The ACP Advocate Blog by Bob Doherty

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

2010-02-04T16:29:00.002-05:00

... 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?

Health reform and the Obama budget

2010-02-02T14:53:00.003-05:00

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?

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

2010-01-28T16:23:00.002-05:00

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?

Which countries have the longest waits for medical care?

2010-01-27T16:25:00.004-05:00

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?

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

2010-01-26T13:21:00.005-05:00

"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.

Will Congress throw the uninsured under the bus?

2010-01-25T16:16:00.004-05:00

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?

"Dazed and Confused"

2010-01-21T13:39:00.003-05:00

... 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.

"I'm not dead ... yet"

2010-01-20T16:24:00.003-05:00

One of my favorite movie scenes is from "Monty Python and the Holy Grail," when an unfortunate soul pleads with the designated collector of corpses (this being after the plague, mind you) that "I'm not dead ... yet." The collector responds by whacking him on the head ... until he is, in fact, quite dead.

This scene comes to mind as I blog about yesterday's stunning GOP upset of the seat-that-used-to-be-held-by Ted Kennedy. If the election of Republican Scott Brown didn't quite kill off health care reform, some Democrats are quite willing to complete the task.

Ezra Klein blogs for the Washington Post that, "a Democratic Party that would abandon their central initiative this quickly isn't a Democratic Party that deserves to hold power. If they don't believe in the importance of their policies, why should anyone who's skeptical change their mind? If they're not interested in actually passing their agenda, why should voters who agree with Democrats on the issues work to elect them? A commitment provisional on Ted Kennedy not dying and Martha Coakley not running a terrible campaign is not much of a commitment at all." Steve Pearlstein, also writing in the Post, argues that the Massachusetts vote was not a referendum on health reform: "There are lots of reasons other than derailing health reform why normally liberal Massachusetts voters may have wanted to send an angry signal to the state's political establishment. For Democrats in Washington, the danger now is not that they will ignore the election returns, but that they will misread them and sound a premature retreat from a historic and game-changing opportunity."

Yet there is no denying that even if the Massachusetts outcome didn't kill health care reform, it has put it on a death watch. Many of Brown's supporters came from independents who, according to pre-election polls, were highly motivated by their opposition to the health care reform bills. But Massachusetts already has near-universal coverage - broadly supported by its voters - so it is hard to view the election as a flat-out rejection of reforms that they themselves enjoy. And, as I wrote in yesterday's blog, there is no denying that the public lacks confidence in the government's ability to deliver on the promises of better care at lower cost to them.

Politico reports on several options available to Democrats to continue to move forward on health care reform, but there is a clear divide among rank and file members in both chambers on how or if to proceed. And, as I write this, CNN is reporting that President Obama may offer a scaled down version of health care reform - bans on pre-existing conditions exclusions and expanding Medicaid to cover all of the poor and near-poor - as a potential fallback.

I understand all of the focus on the politics of health reform, and I suppose that if I were a Democratic member of Congress, that is the main thing I'd be thinking about. But I am reminded that the reasons for health care reform are just as valid today as they were yesterday: tens of millions of Americans lack access to affordable health insurance coverage, many more have difficulty paying their bills, quality is uneven, and costs are rising faster than we as a country can afford. These were true when Obama took office one year ago today - when, by the way, there were only 58 Democratic Senators (Specter of Pennsylvania hadn't yet switched parties, and Franken's win over Coleman in Minnesota was being contested in the courts) - when the popular refrain was "Yes, we can." Now, with 59 Senate votes, some Democrats are saying "no we can't" to health care reform?

In September of last year, I blogged about the plight of a Missouri bartender I met at an ACP chapter meeting:

"She said she has some serious health problems that require expensive medications, which are only partly covered by the health insurance plan offered by her employer. Her company plan also covers her 19 year old dependent daughter with a serious mental health condition. Her husband, an independent contractor who can't find coverage on his own, also relies on his wife's plan for coverage. She said that even with the insurance, her premiums and out-of-pocket health care bills are so high that 'I don't know how we'll make it.' She was planning to take a day off from work to plead with state Medicaid office to cover her daughter, even though she had already been advised over the phone that her daughter wouldn't qualify."

I wrote that, "I hope we don't lose sight of this Missouri bartender, and the millions of working American families, who can't afford health care and are looking to Washington for help. None of the bills making their way through Congress are perfect - far from it. But I believe the litmus test of whether the results are worth it is whether our Missouri bartender and her family can get good coverage at a price that they can afford."

I still believe this. The voters in Massachusetts elected Mr. Brown, knowing that he promised to be the 41st vote against health care reform, and their choice needs to be respected. But Massachusetts has near-universal coverage, is it too much to ask that a Missouri bartender - and the tens of millions like her - have the same? The current Congress and President can still bring home the Holy Grail of health care reform, but only if they - and we the voters - want it bad enough.

Today's questions: What advice would you give to President Obama and Congress? Give up on health reform? Move forward with the basic framework that has been passed by both chambers? Or pass as scaled down version?

Losing and winning the battle for public opinion

2010-01-19T16:49:00.003-05:00

I am not going to speculate - yet - about the meaning of the Massachusetts' special election to fill the vacancy created by Ted Kennedy's passing, mainly because I'd rather wait until the votes are cast. I'll have something to say about it, tomorrow.

But I don't think anyone can reasonably dispute the fact that public opinion, in general, has swung against the pending health reform bills. And the reasons for this require some thoughtful analysis by the health reform advocates if they hold out any hope of turning opinion around. Blaming the polls on "scare tactics" gives too much credence to the worst of the opposition's arguments, while suggesting that the public doesn't "understand" the benefits of reform is condescending, and even more to the point, ineffective. You are not going to win over the public by calling them dupes (to the health care lies) or ignoramuses (because they aren't smart or informed enough to see the benefits to them). At the same time, though, the critics of the health reform bills should think twice before prematurely concluding that the public has decisively bought into their view they will lead to "government-run" health care.

Real Clear Politics reports that when the results of nine different polls, conducted since the first of the year, are averaged together, 51.1% of respondents oppose the health reform legislation while 40.9% support it. But it isn't that simple.

Gallup finds that Americans narrowly favor passage of the bill, by a margin of 49% to 46%. The CNN/Opinion Research poll "finds that 57% generally oppose" the bill while only 40% "generally support" it. But the CNN poll shows that solid majorities favor two of the most "liberal" proposals in the House-passed version: taxing high income people (with 61% support) and the public plan option (with 55% support).

The Kaiser Family Foundation's December tracking poll (not included in the Real Clear Politics poll averages) finds that, "Overall, 54 percent say the economic challenges facing the country make it more important than ever to tackle reform, while 41 percent say we cannot afford to take on reform now." In this poll, "45 percent say the country would be better off if health care reform passes, down 9 percentage points from November, compared to 31 percent who say the country will be worse off and 17 percent who see no impact." At the same time, however, Kaiser reports that "the percentage of Americans who believe they will be personally better off if Congress passes health care reform is down seven percentage points from last month to 35 percent, making for a much more divided public on this measure, with roughly three in ten saying they think they will be worse off (27 percent) and another three in ten not expecting to see much change (32 percent)." In other words, more people believe that the bills will be better for the country than will personally benefit them.

The Washington Post/ABC poll similarly shows that most Americans are not persuaded that they will be better off if health reform passes. 53% say that it will cost them more if health reform passes than if the current system were maintained, and only 38% say the quality of care will be better if health reform passes compared to 50% who say it will be better under the current system. 56% believe that the overall cost of health care to the country will be higher if reform passes compared to 37% who say it will be higher if the current system is left as it is. The Washington Post poll, like CNN's, also shows that more Americans favor a tax on high income persons and the public option than oppose them.

In my mind, the polls show that opponents have been most effective in raising doubts among Americans on two of the core claims for health care reform: that the bills will lower their costs while improving (or at least not hurting) the quality of care they receive. But I don't think that the polls show that there has been a wholesale rejection of the need for health care reform, or that most Americans buy into the view it is too liberal and will lead to government-run health care. Instead, they don't trust that the bills being debated will deliver on the promises of better care at lower cost, and that is why a majority now oppose them. The proponents of health reform have not yet figured out how to make them feel otherwise.

Oh, and one thing about Massachusetts, no matter who wins today's election, the polls show that most of the Commonwealth's residents like their state's universal health insurance program, which consists of individually mandated insurance with subsidies to buy coverage and health exchanges to make it more affordable - just like the bills being debated in Congress.

Today's question: Who do you think is winning the battle for public opinion, and why?

Why do red states gain the most under health reform?

2010-01-14T16:21:00.002-05:00

With news that a tentative deal may have been reached on the contentious issue of a tax on high cost health plans, the negotiations on the health reform bill may be on the verge of overcoming one of the biggest obstacles to reconciling the House and Senate bills. It looks increasingly likely that the House and Senate may strike a deal to allow a revised bill to be sent, as early as tomorrow, to the Congressional Budget Office, for a revised estimate of its impact on the federal budget. This would set the stage for possible passage of the legislation by the end of this month or early February.

Without assuming anything, it isn't too soon to begin talking about who gains and who loses under the likely compromise legislation. Writing in the Health Affairs blog, Claudia Schur and Marc Berk estimate that "the states most likely to 'win' as a result of health care reform are Arkansas, Idaho, Kentucky, North Carolina, Oklahoma, Tennessee, and Utah. All of these states have a relatively high number of uninsured and all are in the bottom half of states in terms of cost under both financing mechanisms." They used a simple metric - "benefits were measured in terms of the state's current proportion of uninsured residents, and costs were assessed by ranking the states to see which would be hardest hit by each of two financing mechanisms, a tax on high earners and a tax on high health insurance premiums" - to determine which states would get more benefit than their contribution to the cost.

"Among the states most likely to 'lose'" they write, "are Delaware, Nebraska, and New Hampshire as well as the District of Columbia. Each of these states has a relatively lower-than-average proportion of uninsured residents, and each would fall in the "High Cost" category under either of the financing options." Other states would do better or worse depending on which financing mechanism - tax on high income residents or tax on high cost insurance plans - is used. Many other states fall somewhere in between.

What do the "winning" states have in common? They have more uninsured persons, fewer unionized workers, lower average insurance premiums (meaning fewer "Cadillac" plans to be taxed), and fewer high income persons (meaning fewer people who fall in the income brackets that may have to pay higher taxes). "The overall pattern therefore shows a curious alignment" they write since, "states with the most to gain under health care reform are overwhelmingly represented by Republicans, while those states likely to do worse are much more likely to have Democratic senators."

This dissonance between a state's partisan voting pattern and how much they will gain is dramatic: "When we examine the seven states most likely to be winners under reform, we see a combined split in their Senate delegations of twelve Republicans versus two Democrats. The three states most likely to lose under health care reform are collectively represented by four Democrats and two Republicans. When we add in the group that would be losers under the income-tax option, the split becomes even stronger, with these states being represented by eighteen Democrats and four Republicans."

If politics was all about bringing home the goods, then one might expect that the states that will gain the most from health reform would be the most in favor of it. But the "red" states that will gain economically from health reform are also the ones whose electorate tends to be most distrustful of government. Because these voters don't particularly like government, they have been willing to tolerate high number of uninsured persons. Now, though they will gain the most if the federal government ends up picking up the tab to cover more people - even though their own Senators (and most of their residents) were against it. Meanwhile, many of the Democratic "blue" states will see more of their tax dollars go to paying for health care coverage in the states that didn't want it in the first place.

The best hope the Democrats have is that once health reform is signed into law, red state voters will eventually discover that they have gained the most from the programs, and may even give the Democrats some of the credit.

Today's question: What do you take away from the dissonance between how much a state will gain from health reform and how little support it has in the state?

What do the health reform bills do ... to increase Medicaid pay for primary care?

2010-01-13T16:04:00.004-05:00

Beyond the "big" issues - like the tax on high cost health plans, employer mandates, and national versus state health exchanges - being negotiated by the House and Senate leadership, there are a myriad of other issues that have to be resolved before Congress votes on a final bill. In some cases, the differences are narrow, but for others, the bills take a very different approach to the policies, priorities and funding issues involved.

Take primary care. The House and Senate alike agree that primary care needs to be supported, and both bills have provisions to increase primary care workforce. But below the surface there is a big difference on how much money the federal government should spend on primary care, particularly when it come to increasing payments to physicians.

Both the House and Senate bills will increase Medicare payments to primary care physicians. But the House would also spend $57 billion over five years to increase Medicaid payments for primary care services so that they are on par with applicable Medicare rates. More than just primary care physicians would benefit under the House Medicaid pay parity proposal, since any physician - regardless of their specialty - who bills for the specified primary care services (mainly, office visits and other evaluation and management codes) would get the fee increase. The Senate bill does nothing to increase Medicaid pay rates.

Yesterday, the American College of Physicians joined with 118 organizations to urge House and Senate negotiators to include the Medicaid pay parity provision. The letter explains that, "Medicaid rates average just 66% of Medicare rates for primary care services and are woefully inadequate to cover the cost of providing care ... The inadequacy of Medicaid reimbursement levels must be addressed in conjunction with the Medicaid expansion or we risk leaving our poorest and most medically-vulnerable residents behind despite the remarkable promise offered by health reform." As reported in MSNBC several months ago, low Medicaid payment rates are the principal reason why few physicians accept large number of Medicaid recipients.

Both the House and Senate bills would add about 15 million more persons (mainly, adults without kids) to Medicaid, but unless the House pay parity provision is accepted, most of them will have a hard time finding a doctor who is accepting Medicaid. Jonathan Cohn writes in the New Republic that, "increasing the reimbursements in an existing public insurance program that already underpays doctors and hospitals would seem like a no-brainer--which, as it happens, it is, for a great many reasons." Also read Jacob Goldstein's Wall Street Journal blog on the same topic.

The House of Representatives is pushing for the Medicaid pay parity provision to be accepted in the final bill, but the $57 billion price tag is making it a hard sell for fiscally-minded conservative Democrats, who want to keep the total costs of the final bill below $900 billion. Still, expanding Medicaid to cover tens of millions more people won't give them access to care, unless Medicaid pay rates are increased to make it possible for doctors to take care of them.

Today's question: Do you accept Medicaid patients? Would you accept more if the Medicaid reimbursement was increased to no less than the Medicare rates?

Keep government out of health care? It's already there.

2010-01-06T13:13:00.003-05:00

As I wrote in yesterday's blog, the federal government is now responsible for about 35% of total national health expenditures. But the public sector's contribution is actually much larger: today, almost one out of every two dollars spent on health care comes from federal, state and local governments. In 2008, combined spending by the public sector (federal, state and local governments) represented 47.3% of the total national expenditures (all sources, public and private, combined). Governments' share has grown over the years: in 2000, 44% of the total national health care bill was paid by public funds, up from 42% in 1980 and 37.6% in 1970.

Another way to look at this is how many people are covered by government or private sources. The Census Bureau reports that in 2008, 84.6% of U.S. residents had health insurance coverage. Of these, 66.7% had private insurance and 29% government insurance. In 1999, 72.5% were covered by private insurance and 24.5% by government programs.

(I wonder if those who argue that the U.S. has the best health care in the world realize that they are talking about a system where more than 87 million people already depend on the government for coverage, and where one out of every two dollars spent on health care already comes from government funds.)

How much would the House and Senate bills expand the government's role?

The Congressional Budget Office estimates that over the next 10 years, the Senate bill would add 15 million more people to the Medicaid and SCHIP programs compared to current law. Four million fewer people would be covered by employers, and five million fewer by the individual insurance market. Twenty-six million people would get coverage through insurance plans offered by a state health exchange, and most of these people would get subsidies from the federal government to help them afford the plans. The House bill too would add 15 million more to Medicaid/SCHIP, but it would actually increase by 6 million the number of persons covered by private insurance offered by an employer. Twenty-one million would get coverage through a national health exchange, which would include private health insurers as well as a public option. (The public option is not expected to be in the final House-Senate bill.) Under the House bill, the number of people who buy individual insurance would decline by 6 million people.

Under both the House and Senate bills, the vast majority of Americans - in excess of 160 million - would get their coverage from employer-sponsored private health plans.

I understand that there is a serious case to be made from the right against the further expansion of the government, just as there is a serious argument to be made from the left that the proposed reforms should do more to expand government's role.

But an honest debate would at least start by acknowledging the fact that the government already is involved in health care, big-time, and its role will continue to expand, with or without health reform, just as it has for more than forty years now. (No politician that I know of - other than maybe Ron Paul - is proposing to keep government out of health care, since this would mean eliminating or at least rolling back Medicare, Medicaid, the Children's Health Insurance Program, the VA, military medicine, and Tri-Care - not to mention eliminating NIH research, funding for graduate medical education, and a whole host of other popular programs.)

An honest debate would also begin by acknowledging that the House and Senate bills would further increase the government's role in health care by enrolling more people in government programs, subsidizing the purchase of private insurance, and regulating insurance companies, but most people would still get coverage from private insurance offered by their employer. You may believe that this is a good or bad thing, but let's not pretend that the current debate is really about keeping government out of health care (it is already there) or creating of a government-run health system (the bills don't).

Today's questions: What do you think the role of government will be in health care, without or without health care reform? What do you think its role should be?

Government spending on health outpaces private sources

2010-01-05T16:51:00.002-05:00

Much of the debate about the health reform has been on whether or not it will lead to government-run health care. But the fact is that the government's share of health care spending already is growing at a faster rate than private spending, a trend accelerated by the recent economic recession.

A new report from Medicare's actuaries, published in the journal Health Affairs, found that "Federal government spending for health services and supplies increased 10.4 percent in 2008 . . . and accounted for almost 36 percent of federal receipts, up considerably from 28 percent in 2007. By comparison, spending for health care by private businesses grew just 1.2 percent in 2008, in part because of a drop in the proportion of employer-sponsored insurance premiums paid for by employers" while "health care spending by households grew 4.3 percent in 2008, a deceleration from 5.9 percent growth in 2007" but still more than the adjusted personal income growth of 2.7%.

The current economic recession, the authors say, had two major impacts on health spending:

* "The economic stimulus bill shifted more federal dollars to Medicaid, causing total Medicaid spending to rise to 58.5 percent in 2008, compared with 56.5 percent in 2007, and there was slower growth in personal health care paid for by private sources of funds, which increased just 2.8 percent in 2008, the lowest rate since the mid-1990s" and
* "The low rate of private spending growth in 2008 occurred as personal income growth slowed, employment fell, and enrollment in private health insurance plans declined."

Overall, U.S. health care spending growth slowed to 4.4% in 2008, "the slowest rate of growth over the past forty-eight years." Yet despite the slow-down, health spending increases "continue to outpace growth in the resources available to pay for it" as the share of gross domestic product (GDP) devoted to health care increased from 15.9 percent in 2007 to 16.2 percent in 2008.

Other study highlights: In 2008 total Medicare spending grew 8.6 percent, reaching $469.2 billion, accelerating from 7.1 percent growth in 2007 mainly attributable to "increased fee-for-service (FFS) spending for hospitals and a further shift in enrollment to Medicare Advantage plans, which have higher average Medicare payments per beneficiary than FFS." National health expenditures, public and private combined, on physician services alone "increased 4.7 percent in 2008, a deceleration from 5.5 percent growth in 2007" and "retail prescription drug spending growth decelerated to 3.2 percent, reflecting the continuation of a slowing trend that began in 2000."

Critics of the current health reform effort often say that they are fighting to keep the federal government out of health care. But the fact is that the government's role in paying for health care has been growing for decades. In 1970, the federal government's share of total national health expenditures (all sources, public and private combined) was approximately 23.6%. The federal share was 28.2% in 1980; 30.8% in 2000, 33.7% in 2007, and 35% in 2008. (See this table for a detailed breakdown of annual spending on health by source of funds.) During much of this time Republicans controlled the White House and/or one or both chambers of Congress.

Enactment of health reform will surely expand the government's role in financing health care even more, but the notion that this fight is over "keeping government out of health care" is, well, out-of-touch with the simple reality that government's role in paying for health care has been steadily increasing over the past forty years, with the support of both political parties and, it seems, the American public.

Today's question: What do these estimates say to you?

Meet the New Year, same as the old year

2010-01-04T16:38:00.002-05:00

Congress returns to Washington tomorrow to begin the difficult process of bridging the differences between the health reform bills passed by the Senate and House. Usually, this would involve creation of a conference committee - consisting of members appointed by the House and Senate leadership and from the committees of jurisdiction - to lead the negotiations on producing a common bill - called a conference agreement - which would then be voted on as a substitute to the original bills as approved earlier by the respective chambers.

But as Jonathan Cohn reports today in the New Republic, Democrats are "almost certain" to substitute informal negotiations for a formal conference process to "avoid a series of procedural steps--not least among them, a series of special motions in the Senate, each requiring a vote with full debate - that Republicans could use to stall deliberations" as they did in November and December. Read Paul Blumental's Sunlight Foundation blog for a good explanation of how the decision to bypass the conference process will allow for speedier consideration of the bill while "potentially limiting both the public's and many of their elected official's ability to consider the changes to the bill."

The decision to forgo the conference process is not that unusual. Both political parties have muscled legislation through, without a conference report, when they have had the majority, and even when a conference committee has been convened, it often has been more of a showcase than the open and transparent process described by House and Senate rules.

But this time, a decision to forgo a conference agreement creates political risks for President Obama, since he ran on a promise of transparency. Politifact, an independent fact-checking web site, reported earlier this year that President Obama promised during the campaign to bring "all parties together, not negotiating behind closed doors, but bringing all parties together, and broadcasting those negotiations on C-SPAN so that the American people can see what the choices are, because part of what we have to do is enlist the American people in this process."

I am sure that administration and its Democratic allies will argue that it is Republican obstructionism that has forced them to bypass the conference process, but my gut tells me that this will play into the hands of critics. They will argue that it is more evidence that the legislation is the product of secret backroom deals, and this will make it harder for President Obama and his Democratic congressional allies to persuade a public that already is distrustful of Washington that the final bill is good for them. At the same time, I also have no doubt that the GOP would use a formal conference process to delay a vote as long as possible, during which they would work to intensify public opposition to its passage.

It would have been nice to think that both parties might have resolved to play nicer in the New Year, but 2010 is starting off the same way as last year, with both parties locked into a take-no-prisoners conflict that leaves no room for bipartisanship.

Today's question: What is your opinion of the Democrats' decision to bypass a conference agreement?

How the Grinch Stole Health Care

2009-12-23T14:00:00.003-05:00

Tomorrow, the Senate is expected to pass its version of health care on a 60-40 party line vote. Visit our website to learn how the bill stacks up against ACP policies and to read the letter ACP sent to the Senate leadership.

Since the vote will be taking place on Christmas Eve, I have taken the liberty of borrowing from, and in the process, butchering much of the rhyme scheme, from Dr. Seuss's famous tale of the Grinch, casting the GOP in the role of doing everything it can to stop ObamaCare from coming. Please ... all of this is intended in good fun, not a partisan or political statement. I will be taking the rest of this week and next off, so I extend my best wishes to you and your loved ones for the happiest of holidays!

Every Dem
In the Senate
Wanted health care, a lot ...

But the GOP
Who sat to their right,
Did NOT!

The GOP hated ObamaCare! The whole legislative season!
Now, please don't ask why. No one quite knows the reason.
It could be their base is far to the right.
It could be, perhaps, that money is tight,
But I think that the most likely reason of all
Is Republicans like their government small.

But,
Whatever the reason,
Their base or their views,
They stood there on Christmas Eve, hating the bill,
Staring down with a sour, disapproving frown
They vowed they would slow the whole thing down.

"They're buying off votes!" they snarled with a sneer.
"Yet Obamacare is coming! It's practically here!"
Then they growled, with their fingers nervously drumming,
"We MUST find a way to keep health care from coming!"
For, tomorrow, they knew...

...The Dems in the Senate
Would wake up bright and early. And vote for the bill!
Then the Democrats, young and old, would sit down to a feast.
And they'd feast! And they'd feast!
And they'd FEAST! FEAST! FEAST! FEAST!
On taxpayers' dollars to feed the government beast
Which was something the GOP could not stand in the least!

And the more they thought of the Democrats winning,
The more they thought, "We must stop the whole thing!
Why all year long we've put up with it now!
We MUST stop ObamaCare from coming!
... But HOW?"

Then they got an idea!
An awful idea!
THE GOP
GOT A WONDERFUL, AWFUL IDEA!

"We know just what to do!" They laughed in their throat.
“We'll stop them from ever taking a vote!"
And they chuckled, and clucked, "What a great GOP trick!
We'll filibuster the bill until they grow tired and sick!

"All we need is one Democrat ..."
They looked around.
But soon discovered there was none to be found.
Did that stop the GOP...?
No! They simply said,
"We'll make them read the bill instead!"
All 2000 pages, every chapter and verse
Sitting through that ... what could possibly be worse?

Then they took to the floor, with a smile most unpleasant,
Around the whole room, and demanded all be present!
Through a snowstorm! At night! You must all be here!
No matter how late! Whether far or near!

It was quarter past dawn ...
When the reading was done
But that wasn't the end of the GOP fun
They did everything they could to bring things to a halt
While telling the public it was the Democrats fault,

"Pooh-pooh to the Dems!" they were heard to be humming.
"At this rate they'll find no ObamaCare is coming!
They're just waking up! I know just what they'll do!
Their mouths will hang open a minute or two
Then all the Dems in the Senate will all cry BOO-HOO!

"That's a noise," grinned the GOP,
"That we simply must hear!"
So they paused. And the GOP put a hand to their ears.
And they did hear a sound rising over the snow.
It started in low. Then it started to grow ...

But the sound wasn't sad!
Why, this sound sounded merry!
It couldn't be so!
But it WAS merry! VERY!

They stared down at the Democrat side
The GOP popped their eyes!
Then they shook!
What they saw was a shocking surprise!

All 60 Democrats, from big states and small,
Had voted for the bill! Reid had gotten them all!
They HADN'T stopped ObamaCare from coming!
IT CAME!
Somehow or other, it came just the same!

And the GOP with their feet ice-cold in the snow,
Stood puzzling and puzzling: "How could it be so?
It came despite death panels! And Rush and Glenn!
Despite the Tea Parties and their angry young men!"
And they puzzled three hours, 'till their puzzler was sore.
Then they thought of something they hadn't before!
"Maybe ObamaCare," they thought, "means something more.
Maybe it would help to provide coverage to even the poor."

And what happened then...?
Well ... in Washington they say
That the GOP took heart
And vowed to fight on anyway!
"We can still kill the bill, if we just do it right,
We'll do it in conference, we'll continue this fight
Next year, we promise the voters, at least

...WE OURSELVES ...!
Can still slay the ObamaCare beast!"

Today's question: How will you be spending the holidays?

Liberals Attack "Government-Takeover" of Health Care!

2009-12-17T16:58:00.004-05:00

The seemingly endless noise over what passes as a health care debate gets more bizarre by the day. (Yet there are still people who want to drag it on longer.) Yesterday, the self-described "Tea Party Patriots" came back to D.C. to rant again about "government take-over" of the health care system. At the same time, prominent liberals went apoplectic about the Senate bill, with former governor and DNC chair Howard Dean leading the charge.

I'm confused. If the Senate bill is a government-taker over of health care, as the Tea Party crowd says, and liberals like Dean are opposed to the Senate bill, doesn't this mean that liberals are against a government-take-over of health care?

Of course, I am being facetious. In my view, the House and Senate bills were never about a government take-over of health care, as much as many liberals have hoped and many conservatives have feared.

Both bills give private insurance companies the central role in providing health coverage. The so-called more "liberal" House bill has a public option, but it would be available only to the 30 million or so Americans who lack private coverage, and of those, the Congressional Budget Office says that only about 6 million would end up the public plan, compared to 168 million in private health insurance offered by their employers. The public option, was never going to be big enough program to have all that much of an impact on coverage, despite the over-heated rhetoric by ideologues on both sides.

Yes, both bills will expand the federal government's role by regulating and subsidizing private insurance and enrolling tens of millions of more people in Medicaid, but private insurers were always going to be the way most Americans would get their coverage, just as they are today. Conservatives can and should make the case that there is too much regulation, and liberals can and should make the case that it has too little regulation, but they should both at least stick to the facts about what the bills will and will not do.

Many liberals see things quite differently than Howard Dean. Read this from the New America Foundation, a progressive think tank, and 20 questions for the left's "Kill the Bill" crowd by Nate Silver, founder of the 538.com web site.

Columnist Ruth Marcus, writing in today's Washington Post, says it best "The bill isn't perfect, although my worries about it are more about whether it does enough to drive down costs and whether it will turn out to be affordable than about whether it gives too much to insurers. The alternative is not, as Dean would have it, starting from scratch and getting it through the Senate with 51 votes; Senate rules, for better or worse, will not let lawmakers get much done that way. The alternative is squandering this opportunity -- leaving millions of Americans uninsured and without the prospect of getting coverage far into the political future."

Today's question: What do you think about the attacks from the liberal "Kill the Bill" crowd?

Pushing drugs to doctors and patients

2009-12-16T16:44:00.002-05:00

Another day has gone by without the CBO producing a "score" of the revised bill. Until it does, the Senate is unable to proceed on scheduling the first of several procedural votes needed to get the bill passed before Christmas. But, I did find a fascinating CBO report on promotional spending on prescription drugs. The CBO director's blog summarizes the highlights. Among the key findings: in 2008, spending on detailing to physicians was by far the biggest outlay of funds ($12 billion); followed in order by direct-to-consumer advertising ($4.7 billion); sponsorships of meetings and events ($3.4 billion); and advertisements in professional journals ($0.4 billion). Total promotional expenditures, "equaled 10.8 percent of the U.S. sales reported by the Pharmaceutical Research and Manufacturers of America, in line with most years since the early 1990s, during which time that share has remained between 10 percent and 12 percent."

Also of interest, according to the full report:

* The growth of pharmaceutical manufacturers' overall promotional spending has slowed from a double-digit annual pace in 2003 and 2004 to a rate that is close to zero. That slowdown is probably related, at least in part, to the decline in the number of new drugs that have received FDA approval since 2000.
* In the second half of the 1990s, the FDA approved an unusually large number of drugs, some of which were the first on the market to treat certain conditions and a number of which treat widespread conditions. Not only are fewer new drugs being approved of late, but more drugs also face competition from generic versions. Those factors may be particularly important in explaining declining spending on DTC advertising, which peaked at $5.2 billion in 2006, because pharmaceutical manufacturers tend to use more DTC advertising for drugs that have especially broad potential markets, drugs with few or no substitutes, or drugs with some combination of those characteristics.
* Of the more than 2,000 drugs included in CBO's data set, 700 to 800 have some promotional spending reported in any given year. For nearly all of those drugs, some spending on detailing was recorded. However, manufacturers purchased DTC advertisements for fewer than 100 of those drugs in each of the years since 1995, the year the data set begins to encompass DTC advertising, making DTC advertising the least frequently used form of drug promotion . . . . Journal ads and professional meetings are used to promote fewer drugs than detailing but more drugs than DTC advertising.

As someone who watches a lot of sports broadcasts -- and with them, way too may ads for ED -- I was frankly surprised that DTC is "the least frequently used form of drug promotion." Most of the money is still being spent the way it always has: to influence physicians and clinicians to prescribe a particular drug product.

The CBO reports a relationship between promotion to physicians and advertising to consumers: "When pharmaceutical manufacturers promoted drugs to consumers, they also spent more, on average, promoting those drugs to physicians. For those drugs in CBO's data set with reported spending on DTC advertising, their manufacturers spent an average of $40.5 million per drug in 2008 on promotional activities directed to physicians -- 14 times the average amount they spent when promoting drugs exclusively to physicians That difference may indicate that manufacturers use promotional activities directed to physicians and DTC advertising to reinforce each other."

The relationship between money spent to persuade consumers to ask for new drugs, and for doctors to prescribe them, will continue to be scrutinized by policymakers. (For relevant ACP policy, see our policy paper on direct-to-consumer advertising and our ethics resources about physician industry relations.) The CBO report makes an important contribution in increasing understanding of how and why the dollars flow where they do.

Today's questions. Why do you think drug companies still spend most of the money on promoting their products directly to physicians? What are your own policies on engaging with drug company sales persons?

Waiting for Godot (a.k.a. Senator Joe)

2009-12-15T17:04:00.004-05:00

With apologies to Samuel Beckett, I take the liberty of adapting lines from his great play, "Waiting for Godot," to describe how President Obama and Majority Leader Reid must be talking about Joe Lieberman:

Obama: Let's go.
Reid: We can't.
Obama: Why not?
Reid: We're waiting for Senator Joe.
Obama: (despairingly) Ah!

Later:

Page: (in a rush) Senator Joe told me to tell you he won't come this evening but surely tomorrow.
Obama: Well, shall we go?
Reid: Yes, let's go. (They do not move.)

In the week since the Democrats announced a tentative deal on a compromise on the public plan option, President Obama and Majority Leader Reid have been waiting for Senator Joe Lieberman (I-CT) to inform them if he will give them the 60th vote needed to overcome a Republican filibuster. This, plus the wait to get a new estimate from the Congressional Budget Office. They need and want to go to the next step, but they dare not move.

The Washington Post reports that Senator Joe is "warming" to the bill, now that Senator Reid has agreed to drop any form of the public plan and a Medicare buy-in. This is what Senator Joe had to say:

"We've got a great health insurance reform bill here. And the danger was that some of my colleagues, I think, were just trying to load it up with too much. And what happens then is that you run the risk of losing everything. So I think what's beginning to emerge -- though I know some people are not happy about it -- is really a historic achievement, health care reform such as we've not seen in this country for decades."

This doesn't mean the bill it out of the woods yet. Lieberman's statement stopped short of the unequivocal "I now promise that I will vote for the bill" commitment that Reid and Obama want. There are still a few other uncommitted Democrats that Reid needs -- most notably, Ben Nelson of Nebraska, who has threatened to vote with the GOP to filibuster bill if language on abortion coverage is not changed to his liking. And the Democrats hold out some hope that Republican Olympia Snow (R-ME) will vote with them.

The problem for the Democrats is that Reid must file the first procedural cloture vote no later than Thursday, if he has any hope of getting it passed by Christmas.

The death of the public option has angered many progressives. But a bill that would expand coverage to 94% of all legal residents, begin to bend the cost curve, and regulate insurance industry practices that deny access to needed care still has a lot to say for it. We'll find out in the next 48 hours if 60 members of the U.S. Senate agree.

Today's question: What do you think of the decision to drop the public option and Medicare buy-in to win the vote of Senator Joe and other uncommitted Democrats?

Should federal spending and taxes be taken away from Congress?

2009-12-14T16:47:00.003-05:00

The Senate debate on health care reform is on hold until the Congressional Budget Office (CBO) produces a "score" (estimate) of the impact of a compromise negotiated between Democratic centrists and liberals. The new score will update a previous CBO analysis, which estimated the Senate bill "would yield a net reduction in federal deficits of $130 billion over the 2010-2019 period" and "small" reductions over the next decade. The CBO has estimated that the House-passed bill will reduce deficits by about $102 billion over the 2010-2019 period, and continue to have a modest positive impact on deficits in the next ten years.

Some believe that the CBO under-states the cost-saving. David Cutler and Commonwealth Fund President Karen Davis argue the bills will have a much greater impact because "an aggressive approach to health care modernization could result in significantly greater cost reductions." President Obama's Council of Economic Advisers (CEA) has issued a new report that concludes, "The [House and Senate health reform] bills would also significantly lower the Federal budget deficit in the upcoming decade, and extend the solvency of the Medicare Trust Fund by five years."

Robert Samuelson, writing in yesterday's Washington Post, disagrees. He believes that the bills will increase national health care spending and make the deficit worse, in part because he is skeptical that Congress has the will to allow the intended savings to go into effect.

Skepticism about Congress' ability to make tough choices isn't limited to critics of President Obama's health reform initiative. The President's economic advisers tout the benefits of having an Independent Medicare Advisory Board, as proposed by the Senate bill, which "would recommend changes to the Medicare program that would both improve the quality of care and also reduce the growth rate of program spending . . . Absent Congressional action, these recommendations would be automatically implemented."

And today, The Peterson-Pew Commission on Budget Reform issued a report that "calls on policy makers to enact both spending cuts and tax increases to shift our nation's fiscal course." This bipartisan group, headed by former members of Congress, recommends that the White House and Congress adopt a target to reduce the public debt to 60 percent of GDP by 2018; negotiate a specific package of spending reductions and tax increases that are gradually phased in to protect the recovering economy; and create an automatic enforcement mechanism that would require that "any breach of the target would be offset through automatic spending reductions and tax increases . . . [applied] equally to spending and revenue."

I understand the rationale of taking decisions on spending cuts and tax increases away from Congress. Politicians have shown themselves to be chronically incapable of voting for unpopular tax increases and spending cuts.

But I am uneasy about turning over the "power of the purse," which our founding fathers gave exclusively to the people whom the voters elect to Congress, to an unelected commission - or to a process to impose cuts and tax increases automatically if a target is breached. We tried that with the SGR - which triggers cuts in payments to physicians when the SGR target is breached - and we all know how that worked out.

Today's question: What do you think about taking the decisions needed to bring federal spending and revenue into line away from Congress?

Poor Grandma!

2009-12-10T11:56:00.003-05:00

The news that Senate Democrats may have reached a tentative deal on a substitute for the public option has lead to another round of rhetoric about what will happen to poor old Grandma.

The proposal reportedly includes a new national network of private health insurers administered by the federal government and a Medicare buy-in for people 55 to 65 who don't have employer coverage. Details about the proposal are few, and key Senators are reserving judgment until the Congressional Budget Office comes back with a new estimate of its impact on the budget.

Still, the lack of details hasn't stopped people from staking out a strong position against the proposal, and especially against the Medicare buy-in. As reported in The Hill blog, Senator Chuck Grassley (R-IO), the ranking Republican on the Senate Finance Committee, opposes the Medicare buy-in because "The last thing you want to think about when the Titanic is sinking [is to] put grandma and more of your family on the boat." (Medicare is taking on the role of the Titanic, I presume.) Last week, Senate critics repeatedly made a similar argument that Grandma would suffer as a result of proposed Medicare cuts in the bill. (Given the average age of U.S. Senators, I would think that their own grandmas would be well over 100 years old, but that is another matter.)

The ACP has not yet taken a position on the public option compromise and the Medicare buy-in, because we would like to see the details before deciding. It is a complicated issue, and accordingly, deserves a thorough understanding of what is being proposed. But I would suggest that there is fundamental illogic to a key argument being made by critics. The argument goes like this:

Medicare is going broke. Therefore, cutting Medicare is wrong because it takes money from a program already facing bankruptcy. Therefore, adding people 55-65 to the program will further accelerate Medicare's demise.

The first statement is true - Medicare Part A is estimated to run out of money by 2012.

The second statement makes no sense. The Medicare cuts (which for the most come from reductions in the rate of payment increases to non-physician providers) in the Senate bill will mean that almost a half a trillion fewer dollars will flow out of the program over the next decade, delaying by years the date when the trust fund will run out of money. As any family knows, if you currently are spending more than you are taking in, and then you start to spend less, your money lasts longer.

The third statement might be true, but then again, it might not. Allowing some people 55 to 65 to buy into Medicare, out of their own premium dollars, would have no impact on the solvency of the rest of the program, if the premiums collected are high enough to cover the costs for this age group and the funds are segregated from the rest of Medicare. If people aged 55 to 65 have lower annual health care costs than those 65 and older, and if their contributions are intermingled with the rest of Medicare, they could actually help the solvency of the rest of Medicare, since it would spread risk more broadly among a healthier beneficiary population. If the Medicare buy-in attracts a sicker group of 55 to 65 year olds and the premiums collected from them are too low, it could hurt the solvency of the rest of the program by drawing funds out of the other trust funds to make up the shortfall.

Beyond the issue of whether the buy-in will help or hurt Medicare's solvency, there is a real concern about the impact on physicians and hospitals of having more patients paid under the discounted Medicare rates. Even here, though, much would depend on whether the buy-in would be open only to people 55-65 who don't have health insurance coverage through an employer or retiree plan, or to all people 55 and older. If the former, the number of people added to Medicare would be relatively modest, and doctors and hospitals would at least be sure of getting Medicare rates for care that they may now be providing on an uncompensated and charitable basis. If the latter, it likely would have a big adverse impact on the bottom line.

I am not suggesting that the current Medicare buy-in proposal is one that the ACP should support, but it deserves a serious analysis - not a knee-jerk response - once we know the actual details. I do know that the argument that taking money out of Medicare will accelerate its insolvency, as the Senate and House bills would do to help pay for health reform, makes no sense, since it will do the opposite and extend the life of the trust fund. It remains to be seen if allowing some people 55-65 to buy Medicare coverage will help or hurt Medicare's fiscal outlook, and what it will do to the "bottom-line" for physicians and hospitals.

Today's questions: What effect do you think the Medicare cuts in the health reform bills will have on Grandma? What about a Medicare buy-in for people 55 to 65?

New member survey shows broad support for ACP's views on health reform

2009-12-07T16:08:00.004-05:00

Some internists who disagree with the ACP positions on health reform assert that we should survey membership before taking a position. They assume that a survey would show that most other ACP members share their opposition to policies advocated by the College.

ACP does not develop policies based on an opinion survey. Instead, as my colleague Jack Ginsburg wrote on this blog several months ago, we develop policy through a consensus process that involves the hundreds of internists and medical student members who sit on the College's committees, councils, Board of Governors, and Board of Regents. As we develop policy, we conduct a review of the evidence, and seek external review by outside experts, consumers, business leaders, and stakeholders.

Such a deliberative process, I believe, results in policies that are more thoughtful, nuanced, credible and evidence-based than if we made our decisions based on an opinion poll, yet they should lead to positions that most members would support.

Surveys are not the best way to make policy, but they can be useful in quantifying member opinions at a given point in time. In October and November, ACP's Research Center fielded a web survey of a random sample of 2,000 U.S. non-student, non-retired, current ACP members ages 65 and younger. It received 290 responses, a 15% response rate and a margin of error of plus or minus 8%. The number-crunchers on the research staff did not find any evident respondent bias, with the demographic and practice characteristics of the respondents generally mirroring those of the 2009 ACP Membership Survey, which had a higher response rate.

Below are the key findings from the Research Center's report:

"11% of respondents are very or extremely familiar with ACP's position on health reform, 59% are somewhat or moderately familiar, and 30% are not at all familiar. 59% of respondents are somewhat or very satisfied with ACP's position on health reform, 16% are neither satisfied nor dissatisfied, 14% are somewhat or very dissatisfied, and 11% are uncertain about their level of satisfaction."

"Respondents were asked whether or not ACP should support twelve different positions for achieving health reform. There was heavy support (over 85% of respondents) for the following five proposals:
- Health reform must include reforms in the medical liability system in order to be effective in controlling costs (93.5%).
- Individuals and small businesses should be able to have a choice of affordable plans through a purchasing pool (exchange) that gives them the same ability as larger companies to get the best group rates (93.5%).
- Insurance companies should not be allowed to turn away patients because they have medical conditions (90.2%).
- All legal residents should have access to affordable health insurance and financial help, when they can't afford it (85.7%). This is in line with data from the 2009 Member Survey (conducted before the executive and legislative branches began to debate health care reform), which show that 71% of members believe 'guaranteeing by law that all Americans have access to affordable coverage, with government subsidies for those who cannot afford coverage' should be given somewhat high (22%) or very high (49%) priority on ACP's advocacy agenda.
- The federal government should create incentives to encourage medical students and young doctors to go into primary care internal medicine (85.5%).This is in line with data from the 2009 Member Survey, which show that 84% of members believe 'policies to increase the number of general internists and other primary care physicians including improved reimbursement and loan forgiveness' should be given somewhat high (28%) or very high (56%) priority on ACP's advocacy agenda.

There was moderate support (between 50% and 85% of respondents) for the following five proposals:
- Insurance companies should be required to cover evidence-based practices that have been shown to prevent disease, as well as screening tests that detect diseases at no out-of-pocket cost to the patient (79.3%).
- Larger employers (defined by such factors as number of employees and payroll) should be required to offer health insurance to employees or pay into a fund to help pay for coverage for their employees (71.8%).
- All Americans should be required to buy health care coverage, as long as there are federal subsidies to make coverage available for those who can't otherwise afford it (65.1%).
- A public plan option should be available to compete with private health insurance plans on a level playing field as long as it has competitive payment rates and participation isn't mandated (63.7%).
-Insurance companies should not be allowed to charge patients more because they have medical conditions (61.8%)

The proportions of respondents who support the final two proposals reflect the fact that the proposals are correlates:
- The federal government should increase Medicare payments to primary care physicians even if this would result in lower pay for other specialties (66.5%).
- The federal government should increase Medicare payments to primary care physicians only if it does not involve reductions to other specialists (30.6%).

There were no differences in the proportion of respondents from different age, primary professional activity and practice size groups in their support for the twelve specific positions on reform ... A higher proportion of general internists (91%) than subspecialists (51%) feel ACP should advocate for the federal government to increase Medicare payments to primary care physicians even if this would result in lower pay for other subspecialties." (ACP has expressed a strong preference for increases for primary care to be funded in a way that does not cause budget neutral cuts to other subspecialists.)

As a very high level survey on broad priorities advocated by ACP (they weren't told what ACP's position was on each), the survey doesn't tell about the questions that weren't asked, like their opinion on raising taxes or the impact on the deficit. Still, it is reassuring to me that large majorities of ACP members support the College's priorities and positions on even on the most controversial issues - like individual and employer mandates, subsidies for health insurance, health exchanges, higher fees for primary care, and the public plan option - that are addressed by the pending House and Senate bills.

Today's question: What do you think the member survey tells us about ACP's advocacy agenda?

Physician organizations split (again) on health care reform

2009-12-04T16:29:00.003-05:00

During the past few days, organized medicine has lived up to its reputation as being anything but organized.

As reported by Jacob Goldstein in his Wall Street Journal health blog, several large physician membership organizations, have come out squarely "opposed" to the Senate bill. The opposition is being led by the American College of Surgeons and 19 surgical specialty societies. Goldstein characterizes the American Medical Association as taking a "middle ground" approach.

What is the basis given by the opposition physician groups? It is not over the big philosophical and ideological issues - like the debate over the "public plan" or the role of government or tax increases or deficits and debt. Instead, the surgeons' opposition is focused principally on issues of payment issues, and particularly, changes that could cause redistribution of dollars among and across physician specialties. Among the policies behind the surgeons' opposition, according to the ACS letter, are:

"Establishment and proposed implementation of an Independent Medicare Advisory Board whose recommendations could become law without congressional action;
- Mandatory participation in a seriously flawed Physician Quality Reporting Initiative (PQRI)program with penalties for non-participation;
- Budget-neutral bonus payments to primary care physicians and rural general surgeons."

(The latter has to do with a 10% increase in Medicare payments for designated services by primary care physicians, and for general surgeons in health professional shortage areas only, half of which would be funded by a one-half-of-one-percent decrease in payments for all other physician services.)

Today, the American College of Physicians sent its own letter to the Senate. Like the ACP has done throughout the legislative process, we determine our positions on the bills based on how closely they meet key ACP priorities and policies. ACP's letter noted that the Senate bill includes important and essential reforms that overall are consistent with ACP, citing provisions in the bill that would expand access to 94% of all legal U.S. residents, train more primary care physicians, reduce student debt for physicians who go into primary care, increase Medicare primary care payments, and accelerate the adoption of new payment and delivery models, like the Patient-Centered Medical Home. ACP also expressed "significant concerns" about other provisions. Some of ACP's concerns, like opposition to penalizing physicians with pay cuts for not reporting on quality measures, are similar to the concerns of the surgeons. But on other issues, like the independent Medicare Commission, ACP recommended ways to improve the provision by adding more safeguards, rather than coming out in opposition to the whole bill.

The surgeons have said that they support the House health reform bill, and that "While we must oppose the Patient Protection and Affordable Care Act as currently written, the surgical coalition is committed to the passage of meaningful and comprehensive health care reform that is in the best interest of our patients."

The problem, though, is that if physician opposition denies the bill the 60 votes needed to pass, it is "game over" for health care reform. Not just now, but for a very long time. Paul Krugman writes in the New York Times if the Senate bill fails "it would be a long time before anyone was willing to take on the challenge again; remember that after the failure of the Clinton effort, it was 16 years before the next try at health reform."

On the basic question of whether the country would be better or worse off if health reform fails, ACP's view is that the country will be better off if Congress passes legislation to provide affordable coverage to all Americans, expand the primary care workforce, and improve payment and delivery, even as we seek changes in positions we don't like. Opposition to the Senate bill by some physicians could kill health care reform, and with it, the best chance in a generation to put health care on a sustainable path.

Today's question: What is your view of the different approaches taken by physician groups to the Senate bill?

The Politicization of Breast Cancer Screening

2009-12-02T17:47:00.009-05:00

I just returned from a hearing of the House Energy and Commerce Committee's health subcommittee on the U.S. Preventive Services Task Force (USPSTF) breast cancer screening guidelines. Donna Sweet, MD, MACP, a general internist and HIV/AIDS specialist from Wichita, Kansas, testified on ACP's behalf. Dr. Sweet is a past chair of the ACP Board of Regents and a member of the College's Clinical Efficacy Assessment Subcommittee (CEAS), which has responsibility for developing the ACP's evidence-based clinical guidelines.

The first several hours of the hearing--and much of the grilling from the subcommittee members--were concentrated at chair and vice chair of the U.S. Preventive Task Force. The Task Force witnesses agreed that they could have done a better job in communicating the revised screening recommendations to the public but stood their ground on the evidence behind the recommendations. The USPSTF witnesses also made the point that breast cancer screening recommendations were voted on and approved late last year, before the Obama administration took office, so the politics of health reform had no role in their deliberations.

This didn't stop the politicians, though, from introducing politics into the USPSTF's recommendations. The headline from Reuter's says it all: "U.S. debate over mammograms splits along party lines."

Who knew that there was a Republican and Democratic view on the value of breast cancer screening? But in today's hyper-partisan and polarized politics, there is no issue that won't be used to divide the voters. Republicans argued that the USPSTF's recommendations were driven by a desire to cut costs - a charge that the USPSTF's witnesses steadfastly denied. (Fact check: the Agency for Health Care Research and Quality website specifically states that "economic costs" are never a consideration in the USPSTF's recommendations.) Republicans also argued that the House and Senate health reform bills would prohibit health insurers from offering prevention benefits that have not received an A or B evidence rating from the USPSTF, ultimately leading to U.K-style rationing. Democrats argued that the recommendations from the USPSTF would set a floor - not a limit - on the preventive services that insurers would have to cover. Both sides accused the other of mis-representing the truth.

ACP's own reading of the bills is that the Task Force's recommendations would improve access to evidence-based preventive services by establishing a floor, not a ceiling on benefits. On this point, ACP, the American Cancer Society, the National Breast Cancer Coalition, and the Susan Susan G. Komen for the Cure Advocacy Alliance all were in agreement.

Why did ACP wade into this fight? Well, for one thing, the USPSTF recommendations were published in our own Annals of Internal Medicine website. For another, in 2007, ACP issued its own guideline on screening mammography for women between the ages of 40 and 49, which recommended that clinicians and patients conduct an individualized risk assessment, discuss the risks and benefits of mammograms for this age group, and make their own judgment. But the biggest reason is that ACP believes that the politicization of evidence-based medicine is not in the public's interest.

This is what Dr. Sweet had to say:

"One lesson is that the public is ill-served when assessments of clinical effectiveness are politicized. For clinicians and patients alike to have confidence in the evidence, we need to know that it has been developed through a process that is independent of political pressure.
...Politicization [of evidence-based assessments], if left unchallenged ... could result in politically-driven changes so that future evaluations are influenced by political or stakeholder interests - instead of science."

Harold Pollack, writing in The New Republic blog, gives ACP high marks for its advocacy. Calling ACP "one of America's most respected medical organizations," he goes on to say this about ACP's stand against the politicization of evidence-based research:

"In its own wonky way, within an often-disheartening health policy debate, that's Change We Can Believe In."

Today's question: What do you think about the ACP's stand on the politicization of evidence-based clinical research?

Emptying the cost control tool kit

2009-11-24T16:26:00.002-05:00

Imagine that it is 2013, and a new President is sitting in the Oval Office. (If you prefer, imagine it is 2017, and we have a new President.) To make things interesting, let's imagine that the new President is a Republican. Imagine that he (or she) was elected on a platform of cutting taxes, rolling back the Obama administration's increased spending, and reforming the Medicaid and Medicare entitlement programs. To make things even more interesting, let's imagine that the Obama administration was able to get a substantial expansion of health insurance coverage enacted into law, but that most of the cost controls were stripped out or weakened as a result of political opposition. Health care spending has continued to rise at breakneck rates, and the Medicare trust fund is about to run out of money.

What is a new President to do?

Because the most promising approaches to gradually "bend the cost curve" - comparative effectiveness research, coverage of evidence-based preventive services, advance care planning, reductions in regional variations in the quality and cost of care, and the public option - were left out the health reform bills, the only cost-cutters left are hugely unpopular ones. Increase the age of eligibility and slash Medicare benefits? Means-test Medicare to exclude the rich? Slash payments to doctors and hospitals? Go back on your campaign promise and raise Medicare payroll taxes? Or let Medicare go broke? You either incur the wrath of the largest generation in history - the tens of millions of boomers who now depend on Medicare - or the younger tax payers who will be called upon to bail out the program.

(If you prefer, you can run a similar scenario with another Democrat President - only in this case, the most likely option is that the new President would propose a complete, U.K. style take-over of the health care system, to give the government all the regulatory levers it needs to control costs.)

These scenarios are very real if the critics of the cost controls in the current health reform bills have their way. Right now, notwithstanding the oft-repeated charge that the House and Senate bills "do nothing" to control costs, Marc Aminder writes in The Atlantic that the cost-benders in the legislation are getting praise from well-respected economists, Republican and Democratic alike.

But the same cost-benders are under unrelenting attack.

John Wennberg and Shannon Brownlee blog in Health Affairs about the efforts by some academic medical centers and hospitals to discredit and explain away Dartmouth Atlas data on regional variations in quality and cost. They fear that the research will lead to policies to reduce such variation, at their institutions' expense. Some physician membership organizations are flatly opposed to any policies that would redistribute payments among physicians based on efficiency and outcomes of care, specialty, or any other criteria, for that matter. They also don't like the idea of an independent commission to develop recommendations to control costs under a fast-track legislative review process. The end-of-life counseling in the House bill has been falsely labeled as leading to death panels. Research on the comparative effectiveness of different treatments has been called rationing of care. A public option is called socialized medicine. Even the medical home, which was developed by physician membership organizations, is labeled as this decade's version of HMO-style limits on care.

My point is that the politicians and interest groups who criticize these and other cost-benders may find that if they succeed in emptying the toolkit of the most promising approaches to gradually slow the cost curve and improve outcomes, they may leave a future President and Congress with nothing but draconian and enormously unpopular cuts in benefits and provider payments, tax increases, or the much-feared government take-over of health care. And it could be their guy and their party who will be in charge when the day of reckoning arrives.

(Oh, and by the way, Happy Thanksgiving to you and your loved ones!)

Today's question: What do you think about the above scenario? And what is your favorite Thanksgiving dish?

A good (and not so good) day for health reform

2009-11-19T16:29:00.003-05:00

Yesterday's unveiling of the revised Senate bill on health reform ordinarily would have constituted a good day for health reform, moving the ball yet another few yards closer to the goalposts. The Washington Post reports that Senate Democrats were "jubilant" that the CBO estimates that the new bill will reduce the deficit by $130 billion over the next decade while providing coverage to 94% of uninsured legal residents. Majority Leader Harry Reid (D-NV) plans to bring the bill to the Senate floor on Saturday for a procedural vote, requiring 60 votes, to halt a GOP filibuster and to allow debate on the bill itself. A final vote, which would require getting 60 votes to overcome more procedural hurdles, likely will not take place until December. ACP is in the process of analyzing the bill compared to policy, so I will have more to say about it in a future blog post, and we also will post updated information on www.acponline.org/advocacy.

At the same time as Democrats were celebrating the release of the Senate bill, the flap over the new mammography guidelines from the U.S. Preventive Services Task Force (USPSTF), published in ACP's own Annals of Internal Medicine threatened to undermine public support for health reform. Now, I am a health policy wonk, not a clinician, and have absolutely no opinion on the guidelines themselves, but I can comment on the political fallout from the guidelines.

In one sense, the mammography guidelines have absolutely nothing to do with health reform. They were in the works long before the current administration took office, they would have come out even if health reform was not on the national agenda, and the guidelines themselves are purely advisory.

But in another sense, they have everything to do with health reform. The House and Senate health reform bills would require that health insurers provide coverage for preventive services recommended by the USPSTF - although insurers would be allowed to offer additional benefits. The Chicago Tribune notes that research on comparative effectiveness is a "central idea in the push to improve American medical care and control its cost: experts studying the effectiveness of treatments and procedures to determine which work best."

KevinMD opines that health reformers should be very worried about what the backlash to the guidelines means for the future of comparative effectiveness research: "If recommendations from an entity like the USPSTF - as non-partisan and robust as it gets - gets so much resistance from doctors, patients, and even the government itself, findings from a comparative effectiveness body stand absolutely no chance of changing medical practice."

NPR reports that Republican opponents of the Democratic bills have used the controversy over the guidelines to argue that it will lead to rationing and "the insidious encroachment of government between the patient and their doctor" according to Rep. David Camp (R-MI). (Notwithstanding the fact that under the bills, the USPSTF's recommendations would still be advisory, or that the independent scientists on the USPSTF are hardly government bureaucrats.) Seeing the threat being created by the backlash, and fearing that the GOP criticisms will resonate with votes, the Obama administration distanced itself from the USPSTF guidelines in a statement attributed to HHS Secretary Kathleen Sebelius.

All of this goes to show why reforming the health care system is so difficult. Scientists would like to believe that we people can rationally make health care decisions based purely on science and evidence. But health care is very personal and emotional, and even the best science will be rejected if people sense that it will take decision-making away from them or limit their choices. And if taxpayers are going to subsidize coverage, decisions will have to be made on what services will be covered, and as this incident shows, such decisions will not come without generating intense debate and opposition.

Today's question: What do you think the flap over the mammography guidelines means for health reform?