Wednesday, September 23, 2009

Health Care Wednesday

They do polls: NBC/WSJ 
And who will get blamed if health care doesn't get passed this year? Per the poll, 10% say Obama, 16% say congressional Democrats, and 37% say congressional Republicans.

The matter of choice in health care 

Sept. 22: Rachel Maddow reviews the eyebrow-raising financial relationship Rep. Mike Ross, D-Ark., has with the health care industry and is then joined by Sen. Ron Wyden, D-OR, to discuss the renewed energy in the Senate in support of the public option.

Humana, among the nation's leading private insurers, is not at all pleased that policymakers intend to pay for health care reform by reducing unnecessary spending in Medicare Advantage. Humana, after all, makes an enormous amount of money through the program.
So, the company, which has already spent $1.2 million on lobbying on health care, initiated a new mobilization campaign, contacting its customers with frightening and misleading letters to try to scare them about reform, and creating a website to send form emails to lawmakers. (The emails identify the sender as Medicare Advantage members, whether they are or not.) This came to the attention of the Centers for Medicare and Medicaid Services, which began investigating Humana's lobbying efforts.
More importantly, at the request of Senate Finance Committee Chairman Max Baucus (D-Mont.), the CMS asked Humana to stop the misleading mailings and shut down the form-email website. The agency has authority on the matter, given all the taxpayer money Humana accepts, and the marketing limits Humana accepted as part of the program.
Republicans aren't happy.
Senate Minority Leader Mitch McConnell, who represents Humana's home state of Kentucky, and has received tens of thousands of dollars from the company over the years, called the CMS actions a "gag order" -- a characterization that has been echoed by House Minority Leader John Boehner and Rep. Dave Camp (R-MI) -- ranking member on the House Ways and Means Committee -- who fired off an angry letter to CMS acting administrator Charlene Frizzera.
"In light of CMS' seemingly uneven and potentially politically-motivated use of its regulatory authority," Camp writes, "I therefore request that...CMS immediately suspend this virtual gag order on efforts by an MA plan to let its enrollees know how they could be hurt by the health reforms plans being pushed by President.
Just so we're clear, Republican politicians, some of whom get plenty of money from Humana, are defending an insurer misleading Medicare recipients with taxpayer-subsidized communications.
Senate Minority Whip Jon Kyl (R-Ariz.) said he's only looking out for free-speech rights. "You don't lose your rights because you happen to sell insurance for heaven's sake," he said.
That is, of course, a foolish argument. The government is paying the bills here. Humana accepted lobbying and marketing limits when it started collecting tax dollars. As Ryan Grim noted, "Communication between the private Medicare Advantage providers and beneficiaries is strictly regulated because the private companies are using public dollars."
Republicans shouldn't decry the attached strings simply because Humana and the GOP have the same goal -- attacking health care reform.
In the meantime, Democrats on the Hill were quick to note the background of the company Republicans were desperate to defend: "Humana was recently featured in a HuffPost story for denying health care due to lack of an enema. In 2005, it settled a racketeering suit for $40 million. It settled a fraud lawsuit in 2000 for $14.5 million. Since 2000, its profits have soared from $90 million to $834 million."
Republicans often pick the wrong friends, don't they?
Chris in Paris (AmBlog): Democrats to end anti-trust exemptions for insurance industry 
This is exactly what we need to see from Democrats. Let the GOP defend their friends in the insurance business and see what the public thinks about it. (h/t Cat)
House Judiciary Committee Chairman John Conyers, Jr. (D-Mich.), Chairman of the Subcommittee on Courts and Competition Policy, Representative Hank Johnson (D-Ga.), and Energy and Commerce Committee Vice-Chair Diana DeGette (D-Colo.) today introduced the Health Insurance Industry Antitrust Enforcement Act, legislation to end the broad antitrust exemption enjoyed by health insurance companies.

Both the House and Senate today have introduced identical language to reduce insurance prices for consumers. This legislation would extend antitrust enforcement over health insurers and medical malpractice insurance issuers, which currently enjoy broad antitrust immunity under the McCarran-Ferguson Act. This immunity can serve as a shield for activities that might otherwise violate federal law.

"This legislation would specifically prohibit price fixing, bid rigging, and market allocation in the health insurance industry," said Conyers. "These pernicious practices are detrimental to competition and result in higher prices for consumers. Conduct that is unlawful throughout the country should not be allowed for insurance companies under antitrust exemption. The House Judiciary Committee held extensive hearings on the effects of the insurance industry’s antitrust exemption throughout the 1980s and early 1990s. It became clear then that policyholders and the economy in general would benefit from eliminating this exemption.

At a forum this week, House Minority Whip Eric Cantor (R-Va.) heard from a constituent about a serious health care dilemma. Her question was sad but common, and Cantor's response was illustrative.

The constituent noted that she has a close relative in her early 40s. She had a lucrative career and great insurance, right up until she recently lost her job. A couple of weeks ago, she was diagnosed with stomach tumors and needs an operation soon, but she's no longer covered.
Cantot encouraged her to look to "existing government programs," or perhaps "charitable organizations." He added, "No one in this country, given who we are, should be sitting without an option to be addressed."
That's worded rather awkwardly, but it's a sentiment I can agree with. Americans who need care should have "options." There should be "government programs" to provide coverage to those who don't have it.
The problem, which Cantor fails to appreciate, is that he and his colleagues are opposed both to giving Americans "options" and creating "government programs." If he meant what he said, Cantor wouldn't be leading the charge against health care reform.
Indeed, the follow-up question is obvious: what is Eric Cantor doing to help provide "options" and strengthen "government programs" for those Americans who need help?
As for relying on charities and the kindness of strangers to save those facing life-threatening illnesses, what Cantor may not realize is that these charities, through no fault of their own, necessarily have to ration care and force patients to endure long wait times -- there are fewer resources than patients.
In other words, Cantor's warnings about the perils of a reformed system are already a reality.
Ezra Klein: Delivery System Day: Peter Orszag
You all know who Peter Orszag is. So rather than wasting time on an introduction, I'll just jump right into our interview on the delivery system reforms.
You’ve been in a lot of these internal discussions. How much of the work here has focused on reforming the delivery system?
The Finance Committee mark includes most of the proposals that have been put forward. That’s why folks from Mark McClellan on the right to lots of folks on the left have said the mark is impressive. You don’t get to that point without having done a lot of work ahead of time.
Why do they get less attention than insurance market reforms?
For a few reasons. Insurance market reforms are more immediately salient., Everyone knows what it means to say no more preexisting conditions in terms of affecting coverage. What exactly you mean by accountable care organization, or bundled payments, is more esoteric. People don't really see the plumbing beneath the system.
Many of these changes seem modest. As opposed to the insurance market, where we ban practices we don't like, or add structures we do like, the delivery system side of things seems concentrated around pilot programs and demonstrations and experiments.
I’d say it’s a mixture. But yes, what needs to happen is we need to put into place the infrastructure to aggressively experiment with what works and what doesn’t, and a lot of what this bill is doing is putting that infrastructure in place, through the Innovation Center and the demonstration projects. But don’t forget that there are direct and immediate changes taking place to provider payment updates and home health reimbursements and so forth.
Which of the policies strike you as most promising?
Let me answer that by harkening back to what I think is the key to a higher-value, lower-cost system over time. The first is we need to digitize the system, and that was part of the Recovery Act. We need a lot more evidence on what works and what doesn't, and Recovery Act had some of that, and the Mark goes further. The third is we need to move away from fee for service and towards fee for value, and the Chairman’s Mark does a lot of that through bundled payments and medical homes and value-based payments for hospitals and accountable care organizations.
I would also include in that bucket the Innovation Center and the Medicare Commission. Both are aimed at trying lots of things, seeing what’s working and what’s not, and having policy adapt to what’s working immediately. This allows for the dynamic and iterative nature of cost containment over time. We don’t know exactly how to get from here to a high value, low cost system because the health-care sector dynamic. So you need a process.
What's the Innovation Center?
The Innovation Center is a $6.6 billion fund to test out different ways of linking payments to quality. The key is that they’re creating a structure in which you can try out different things. That then feeds into the commission that will help expedite changes in Medicare policy. You can go from aggressively testing something out to implementing it quickly.
That's a point I hadn't heard before about the MedPAC proposal: that it's part of a whole chain. In that telling, it sounds like much of this is providing support for MedPAC's work.
Exactly. You need these feedback loops. You can digitize medical records, so then you have much more information on what outcomes are. That gets fed into experiments to see what works and what doesn’t. Which gets fed into policy changes. And hopefully, the electronic health records system will also have decision-making tools so the doctor has research at his fingertips helping show what's best for the patient.
It's like a Google brain for doctors.
Right. This is building out the Google brain for the medical system. And just like with Google, we can’t just put in an IT system where physicians scroll through 30 pages of data. Doctors are people too. The system needs a simplified template. Your patient seems to have the following conditions, you might want to test for x. And you can click through for more.
I'd heard that the IT system was still troubled, as crucial decisions about standards and interoperability hadn't been put into place.
David Blumenthal is now in place as the Health IT coordinator over at HHS. A lot of progress is being made. There’s a process.
How do the delivery-side reforms interact with the insurance market?
Several ways. Perhaps most immediately, your premiums will ultimately be driven by the underlying cost of health care. To the extent these reforms help to contain costs over time, they have a significant influence in the insurance market through the level of premiums. It’s also the case that Medicare can lead the private insurance market in terms of moving towards a value-based system, and we’ve seen that in past examples. In the ’80s, Medicare moved towards fixed payments for each hospital stay, and that created an incentive for hospitals to reduce the length of stays. The result was shortened stays for everyone and not just Medicare patients. And many of the changes floating around with regard to Medicare in this bill have similar potential.
In many cases, Republican lawmakers asked Democratic leaders to make specific concessions on health care reform. When Dems like Max Baucus agreed, the GOP balked anyway.
But there are other areas in which Democrats simply embrace policy ideas endorsed, or even created by, the right. For quite a while, conservatives liked the idea of giving an Independent Medicare Advisory Council more power to determine what the program should pay for. It's a straightforward, money-saving measure. When the Obama administration agreed, Republicans decided they didn't like their own idea anymore.
The same thing is happening with an individual mandate, which Republicans trashed during the first day of Senate Finance Committee debate yesterday.
Advocates of a coverage mandate say it is needed to ensure that young, healthy people get insurance and contribute to the system. They say this will ease costs associated with an influx of less-healthy people who are expected to get coverage under the Baucus legislation.
Republicans, who are trying to slow Democratic efforts to pass a health overhaul by the end of the year, rushed to criticize the proposal.
Iowa Sen. Charles Grassley, the Finance Committee's senior Republican, said the mandate is among the reasons that he couldn't support the bill despite months of negotiations with Mr. Baucus. "Individuals should maintain their freedom to chose health-care coverage, or not," he said.
"This bill is a stunning assault on liberty," said Sen. Jon Kyl of Arizona, the Senate's second-ranking Republican.
That's pretty strong rhetoric under any circumstances, but it's especially striking since the GOP used to think individual mandates were fine. Indeed, Sam Stein noted yesterday that the idea was "once considered so non-controversial that it was endorsed by several major Republican officials."
As recently as a month ago, Chuck Grassley, the same senator bashing the idea of a mandate yesterday, announced that the way to get universal coverage is "through an individual mandate." He told Nightly Business report, "That's individual responsibility, and even Republicans believe in individual responsibility." Earlier this year, Grassley told Fox News that there wasn't "anything wrong" with mandates even if some may view them "as an infringement upon individual freedom."
Now, apparently, he disagrees with himself. There's a lot of that going around.
Congressional Republicans could probably save themselves a lot of trouble by simply saying, "Whatever Democrats are for, we're against," in response to every question.

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