To listen to the Glen Becks/Sally Pipes/Charles Krauthammers/Neil Cavutos you’d think President Obama and the Democratic Congress is 100% full-bore absolutely committed to a health system run by the Feds where all docs are Federal employees and hospitals are owned by the gub’mint.
They are nothing if not consistent in decrying ‘socialized medicine’, unfortunately they have no idea what they’re talking about. Nowhere in President Obama’s history – not in any position papers, speeches, responses to questions, or writings – is there any credible evidence of any support for a socialized health system (one where the payers and providers are government workers).
Nowhere.
This isn’t a “you say po-tay-toe, I say po-tah-toe” thing. We are not splitting hairs arguing about policy niceties or nuance, this is a flat out complete distortion of the Democratic reform platform. It is an active, aggressive, coordinated, consistent effort on the part of these wingnuts to distort the Democrats’ position and scare Americans. These right wing talking heads are not idiots, and they can read; clearly they know they’re lying.
Why?
Simple – the real Obama/Democratic health reform plans aren’t scary big government takeovers of health care; they leverage the existing private insurance industry – and don’t even assure universal coverage.
In fact, the voters might actually like the Obama plan. What’s unfortunate is by lying about the Dems’ reform initiatives, these folks have lost all credibility. They could contribute to the discussion, instead they’re standing on the side lines screaming.
What does this mean for you?
If the D’s plans were that bad, the wingnuts wouldn’t need to lie about them.

OK, so the Dems will have more control over legislation when Franken joins the Senate. With PA Sen. Arlen Specter changing sides, they have passed the magic 60-vote threshold, making it theoretically possible for health reform legislation to pass without any votes from the other side of the aisle.
‘Theoretically’ being the operative word.
Before anyone starts chilling the champagne and covering the lockers with plastic, think about what hasn’t changed; health care reform – as currently conceived – is unaffordable.
None of the recent developments – or any of the current proposals (except the Wyden/Bennett Healthy Americans Act) do anything to resolve the cost issue.
And as Bob Laszewski points out today, without cost reform, there will be no health reform.

Yesterday’s revelation of a compromise on health reform by two key Senators – a Republican and a Democrat – was the first public statement of the long-simmering plan to significantly change physician reimbursement.
It wasn’t much to start – a call to increase reimbursement for primary care services by 5% along with bumps in payments to rural physicians. But is also noted a decrease in reimbursement for other specialists. And that’s where things are going to get very contentious.
The proposal by Senators Max Baucus (D-Mont.) and Charles E. Grassley (R-Iowa) indicates there’s been significant progress between the two parties on health reform; according to the LATimes, “the senior members of the Senate Finance Committee have reached some bipartisan agreement about how the federal government should pay providers through its Medicare program.”
This bipartisan agreement, coupled with the earlier announcement of Sen Arlen Specter’s move to the Democratic party and the decision by Democrats to subject health reform to the reconciliation process (where it can pass the Senate with a simple majority) may well kick health reform into high gear. Politically, more Republicans may be realizing that a continued policy of pure obstruction will not help turn around the fortunes of the party.
With health reform a highly visible issue, at least some members of the minority party may have decided to try to steer the bus instead of continuing to lie down in front of it. Politico reported late yesterday that Rahm Emanuel met with Senate Minority Leader Mitch McConnell yesterday to discuss health reform – a meeting that may well indicate the GOP leader is willing to engage.
I’d expect there is some serious horse-trading going on in the back offices, and one of the chips is very likely the public plan option. If the Rs can keep that off the table in return for their acceptance of other health reform provisions, we just may see reform this year. As I’ve noted repeatedly, the protests over the public option are generally overblown. Be that as it may, killing the public option would enable Rs to claim a significant victory and retain some political capital amongst their core supporters.
What does this mean for you?
Watch what key Democrats say about the public option; a cooling of enthusiasm may well indicate a compromise is in the offing and reform may actually happen.

As I’ve been reporting for several months, Congressional Democrats and the President are working hard to increase reimbursement for cognitive services by up to 10%.
This would go a long way towards fixing what is perceived to be a core problem with US health care – overly generous compensation for procedures (surgery, imaging, etc) leads to over-utilization of those procedures, while under-reimbursement for office visits and other ‘primary care’ services results in a shortage of physicians willing to do primary care.
This morning’s New York Times features a headline story about the conflict in Washington, noting that the Obama Administration is very concerned about the shortage of primary care docs. The solution being discussed in DC is to get more applications into med schools.
Wrong answer.
The ‘right’ answer is staring us in the face – there are too many specialists, physicians who have already graduated from medical school and have lots of experience and training. It would be far easier, faster, and cheaper to re-train these physicians to take on more primary care responsibilities, albeit primary care with an orientation towards their specialty. Would this be difficult, and expensive, and meet with strong resistance from those docs?
Absolutely. But on balance it would be much easier, and faster, than waiting at least eight years for the supply of primary care docs to begin to meet anticipated demand.
Compensating docs more for primary care would potentially have another effect; it might reduce the volume of procedures performed, as specialists would also benefit from the higher compensation for evaluation and management services. I wouldn’t bet too much on this, as docs – like the rest of us – won’t change dramatically overnight. That said, increasing compensation for primary care service codes (the 99xxx CPTs) would help take a bit of the sting out of reduced reimbursement for surgery etc.
What does this mean for you?
A lot.
Most network contracts are based on Medicare’s RBRVS; if the Feds change, your provider compensation will too. Think about the potential impact, and think deeply. The trickle-down will likely cause specialists to seek higher network reimbursement for two reasons – first the base from which their reimbursement (RBRVS) has declined, and second, they’ll want to make up their lost revenue from Medicare by increasing reimbursement from private payers.
Oh, and you can bet utilization is going to see a big jump, so get your data mining and evidence-based utilization review processes tuned up.

Argument two – Universal coverage would result in the government running the health care system making it worse than it is today – because the government can’t do anything right.
There are two separate statements here – first that UC will result in the Feds running the healthcare system, and second that the Feds can’t do anything right.
Let’s take the latter first – but in no way does that mean I concede the first statement is accurate.
I strongly disagree with the statement that government can’t do anything right. I’d also note that ‘the government’ is us; and if it can’t function effectively than we need look no further than the mirror. But it can, and does, work pretty well in many instances.
Among the numerous examples of relatively effective government are the Centers for Disease Control, US Coast Guard, National Oceanic and Atmospheric Administration, Head Start, AmeriCorps, NIH, the GI BIll, and the National Weather Service. No, none are perfect, but then again our private sector is not exactly stuffed with competence these days.
It is not the fact that an organization is ‘government’ or private that makes it competent or not, it is the leadership of that organization that is the determining factor.
But perhaps the best is the Veteran’s Administration health care system. As I noted last month,
– compared to commercial managed care plans, the VA provided diabetics with better quality care on seven out of eight metrics by NCQA.
– In 2005, VA hospitals were the highest-rated health system, outperforming other systems including the Mayo Clinic and Johns Hopkins.
– the VA achieves higher scores than private hospitals for patient satisfaction, staffing levels, surgical volume and other significant quality measures
– for six years running, VA hospitals scored higher than private facilities on the University of Michigan’s American Customer Satisfaction Index.
And costs haven’t increased nearly as fast as they have in the private sector. In the ten years ending in 2005, the number of veterans receiving treatment from the VA more than doubled, from 2.5 million to 5.3 million, but the agency needed 10,000 fewer employees to deliver that care – as a result the cost per patient stayed flat. (costs for care in the private sector jumped 60% over the same period).
The VA did this by closing down unneeded facilities, developing an industry-leading electronic health record system, opening clinics, and dramatically increasing the quality of care, especially for patients with chronic conditions.
Oh, and patients can access their own health records – securely – anytime on the web.
Sounds pretty good to me. But alas, universal coverage will not result in the Feds running the health care system. The current proposals under consideration keep providers private (for-profit and not-for-profit), brokers will keep broking, insurance companies doing their thing. Yes, there may well (and should) be a public insurance option, but there is precious little evidence to suggest that the public option will dominate the market. And the evidence that is touted is not compelling.
In fact, providers would not have to participate in a public option – they could refuse to sign up if reimbursement was too low or other terms not to their liking.
And, the governmental option would have to compete with what is already a very mature market, dominated by very few healthplans with overwhelming market share. Here’s just one statistic – In almost two-thirds of all HMO/PPO market areas, one healthplan has more than 50% market share.
Good luck to the Feds fighting for share in Texarkana where the Blues’ share is 97%, or Gadsden Alabama (95%).
Finally, those arguing against UC with the ‘government is incompetent’ meme must not have followed the accounts of healthplans canceling coverage for individuals without justification, employing medical underwriting to refuse coverage for any pre-existing condition, using skewed data to avoid paying what they should for out of network care, fraudulently enrolling seniors in Medicare Advantage plans, and slashing provider bills with the thinnest of justifications.
It would take a good deal of hard work to be more incompetent than some of the health plans out there today.
I’m thinking the VA stacks up awfully well against WellCare.

I haven’t read their report in detail, the one that some are claiming proves a governmental healthplan option will quickly dominate all the private plans. But a couple of worthies have, and I suggest you peruse their thoughts if you’re interested.
Merrill Goozner’s take is “the Lewin study may have overestimated the shift to the public plan.”
Roy Poses highlights a potential conflict of interest: Lewin is owned by Ingenix which is owned by United HealthGroup.
I’d be remiss if I didn’t note that I’ve worked with several Lewin folks in the past, and been impressed by their capabilities and intellect. I don’t know what part, if any, they played in the report. I do know that they aren’t the type to slant findings.
But here’s the problem; Lewin’s study assumes the governmental plan would pay Medicare rates, which would enable the Feds to undercut private payers’ premiums by more than twenty percent.
That’s a huge assumption as providers would not have to accept Medicare rates. In fact, as I’ve pointed out before, they could refuse to participate at all, making it kind of hard for the Feds to sell a health plan with few physicians or hospitals in the book.
What does this mean to you?
Question your assumptions.

We’re going to start off the discussion about universal healthcare with one of the more common concerns voiced by opponents – Universal ‘coverage’ does not mean universal care, as it will lead to rationing of care, either overt or via extended waits for care.
Before we begin, lets not confuse ‘universal healthcare’ with ‘single-payer’. Single payer is one mechanism to deliver universal healthcare, but it is by no means the only one – as has been demonstrated by many European countries where private insurers are active and significant players in the market.
Let’s start with a key – if obvious – statement. No one I know would assume that universal coverage means anyone can get any medical service at any time from anyone they choose for free. Some ‘strict-intrepretarians’ may call that rationing, but the vast majority of people would undoubtedly say, “well, of course it isn’t!”
There’s a difference between rationing and appropriate buying behavior. According to Wikipedia, “Rationing is the controlled distribution of resources and scarce goods or services. Rationing controls the size of the ration, one’s allotted portion of the resources being distributed on a particular day or at a particular time.”
The operational word is ‘controlled’, and the question is by whom?
‘Rationing’ in today’s US health care system
In today’s non-elderly market, health plans ‘control the distribution’ of care; big insurance companies like United HealthGroup, Aetna, Wellpoint, CIGNA, Humana. Through their pre-certification processes, reimbursement arrangements, summary plan documents, provider agreements, and other business policies they try to make sure they only cover what they are legally required to cover (no cosmetic stuff) allow only those procedures that are appropriate for that condition delivered by an appropriate provider, and pay only what they have to for those procedures and services.
But there’s a big group of folks who don’t have access to any insurance (although they can access care on a limited basis through EMTALA) – the uninsured, a population that is likely pushing close to 50 million these days. Is their care ‘rationed’? No, they just can’t get any that’s not driven by an emergent condition. Hypertension medications, COPD treatment, asthma prescriptions are all not available (except in a few cases where provided by charity) unless and until the patient has to be admitted to an ER.
So, what do the data show? We’re living in a very expensive glass house. In 2007, Troy Brennan, Medical Director of Aetna, Inc, said “the (U.S.) healthcare system is not timely…” citing “recent statistics from the Institution of Healthcare Improvement … that people are waiting an average of about 70 days to try to see a provider. And in many circumstances people initially diagnosed with cancer are waiting over a month, which is intolerable…”
Conclusion? Today, Americans with coverage do not have unfettered access to any type of care.
‘Rationing’ in countries with universal healthcare
Opponents of universal healthcare often make the logical leap that somehow it will inevitably lead to extended waiting times. I’ve never understood the connection. How better access to care, leading to more preventive care, will lead to waiting lines for procedures has never been made clear to me. Moreover, the data refute that opinion.
The logic (an admitted misuse of that term) appears to go something like this: “In Canada (or the UK or France or wherever) they have universal healthcare and people have to wait forever for care, especially costly types of care”. We’ll leave aside the delays that exist in this country even for those with health insurance, the difficulty in finding a primary care doc who is still taking new patients, the waits to see specialists (god forbid you need specialty care from a chronic Lyme expert, the delays are months).
Or perhaps we won’t. In fact, A Commonwealth Fund study of six highly industrialized countries, the U.S., and five nations with national health systems, Britain, Germany, Australia, New Zealand, and Canada, found the United States ranked last on four measures of continuity of care and access problems reported by patients.
Here’s what a bit of specific data show (excerpted from the Commonwealth Fund report).
* The percentage of U.S. patients who waited six days or more for a doctor appointment when sick was not significantly different from the rate in Canada (23% v. 36%), the worst-performing country.
* Only 47 percent of U.S. patients were able to see a doctor on the same or next day when sick, versus 61 percent to 81 percent of patients in the four better-performing nations.
* U.S. patients were less likely than patients in Canada (12% v. 24%) but more likely than patients in Germany (4%) to wait four hours or more to be seen in the emergency department.
* U.S. patients were less likely than patients in four countries (except Germany) to wait four weeks or longer to see a specialist (23% v. 40%-60%) or to wait four months or longer for elective surgery (8% v. 19%-41%) (Schoen et al. 2005).
Another way to look at rationing is the volume of care delivered to those patients that actually receive care. Tom Lynch did a terrific comparison of the US to other OECD countries, within which he said this:
“Hospital discharges per 1,000 people in the US are 25% lower than the average for all OECD countries, and doctor visits are 42% lower.
Well, maybe people have significantly more intense and aggressive service while they are hospitalized in the US? One indicator of intensity is the average length of acute care hospital stay. In the US, the length of acute hospital stay is 5.6 days, which is less than all but eight of the other 29 OECD countries. But shorter stays could mean higher efficiency. A better way to look at it is to look at specific causes for hospital stays, like heart attacks, for instance. The US average hospital stay following acute myocardial infarction is 5.5 days, the lowest in the OECD.”
Clearly folks in countries with universal healthcare are not getting kicked out the door, or discharged “quicker and sicker” as we in the US do so well. Nor are they subjected to waiting times significantly different from those in the US.
What does this mean?
In several areas the US already has longer waiting times and poorer access to care than countries with universal healthcare. If the US adopts universal healthcare as practiced in other countries, the evidence indicates access will go up and waiting times may well go down.

There are many arguments advanced by the opponents of universal coverage, from the sublime to the ridiculous, the practical to the ideological, the informed to the ignorant. I’ve attempted to identify ten of the most common and acknowledge there is overlap amongst these objections.
That’s fine, as the purpose of this series is to confront the issue where it has the most traction – in the minds of the layperson.
After some considerable research, here is this year’s top ten list of reasons universal coverage is bad.
1. Universal coverage does not mean universal care, as it will lead to rationing of care, either overt or via extended waits for care.
2. Universal coverage would result in the government running the health care system making it worse than it is today – because the government can’t do anything right
3. Competition is what made this country great, and universal coverage is anti-competitive as the government is involved.
4. It’s unfair to ask the young and healthy to pay for the health care costs of the older and sicker.
5. Universal coverage will lead to a decrease in innovation.
6. Solutions such as ‘health status insurance’ can provide long-term, secure health insurance, obviating the need for universal coverage.
7. Even though every other industrialized country has some form of universal coverage, many are looking to add market mechanisms to their plans. This shows universal coverage doesn’t work.
8. The problems with the US health care system are not caused by the private market, but by over-regulation and over-involvement of the government in the current market.
9. It’s unaffordable.
10. Health care is not a right; if we are guaranteeing health care why not guarantee food, clothing, housing…

Way back in 2007 I did a series of posts on the top ten reasons universal coverage is bad. Back then the arguments against socialized medicine included:
1. We can’t afford it.
2. People aren’t insured because they choose not to be.
3. UC won’t help solve the health care crisis.
4. UC will give the government too much power.
5. UC is a devastating blow to personal liberty.
6. A mandate is not necessary as the free market will solve the problem.
7. If you give more people health insurance, they’ll use it, which will cause costs to increase. (the moral hazard argument)
8. It will drive up costs, which will inevitably lead to forced rationing.
9. It’s just a replacement for a failed Medicaid/Medicare system that should be covering those folks without employer-based insurance. Once we fix the ‘M’ programs we’ll be fine.
10. It’s socialist. And that’s bad.
Times have changed, more research has been done, and more arguments advanced pro and con – it’s high time to re-examine the topic, identify any new anti-universal coverage arguments, and separate the valid from the non.
The fun starts tomorrow.

That, in a phrase suitable even for twitter, is the future of health care reform.
We can afford universal coverage – if we cut provider costs drastically, through reduced prices, reduced services, or more likely, reductions in both. So far, no one, and I mean no one, with any political power has even broached this subject.
Or, our elected officials can decide to avoid the lynching that would follow immediately after they start talking about slashing provider reimbursement, and instead decide to just pass universal coverage-based reform now and worry about paying for it later. This has worked really really well for past Congresses and Presidents, so what the hell?
As for budgeting money to pay for reform, as Bob Laszewski has pointed out, the $635 billion President Obama has allocated won’t be near enough; and even that figure is highly dubious.
One option that will not get serious consideration (I can feel the anger coming thru the ether already) is single payer. Sure, it would solve a lot of problems, but it just is not going to happen in the US. Never ever ever. Politics is indeed the art of the possible, and single payer is just not possible. Accept that and move on.
So we’re stuck on the very long and very sharp horns of a dilemma, or more accurately, Congress and President Obama are.
Does anyone believe Congress has the intestinal fortitude to cut reimbursement, no matter how that ‘cut’ is described/presented/packaged? Anyone?
We know that there is a cabal that is in favor of ignoring the red ink and just passing universal coverage, with the assumption that the $1.6 billion spent on comparative effectiveness will cut medical spend by, oh, say, $600 billion per year a decade from now. But thankfully that group of irresponsibles are getting little traction.
I just don’t see health reform happening anytime soon – with ‘soon’ defined as within the next few years. I don’t like it, you don’t like it, no one likes it. But that’s reality.
That doesn’t mean I won’t keep hoping it will happen, and working towards that end.