Thursday, July 2, 2009

Health Care Tuesday

via Daily Kos ...


The city and province of Buenos Aires have announced a health emergency to fight a swine flu outbreak that has killed at least 26 people in Argentina.

Benen: IS 'HELP' ON THE WAY?...
Just two weeks ago, the Congressional Budget Office (CBO) scored a health care reform plan crafted by Democrats on the Senate Health, Education, Labor, and Pensions (HELP) Committee. The results were ugly: the plan would cost at least $1 trillion over the next decade, but leave tens of millions of people without insurance.

The problem, of course, was that it wasn't the actual plan -- the CBO relied on out-of-date details to score a proposal that wasn't finished and was missing key provisions. Regardless, Republicans pounced, using the misleading CBO analysis as a cudgel to beat reform advocates. House Minority Whip Eric Cantor (R-Va.) went so far as to call the CBO breakdown "the turning point in the healthcare debate."

The good news is, the actual HELP bill is complete. The better news is, the committee seems to have put together a solid plan. Jonathan Cohn explained:

According to the official CBO estimate, which a Capitol Hill source provided late Wednesday afternoon, the provisions over which HELP has some jurisdiction -- which include employer contributions and subsidies to people who can't fully pay for insurance on their own -- would bring insurance to 21 million additional people by 2019, the end of the ten-year budget window. (Erosion of job-based coverage would be virtually zero.) An expansion of Medicaid, something HELP supports but can't officially legislate -- because of committee jurisdiction -- would cover another 20 million.

So what does that mean in context? The official CBO projections suggest that, given current trends, there'd be 54 million uninsured people in America by 2019. Therefore, the reforms HELP envisions would reduce that number by three-quarters. Overall, if my math is correct, 95 percent of the population would have health insurance; more than 97 percent if you discount undocumented workers.

The plan would cost -- including net outlays, Medicaid expansion, Medicare/Medicaid savings, and new revenue -- about a $1 trillion over the next decade.

The HELP Committee's proposal also, thankfully, includes a public option, though the details have not yet been published.

As for the Republican lawmakers who used the incomplete CBO analysis to practically announce the death knell of reform, Faiz Shakir asks the right question: "[W]hat excuses will McCain, Boehner, Graham, and other Republicans offer now? Their attacks were not only found to be baseless, but their concerns about the costs and coverage have also been addressed."

I'm sure they'll think of something. They always do.

from Salon's Tom Tomorrow: Healthcare reform: Here we go again!

This Modern World By Tom Tomorrow

The Wall Street Journal ran a very odd op-ed today from someone named George Newman, described as "an economist and retired business executive." The point of the piece was to try to debunk some of the common arguments in support of health care reform. Towards the end of the piece, Newman tackled the notion that we need a public option "to keep the private plans honest."

The 1,500 or so private plans don't produce enough competition? Making it 1,501 will do the trick? But then why stop there? Eating is even more important than health care, so shouldn't we have government-run supermarkets "to keep the private ones honest"? After all, supermarkets clearly put profits ahead of feeding people. And we can't run around naked, so we should have government-run clothing stores to keep the private ones honest.

ABC News' John Stossel was "especially" impressed with this argument. That's a shame.

Jamison Foser explains why Newman's analogy doesn't make sense.

Supermarkets make money by selling people food. Clothing stores make money by selling people clothes. If they don't give people food/clothing, they don't get money.

Insurance companies, on the other hand, make money by selling people insurance -- and they make even more money by selling insurance, and then denying claims.

I would have hoped this was obvious, even to Stossel and the editors of the Wall Street Journal's op-ed page. Oh well.

I'd just add, by the way, that Newman is convinced that American consumers already benefit from the competition among existing private insurance plans. Perhaps, before his next op-ed, Newman could look into the phenomenon of "highly concentrated" insurance markets.

digby: Blanche!

As you all know, Blue America has been collecting money to run some ads in Arkansas to ask Blanche Lincoln to support a Public Plan. We shot three spots but couldn't decide which one to go with, so we've decided to ask you to make the decision for us, by coughing up yet another buck or two for the ad of your choice.

All you have to do is go to the Act Blue Campaign For Health Care Choice Page and follow the instructions.

Here are the ads:

#1 "I Thought We Had Insurance"

#2 "Bonuses"

#3 "Bailout"

Vote here! Vote often!

John Amato has a thorough post about the campaign and the contest, here.

Previous posts about the campaign:

Campaign For Health Care Choice
Monopoly Money
A Votre Sante
Private Dancers
Code Blue
Learn, Damn You, Learn!
Washington To Constituents:STFU
Sargent: Happy Hour Roundup

* Sam Stein reports on an interesting new effort being spearheaded by blogger Jane Hamsher and liberal groups like MoveOn that will make breast cancer survivors the public faces of the push to get wavering Dem Senators to back the public health care option.

Here’s the first spot, targeting Senator Mary Landrieu:

More from Hamsher, a breast cancer survivor herself who has already made trouble for the White House by whipping votes against the war supplemental, right here.

* Speaking of a public plan, at an online town hall today, President Obama voiced strong, unequivocal support for the public option:

I also strongly believe that one of the options in the Exchange should be a public insurance option — an option funded by premiums, not the government. This public option is important because if the private insurance companies have to compete, it will keep them honest and help keep prices down.

* Here’s a good rundown of the health care questions thrown at Obama at the forum.

* A smart post from Eric Kleefeld, who reminds us that the Rupert Murdoch media empire, which is now going batty about Al Franken’s victory, was what originally sued Franken and put him on the political map. Life is funny that way!


Yglesias: Health Care: What’s in it for Me?

Jon Cohn and Kevin Drum ring the alarm bells about something that I think the Democratic Party leadership is overlooking to a dangerous degree—the possibility that by the time they’re done trimming Barack Obama’s health care philosophy down to something acceptable to Max Baucus and Kent Conrad that you’ll be left with something that the public doesn’t actually support. A public option, for example, is wildly popular with the public and supported by almost seventy percent of voters. But it doesn’t have nearly so many fans in the United States.

And as Kevin says, absent a public plan or really generous subsidies, “[m]ost people will just see higher taxes funding better coverage for the poor, and you don’t have to be the world’s biggest cynic to understand that this isn’t going to be overwhelmingly popular.” Now to be clear, people actually would, under this scenario, benefit from a variety of regulatory changes that congress wants to make. But the benefits of those changes would be cumulative over time, and not like a nice Christmas present to voters. Under the circumstances, you could easily imagine any number of Senators who have thus far not been allowed to dominate the political process—ordinary, mainstream Dems who don’t sit on the Finance Committee—looking at the final bill and kind of shrugging. Reducing the long-run trajectory of health care costs is an obsession for DC health policy wonks, but there’s very little evidence that it’s high on the public’s list of concerns. If you don’t do anything to make middle class health care cheaper in the short run, or to open up some new options to people, then you may have appeased some of reform’s critics at the cost of producing a bill with few real fans.

Ezra Klein: Does Medicare Pay Below "Cost?" (Wonky!)


Over at Movin' Meat, Shadowfax has a useful reply to my post on Medicare's method of payment. In particular, he makes the important point that Medicare overpays many specialists and underpays many primary care providers. Agreed. In fact, one of the important and quiet wrinkles of health reform will be how it redresses that imbalance. If you want an affordable health-care system, you can't have your largest insurer tilting the playing field toward specialty care.

But he ends his post the wrong way. "Yes, Ezra," he says. "Medicare does work by dictat." But no! It doesn't! Hospitals and doctors are not forced to accept Medicare's rates by Medicare. (It is true, as Shadowfax says, that many hospitals choose to contract with Medicare and thus the doctors who practice at hospitals have to do so as well. But that's a rather different situation.). There may be a lot of reasons a doctor ends up working with Medicare, just as there are many reasons a supplier ends up working with Wal-Mart. You can argue that they're good reasons or bad reasons, and that policy should or should not change them. But the reasons are not that the law says they have to accept Medicare patients. And that's the argument I'm addressing here.

I also want to say a word on this idea that Medicare pays hospitals "below cost." You can see it clearly in the Blue Cross/Blue Shield slide that mbp3 contributed in comments. "This would seem to be at odds with your post," he/she wrote. The graph is very simple, as you can see. There's a dotted line marked "cost." Medicare is below it. Blue Cross Blue Shield is above it. But the argument here boils down to a very simple question: What is "cost?"

On March 17th, Glenn Hackbarth, the chairman of MedPAC, testified before the House Ways and Means Committee on this very issue. Hospitals, Hackbarth argued, are inefficient. Their costs are too high. And this was backed up in the data. "MedPAC analysis has identified a set of low-cost hospitals that consistently out-perform other hospitals on a series of quality measures, including mortality and readmissions," Hackbarth explained. "Among this set of hospitals, we found that Medicare payments on average roughly equaled the hospitals’ costs." In less "efficient" hospitals, Medicare's payments were below costs. You can see this in the following table:


Among the major differences between "efficient" and "non-efficient" hospitals was that the less-efficient hospitals were not under financial pressure: They made a lot more money from other sources. As such, they spent a lot more money on things like capital expansion. As example, compare the amount a young journalist spends to the amount a young investment banker spends. The banker requires more income to break even on that lifestyle. His "cost" is higher. But he doesn't need that lifestyle. He doesn't need that "cost." And if that banker is being paid on taxpayer dollars, I don't want him to have that lifestyle. I want him to have what he needs, rather than what he wants. Because I'm paying for it.

And so too with Medicare payments. Indeed, what MedPAC found was that hospitals under "financial pressure" -- hospitals that made less money, in other words -- managed to control their "cost" better. Medicare's payments sufficed for them. And their quality outcomes weren't any worse.

Put another way, the question is simple enough: Do you think hospitals are efficient? My read of the evidence is that they are not. "Cost" is too high. I think we need to cut costs. I think that the health-care system needs to spend less money than it currently spends. Another way of saying that is I want the system to begin paying below projected "cost." That, after all, is how you save money.

My read of the data is that there's sufficient room to do that without harming quality. The fact that the vast majority of hospitals continue to accept Medicare patients proves that, I think. Medicare's rates aren't where they'd like them to be. But it's still worthwhile for them to do business with Medicare. That suggests there's significant space between where hospitals are today and where they could be in a more efficient system.

That's not true for everyone, of course. As Hackbarth admits, Medicare underpays primary care providers, and it needs to redress that balance. And Medicare itself does a lot to increase costs across the system (in particular, it's fee-for-service payments give doctors incentive to increase volume). But in the aggregate, I think it's a feature, not a bug, that Medicare's payment rates are pushing hospitals to close that cost gap.

For people who want to dig deeper on this, Hackbarth's testimony is here.

Madrak (C&L): Compare and Contrast: A Woman With Pneumonia Goes to The Local Clinic

From Coalition of the Obvious, via Avedon, this useful "compare and contrast" on national health care systems. It especially means something to me because a few years back, after my unemployment ran out and I was working an hourly job, I developed pneumonia and couldn't afford to pay for a chest x-ray. I'm glad I'm still alive to tell the tale:

During my time in Venezuela, I developed a cough that went on for three weeks and progressively worsened. Finally, after I had become incredibly congested and developed a fever, I decided to attend a Barrio Adentro clinic. The closest one available was a Barrio Adentro II Centro de Diagonostico Integral (CDI) and I headed in without my medical records or calling to make an appointment. Immediately, I was ushered into a small room where Carmen, a friendly Cuban doctor, began questioning me about my symptoms. She listened to my lungs and walked me over to another examination room where, again without waiting, I had x-rays taken.

Afterwards, the technician walked me to a chair and apologized profusely that I had to wait for the x-rays to be developed, promising that it would take no more than five minutes. Sure enough, five minutes later he returned with both x-rays developed. Carmen studied the x-rays and informed me that I had pneumonia, showing me the telltale shadows. She sent me away with my x-rays, three medications to treat my pneumonia, congestion, and fever, and made me promise to come back if my conditioned failed to improve or worsened within three days.

I walked out of the clinic with a diagnosis and treatment within twenty-five minutes of entering, without paying a dime. There was no wait, no paperwork, and no questions about my ability to pay, my nationality, or whether, as a foreigner, I was entitled to free comprehensive health care. There was no monetary value connected with my physical well-being; the care I received was not contingent upon my ability to pay. I was treated with dignity, respect, and compassion, my illness was cured and I was able to continue with my journey in Venezuela.

This past year, a family friend was not so lucky. At the age of 56, she was going back to school and was uninsured. She came down with what she thought was a severe case of the flu, and as her condition worsened she decided not to see a doctor because of the cost. She died at home in bed, losing her life to a system that did not respect her basic human right to survive.

Her death is not an isolated incident. Over 18,000 United States residents die every year because of their lack of prohibitively expensive health insurance. The United States has the distinct honor of being the “only wealthy industrialized nation that does not ensure that all citizens have coverage”.(8)

Instead, we have commodified the public health and well being of those live in the US, leaving them on their own to obtain insurance. Those whose jobs do not provide insurance, can’t get enough hours to qualify for health care coverage through their workplace, are unemployed, or have “previously existing conditions” that exclude them from coverage are forced to choose between the potentially fatal decision of refusing medical care and accumulating medical bills that trap them in an inescapable cycle of debt. And sometimes, that decision is made for them. Doctors often ask that dreaded question; “do you have insurance?” before scheduling critical tests, procedures, or treatments. When the answer is no, treatments that were deemed necessary before are suddenly canceled as the ability to pay becomes more important than the patient’s health.(9)

It is estimated that there are over fifty million United States residents currently living without health insurance, a number that will skyrocket as unemployment rates increase and people lose their work-based health care coverage in this time of international financial crisis.(10)

Already this year, 7.5 million people have lost work-related coverage. Budget cuts for the state of Washington this year will remove over forty thousand people from Washington Basic Health, a subsidized program which already has a waiting list of seventeen thousand people.(11)

As I returned to the US from Venezuela, I was faced with the realization that as a society, the United States places a monetary value on life. That we make life and death judgments based on an individual’s ability to pay. And that someone with the same condition I had recently recovered from had died because, according to our system, her life wasn’t insured.

ChrisinParis (AMBlog): Privatization fails over and over in the UK

The Margaret Thatcher Tony Blair privatization plans all sounded so wonderful. Basic services such as public transportation and the mail could be spun off and the free market would save everyone lots of money! Hooray! Except it didn't quite work out that way. Public transportation privatization has been a fiasco and costs to consumers have hardly decreased. As a regular consumer of public transportation in France I'm horrified with the outrageously high costs when I travel to the UK. It's very expensive and the quality is generally sub-standard.

The rail privatization took a hit as another rail operator notified the government that it has had enough. Like many business ideas from the recent past, what sounded impressive during the credit boom suddenly looks like a very bad idea. Politicians such as Blair and "modern" lefties all bought into the idea that government services could become sexy and profitable if only they had a bit of faux capitalism. Only a politician who spent their life working in government could have viewed this as a good idea.

The DfT's financial constraints were exacerbated as National Express announced it will hand back its £1.4bn east coast contract at the end of the year, the second time in three years that a company has bid more than £1bn for the route and then quit after admitting that it could not afford it. GNER gave up its £1.3bn contract in 2006, only for National Express to place a higher bid less than a year later.

The east coast withdrawal marked a new low in the tense relationship between struggling train operators, who are battling to honour expensive contracts signed before the recession, and the transport secretary, Lord Adonis. He warned that National Express would be barred from the rail market amid uproar that the company was preparing to avoid fulfilling its £1.4bn pledge.
In yet another blow, the UK government is now backing down from its privatization of the post office. The government was becoming addicted to the easy money and ignoring the real world results. The post office privatization is thankfully gone though the UK government is now eying some very steep financial hurdles. All of these programs still require money but there's none left. It was all spent bailing out the banks and covering some of the basics. The UK is in the difficult situation of either requiring a new economic surge (not likely) or raising taxes. The government was drunk on credit and the phony economy that they created and now they have to figure out how to survive without either. The Conservatives may be howling but if anything, they would have gone even deeper into credit and privatization. Their strongest selling point today is that they are not Labour.

1 comment:

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