Writing As I See The World

Video: Why We Need Government-Run Universal Socialized Health Insurance

I thought this was well-done and adds something to the conversation about health care reform.

YouTube - Why We Need Government-Run Universal Socialized Health Insurance

Health Care Reform: Suggested Information Sources

More and more good information is available about health care reform that will help people to become informed, hopefully understand first-hand what is being proposed, and then draw an informed opinion. Unfortunately most news media sources have done a very limited job of offering good information to the public.  

There are various sources that provide excellent information about what is, and is not, in the proposals. These include the following, loosely in order of ease of reading:

1. AARP Myths vs. Facts:  This is an easy-to-read single page document that discusses some of the myths that have been circulating about the health care reform proposals and offers up factual information that counters these myths.

2. White House Reality Check: Clearly, this is coming from the Administration and has a bias toward passing health care reform, and if that is a problem for you, move on.  Among the pieces of information are easily-digestible video presentations by various individuals concerning issues around health care reform.  

3. FactCheck.org:  Fact Check has done a reasonable job of taking a look at all sorts of issues, including health care reform and various pieces of information that are in the media.  They present the facts and tend not to be too overtly partisan.

4. Kaiser Family Foundation Side-by-Side Comparison of House and Senate Proposals: The Kaiser Family Foundation has put together a very nice side-by-side analysis of proposed legislation, including detail on proposals by broader topic heading. It requires a fair amount of reading, but is very well put together and helps put the legislative proposals into more 'readable' form that I frankly wish more of our legislators would take the time to read.

5. HealthReform.gov:  Contains a wealth of information about health care reform, and includes a click-able map to find out more specifically what issues are identified in your state, and how the proposals would address these issues.  The issues that are brought up on the site are good and pertinent (and I haven't seen many of them elsewhere).  I am cautious about the numbers that are presented, such as the amount of health care 'bad debt' resulting from care legally required to be provided to people who are uninsured and which is ultimately passed along to consumers, but the issues are very real and the numbers, if likely a little skewed due to how this information is reported, nonetheless give a sense of the size of the issues.

6. The Legislation:  There are two pieces of proposed legislation, including those from the House and Senate.  A legislative summary is also available for the House.  The bill text for the House is much more user-friendly than the Senate proposal, and is the legislation generally referred to in health care reform discussions.  For example, President Obama recently referred to section 1233 in a discussion of end-of-life issues for the elderly.  For the text in the link to the full legislation, scroll down to 'Sec. 1233: Advanced Care Planning Consultation' and you can read the actual text, which refers to Medicare paying health care providers to offer consultation on completing a living will. This is what has been referred to as the part of health care reform which encourages killing the elderly.  It is simply about encouraging more people to complete a living will to let their families, caretakers, and health care providers know their wishes for end-of-life care.

Hopefully this information (or at least some of it) will help others to understand the health care reform proposals.

  

Keep Your *BLEEP* Government Hands Off My Medicare!

I can't resist commenting on this.

If you have noticed, a good number of the people protesting at town hall meetings about health care reform happen to be elderly.  A number of them are shouting "no socialized medicine" and "keep the <bleep> government out of my Medicare."

Who are these people and what exactly do they think Medicare is?  

Medicare is socialized medicine.  Medicare is operated by the federal government.  And, by the way, the taxes current elderly beneficiaries paid to participate in Medicare do not cover the cost of the services they currently receive.  They are subsidized by people currently employed and paying Medicare taxes. And, oh yeah, these people are shouting to try to keep other citizens from benefitting from health care programs similar to the one they love so much.  Some of them likely also receive not only Medicare benefits, but also government-sponsored Veteran's Administration socialized health benefits.

As if this were not enough, right-wingnuts are shouting about how health care reform is cover for offing elderly people, getting these same people even more riled and loud.  For the record, there is nothing about the current reform package that would deny services to the elderly.  What they are talking about are living wills, which, quite sensibly, serve as a person's legal voice about what sort of treatment they would and would not like to receive should they become incapacitated and unable to speak for themselves.  This saves families from having to make these decisions for the incapacitated person at a time of emotional crisis, and health care providers from being forced by law to provide treatments that could unnecessarily prolong pain and suffering.

Bizarre.  If it wasn't so pathetic it would really be quite funny.

Making Profit is the American Way

"Making Profit is the American Way."  This was a sign that stood out to me during coverage of the raucous town hall meetings on health care reform occurring this week as our legislators are back in their districts on August break.  It couldn't be more true.

What does that mean exactly?  In health care, let's start with insurance companies.  Back in the mid-1990s I served on the Hospital Advisory Board of Blue Cross of California, representing 225 hospital members of the Hospital Council of Northern and Central California.  In 1995, CaliforniaCare, a for-profit subsidiary of Blue Cross of California, had a 'medical loss ratio' of 73%.  This means that CaliforniaCare paid 73 cents on every premium dollar for health care services.  The remaining 27 cents included plan administration and a very healthy profit.  For comparison, the medical loss ratio at Blue Shield of California, a non-profit, was in the vicinity of 88%, and at Kaiser Permanente, also a non-profit, 96%.  

I don't really mean to single out Blue Cross of California, as the 'medical loss ratio' of CaliforniaCare, while low, was not out of the range of experience for for-profit health plans in California and nationwide.  To note, as medical inflation has escalated, 'medical loss ratios' have increased as health plans have been pressured to reduce premium increases.

In 1996, after years of negotiation with regulators, Blue Cross became a fully for-profit organization. The State of California required that Blue Cross divest substantial assets in this process in recognition of the 60 years the organization operated as a tax-exempt entity. The amount of this divestiture was $3 billion, creating two of the largest health care foundations in the country.

The Board of Blue Cross of California deemed this $3 billion divestiture to be a worthwhile business exchange to become a for-profit organization.  That says volumes about the level of profit made by health plans nationwide, and the potential for greater financial success as a for-profit entity.  Blue Cross became Wellpoint, Inc. and their stock did extremely well.  In 2003, Wellpoint was purchased by Anthem, an Indianapolis-based holding company with health plans throughout the country, for $14.3 billion. 

The stockholders of Wellpoint did exceptionally well with their investment.

During this transaction, I had to contrast all of this incredible wealth with perpetually cash-starved public health organizations throughout California.  I had to wonder about our collective priorities in a state with over 6 million people uninsured at any given time.  Given the current economic downturn and accompanying job-losses (the California unemployment rate hovers near 12%), it is likely that the number of people without health insurance in California is substantially higher today.

The Health Insurance Association of America (HIAA) is one of the most powerful lobbying entities in Washington.  The HIAA nearly single-handedly killed health care reform efforts under the Clinton Administration (remember the 'Harry and Louise' ads?), making health care reform a political 'third rail' for the the next 16 years.

They are doing an excellent job of re-creating their success.  If you really want to understand the underlying dynamics of the health care system in the US, follow the money.

Reflections on Complexity and Confusion

My last post on health care reform was painful.  I felt like there was so much there to write about, and simultaneously had a difficult time conveying thoughts in a concise and straightforward manner.  After sleeping on it and talking to a colleague also very engaged in health care economics and reform, it occurred to me that this is exactly the issue.  There is no real consensus on direction because one can look at the health care industry from so many different perspectives it can make your head hurt.

"Health care reform" is a bit like "financial services reform" times two (or more).  Health care reform can mean changes in health care financing (long overdue), health care delivery (which is happening incrementally on many fronts), health care regulation and oversight (with changes also happening in increments), and public health programs.  "Health care reform" also includes, if you will, many "industries" and interests that are not cohesive, often are at odds with one another due to competing views, and occasionally find themselves in agreement. This includes: Hospitals; Physicians and medical groups; Nursing; Ancillary services (a large grouping of entities like laboratory, radiology, physical therapy, etc.); Federal, state and local governmental programs that are often very distinct from one another and periodically overlap; The health insurance industry; The pharmaceutical industry; Business coalitions that have developed or are developing their own means of ferreting out distinctions between health care providers; Non-profit health programs run independently of government and which also occasionally overlap with each other and governmental programs; An entire industry of alternative health care with innumerable distinct subsets, some of which are recognized by governmental and private financing programs and most not; Long-term care, including nursing homes; Mental health care and mental health advocacy, which are frequently at odds with one another; Palliative care options, which are sometimes connected to other components of the health care 'system' and sometimes not; Durable medical equipment makers and distributors; and research entities engaged in all sorts of capacities throughout the 'system.' This is not intended to be an exhaustive list, but rather an attempt to highlight how many disparate voices are engaged in this debate.

The complexity of the health care delivery system is exactly why the conversation about health care reform is so incredibly difficult.  If one takes it in one large lump, it is very difficult to differentiate between issues and to make judgments about direction.  There is not a clear direction even among the people are engaged in health policy research who are immersed in the possibilities for health care reform.  

What many, if not most, people in health care can agree on is resounding skepticism that the health insurance industry has your best interests at heart, the pharmaceutical industry is unlikely to advocate change in your best interests, and the American Medical Association is a mixed bag of interests with a significant focus on maintaining the status quo for specialist physician incomes.  Together, they form the bulk of lobbying efforts directed at Congress.

It is amazing what a night's sleep will do for a twisted brain.  I live in the world of health care economics and financing and it was hard for me to ferret out what I wanted to say.

All of this said, we must do something.  The more I think about it, the more it appears that the only real answer is an incremental plan which builds upon the many programs we already have and decreases the likelihood that you or I will find ourselves in a situation where a health condition or accident occurs and creates financial ruin, emotional and familial stress.  It doesn't take a lot for this to happen. The 'safety net' is not designed for middle-income people who have lost their jobs and therefore their health coverage.  There are millions of people in this country who are one illness or accident away from poverty.  And that is completely unacceptable in a country as wealthy as the United States.

Health Care Reform: Expectations for Results from Elected Representatives

The biggest hurdle 'health care reform' has is that it's existence is predicated on the ability of elected representatives to make it happen.  Creating a major reform of an industry as complex as health care through the political process is unlikely to produce results that make sense.  We will be very fortunate to focus on a handful of incremental reforms that actually address some of the burgeoning need for change. 

Why is this?  Two words:  Campaign Financing.  Getting elected to Congress costs huge sums of money. Most of that money comes from special interests.  To survive, one needs to keep that pipeline of dollars open.  

As an example, Congress tackled a health care reform issue just a few years ago in Medicare Part D: The prescription drug benefit.  You would be hard-pressed to find many Medicare beneficiaries who truly understand their drug benefit.  The system is ludicrously complex, and, while offering an important enhancement to coverage, serves less as a benefit to the elderly and disabled as Medicare Part D serves as a give-away to the pharmaceutical industry. Those who choose to participate in Medicare Part D are faced with a confusing array of options.  Most people wade through this by finding an option that includes the medications they currently take as part of it's formulary.  That doesn't mean that this same formulary will include any medications that may be needed in the future, nor does it guarantee that the medications currently in the formulary will remain there.  There is no established requirement for formularies in the program, leaving each of the 1,800+ drug plans to establish (and periodically change) their own formularies.

As if that wasn't enough, the new program prohibits the federal government from negotiating drug prices. The Veteran's Administration, which is allowed to negotiate with pharmaceutical companies, pays on average 58% less than Medicare Part D plans.  The federal government is, in effect, subsidizing the pharmaceutical industry.  If a Medicare beneficiary spends more than $2200, they pay 100% out-of-pocket until they reach $5100.  Many find it cheaper to buy their non-generic drugs in Canada, where prices are generally much lower because drug prices are regulated by the Canadian government.  

Which brings me back to the current health care reform debate.  

Congress is the wrong venue for putting together a coherent global plan for health care reform. There are too many inputs from too many interests competing for attention.  We are more likely to get something meaningful and usable if the development process were taken out of the political arena.  

The biggest problems with the US health care system include:

1. Health insurance is obtained through one's employer and is not portable: If you change employment, your health insurance coverage changes, with the strong possibility of needing to find a new panel of health care providers.  In addition, if you leave or are severed from your employer, you lose your health coverage.  This may be less of an issue if one is healthy, but can be severely problematic if one has a chronic illness or other pre-existing condition.

2. The focus on disease processes rather than prevention: Far too many people have no coverage for primary and preventive care, or are in systems lacking adequate chronic disease management.  As a result, people with chronic conditions often do not have their conditions managed by health care professionals and wind up presenting in hospital emergency rooms with advanced conditions that cost far more than would preventive efforts.

3. The fragmented nature of the system: Health care professionals and facilities are not connected to one another in much of the country.  This results in duplication of diagnostic procedures, an inability to access services, and often requires the patient to be the source of communication between clinicians about histories, drugs taken, and diagnoses.  A handful of model programs for integration exist, including Kaiser Permanente and Group Health (in Washington and Idaho).

4. Lack of connection between health care conditions and personal responsibility: On the positive side, the US has done an very good job connecting smoking with a host of disease processes, resulting in substantial reductions in smoking prevalence.  A challenge still largely under-addressed is connecting the relationship between what one eats and disease processes.  Obesity is fast becoming a health crisis that will cost everyone enormous sums of money to treat.  There needs to be clearer connections between obesity and diabetes, asthma, cardiovascular and heart disease (among the host of disease possibilities).

My message to Congress:  Think incrementally.  It is potentially an enormous undertaking well outside of the possibilities for Congress to address in one piece of legislation.  An incremental approach makes a whole lot more sense.

Try starting with a focus on a few substantial problems that also have the potential to save money in both the short and long term:

1. Every person in this country must have access to a primary care physician.  There is no other way to detect health issues early in their process without a regular check-up.  We already have clinical guidelines as to what these these check-ups should include, existing networks of providers, and reimbursement rates (a current Congressional land mine courtesy of the AMA).

2. Focus on chronic conditions and grant universal access to programs offering disease management and treatment.  Most of the money we spend on health care is for hospitalization, and much of that is the result of unmanaged chronic conditions.  The potential savings is enormous.

3. Maintain existing safety nets (e.g., Medicaid programs, local health programs) and integrate them with enhanced primary care and chronic disease management programs.  The safety net programs are not perfect, but they are meaningful.

4. Focus on nutrition.  We have a start at nutritional labeling, but it is confusing at best.  The food pyramid is largely ignored.  We need a program that tackles the issue of the relationship between fast food, soda consumption, obesity and health.  Imagine funding school lunch programs that actually included healthy food and taught children about healthy eating (remember the Reagan administration assertion that catsup is considered a vegetable in school lunches?). Consider it the anti-smoking campaign for the 21st century.

5. Reinvigorate required school exercise programs that teach the relationship between exercise and good health. Texting is not exercise.

6. Start a national dialogue about how one would like to live at the end of one's life.  We spend vast sums of money on treatments at the end of people's lives that have questionable clinical efficacy, and often create more suffering than if we offered universal palliative care (e.g., hospice care).  There is a lot to be said for dying with dignity intact rather than being kept alive in pain.  As a people, we need to open this discussion and shift perceptions about death and dying.

Imagine a government that initiates and funds a meaningful set of programs focusing on healthy living. That would a great start toward reforming not only the health care system, but our collective consciousness about how health starts at home and the way we treat our bodies.

$1.5 Trillion for Healthcare Coverage?

Today's news included the announcement that insuring everyone who is currently uninsured in the United States would cost $1.5 trillion over the next decade.  This has led to quite the debate about whether this is a direction this country should go at this moment (or ever).

The answer needs to be a resounding YES to reform.  We cannot afford to continue with 46+ million people uninsured and another 25+ million people underinsured in this country.  That doesn't include people who have lost their jobs and their employer-based health care coverage in recent months, or are about to when COBRA coverage runs out.

However,Republicans seem to be closer to the right track on this one.  They are absolutely correct that we cannot offer universal health coverage under our existing broken system.  We continue to throw vast resources at problems that are largely preventable.  Our entire health system is based on what we can do about disease processes.  It is not about health.  We need a radical shift of mindset and restructuring of the system from a disease-based system to a health-based system.

It's about chronic illnesses.  These include diabetes, asthma, cardiovascular disease, congestive heart disease, HIV, stroke, arthritis, cancer, kidney disease, chronic respiratory disease, etc.  Seven out of 10 Americans who die each year, or 1.7 million people, die of a chronic disease.  Chronic diseases consume 75 percent of all health care costs ($1.5 trillion in 2006).  Diabetes alone consumes $174 billion each year, costs related to smoking (heart disease, respiratory disease) are around $195 billion, and those related to heart disease and stroke $448 billion annually.

The vast majority of these costs are preventable.  We can start by ensuring that every person in this country has access to preventive care and chronic disease management.  The system we have today is significantly based upon people showing up at hospitals in acute stages of illness, and then consuming huge resources.  If these same people engaged, and were engaged by, a health system that was truly oriented toward health and prevention many, if not most, of these people would not be presenting at hospitals in acute stages of illness requiring dramatic intervention.

As if it the state of health care financing were not bad enough, it is only going to get worse.  Two huge trends are creating a health care financing nightmare.  The first is an aging baby-boomer population, and the second is obesity.  We now have generations of people in this country who are likely to become diabetic (chief among a host of chronic illnesses) due to their chronic obesity. The cause of the vast majority of cases of obesity is diet, particularly fast food, and lack of exercise.  If we don't do something to plug people into a health-based system of care, including nutrition counseling, a focus on changing the way we eat (similar to the success of smoking cessation campaigns), and exercise, our enormously bloated health care system will fail.  It cannot support it's current trajectory.

Prevention pays off huge dividends.  As a reminder, we pay twice as much per capita than any other country in the world for the health care we receive.  Health care costs were $2 trillion in the United States in 2006 and overall costs are growing dramatically each year.  This means that in 2006 we likely spent $1 trillion more than we needed to on health care.  Despite that vast investment, our overall health status is somewhere around 37th in relative healthiness in the world.  It is a disaster.  The French pay less than half per capita on health care than in the United States, are deemed by the World Health Organization to be the healthiest population in the world, and their system focuses on chronic illness.  They are on the right track, not us.

We cannot afford "health care reform" that doesn't include real reform.  Make prevention the priority. Create a system that rewards personal responsibility.  It requires a change in mindset in the health care system and in each one of us.  We need to shift the concept of health care from acute illness to being healthy.  It will be good for all of us.

Health Care Reform

In my mind, as I typed the words 'health care reform' I heard a long sigh.  Health care reform got attention from candidates throughout the Presidential campaign cycle.   Each candidate acknowledged that there is a problem.  However, nobody really came up with anything other than incremental change. We need more than that.  At the risk of eye-glazing, here are just a few bullet points from a largely macroeconomic level:

1. We spend twice as much per capita as any other country in the world for the health care we receive. 
2. The World Health Organization ranks the U.S. health care system 37th in terms of quality (2000 data - it hasn't improved), with the list topped by France, Italy, Spain, Austria, Norway - countries with national health systems.  The U.S. is right behind Chile and Costa Rica, and just ahead of Slovenia and Cuba.  This isn't the image most Americans have of their health care system, which is part of the problem.
3. The U.S. has one of the worst rates of infant mortality in the developed world, largely due to the lack of universal availability of prenatal care. 
4. We spend 70 percent of our health care budget on chronic illnesses, largely because our health system does a terrible job of managing those illnesses.  We have a system that often waits until people are so sick they show up in hospitals.  Then we chew up resources.
5. We continue to refuse to make hard decisions about offering, and accepting, extraordinary means of keeping people alive in the last stages of their lives.  Instead of allowing ourselves to die with dignity, we often continue to accept every possible last-ditch attempt to keep us alive a bit longer (with Medicare picking up the tab - hold that thought).  

Our health care system is not economically sustainable.

We like to point our finger at the pharmaceutical industry, and there is a lot wrong there.  However, pharmaceutical costs make up only 10 percent of overall health care expenditures.  Tackling the pharmaceutical industry is only a small component of reform.  Health care reform would be most meaningful by creating a system that truly manages illness and keeps people healthier and out of the hospital.  

The concept is hardly new.  That is the core idea behind health maintenance organizations (HMOs). HMOs do manage care, but are really mostly cost-management organizations.  Unfortunately, the system is fraught with some basic conceptual problems.  First, HMOs are largely publicly traded entities beholden to shareholders and not their members.  In addition, we are saddled with an employment-based insurance system. There are so many problems with an employment-based system, I'll only point out only a few:

• The obvious, you lose your insurance if you are no longer employed.  COBRA can help, but generally the breadth of coverage of most employers yields very expensive individual premiums. Plus, COBRA is only a short-term program intended to offer coverage between jobs.
• The days of a career with one employer are largely gone.  People switch employers often, which usually means switching to a new health plan.  Care becomes fragmented as one needs to navigate a new provider network, and health plans have little incentive to keep people healthy when a sizable portion of their covered population (often 25% or more) moves to a new plan each year.  
• If you leave or are otherwise severed from your employment and have a chronic illness, you will be uninsurable as an individual and liable for your own health care costs.  It can happen to anyone.
• One in five people in the U.S. has no health insurance.  When they need services, they generally go to hospitals, the most expensive location for providing care.  We all pay for that.
• Most new employment in this country is created through small businesses.  How often are people tied to their current employment situation and thus unable to create new ventures simply because they have a non-life-threatening chronic illness and need insurance coverage?  

Our system needs more than incremental change.  We need a wholesale change in the way we finance and manage health care.  Unfortunately, this would require consensus in Washington.  The early signs from Congress are not encouraging.  We may get some change, but it will likely involve tinkering with a broken system.  We pay far too much for health care in this country, and the economic impact of health care costs is affecting all of us.

Medicare is a system of universal coverage in the U.S.  It works.  It is far from perfect, and unless we collectively make some hard decisions in the short term, it will become bankrupt.  It too is unsustainable as the population of the country ages and fewer people are actively employed and paying taxes to support the system. However, it can be.  Actively managing chronic disease in a way that reduces hospitalization would in itself help keep the program solvent. 

As Americans we have a strong notion of individual responsibility.  This has, and continues to, serve us well.  It has fostered an environment of creativity and industry.  It does, however, have its limitations. Health care is at the top of the list. The notion of health care as a privilege creates an environment that puts all of us in jeopardy. The word 'socialized' in conjunction with 'medicine' is a sure way for politicians to avoid having to intelligently discuss the issue.  Brains turn off.  Simultaneously, Medicare beneficiaries will rally against anything that impacts their entitlement program. Medicare is socialized medicine attempting to act like any another health plan (hence the financing problem).

Real reform is no longer optional.  Health care costs have an enormous impact on our economy. We live in a country that has the capacity to make anything happen, including creating a new model for universal health care that works.  The first step is acknowledging that incremental change is like holding together our life-support system with duct tape.