ACP American College of Physicians - Internal Medicine - Doctors for Adults

We're #1! We're #1!

... in national health care expenditures, that is. This, of course, is nothing new: spending on health care in the U.S. has long out-paced any other industrialized country. What is noteworthy is "the largest one-year increase in [health care's] GDP share since the federal government began keeping track in 1960" blogs Chris Fleming, of Health Affairs. He writes that a new study shows that health care spending increased by an estimated 5.7 percent since 2008 despite a projected decline in the gross domestic product (GDP) in the same period.

The recession is having a big impact on respective roles of the public and private sectors. "Health spending by public payers is expected to have grown much faster in 2009 (8.7 percent growth, to $1.2 trillion) than that of private payers (3.0 percent growth, to $1.3 trillion)" Fleming writes, which is attributable to an increase in "projected growth in Medicaid enrollment (6.5 percent) and spending (9.9 percent) as a result of increasing unemployment related to the recession. Conversely, enrollment in private insurance is expected to have declined 1.2 percent in 2009, despite federal subsidies for Americans who have lost their jobs to extend their private insurance coverage via the Consolidated Omnibus Budget Reconciliation Act (COBRA) that increased participation in these plans."

"For the first time, government programs next year will account for more than half of all U.S. health-care spending, federal actuaries predict, as the weak economy sends more people into Medicaid and slows growth of private insurance", writes Peter Landers in the Wall Street Journal.

Free-market advocates would be loath to admit it, but in an employer-based private insurance system, when people lose their jobs, they also lose their coverage, unless the government steps in to provide it. If it wasn't for Medicaid and the government subsidies for COBRA coverage, far more Americans would have been without health insurance during this recession.

And for all of the anti-government sentiment among much of the electorate, I don't see people demanding that Congress repeal Medicaid or eliminate COBRA subsidies, or get rid of Medicare or the VA, for that matter. People dislike government, except when they need it.

What the health reform bills propose to do is replace the current patchwork system with an improved safety net - expanded Medicaid for the poor and near-poor, tax credit subsidies for people up to 400 percent of the federal poverty level, limits on pre-existing condition exclusions, and subsidies and purchasing pools to make coverage more available and affordable for small businesses. They would build upon what the government already does - provide people with affordable coverage when the private, employer-based system fails them - but in a more organized and coherent way.

Today's question: What is your reaction to the new estimates on government and private sectors spending on health care?

posted by BDoherty at 4:29 PM   5 Comments

Health reform and the Obama budget

Does the President's new budget mean that the White House is shifting toward smaller-scale health reforms in lieu of comprehensive legislation?

Time magazine's Katie Pickert blogs that "the HHS budget doesn't do what massive health reform legislation was supposed to do." She notes that an AP reporter asked HHS Secretary Kathleen Sebelius "to clarify what was obvious already - that the 2011 HHS budget doesn't make any real headway toward solving the country's health care crisis." Sebelius responded that the "budget 'in no way replicates the efforts in the health reform legislation to reach out to the 30 some million Americans who have no health insurance at all and those who are woefully underinsured, … This budget - absent health reform - will still leave a major gap.'"

The National Journal writes that the budget "focuses more on the economy than on health reform." ABC's Jake Tapper explains that "the budget assumes $150 billion in deficit reduction from enactment of the health reform legislation," while the Wall Street Journal's Janet Adamy blogs that the budget offers a "back up" plan should the "embattled" health reform legislation fail. Jacob Goldstein reminds readers of the WSJ's health blog that "the big [cost] drivers are mandatory spending on Medicare and Medicaid - huge, rapidly growing costs that are outside the purview of Obama's (or any president's) annual recommendations for discretionary spending."

My take is that the President's budget doesn't itself signal a retreat health reform, but tries to have it both ways - pledging fealty to enactment of a comprehensive bill, while suggesting ways to advance smaller-scale reforms should the broader effort fail. Among the President's health funding priorities are:

-- Primary care training: $2.5 billion for community health centers, enough to fund current centers and create 25 new ones; $169 million to the National Health Service Corps, to train up to 400 more primary care physicians, nurse practitioners, and dentists to serve in underserved areas, bringing the total to 8,500 clinicians. $54 million for Title VII primary care training programs, the same as FY2010, but the current preference for family medicine programs (over internal medicine) would be eliminated.

-- Health information technology: $110 million for "continuing efforts to improve health IT policy, coordination and research activities."

-- Comparative effectiveness: $286 million for the Agency for Healthcare Research and Quality to study the effectiveness of different medical options.

-- Coverage: $25.5 billion to support State Medicaid programs by temporarily increasing Federal Medicaid funding for six months through June 2011.

-- Delivery system reforms: "new Medicare and Medicaid demonstration projects that evaluate reforms to provide higher quality care at lower costs, improve beneficiary education and understanding of benefits offered, and better align provider payments with costs and outcomes. Special emphasis will be placed on demonstrations that improve care coordination for beneficiaries with chronic conditions, that better integrate Medicare and Medicaid benefits, and that provide higher value for dollars spent."

-- Medicare physician payment: the budget includes an increase in Medicare baseline spending of more than $200 billion to accommodate enactment of legislation to end the annual cycle of SGR cuts. (Congress, though, appears to be leaning toward setting aside enough money to prevent cuts for the next five years but not enough to permanently repeal the SGR.)

For the past year, President Obama has pursued a "Big Bang" approach to health reform, centered on getting Congress to pass sweeping expansions of coverage coupled with other reforms to make insurance more affordable and available - yet the effort remains (hopelessly?) stalled in Congress. The new budget doesn't necessarily mean that he is walking away from big changes. But the budget does suggest to me a grudging awareness, if not acceptance, by the White House, that smaller, incremental steps could be all that he will get.

Today's question: What is your reaction to the President's budget?

posted by BDoherty at 2:53 PM   3 Comments

Did Obama's SOTU address give enough of a lift to health reform?

In my mind, President Obama's State of the Union speech settled, at least for now, the question of whether he remains committed to health reform:

"So, as temperatures cool, I want everyone to take another look at the plan we've proposed. There's a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo. But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. Let me know. Let me know. I'm eager to see it. Here's what I ask Congress, though: Don't walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people. Let's get it done. Let's get it done."

But will Obama back up his words by putting the full weight of his office behind the effort? Roll Call reports that Democrats are looking to the President to help them find a "clear path" to break the gridlock, and some remain doubtful about its chances.

Perhaps the most important development, other than Obama's speech, is a declaration today by Speaker Nancy Pelosi (D-CA) that she has the votes to pass health reform if the Senate agrees to adjust the bill through the budget reconciliation process, which requires only a simple majority. Channeling Winston Churchill, Pelosi is quoted as saying, "We'll go through the gate. If the gate is closed, we'll go over the fence. If the fence is too high, we'll pole vault in. If that doesn't work, we'll parachute in. But we're going to get health care reform passed for the American people." Senator Majority Leader Harry Reid (D-NV) also is "looking very closely" at the reconciliation option, according to Roll Call.

There are big differences between the House and Senate bills, though, so it will require President Obama's direct involvement and leadership to get agreement on the changes to be made through reconciliation and persuade a majority of Democrats to go along.

What about the GOP? I would like to believe that there could be agreement on an approach that would attract bipartisan support, but I doubt it. Republicans uniformly will oppose use of reconciliation to "force" enactment of health care. The Democrats will counter that reconciliation is justified to overcome Republican "obstructionism" in the Senate, which prevents legislation from being passed by a simple majority vote, and they will remind people that reconciliation was used to pass the Medicare Part D prescription drug program and the Bush tax cuts when the GOP controlled Congress.

The one area that could have been a fertile ground for bipartisanship is medical liability reform, but it is probably too late for that. The President asked for "better approaches" from either party to reduce the deficit and lower premiums. The CBO estimates that tort reform would "lower costs for health care both directly, by reducing medical malpractice costs - which consist of malpractice insurance premiums and settlements, awards, and legal and administrative costs not covered by insurance - and indirectly, by reducing the use of health care services through changes in the practice patterns of providers" and "reduce federal budget deficits by about $54 billion during the 2010-2019 period." Unfortunately, I don't see the President doing the heavy lifting within his own party to enact tort reform, and I don't see Republicans agreeing to support the broader health reform bill even if he did.

Finally, the wild card in all of this is whether the President's speech and subsequent actions will slow the erosion of public support. Last night, the President acknowledged the problem:

"Still, this is a complex issue, and the longer it was debated, the more skeptical people became. I take my share of the blame for not explaining it more clearly to the American people. And I know that with all the lobbying and horse-trading, the process left most Americans wondering, What's in it for me?"

The Kaiser Family Foundation's latest health tracking poll, fielded earlier this month but before the Massachusetts special election, found the public evenly divided overall about the health reform bills, but that, "Majorities reported feeling more favorable toward the proposed legislation after learning about many of the key elements, with the notable exceptions of the individual mandate and the overall price tag."

President Obama's speech provided a lift to health reform, but he will need to do more to persuade a skeptical public about what's in it for them.

Today's question: Do you think Obama's the State of the Union address lifted the prospects for health reform?

posted by BDoherty at 4:23 PM   6 Comments

Which countries have the longest waits for medical care?

Yesterday, I borrowed liberally from Dr. Seuss' "Oh, the Places You Will Go" to describe the "weirdish, wild space" - The Waiting Place - in which we now find health reform.

This got me thinking about The Waiting Place in a different context: the time it takes to get an appointment with a physician. Anyone one of us who has had to wait weeks, or even months, for an appointment would agree that The Waiting Place is, as Dr. Seuss described it, a "most useless place" to be.

Critics of the pending health reform bills, like Conservatives for Patient Rights argue that they will lead to longer wait times for appointments. Their argument being that "government-run" health care, as exists in Canada or the United Kingdom, has been demonstrated to result in long waits for medical appointments.

I would dispute the premise that the reforms being considered by Congress are akin to the systems in place in Canada or the United Kingdom. Like it or not, the House and Senate bills would maintain private, employer-based health coverage as the principal source of insurance coverage. Still, I began to wonder about what the data show about wait times in different countries.

In 2007, the Commonwealth Fund released a report that compared U.S. health care against several other countries based on a variety of benchmarks. The data were principally derived from statistically random surveys of adult residents and primary care physicians from 2004 to 2006, in the following countries: United States, Canada, New Zealand, United Kingdom, Germany, and the Netherlands. This is what the researchers found:

* Canada had the highest percentage of patients (36%) who had to wait six days or more for an appointment with a doctor, but the United States had the second highest percentage (23%) who reported that they had to wait at least this long. New Zealand, Australia, Germany, and the U.K. all had substantially smaller numbers of people reporting waits of 6 days or longer. Canada and the United States, in that order, also had the lowest percentage of persons who said they could get an appointment with a doctor the same or next day.
* The United States had the largest percentage of persons (61%) who said that getting care on nights, weekends, or holidays, without going to the emergency room, was "very" or "somewhat" difficult. In Canada, it was 54%, and in the U.K, 38%. Germany did the best, with only 22% saying that it was difficult to get after-hours care.
* The United States, though, scored well on physicians' perceptions of how many patients experience long waits for diagnostic tests. 57% of physicians in the U.K, and 51% of Canadian physicians reported that their patients experienced long waits for diagnostic tests, compared to only 9% of U.S. physicians who reported the same.
* The U.K (60%) and Canada (57%) had the highest numbers of persons who had to wait four weeks or more to get to see a specialist physician. In the U.S., only 23% reported a wait of four weeks or more for specialty care.
* The U.S. also did very well on measures of wait times for non-emergency or elective surgery. Only 8% of surveyed patients in the United States reported a wait time of four months or more for elective surgery, compared to 33% in Canada and 41% in the U.K. Germany scored the best, with only 6% reporting a long wait for elective surgery.

The take-away message is that both the United States and Canada do pretty poorly, compared to most other industrialized countries, on how long patients have to wait to get a regular appointment with a primary care physician or after-hours care, but the U.S. does better than most on having shorter wait times for diagnostic procedures, elective surgery, and specialty care. Each of these countries, though, with the exception of the United States, has universal health insurance coverage, funded and regulated in large part by the government, so it doesn't seem likely that government-subsidized health care, in itself, is the sole factor in determining how long patients are stuck in The Waiting Place. Other factors, like the numbers of primary care physicians and specialists in each country, may be more important.

Today's question: What is your reaction to the data on each country's experience with wait times for medical care?

posted by BDoherty at 4:25 PM   1 Comments

Dr. Seuss' Rx for Obama's health reform slump

"Oh!
The places you'll go!

You'll be on your way up!
You'll be seeing great sights!
You'll join the high fliers
Who soar to high heights.

You won't lag behind, because you'll have the speed.
You'll pass the whole gang and you'll soon take the lead.
Wherever you fly, you'll be the best of the best.
Wherever you go, you will top all the rest.

Except when you don't.
Because sometimes you won't.

You can get all hung up
In a prickle-ly perch.
And your gang will fly on.
You'll be left in a Lurch.

You'll come down from the Lurch
With an unpleasant bump.
And the chances are, then,
that you'll be in a Slump.
And when you are in a Slump,
You're not in for much fun.
Un-slumping yourself
Is not easily done.

You can get so confused
that you'll start in to race
down long wiggled roads at a break-necking pace
and grind for miles across weirdish wild space,
headed, I fear, toward a most useless place.

The Waiting Place ...
... for people just waiting.
Waiting for a bus to come, or a plane to go
or the mail to come, or the rain to go
or the phone to ring, or the snow to snow
or waiting around for a Yes or NO
or waiting for their hair to grow.
Everyone is just waiting."

The above excerpts come from Dr. Seuss' final, masterful book, "Oh, The Places You'll Go!," a motivational tale of overcoming life's challenges to arrive at great places.

I can't think of a better description of the present health reform slump, and of the weirdish, wild, space - the Waiting Place - in which members of Congress now find themselves. Waiting for President Obama to signal his intentions. Waiting for Speaker Pelosi and Majority Leader Reid to come up with a plan. Waiting for another chance to get health reform done, right.

(Meanwhile. Kristen Gerencher blogs in Market Watch about efforts by various stakeholders to ramp up pressure on Congress and the president to move forward on reform, including a joint letter sent yesterday to Congress and President Obama by the American Academy of Family Physicians, American College of Physicians, and American Osteopathic Association, advocating that a pathway be found to move forward on "essential" reforms to expand coverage, ensure a sufficient primary care workforce, reform payment and delivery systems, and support alternatives to the medical liability tort system.)

Dr. Suess wraps up by saying:

"On and on you will hike.
And I know you'll hike far
And face up to your problems
Whatever they are ...

And will you succeed?
Yes, You will, indeed!
(98 and 3/4 percent guaranteed)

KID, YOU'LL MOVE MOUNTAINS!"

President Obama's State of the Union address tomorrow will tell us much about whether he can face up to his problems, regain the initiative, and move mountains to achieve comprehensive health care reform for all Americans.

Today's question: What do you think President Obama should say about health reform in his State of the Union address?

P.S. The ACP Advocate Blog is a finalist in the sixth annual Medical Weblog Awards for the Best Health Policies/Ethics Weblog. Voting begins on January 27 and will close at 12 midnight on February 14. Please take a moment to vote for the ACP Advocate Blog.

posted by BDoherty at 1:21 PM   2 Comments

Will Congress throw the uninsured under the bus?

The Wall Street Journal reports that the Democrats may put aside the party's goal of providing health insurance coverage to (almost all) legal residents. Instead, they might push for more scaled-back reforms including, "modest coverage for the uninsured, perhaps aid for small businesses, new rules for insurance companies and some policy changes to control federal health spending." To be clear, as the WSJ points out, no decisions have been made, and likely won't be, until after President Obama's state of the union address Wednesday.

I understand the political reasons why some members of Congress may want to put aside the goal of achieving near-universal coverage. Most voters have health insurance, and polls show that voters with health insurance increasingly are concerned that the health reform bills will increase their costs and reduce the quality of care they receive. So the political calculation appears to be: why pass something that is disfavored by a good proportion of the 85% of your constituents that have health insurance, so as to provide coverage to the 15% who don't, many of whom don't vote? Especially since most of the almost trillion dollar cost of the proposed bills is to fund programs to expand coverage.

We've seen this before. In 1995, when President Bill Clinton's efforts to reform health care collapsed, 40.6 million people in the United States, or 15.4% of the population, were without health insurance coverage during the entire year, according to the Census Bureau. In 2008, the exact same proportion of the population -15.4% - went without health insurance, but because of population growth, the total number of uninsured persons reached 46.3 million. The uninsured rate would be much higher, if it were not for enactment and reauthorization of the State Children's Health Insurance Program, which in 2008 provided coverage to 7.4 million low-income kids. The best one can say is 15 years after Clinton's health reform initiative collapsed, we have made absolutely no progress in reducing the percentage of the population without health insurance.

One big difference now is that both the House of Representatives and the Senate have passed bills that would cover between 94-96% of legal U.S. residents - the farthest this has ever advanced in the legislative process. Yet Congress and maybe President Obama may be on verge of deciding that the politics make it too hard to get the bills over the finish line.

I understand that the bills are controversial, and that people are troubled by the deal-making that went into getting the necessary votes. I appreciate that people are concerned that the U.S. can't afford to take this on now, even though the CBO says that the legislation will reduce the federal budget deficit. I "get it" that many people don't trust the government to deliver on the promise of better care at lower cost. I know that changes will need to be made in the bills to increase public support, such as elimination of some of the special deals made in the Senate. What I don't get is the apparent willingness of politicians to again throw the uninsured under the bus.

I don't know if providing everyone access to health coverage is a right, but I do believe that it is the right thing to do. I continue to have some hope that President Obama and Congress will find a way to ensure that "the U.S. health care delivery system provides access, best quality care and health insurance coverage for 100%" of Americans, as called for by ACP's vision of a desired future for U.S. health care. Tomorrow's state of the union address should at least tell us where the President stands.

Today's question: Do you think Congress and the President should throw in the towel in providing affordable health insurance coverage to all?

posted by BDoherty at 4:16 PM   2 Comments

"Dazed and Confused"

... is how Chris Frate aptly characterizes the Democrats' state of mind on how to proceed with health care reform. It doesn't help that President Obama and his White House staff are sending mixed signals.

It seems as if there are only a few options left:

- The House passes the Senate bill "as is" but with a commitment to modify parts of it through a separate budget reconciliation bill. This has the advantage of not requiring 60 votes because a filibuster is not in order in the Senate for a bill that has already passed and is awaiting action by the other chamber. Any changes made through budget reconciliation can also be passed by a simple majority. But as the Washington Post reports today Speaker Pelosi has rejected this option, at least for now.

- The House and Senate could drop the current bills and start anew with drafting a new bill to be passed strictly through budget reconciliation on a strict majority vote. This though creates all kinds of political and procedural hurdles - including the need for the committees of authorization to have to "mark up" a new bill. The reconciliation bill could only include provisions with a direct effect on federal spending and revenue, so popular regulatory provisions, like banning pre-existing conditions exclusions, likely would have to be left out. And, with the Democrats eager to get health reform behind them, I don't see them wanting to start anew.

- Reid and the White House could reach out to a small handful of Republicans, like Olympia Snowe (R-ME) and Susan Collins (R-ME), to get them to support a compromise that gets them to 60 votes. Not impossible, but difficult, because the Democratic leadership may have burned bridges with them, and the few Republicans who might be "in play" will be under tremendous pressure from their party not to play ball. Compromises to get GOP votes will run the risk of losing votes from Democrats, and I would not be surprised to see some of the Senators who voted for the current bill having second thoughts. The back-and-forth negotiations that would be required would drag the process out longer and lead to more deal-making, the last thing the Democrats want.

- Or the Democrats could themselves break the bills up into individual parts and force Republicans to vote for or against provisions that may be popular. The likely result would be a far less expensive bill that would make modest changes (like banning pre-existing conditions and voluntary pooling arrangements, maybe with Medicaid expansion and some limited subsidies targeted to the poor). This too, though, would require new committee "mark up" and drag the process out for months, with no certainty of success. And disaggregating the bills could lead to an unworkable result: for instance, requiring that insurance companies accept people with pre-existing conditions (popular with voters) likely will require a mandate that individuals buy insurance (less popular) and subsidies (very expensive) to make coverage affordable.

- The White House and Congressional leadership could just walk away from the process of trying to get health reform passed and try to blame it on Republican obstructionism, making the midterms a referendum where both sides would point figures on why health reform failed.

Where does this leave ACP and its public policy agenda? We don't control the politics, process or procedures of health care reform. Our agenda is determined by our own policies - not the politics of the moment. As such, we will continue to advocate that Congress enact legislation to advance our four priority areas: coverage for all, workforce and primary care, payment and delivery system reform, and medical liability reform. We have been pushing this agenda long before the latest political developments, and will continue to do so until progress is achieved.

There is no easy way forward. But if health reform fails, the best opportunity we've had to advance fundamental reforms to achieve key policy objectives - like reforming Medicare payments to support primary care, training more primary care internists, funding research on comparative effectiveness, and of course, affordable coverage for all - will be set back. And if health reform fails, health care spending will rise at a rate that that the country simply can't afford.

Kevin Pho, MD, may have said it best, in his admonition to his colleagues on the Right:

"With the potential defeat of ObamaCare, you may have won the battle, but will lose the war. The current health reform efforts, in the grand scheme of things, were very incremental in nature. Without it, the number of uninsured will rise, and health costs will continue to spiral upwards. That will eventually bring America's economy to its knees, and, as I said a few months ago, 'once that happens, more draconian measures will be forced upon us. Measures that assuredly will not be friendly to doctors.'"

Today's question: Do you agree with Kevin Pho that defeat of Obama's health care reform will lead to more draconian measures being forced upon physicians?

P.S. - The ACP Advocate Blog with Bob Doherty has been nominated for consideration in the Best Health Policy/Ethics category in the 2009 Medical Webblogs Award Program sponsored by epocrates. (It may not yet show up yet in the list of nominees, since it usually takes a day or so for the latest nominees to show up.) If you would like to support the nomination, you can do so by following the instructions "to place a nomination." The editors ask that when nominating, you indicate the blog's name and URL, as well as your thoughts why this particular blog deserves recognition.

posted by BDoherty at 1:39 PM   8 Comments

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