Health care reform

I work on other programs affecting low-income families, not health care.  But if Congress passes a true health care reform year, and no improvements in the programs that I work on, I'll consider it a success.  And if we get everything on my organization's policy agenda for 2009 but health care reform crashes and burns, I'll be disappointed.

Ezra Klein is blogging for the Washington Post now, and he's got two really good pieces today, one from this morning on why the CBO cost estimates are putting health care reform in danger and one from tonight on the Finance committee's revised plan. Basically, the budget office has told Congress, no, you're not going to save enough money with comparative effectiveness research and improved health care IT to pay for the expansions in coverage you want to see.  If you want real health care reform, the choices are to come up with the money from some other source (e.g taxes of one sort or another) or to get serious about cost-controls (e.g. take a chunk out of insurers' hides, and possibly out of doctors' as well.)  The no-hard-choices fairy isn't going to save you.

It's looking like Congress isn't really going to tackle these hard choices until after the Fourth of July recess.  Which means that the next few weeks are a great time to weigh in with your Representative and Senators about the need for real health care reform — including a public plan — and the need to pay for it with comprehensive tax reform.  If you really want single payer, go ahead and tell them that, but then tell them about what you think is second best, because single payer isn't happening, not this time around, and it won't be more likely in 10 years if this round collapses.

Are you paying attention to the health care debate, or have all the different bills made your eyes cross?  Are you waiting until things sort out a bit to pay attention?  What burning questions would you like answered?  As I said, this isn't my area of expertise, but if I don't know the answer, I probably know where to find it.  If you want to get into the wonky details yourself, my favorite health policy sites are Families USA, the Kaiser Family Foundation, and the Center on Budget and Policy Priorities.

8 Responses to “Health care reform”

  1. Lee Says:

    Elizabeth, Thanks for the links. Tell Me More had an interesting segment today with some doctors who serve low-income populations. They emphasized preventive healthcare and referenced Dr. Barbara Starfield from Johns Hopkins. What can you tell us about reform through primary care?

  2. TheLuckyGal Says:

    Wow. So many questions / thoughts. I’ve not been paying as close attention as I could … because I am not there anymore. (We moved from Seattle to Melbourne Australia in September.) But, I “get” a lot more than a “lay person” (I used to work for an insurer) so it might be a break even in terms of how much I understand. I worked for an insurer – in a position required me to really understand healthcare laws, rules, financing, etc. – and I must admit (and this is hard as a dyed-in-the-wool Dem) I would be terrified of a single-payer system there. I believe in government … but not in that of the USA trying to piece together a single-payer health system. Medicare is so fucked up; there is so much waste. And, I really believe that a lot of what insurers do is a lot more value-added than they usually get credit for. I do nonetheless agree that insurers (and yes, doctors … and drug companies) will have to feel some pain if real reform is in the future. But, since Medicare is so screwed and thus I don’t think the govt can do it all, I think insurers should play a role. One thing that frustrates me is the lack of meaningful comparisons to other countries’ systems (in mass media). There was a piece the other day (NYT) re: “rationing” that compared survival rates for a number of diseases and showed other countries ahead of the US for most. I think studies / articles like that are really valuable and could go a long way towards convincing a sceptical American public. So far I have been impressed by the health care system here in Oz, which has a fully public system running alongside a private system, with tax incentives to those than can afford it to “buy” out of the former into the latter. BUT, the care in the public system is still excellent. (And for emergent conditions, no, you don’t wait forever. For some elective stuff, yes, you do wait.) Why don’t Americans know about this as a model?! RE: the primary care comment from @Lee, BTW, no one here sees a specialist without a referral from a general practitioner – no one. And, from what I can tell, a lot fewer people attempt to get their primary care needs met via the emergency departments … which then brings in the issue of other programs, in that there is a stronger social safety net in general (esp. for, e.g. maternal / child care & mental health) so routine health stuff can be looked after even if you’re poor. Another example of a model to look at: I’ve heard that the NHS in the UK is piloting “Lean” (a system of removing waste to improve efficiency and quality based on Toyota production) in some of its hospitals. I know that hospital systems in the US have had success with this (Park Nicollet, Virginia Mason) – why doesn’t someone look at the NHS program as a possible broad-based waste-cutting / quality-enhancing approach in the US? I’ve realized since moving here how very navel-gazing American media can be … there are so many models of state-subsidised healthcare in the western world, why aren’t they highlighted in US media? Ack. Sorry this got so long.

  3. jen Says:

    All the talk about single payer, etc., totally misses the point in my opinion. To reign in costs you have to stop the fee-for-service model, period. Hospitals and doctors make more money from people who need lots of services, because they are paid for those individual services. Everyone wants to cut margins: pay less for each individual service. Well, then the physicians/hospitals have to make up in volume what they no longer get in profit for each service provided. Think of CT scans: they used to reimburse $325 for one CT scan, and now they’re only reimbursing $275. But the loan payment on that CT scanner is not going anywhere, and the hospital gets $0 when a scan is skipped. Plus no one has set out any new guidelines for who needs a CT scan and when.
    This type of cost containment effort is not going to help. What we need, regardless of who pays for it, is something called “bundled payment”: if a person has condition X (with or without complications, other illnesses, etc.) then the provider gets paid $Y to treat them, end. If a CT scan is called for in this treatment, then that’s factored into the bundled payment. And BTW, provider, here’s the list of cases where the CT scan is called for, in case there’s confusion.
    Such a scenario would need to reign in the independence of individual physicians, and would also result in some sort of national board that determines what the best treatment protocols are for various different medical situations. I personally think this is a good thing. We as consumers can’t tell if our doctors are overprescribing.
    BTW I also believe part of this should be free med school educations for physicians. Part of what drives physicians to seek profit margin, where they really should not be looking for it, is heavy debt load. Let’s just take that off the table. Plus it will ensure that the best and most capable physicians are trained, regardless of their ability to pay for the schooling.

  4. trishka Says:

    i have to say that i’m a huge fan of ron wyden’s healthy americans act. i love the fact that it decouples health insurance from employment, and also that it is not only revenue neutral for the first few years but will make money after that.
    to learn more.

  5. TheLuckyGal Says:

    I think you’re right @jen re: the fee-for-service model driving costs – it’s a vicious cycle wherein doc / facilities get paid more for doing more … sometimes regardless of what treatment is actually indicated. But insurers already pay contracted facilities based on bundled payment (or, DRGs) … but if a line item on a claim is not part of the contracted bundle, and the insurer asks why it was done, everyone freaks out. I don’t know if shifting that responsibility to another entity will make it more palatable for facilities.

  6. Jennifer Says:

    You know, I have so little faith in Congress. Do you really believe they can improve the system? My feeling is that they’ll change things but to no real benefit, and my taxes will go up.

  7. jen Says:

    It’s totally true that bundled payments in the form of DRGs are present on the inpatient side, sorry for the confusion. I was speaking more of the outpatient side where the concept has not been implemented. This is part of the reason you see so many outpatient imaging facilities — their fees were in the past higher when the imaging was conducted in the outpatient setting. That’s been rectified in the last year or two, I believe, but was a big driver. Also in the past year or so it’s been ruled illegal for a physician to refer patients to an imaging facility that they (the physician) own – a clear and appalling conflict of interest that existed for years and years.
    I’m not sure what the deal is with bundled payments and diagnostic services such as scans and invasive testing. Does the DRG only cover the treatment once the condition has been determined?

  8. amy Says:

    Our capacity for refusing to face the music is beginning to overwhelm me.
    I do not think we’re going to make any sort of national health work without a QALY-type rationing/queueing system, which means public with a private layer up top if you can afford it. It also means an end to hip replacements and new teeth for 80-year-olds, possibly a pullback in heroics for very premature babies, an end to organ replacement for those with diseases that are likely to trash the new organ, etc. Unfortunately I don’t think we’ll be able to get there until the boomers are too feeble to mail in their ballots. We Gen Xers haven’t got the numbers to stop such a scheme, so maybe there’ll be a shot then.
    I am suspcious, too, about the costs involved in testing, esp. testing that involves very expensive equipment where amortization is a major issue. I wonder what the savings would be if we compensated inventors of such machines lavishly, then took over production (apart from the possibility that the public sector would do a disastrous job with it).

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