GOP Senators better wear their cheap suits while marching in Independence Day parades this weekend, as it is tough to get tomato stains out of nice wool.
As Bob Laszewski pointed out, Republicans were boxed into a very tight corner by their Democratic colleagues after GOP Senators blocked a bill that would have prevented a drastic cut in physician fees. The maneuvering was ugly, as the Dems apparently backing out of an earlier deal that would have restored the cuts. Once the bill was overwhelmingly passed by the House, Senate Democrats were presented with a very big cudgel they could use to smack their Republican colleagues around. And with Congress heading out for the 4th of July recess, they have done so – publicly, loudly, and repeatedly.
Republican Senators now find themselves defending their vote to reduce physician fees by 10% (that’s not exactly what happened, but close enough for politics) while refusing to reduce payments to big insurers. Payments that most view as far too generous.
Politically, the picture could not be better for Democrats. Republicans will be vilified for their vote to cut payments to Dr. Welby, everyone’s kindly neighborhood physician while continuing to pay huge sums to big, faceless, bureaucratic insurers located far away staffed by nasty clerks who delight in forcing new moms to leave the hospital mere moments after giving birth.
And in an election year too.
There is a good bit of substance to the argument against continuing the massive subsidies for Medicare Advantage (MA) and Private Fee for Service plans (PFFS). These payments were supposed to be temporary, used to motivate health plans to set up alternative Medicare programs, to make it worth their while to get started. Now that many of these plans have been up and running for several years, they should be able to survive on their own.
And as far back as 2005, health plans in these programs were doing just fine. In an example of exquisite timing a GAO audit revealed health plans in the program made over a billion dollars more than they expected; $1.14 billion in extra profit.
Yet healthplans are fiercely lobbying to hold onto the subsidies, and their GOP allies are marching in lockstep – right off a cliff.
Health plans, and their Republican allies, now look like they won’t pull their heads out of the public feedbag, even when it is obvious they are getting fat on taxpayer-funded subsidies.
Politically, both the GOP and health plans are being stupid. There’s no other word for it. Not only is this politically suicidal, the longer term implications are obvious. Health reform is coming, and private health plans will want to play a major role. They will claim that the market is the solution (a point I have also been making).
Yet these free-market companies continue to argue they can’t compete with the government-run Medicare program without massive subsidies.

Opponents of universal care often cite awful stories of Canadians and Brits hurt, killed, or dead of neglect or bad care. And there’s no doubt that people in Canada and Britain are the victims of poor medical care.
There is certainly some truth to the stories of bad Canadian and British medicine. It is also true that raising this issue doesn’t help make the case against universal health insurance.
News flash – American patients often suffer pain, injury, or death from bad medicine. Here are a few examples. California hospitals recently disclosed hundreds of medical errors, “including wrong-organ surgeries, administration of incorrect drugs and neglect of serious medical conditions. This is a small percentage when weighed against the 4 million hospital admissions that occur in California each year, but still serious…” (quote from FierceHealthcare citation).
In Pennsylvania, wrong-site surgeries happen often – very often.
Nationally, between 48,000 and 98,000 Americans die each year due to medical errors. More people are killed by bad medicine than die in auto accidents or succumb to breast cancer.
A report on medical errors in the US blamed the system. Our system, one that does not offer universal coverage. According to the Institute of Medicine‘s 2000 report; “most of the medical errors are systems related and not attributable to individual negligence or misconduct. The key to reducing medical errors is to focus on improving the systems of delivering care and not to blame individuals. Health care professionals are simply human and, like everyone else, they make mistakes. But research has shown that system improvements can reduce the error rates and improve the quality of health care.”
(I’d note that the IOM is a universally respected, highly regarded organization, unlike the agenda-driven think tanks typically cited by opponents of universal coverage).
Let’s not forget the people without health insurance who die as a result of poor access to health care – late diagnosis of cancer, poor preventive care, and untreated hypertension, cardiovascular disease, asthma and diabetes.
And in the “did they even think about this before they wrote it” category comes this gem from biggovhealth.com; “Since 1997, the U.S. has made further improvements to the quality and accessibility of our health care, including the creation of Medicare Part D.”
Uhh, folks, Part D is a government-run drug program that has resulted in many seniors getting access to pharmaceuticals, thereby potentially improving their health. Kind of like what universal coverage aims to do.
Contrasting the IOM’s estimate that there are 18,000 excess deaths in America among uninsured adults to the anecdotal examples of poor care in Canada and Britain provides a much clearer picture of the ‘dangers’ of universal medicine. A picture of kids getting health screens, diabetics getting insulin, asthmatics receiving education and primary care, expectant mothers getting pre-natal care, and high-risk women getting mammograms.

Now that’s a scary world.

It is looking increasingly likely that the Democratic party will win big in November – with GOP strategists expecting a loss of 20 House and 6 Senate seats, along with the White House. Optimistic Dems are hoping for even more; it is possible they could win up to 11 Senate seats and another ten in the House. (for purposes of this post, we’re assuming there is a Democrat in the White House in 2009)
Analyst Larry Sabato predicts 8-14 seats moving to the Democrats; given he accurately predicted the result of the 2006 midterm election his opinion bears consideration.
If we go with the Sabato midpoint, 2009 will begin with a 247-188 Democratic-Republican split in the House. But the House is not the key, the Senate and the White House are. In the Senate, look for the split to end up somewhere around 56 – 44.
House Speaker Nancy Pelosi (D CA) has been biding her time, building her power base and infrastructure while waiting for what she anticipates will be an increasingly Democratic House. If the numbers come in as expected, the Speaker will be able to deliver on her commitment to avoid the “dangerous narcotic of incrementalism.”
But without a supermajority in the Senate, Pelosi, and Pres. Obama, will not be able to get much through Congress. That’s the conventional wisdom; conventional, but when it comes to health care, wrong. Not only will there be a new political climate in Washington, there will be increasing pressure on both parties to deliver on their campaign promises. Moreover, there is bipartisan agreement on some of the thornier issues related to health, with broad support for incremental (increasing SCHIP funding) and major (overhaul of the health insurance system) changes. This agreement has been overshadowed by Bush’s unwillingness to compromise on most issues, forcing members of his own party to craft legislation that will pass the President’s requirements.
Add to the mix the likelihood that Sen Clinton will become majority leader of the Senate. Despite the demonization of Clinton by some on the right, she has a well-deserved reputation for working effectively with her Republican colleagues, a reputation that will serve her well in her new role.
While the Dems would love to begin with a huge overhaul of the entire health system, they’ve learned that doing really big things takes time, consensus, and foundation-building. Instead, the new year will likely start with fixes to current programs and ‘corrective action’ to address issues of little concern to the Bush Administration.
Expect the new political year to begin with incremental fixes to specific programs – SCHIP likely first out of the blocks. After the back and forth battles, marked by confusion and consternation from Republicans who felt Pres. Bush threw them under the bus by vetoing a bi-partisan bill to extend SCHIP earlier this year, enough Republicans are likely to cross the aisle to support funding of a somewhat-expanded program.
Also on the table will be reduced funding for Medicare Advantage, a program that has long struck Democrats as a giveaway to big healthplans. Foolishly. the insurance industry worked hard, and effectively, to block reductions in MA this year. As Bob Laszewski notes, with Congress and the White House changing hands, the bill they stopped this year will look great compared to what they’ll get next. Expect MA subsidies to be slashed, in what could, and should, be seen as a shot across the bow of the insurance industry.
The FDA will also be under the microscope. Despite passage of the Food and Drug Administration Amendments Act of 2007, ostensibly fully funding the FDA and giving it the staff needed to do its job, the FDA continues to stumble. With a Democrat running the Administration, expect increasing oversight, much more post-approval monitoring, and much less tolerance for patent-extending gamesmanship.
The biggie will likely be Medicare physician compensation. With docs scheduled to see their reimbursement drop by around 15% in 2009, the caterwauling will be heard loud and clear inside the Beltway. Don’t look for a major policy change, but rather something to satisfy the physician community and build a little equity for the future.
That future will likely begin in January of 2010, when the Congress and President will take on health care reform.

If recent (and past) electoral history is any guide, this Presidential election, or at least the health reform part of it, is going to be fought with sound bites. We can already hear the right screeching about the ills of ‘socialized medicine’ while the left howls about the evils of privatized health care. The right trots out Canadians and Brits who allegedly suffered maltreatment (or no treatment) from the numb grey bureaucracy that is their ‘national health system’. The left counters with stories of under-insured Americans bankrupted by health care costs.
Conservatives decry waiting lists, progressives bemoan the US’ health care system’s lowly international ranking.
This is a hugely complicated issue. Pat answers and bumper-sticker slogans are meaningless and should be treated as such. Yet few of us have the time to really dig into the issues, to fully understand the WHO’s national health rating system or the reality of waiting lists in the OECD.
What’s a concerned citizen, one really trying to understand, to make informed decisions, to do?
First, when approached at a cocktail party, kid’s lacrosse game, or backyard barbecue by someone touting the latest statistic or quoting a health care horror story, just ask for the details. What is the source? Where did this happen? What caused it to happen? Who was involved? When did it occur?
I’m betting that in most cases the source will be vague (the internet…), location undefined, causality undetermined, and timing uncertain. So you’re left with an impression, albeit one based on a vague, unsubstantiated source, an impression apparently designed to give you, the listener, a negative perception.
Second, ask what the solution is. How could this be fixed? What could have been done better/faster/cheaper/smarter and what conditions need to exist to make that happen? What do you think would solve this? How would we pay for it?
Third, ask for definitions. What exactly do they mean by ‘socialized medicine’? Are providers government employees? Is this single payer? Are prices fixed? Is it universal coverage?
You don’t have to be an expert/wonk/policy geek, but you do have to be curious and willing to push back on folks spewing mindless sound bites.
People who just want to complain, criticize, and demonize those with differing views are not going to help solve this problem, rather they are miniature ‘Harry and Louise’ bomblets, programmed to go off at random intervals, triggered by a headline or patently false email. They spread fear and uncertainty, worry and hesitation. Their victims retreat into the status quo as the devil they know sounds a lot better than the garbage spouted by these Harrys and Louises.
That’s not to say we can’t have strong disagreements (as loyal readers have undoubtedly noticed, we like spirited fights around here). As long as they are fact-based, supported by solid data and the argument is logical, have at it.
But leave the fear-mongering and logic-twisting to the John Stossels and Ann Coulters.

Now that the Democratic primary season is over (and boy don’t we miss it!), it is time to focus on the presumptive nominees’ rather different approaches to health care reform. (If Hillary ‘unsuspends’ her campaign and Obama drives off a cliff between the time I write and you read this, don’t despair, the Democratic candidates’ plans are more similar than they are different.)
The differences between the McCain and Obama plans are big – really big. Philosophically, McCain’s approach is market-based and tax policy driven, relying on individuals to make the best decisions on health care procedures and treatment. His plan would remove the favorable treatment of employer-funded health insurance, instead providing a refundable tax credit of $2500/individual or $5000 per family to help them buy insurance (note – the average individual policy now costs over $4000 and the average family policy cost exceeds $12,000). Conversely, Obama’s plan is more pragmatic, focused on fixing the problems with the current market-based system with a ban on medical underwriting, a comprehensive ‘minimum’ benefit design, financial help for small employers buying health insurance, and some sort of stop-loss insurance for high dollar claims.
As does McCain, Obama relies on private insurers to provide health insurance, but from there the two candidates’ plans diverge dramatically. One area where the plans appear to be similar is their stance on mandated universal coverage. While neither mandates coverage, Obama comes much closer, requiring universal coverage for children. But the Senator’s plan and public statements are a little disconnected; in Obama’s speeches and ads the Senator does appear to endorse mandated coverage – eventually.
Obama’s plan requires insurers take all comers, regardless of pre-existing medical conditions. Notably, although McCain’s original talking points did not mention guaranteed insurability, his campaign website now at least speaks to the issue – but his plan does nothing to change the status quo.
McCain wants to allow wide variation in benefit plan design and speaks glowingly of HSAs, while Obama is calling for a plan similar to the Federal Employee Health Benefit Plan. Both candidates’ policies appear to dramatically reduce states’ ability to mandate certain types of care (e.g. acupuncture) with the result that regulation of health plan benefits will shift from a state to a Federal responsibility.
While most other candidates are talking about covering the uninsured, McCain is focused on cost. More specifically, the cost of chronic conditions such as diabetes, asthma and CAD which account for 75% of the US’ entire $2 trillion health care bill. McCain is not just pointing out the obvious, he also plans to attack these costs by altering reimbursement – paying providers for maintaining health rather than reimbursing for specific procedures.
Here’s how McCain put it: “We should pay a single bill for high-quality health care, not an endless series of bills for presurgical tests and visits, hospitalization and surgery, and follow-up tests, drugs and office visits,”
McCain is dead on when he talks about the need to pay for health, not reimburse for procedures. His focus on the need to aggressively improve care and outcomes for patients with chronic conditions is creditable.
But he’s dead wrong in his blind faith in the market to solve the problem of insurability, and just plain blind in his belief that the individual insurance market is the answer. Today, in the vast majority of states, there is a free market for insurers writing individual insurance. And no insurers that can medically underwrite don’t, with the result that those who most need insurance can’t get it. You can’t blame the insurers; why would they want to cover an individual with heart disease, cancer, MS, depression, or asthma, or all of the above? They wouldn’t, no matter what kind of ‘risk adjustment’ plan is in place. It would be irresponsible, especially for those insurers that are owned by stockholders (think Aetna, United HealthGroup, CIGNA, Humana, Coventry, Wellpoint…)
Notably, nowhere on McCain’s website or in his policy papers does he say what the plan will cost. But his statements leave little doubt as to what he wants to do, and the Joint Committee on Taxation’s report on the McCain health plan clearly demonstrates the financial impact of his plan. The cost of the tax credits would be $206 billion in FY 2009 and $3.6 trillion over 10 years. That is about double what Obama’s plan is projected to cost.
Equally notable, Douglas Holtz-Eakin, one of McCain’s key advisers agreed that the McCain plan would increase the budget deficit, saying “It will make deficits expand up front, no question…”
The difference between the elephant and the donkey can perhaps be best summarized in two slogans.
For McCain, it might be “More expensive, less coverage.”
For Obama “Coverage just like I have, for only a hundred billion.”

Here, cribbed from Dr. Val and the Voice, are quotes they collected from yet another person, with my comments interspersed:
“Half of the people in the US have some sort of chronic illness. Health insurance is like having car insurance when 50% of people are having accidents. Of course nobody can afford it.”
This is especially true because the wrecks are often caused by poor routine maintenance.
“We need to keep employer-based healthcare because when employers have ‘skin in the game’ they have the incentive to promote healthy behavior at a local level. Monolithic government programs aren’t good at influencing people at the individual level. Employers know each of their employees by name, they are invested in their lives, they provide childcare services and other benefits to them, and each employee’s health affects their bottom line. Employers are a critical force for promoting and facilitating healthy behaviors.”
And employers have the financial motive to keep workers working and their families healthy so workers aren’t worried about and/or taking time off to deal with family health issues.
“Alternative energy sources aren’t that interesting when gas is $1/gallon. But when gas hits $4/gallon suddenly everyone is very interested in alternative energy. The same goes for healthcare. It takes a cost crisis to bring it to everyone’s attention. And now the audience is listening.”
A great analogy – our addiction to oil looks like it has limits, and our addiction to all the expensive health care we can waste may be hitting its own hard stop.
and thanks to Ann in Florida for the heads up.

It has become fashionable of late to accuse the Democrats of backsliding on their ‘commitment’ to health care reform. Pundits have been opining that there isn’t the political will, there isn’t enough cash, the Dems can’t get their act together, it’s too much work, and other variations of “it’s just soooooo hard”.
I don’t buy it.
I’ve been forecasting major reform for over a year, and nothing in the recent past makes me change that prediction. In fact, my take is recent developments make it more likely that we’ll see major reform in the next Congress.
The Columbia Journalism Review disagrees, (I had problems w their site, apologies if the link doesn’t work) quoting a few Democratic legislators’ comments that appear to bode ill for reform. Their premise, that the Dems will have to push it, is obvious. The doubt is appropriate, but the careful selection of quotes appears designed more to support their thesis than to present an objective view. Here are a couple of those ‘other’ quotes’.
One of the pols the CJR took to task for wimpy words was Max Baucus (if you’re going to pick a dissembler in Congress, there are a lot better targets than the Montana Senator). The Senator has said a lot about health care; has Baucus said “if reform isn’t passed I’ll move to Canada”? Of course not – but he did say “The moral and economic case for reform has never been stronger.” Along with Baucus, Nebraska’s Chuck Grassley is co-hosting a confab (of the major public variety); commenting on the meeting, Baucus stated “Our broken health care system is endangering families and sapping this country’s ability to compete economically, and Americans want something done about it. But comprehensive health reform won’t drop out of the clear blue sky – we have to do some legwork first…”
Baucus et al’s opinions are supported by other eminent lawmakers such as Durenberger of Minnesota and Corker of Tennessee.
CJR followed up the original piece with a bit of clarification, concluding with the observation that principles (as stated by a few elected officials as the basis for developing legislation) did not mean anything will happen. Not exactly burying the lead, and not terribly informed or informative either.
It may well take 60 Senators to pass reform. Even if the Dems win big in November, they will still be well short of that magic number and need help from their colleagues across the aisle. A few Republicans will have to support any reform initiative, but that isn’t as far-fetched as it may seem.
For example, Utah’s Bob Bennett (R) is a co-sponsor of Ron Wyden (D OR) Healthy Americans Act – along with six other GOP Senators and an independent (Lamar Alexander (R-TN), Bob Corker (R-TN), Judd Gregg (R-NH), Chuck Grassley (R-IA), Norm Coleman (R-MN), Joe Lieberman (ID-CT), and Mike Crapo (R-ID). (btw, Corker is a relatively recent addition, which would logically indicate growing support)
The math works. Using current projections of electoral changes gives us between 54 – 57 Dems, and a handful of Republicans joining in puts the measure (which measure exactly is another question) over the top.
Sure, it is going to be hard, and tough, and there will be back- and side-steps amid the forward progress. But the odds remain in favor of health reform – and may actually be improving.
In the meantime, look for the reality behind the quotes. And nothing says reality more than a Senator’s name on a big health reform bill.

Bob Laszewski posts today on the Center for American Progress’ report on the additional costs inherent in Sen McCain’s health care plan.
Bob – one of the most insightful people in the industry – notes:
“It’s interesting that when I am out in the country meeting with insurance execs in their conference rooms–people who do understand the market–it never fails that they all just roll their eyes at the lack of sophistication when we discuss McCain’s market-based solution–specifically his individual health insurance product ideas.”
And this demographic – well compensated executives – is one that you would think would be in favor of McCain.
I’d echo Bob’s observation. Industry insiders may disagree with Obama’s platform, but most agree that it is fairly well thought thru. In contrast, McCain’s is superficial – by that I mean a few microns thick superficial.

A while ago I posted on the use of distorted data by folks seeking to promote an agenda. Recently Insurance Newscast arrived on my virtual doorstep with a textbook example under the intriguing headline ” Most Companies Oppose Single-Payer Health Care System, State Coverage Mandates”.
The survey purportedly found that “Most U.S. companies do not support a single-payer health care system or state legislation mandating coverage[italics are mine].”
The press release noted that the number of respondents that did not support “Universal system such as single-payer” was 50%. What exactly does that mean? Did respondents not like universal coverage mandates, or a universal ‘system’, or single payer? Or all three? What is a ‘universal system’ exactly? Given the poor phrasing of the report, the reader is left with no idea what the results mean.
Further complicating matters is the position of the survey’s sponsor, the National Business Group on Health on mandated universal coverage – they endorse it, unequivocally. To wit: “the National Business Group on Health announced today that it would support efforts to require individuals to have health insurance coverage for themselves and their dependent children.” I know, this is an individual rather than employer mandate, but that distinction may well be lost in translation.
The reason for my upset should be obvious; the response to this survey of larger employers, co-sponsored by a widely-respected business group, will find its way into the popular press, to be bandied about by pundits and ‘experts’ while suffering further distortion along the way.
The question itself (which was not provided and not on the sponsors’ websites, neither of which provided access to the detailed survey report) looks to be specifically designed to promote an anti-universal coverage, anti-single payer agenda.
This is neither helpful nor ethical, nor is it consistent with the stated objectives of the NBGH. If business groups and consultancies that promote themselves as objective want to be taken seriously, they need to do a much better job than this.
Note – I am no fan of single-payer, I am a fan of universal coverage, but have no idea what a ‘universal system’ is.