Monthly Archives: July 2009

Lazy Sundays 3

Saturday is the first day of August, and it’s going to be a busy month both in and out of Washington. If you happen to live in a “swing state” — especially if you have a moderate Republican representative (e.g., Olympia Snowe and Susan Collins) or are home to one of the now infamous “Blue Dog” Democrats (If you’re representative is on this list, I’m looking at you)– be prepared for what is going to feel like part 2 of the ’08 election.

As interest groups try to influence the public and their elected officials on health reform, here’s a look at what you can expect.

Health Bill Boils Down to August Battle
by Ben Smith and Kenneth P. Vogel

The Future of Universal Health Care, as of Now
by Robert Reich

And to prepare you for the battle ahead, a lighthearted take on health reform from Walt Handelsman

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Posted by on July 31, 2009 in Good Reading


Stop-Gap: Providing Health Coverage at the Margin

Look for “Lazy Sundays 3” later today, but first, I welcome a guest contributor to the blog. I think you’ll enjoy what she has to say….

Katherine Rogers is currently working on a PhD in Public Policy and Administration at the George Washington University, where she also received a Master of Public Health degree in health policy. She has worked in state health policy and in international alcohol policy, and her current work focuses on adolescent health. She also holds degrees from Cornell University and the University of Pennsylvania.

Most people expect, across the years of their working lives, that if they work hard, they will improve their circumstances. Years of experience and education lead to promotions, raises, and better benefits. By the time you retire, you’re at the top of your game.

But all of that makes you very expensive for your employer, and in an era of job losses and slashed benefits, more and more older adults – a little too young to retire but too qualified and expensive to find employment – are losing their jobs and the benefits they offer.

For adults ages 55 to 64, this situation can have dire consequences for health care coverage and personal health. This group – the oldest in America not covered by Medicare – tends to have more health problems and more health care costs than other age groups (simply because of their age). It is tougher for them to find affordable insurance outside of employer-sponsored options; adults ages 60 to 64 are rejected by insurers three times as often as adults ages 35 to 39. The coverage that is offered might come with high deductibles or substantial coverage exclusions.

How can we help this group? One good option already being considered in most health reform plans is a Medicare buy-in.

Such a program has some drawbacks – without subsidies, it might be subject to adverse selection and may fail to attract lower-income adults, thereby failing to make a significant dent in the uninsured population in this age group. But it also is widely popular with the public (according to a recent Kaiser poll, 77 percent of the public supports it). The option becomes more feasible (and affordable) when we limit eligibility – by income, by insurance status, or by spouse’s insurance status (i.e., if an individual is over 65, their spouse could be eligible for Medicare as well).

We might also consider some other possibilities. We could prohibit or limit insurer coverage denials in this age group to boost private individual insurance coverage. Or we could establish some form of connector that pools older adults into cheaper private group coverage regardless of employment status.

Regardless of the policy implemented, the argument for reforming health insurance options for this group is emblematic of the argument for reform on a greater scale. If we’re attempting to frame health reform as a moral issue – to establish as a symbol of our culture that we value life and health for all of our residents – than who better to illustrate that than our oldest workers?

Consider Tom Waldron, who in 1972 began working for a company and worked there for decades – until he was laid off when the economy hit the skids last year. He’s 59, probably unattractive to employers who think he’ll just retire in a few years – and the job offers he gets are on a contract basis and won’t offer him health insurance.

Currently, our national policy to address this problem is, “Sorry, but we can’t help you until you turn 65.” We need to do better – and there’s a good chance that current health reform will enable us to do so.

– Katherine Rogers

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Posted by on July 31, 2009 in Uncategorized


The Real Health Care Coverage Threat

I’ve spent a lot of time talking about unwarranted fears over the past week in an attempt to ameliorate the concerns of many who oppose health reform based on inaccurate information they believe to be true. By contrast, I’m not out to convince opponents of reform to change sides, provided they have their facts straight.

The propaganda keeps coming though. Seriously, these folks are relentless. Now, the fear mongering is targeting the elderly. The–honestly very scary if it were true–misinformation: you’re going to lose your Medicare coverage. Well, not completely, but a lot of your benefits are going bye-bye. All of this is patently false, but it’s having a powerful effect on the country’s senior citizens. This is why the New York Times and Slate both have articles examining the issue in which the elderly express their concerns that proposed health reform legislation is putting the nation on a slippery slope towards euthanasia of seniors. It’s both morbid and ridiculous.

What’s flying under the radar, however, is the current–and very real–threat to health care coverage: recission. You may not have heard of this word before, but you may likely know someone to whom it has happened. Recission happens in the wake of filing an insurance claim, when the insurance company denies you your benefits–which ordinarily would be covered–by canceling your policy. The basis for the cancellation goes something like this: You file an expensive claim. The insurance company doesn’t want to pay it (i.e., lose money). They find something technically wrong with your paperwork that “justifies” cancellation of your policy.

Now, there are certainly cases where recission is a necessary protection for the insurer. For example, if you failed to disclose prior treatment for breast cancer, and you later seek coverage when you suffer a recurrence, that’s tantamount to fraud on your part. If, on the other hand, you filled the forms out incorrectly, or failed to disclose something you didn’t know about or that turns out to be completely unrelated to the current claim you’re filing, and the insurer cancels your policy? Well, that makes for something you could grow a nice crop of tomatoes in.

This kind of thing happens all too often, and is mentioned in Michael Moore’s notorious film Sicko as well as two articles appearing this week from Timothy Noah and Jonathan Weber. As reform moves forward, there’s mention of outlawing coverage denial on the basis of pre-existing conditions, and that’s important both for expanding coverage and severing one of the links on which recission is based: If there are no “pre-existing” exclusions, the accuracy of your health history should not be grounds for future claim denials. Still, if consumer protections are such a big part of reform, shouldn’t something more be done to prevent the practice of unjustified recission?

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Posted by on July 30, 2009 in Uncategorized


Understanding $1 Trillion

WARNING: This post contains data. I’ve tried to make everything very clear by putting it in graphic form, but if you are allergic to numbers you might want to pop a couple of Benadryl before you read any further.

Glad you’re still with me. Today, I want to talk about $1 Trillion. That’s at least one of the numbers we’ve been told is going to be the 10-year cost of health reform, and according to the folks at the Congressional Budget Office (CBO), the preliminary analysis of both the House and the Senate bills look quite similar.Other lower figures have been cited, but they just aren’t as fun to say as “One…..TRILLION…..Dollars…..!” (Certainly has a Dr. Evil-esque ring to it, doesn’t it?) But what in the world does it mean? Granted, it’s a lot of money. So much, in fact, that it makes it hard to comprehend. In cases like this, a fun thing some people do is try to put it into more concrete terms that people can identify with. “It’s like buying a movie ticket, a tub of popcorn, and a Coke for every man, woman, and child in China every day for nearly two months.” (I made that one up, but I think the math comes close.) Jerry Seinfeld has a funny clip about McDonald’s that makes this point about the ridiculousness of extremely large numbers.

Well, first of all, the big “T” is the net cost (i.e., additional government outlays not offset by increased revenues or savings from other programs). It’s also the total amount for 10 years, which is the longest budget window the CBO permits itself to practice fortune-telling. So, if we want to look at an annual number (assuming costs were even over all years, which they’re not), it would be $100 Billion a year. That’ll take all of China to the movies for about a week.

But, alas, we’re not talking about taking China to the movies, we’re talking about healthcare. So what does $1 Trillion get us, exactly? Well, it depends on whose doing the buying. First, it helps to see what the “status quo” so ominously referenced by President Obama during his press conference last week, will look like:Alright, with our starting point established, what does the CBO say the House bill would do to enrollment? Well, it seems to keep employer based coverage robust, increase Medicaid enrollment, cover a bunch of people through the new exchanges, and significantly reduce the number of uninsured. The Senate bill looks fairly similar according to CBO’s analysis, but the biggest differences are that employer-based coverage and Medicaid coverage shrink somewhat and the number of uninsured doesn’t decrease nearly as much under the Senate’s version:

All of this left me asking: If one of the primary goals of health reform is to help everyone get coverage, shouldn’t we be looking more closely at the connection between what reform will cost and what we’re getting in terms of newly covered individuals? So, I took a look at what the additional annual federal outlays would be for each additional person who moves from uninsured to insured. I was a bit surprised. The House bill looks to extend coverage at a much lower incremental cost.

In fairness, though, we can see that the House bill would not reduce the number of uninsured at all in the first three years (that’s why there aren’t any maroon bars there). So, I decided to take the total net costs (remember, that’s the $1 Trillion CBO scored for both the House and Senate bills), divide it by the reduction in the number of uninsured persons over the 10 year period, and then divide that by 10, to get a better yearly average with which to compare the two plans:
Yep. The House comes in as the much better way to spend $1 Trillion if we’re most concerned about covering everyone. For all of the talk about making the health care system more efficient, I hope that someone pays attention to the need for that efficiency to start at the beginning, with the drafting of health reform legislation.
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Posted by on July 29, 2009 in Uncategorized


You Need a Lobbyist

This comes a bit late, but some of you may have missed David Leonhardt’s July 22nd piece in the New York Times. You need to read it. I’ve not come across a more concise explanation of the obstacles to health reform since my adviser, Jonathan Oberlander, told me the fundamental paradox of health care cost control: HCE = SEI (health care expenditures = someone else’s income).

The point, which Leonhardt makes painfully clear, is that neither you nor I have the weight (read: money) to make much of a difference in this debate. It doesn’t help that we are so insulated from much of the cost associated with the care we receive. It makes rising costs a less urgent concern. Once we feel the pinch, things have gotten quite out of hand. Then, while we might like to see cost control, those whose income it is are adamantly opposed to taking a cut in pay. And in fairness, wouldn’t you be too?

Those interests–think insurers and healthcare providers–are well-heeled, and that permits them to line the pockets of the men and women who hold leadership positions on key Congressional committees. There is no such thing as a free three martini lunch. Trust me, organized interests (i.e., lobbyists) get things done. Fortunately, there are interests aligned on both sides of the issue. But what about you and me? Are our interests being represented? Sure, we can call or write our representatives, and in large enough numbers they’ll take note. We might be members of organizations with a government affairs division that takes up “our” fight on Capitol Hill. Then again, we might not.

At the end of the day, no matter which side of health reform you’re on, you’re placing your trust in politicians, hoping that they’ll decide to do what you think is right. Maybe they will. But if I were you, I’d seriously consider hiring a lobbyist.

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Posted by on July 28, 2009 in Uncategorized


The Land of 50/50: Tracking Health Reform in the Media Headlines

It’s no secret that health reform is center stage in the media these days, but what exactly is being said? To find out, I searched for all occurrences of the phrase “health reform” appearing in Google News (which searches multiple online news outlets) over the last month, and classified the headlines according to whether they framed health reform in a positive or negative light.

First, I thought it important to summarize the total number of news headlines in which “health reform” appeared. As you can see, there has been a fair amount of fluctuation. The red line indicates the average daily number of articles (18.5). As you can see, the two biggest spikes in activity correspond with the House’s July 14 release of their draft legislation and Obama’s July 22 health reform press conference.

Of more interest, however, is the broad picture that these headlines paint about health reform. Is there a trend in favorable versus unfavorable coverage? Over the past month, approximately 58% of “health reform” headlines have been favorable, while 42% have been unfavorable. On the whole, then, the media seems to be covering health reform as a “good thing.” But what is happening over time?
From this chart, we see that the “good” and the “bad” stories tend to fluctuate a fair amount from one day to the next. Again, it’s interesting to note that coverage was split 50/50 on the day the House draft bill emerged, but became predominantly positive again for the next few days. However, coverage grew increasingly negative prior to Obama’s press conference, and while some positive ground was gained in the days after the President’s remarks, it is very apparent that the “positive” peaks never return to their halcyon days of early July.

What are we to make of this? Well, I’d say that some fluctuation is completely predictable, and I’d also point out that the most reliable (i.e., stable) percentage estimates coincide with the days in which the most stories were run. That’s just simple math. Fewer total stories means a smaller absolute difference will appear as a larger percentage difference. The two days to hone in on, then, are July 14 and July 22. What we see is fairly balanced reporting on health reform, and I think that’s a healthy thing in a democracy like ours.

What do I think we’ll see as the month draws to a close? Inevitably a shift towards more negative coverage, as questions are raised about the August recess and whether failure to pass a bill before the break will stall reform efforts indefinitely, leading to its ultimate demise. That is, until another news item breaks, and we get back to the land of 50/50.

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Posted by on July 28, 2009 in Uncategorized


Framing Health Reform: Why You Think the Way You Do

Back in 2004, Berkeley cognitive linguistics professor George Lakoff published the book Don’t Think of An Elephant! Know Your Values and Frame the Debate. It’s a fascinating book, and I encourage you to pick it up if you’ve never read it. More on that momentarily.

First, I’d like you to try out a little experiment. I’m going to describe two scenarios to you, and after you read them, I want you to think about which scenario you most identify with. Put aside for a moment the fact that you may identify to varying degrees with both scenarios, or that the scenarios seem to overlap in your view. Just pick one. Ok, here we go:

Case 1

“The world is and always will be dangerous and difficult. The world is competitive and there will always be winners and losers. There is an absolute right and an absolute wrong. Children are born bad and must be made good. The father, as head of the family, is the moral authority who must support and defend the family, tell his wife what to do, and teach his kids right from wrong. Doing that requires painful punishment–physical discipline that by adulthood will result in the children having developed internal discipline. This discipline is demonstrated by following certain moral precepts and becoming self-reliant through the pursuit of one’s self-interest. Once on their own, the father should not meddle in his children’s lives. Children who remain dependent should be further disciplined or cut off, forcing them to become independent by the discipline of the outside world. Disciplined individuals will be successful, and they will prosper and amass material wealth. They should be rewarded. Those who are not successful are not successful because they are not disciplined, and to provide them with any type of outside assistance would be to enable their lack of discipline, which would be a bad thing to do.”

Case 2

“The world, despite its dangers and difficulties, is basically good, can be made better, and it is our responsibility to work towards that. Children are born good and parents can make them better through empathy and responsibility. Both parents share the responsibility for raising the children. Their job is to raise their children: To protect them from all sorts of harm, help them have happy fulfilling lives, treat them fairly, and ensure their freedom (age appropriately of course). You realize that you will only be able to do these things for your child if you yourself are happy and fulfilled. Trust, two-way communication, and opportunity are essential if your children are to grow into fulfilled individuals.”

So which one are you? Do you see the world more as it is depicted in Case 1 or Case 2? I know you’re asking what in the world this has to do with health care, but as Lakoff describes in detail, these views of the family shape our views on nearly everything else we encounter. Individuals who are oriented more in favor of Case 1, the “strict father” model, tend to be more conservative, while individuals who see the world more in Case 2 terms, the “nurturing family” model, tend to be more progressive.

In fact, we often personify views of the family onto other issues. We even conceptualize entire nations as if they were individuals. North Korea is a hostile nation. But does that mean all of its people are hostile? No. If we were using mean population values to label nations, we would more accurately refer to North Korea as a starving nation. Similarly, for those of us who believe in a Supreme Being, we tend to view that being in one of two ways: A strict father, who demands obedience and punishes us for our mistakes; or a nurturing father, who models grace and love to us by example.

Nothing activates frames better than fear, and with the current economy in the shape it’s in, there’s plenty of fear to go around. According to Lakoff, every story conveyed by a frame has a “hero, a crime, a victim, and a villain.” I know that I have readers of this blog who are on both sides of the health reform debate. Therefore, I ask you to write a comment on not only who or what you believe to be deserving of each of these four titles, but also–and more importantly–why you think the particular title is deserved. This should give you an opportunity to explore the subconscious thoughts you have about health reform and assess their validity… well are your thoughts supported by the facts? If you’re honest with yourself, I believe you’ll find that facts often take a backseat to the frames we use to process information–no matter which side of the issue you’re on.

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Posted by on July 27, 2009 in Uncategorized

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