be honest, I'm kind of surprised Moore does.

Here's a great AP article on some contentious points of the movie.

No Mandate for Moffit

Interesting McClatchy piece in yesterday's Charlotte Observer, written by Robert Moffit of the Center for Policy Studies, about individual mandates. I am an unlikely candidate to support anything that comes from the Heritage Foundation, but I've got to admit, I'm with Moffit about 95% of the way.

Moffit's basic point is that individual mandates already exist, since taxpayers are already paying for health insurance in the form of uncompensated care and Medicaid and Medicare. He appears to put a lot of the blame on "people who can protect themselves through health insurance" but "are failing to do so."

I'm not sure I agree with that, since he doesn't clarify who he's referring to (I mean, what qualifies as affordable? What makes you too "low-income"? ... I want some percentages on why people don't buy insurance before I'm sold on this), but he has a point that unpaid medical bills are distributed to the rest of us in the form of higher premiums. He calls it "irresponsible" for people to ask others to pay for their bills. Fair enough.

Moffit writes

That's why my Heritage Foundation colleagues and I support the "personal responsibility principle." It's a simple idea: All adults have a responsibility to buy their own health insurance, pay their own health-care bills, and not shift those costs to others.

He supports the purchase of "catastrophic" insurance policies as a minimum form of coverage, which I assume can be purchased at a lower price than every day insurance plans. However, he writes, "People who do not wish to buy health insurance for whatever reason should be free to do so."

So no individual mandate for Moffit. I guess I shouldn't be surprised. His suggestion instead? People who "choose" not to purchase insurance "must demonstrate in some tangible way that they are really going to pay their own hospital bills," such as by putting thousands into an escrow or by providing some sort of financial guarantee that they can indeed pay those medical bills, should they incur them.

And if they don't?

The people who choose this option should no longer be able to claim a personal tax exemption when filling out their IRS and state tax forms every year. Somehow, these people should pay something that could be used to offset, to some degree, a portion of the rising costs of the uncompensated care.

I guess my problem with his whole argument is that he is operating under the assumption that people choose not to have insurance. And while I admit I live in a little health care news bubble, which tends only to focus on the cases that make you sympathetic, and have my young adult "invincible" tendencies, I'm just not buying it. I don't have a couple thousand to throw in an escrow, Mr. Moffit (in fact, I'm not really sure I even know what an escrow is), unless somehow my college loans and credit card debt are magically transformed into profit. As it stands, I struggle enough with my day-to-day living expenses. And from everything I read, the people without insurance are the self-employed with previous medical conditions, who maybe are solidly middle-class, but can't afford the hundreds or thousands per month that insurance companies want them to pay, or are people who just can't get insurance because they're too sick. To imply that people don't get health insurance because they don't want it is a little elitist/health-ist for my tastes.

To his credit, Moffit does suggest tax credits or vouchers for those who can't afford catastrophic care policies. But at what levels? Is he talking Medicaid levels? Because seriously, those income requirements are a joke. Just because someone makes 110% of the poverty level doesn't really mean that they are any more able to afford health insurance than those making 99% of the poverty level. (100% of the federal poverty level is an annual income of $10,210 for an individual.)

Alright, I'm changing my mind, I agree with Moffit about 70% of the way -- I should have known better than to almost agree with anything the comes out of the Heritage Foundation. In conclusion: Personal responsibility, good. Finger pointing at the uninsured, bad.

You're making me sick, Moore

Started this last week about Michael Moore's new documentary on the U.S. health care system. I'm looking forward to the movie coming out of Friday, so I can watch, and then really (knowledgeably, promise) rip it to shreds. I am a huge liberal, but Michael Moore just pisses me off. Enough with the theatrics already. Plus, I really disagree with the single-payer system and if this movie starts some movement, I will be angry.

UAW Shows "Flexibility"

UAW President Ron Gettelfinger said on a Detroit radio program on Monday he is considering offering some health care concessions to Chrysler, now that the company is posting losses. Gettelfinger said, "We've been talking to Chrysler quite frequently -- we do need to find a way to fix the problem there now that Chrysler is in a downward mode."

Detroit News reports

While the UAW has historically fought to preserve top-tier health benefits for retirees, the union has shown some flexibility in light of the severe financial issues facing Detroit's automakers.

Gettelfinger is looking for a deal similar to that offered to Ford Motor and General Motors back in 2005, which were posting high enough losses to warrant the reduction in health care benefits.

The deal required GM and Ford retirees to accept modest co-pays and deductibles, while active UAW employees gave up $1 an hour in raises.

Personally, this doesn't sound like such a big deal, considering Chrysler is in the red, although I admit I have NO idea how much autoworkers earn. If the reduction in benefits amounts to increased competitiveness with foreign imports, that would be a good thing, in turn perhaps keeping a greater number of workers employed in the long-run.

I think retirees are going to be screwed though. If you're promised one thing when you retire, and then a couple of years down the road it changes, it doesn't give you proper time to adjust your budgeting. Gettelfinger does seem particularly concerned about this, which is good. I personally think retirement benefits will go by the wayside in favor of 401(k)s, it's just going to be a painful phasing out.

**Closing quote from Troy Clarke, GM's North America's chief: "If there is a cost that keeps me up at night, it's health care. We have the retiree health care issues and it's very stressful. We've got to come at that some way.

More coverage from the Associated Press.

More coverage from the Detroit Free Press.

Haha, suckers

Fast food sucks, doesn't it?

Many were once convinced that Japanese people lacked the fat genes found in other groups. According to figures compiled in 2005 by the Paris-based Organization for Economic Cooperation and Development, only 3.2 percent of Japanese people had a body mass index greater than 30, compared with 30.6 percent in the United States.

Candidate Updates

I'm going to be honest here, I really only plan on blogging about the candidates who I personally think are viable.

For the Democrats:

• Hillary Rodham Clinton
• Barack Obama
• John Edwards

For the Republicans:

• Rudy Giuliani
• Mitt Romney
• Tommy Thompson (not really because I think he's viable, but because his whole platform is basically about health care ... at least, so you'd think from the coverage)
• Fred Thompson (again, not really because I think he's viable. I just really love Law & Order)

That said, here are some updates on their stances on health care:

• "Bearing scars, Clinton cautious on universal plan," McClatchy. Clinton's being a bit vague on her health care proposal to avoid comparisons to her last plan, while playing up her health care "scars." Smart move.
  
• "Edwards to Detail Health Care Plan," Associated Press. I personally thought he had already detailed it enough, but apparently he did it again today in Michigan. Also, he's added proposals to end patents on breakthrough drugs and require insurance companies to spend 85% of premiums on patients care.
• Gialiani has a 12 Step program for the country, one of which is increasing access to health care: "Giuliani Offers Up 12 Steps to a Better Future," Washington Post. "Rudy's Plan for the U.S.: 12 Promises to Keep if he Becomes Prez," New York Post.
  

Side note on party differences from the article on Clinton:

Democrats describe the escalating cost of health insurance and the rising number of uninsured Americans as "a crisis." All say they want universal coverage.

Republicans rarely mention health care, except when asked about it. Former New York Mayor Rudy Giuliani and Sen. John McCain of Arizona don't list health care in the "issues" section of their campaign websites. Former Massachusetts Gov. Mitt Romney rarely talks about his successful effort to make health insurance mandatory for Massachusetts residents.

Carmaker drama continues

Associated Press today reported more on the high cost health care puts on car manufacturers.

General Motors, Ford and Chrysler will seek labor cost reductions that put them on par with their Asian rivals during summer contract talks with the United Auto Workers, officials of the three automakers said Wednesday.

Detroit News columnist Daniel Howes, citing people familiar with Ford's bargaining strategy, reported earlier Wednesday that Ford would seek to cut hourly labor costs by 30 percent, from about $71 to around $50, including wages, pension and health care.

That's a pretty huge cut for workers and while UAW can fight some of it, I don't think Gettelfinger will be completely successful in blocking health care and pension benefit reductions. AP continues

UAW spokesman Roger Kerson would not comment Wednesday, but union President Ron Gettelfinger said in March that it made major health care concessions in 2005 to Ford and GM that saved the companies billions, and he implied that the union wasn't willing to give more. The UAW has completed an evaluation of Chrysler's finances but won't say whether it will give Chrysler the same deal.

Thoughts on high-deductible health plans

Okay, don't want to go into this in too much detail, but the Wall Street Journal today published a piece about how high-deductible health plans (HDHPs) with health savings accounts aren't gaining traction with workers. To me, this seems kind of self-explanatory. I mean, when given a choice between a plan that will pay for a lot of things for me, and a plan in which I have to save my own money and make a lot more choices, I'm going to choose the easy, cheap one. Of course, if you are telling me I have a choice between no health care and a HDHP with an HSA, I'm choosing the HDHP/HSA. Something is better than nothing.

One huge problem is, and the Journal notes this, that there simply isn't enough information out there for consumers to make educated choices about price versus quality in choosing doctors. If I was looking for a doctor to perform a heart bypass, would I really want the cheapest? But if I have this plan, that's what I'm constantly going back to. Not to mention, plenty of sites looking to compile data on costs have found that hospitals don't just toss out a price for any given procedure. Hospitals have one price for one insurance company, one price for another, one price for Medicaid and Medicare, and one price for the uninsured. Trying to get a straight answer about final cost is not easy.

On top of costs, where would I find information about quality of care? There isn't easily comparable data out there. I read some recent coverage (I forget where) about different companies trying to set up quality data about hospitals and even states, like New Jersey for heart surgery, that rate doctors and hospitals about very specific procedures. But really, the U.S. health care system just isn't there yet. It's not comparable data ... some sites measure quality in different ways, making a hospital good on one site and bad on another.

So really, it's no surprise that HDHPs/HSAs haven't caught on yet. They are just TOO much work. Health care is important, but I just want it, I don't want to have to research it. I have other things to do. Maybe Bush is right when he says we need a culture shift toward people acting more like consumers about their health care. But right now, it's just not easy enough to make it worthwhile.

The Individual Mandate

Last Thursday, Republican presidential candidate Rudy Giuliani psuedo-announced his national health care proposal on the Sean Hannity radio program. According to the Long Island Newsday, Giuliani made "no mention of covering everyone" in the U.S. during the interview. Meaning no individual mandate, popular in most Democratic candidates' plans (not particularly surprising, but still...).

Obama received quite a bit of criticism for his health care proposal, which makes health insurance a requirement for children but not for adults. A Boston Globe editorial states:

Senator Barack Obama came out yesterday with his plan, which comes close but doesn't cover everyone, though he implies it does. ... without a broader mandate, he can't be sure adults will buy insurance."

An opinion piece in the Chicago Sun-Times writes

Obama proposes mandating coverage of children but not adults, opening the question of whether his plan will lead to Obama keeping his first pledge, to sign a universal health care law by the end of his first term.

Apparently Obama felt a bit threatened by the criticism and wrote in a letter to the editor in the Boston Globe that

The major reason that 45 million Americans don't have health care is not that they don't want it, it's that they can't afford it. If we require people to purchase insurance before we bring down its cost, we'll make a bad problem worse.

He added that the editorial was "inaccurate" when it "stated that my universal health care plan would not cover everyone," adding, "My plan will cover every American."

I agree with Obama in that requiring people to purchase insurance right away will most likely create significant problems for a lot of lower-income people. Massachusetts is having problems with that right now ... the only age group for their new insurance law that has affordable coverage is young people ages 19 to 26. The state is going to have significant growing pains come July 1, the date set for the law's enforcement, which maybe could have been lessened if the state slowly implemented the mandate.

In the long run though, the individual mandate is necessary to balance the risk pool for insurance companies. If 19- to 26-year-olds -- the healthiest age group and the one least likely to purchase insurance -- don't buy insurance because it's going to cost them $150+ per month (I personally fall into this age range and would find it difficult to come up with the extra $150, in addition to my student loans, credit card debt, and overpriced rent), then insurance companies are going to be over-burdened with health care costs for the sick. If a mandate is what it takes to get healthy people to buy insurance, then it's necessary in order to lower premium costs across the board.

More news on health care cost crisis for car makers...

CEO and Chair of General Motors Rick Wagoner discussed the effects of health care costs on the company's bottom line. AP/Philadelphia Inquirer reports:

[Wagoner] said that the company had made progress with the United Auto Workers in becoming more competitive, but that more needed to be done in forthcoming national contract talks this summer.

GM, he said, needs to "further reduce our still-unsustainable health-care bill, which was a staggering $4.8 billion in 2006."

A couple of the big automakers are discussing creating a trust fund of sorts for workers' health care, which would allow them to put in a set amount and allow the unions to control how the money is spent (called a VEBA, or Voluntary Employee Benefit Association). A May article in Business Week, writes that leaders at GM, Ford , and Chrysler "believe they may have a cure for Detroit's epic health-care woes" in VEBA.

VEBAs would hand "over the companies' long-term liability to an independent fund managed by the UAW, which would be financed by a huge one-time injection of cash and stock. Union workers would probably contribute more toward their own coverage costs but would gain protection from the devastating prospect of bankruptcy."

I'm not sure how I feel about VEBAs yet, but they seem like a pragmatic compromise if done fairly.

Welcome

Welcome to Health Care Policy 101. My name is Emily is I will be your blogger, from now until ... I lose interest, most likely. A little bit about myself: I've been writing for a couple of different health policy publications for about 7 months now and the experience has taught me some things:

1. Health care is incredibly, and I mean incredibly, complicated. Managing a hospital is complicated, health care law is complicated (one exec at the company I work for actually used the phrase, "I feel sorry for anyone who entered health care law"), and crafting health care legislation that can actually pass through one or both of the chambers -- not to mention the White House -- is really complicated.
2. Health care is so important right now. Which could be because there's a presidential campaign going on ... but more likely it's because the whole employer-based health insurance system is falling apart. Some 46.6 million U.S. residents were uninsured in 2005, according to the U.S. Census Bureau, and companies are increasingly having difficulty dealing with the rising costs. Chrysler has said repeatedly that the costs associated with health care for workers adds $1,000 per car as compared to competitors (see recent coverage by the AP/Houston Chronicle). You know when you have businesses like Wal-Mart teaming up with the SEIU and corporate giants like Safeway calling for health care reform something is very, very wrong.
3. It's going to be a long time before anything gets done. It just is. Any candidate who claims they can get universal coverage by 2012 is being incredibly optimistic. Democratic candidates, you know who you are.

So with those very basic assumptions, I begin to blog. Looking forward to the months ahead, and to hearing your thoughts.