Health Wonk Review: Kabuki Theater Edition

04 Mar

A week ago today, literally dozens of people across the country were tuned into C-SPAN to watch the President’s Health Care Summit being held at the historic Blair House across the street from the White House. Going into the event, a number of questions were raised, most having to do with the Republicans’ response to being invited to a bipartisan summit: Will they attend? (They did.) What will they say? (Lots of things, including “Scrap these bills and start over.”) Will they present their own reform proposal? (Sort of.)

Perhaps feeling threatened, the right raised some questions of their own: Will Democrats agree to drop their bills and start the summit with a clean slate? (They didn’t.) Will rational discussion and compromise be possible, or will this just be Kabuki theater? (Kabuki what?)

Kabuki theater is a Japanese dramatic art form known for its elaborate costumes, make-up, and over-the-top performances. Like the Health Care Summit, most Kabuki plays last for the majority of the day, and are divided into five acts. They begin with a slow opening act to introduce all the key players (the President went around the room and greeted everyone), progress through three acts that build at increasing speed to a dramatic climax (they exchanged ideas stopping only for lunch and a vote in the House), and end with a swift conclusion that resolves the drama. (Oh, so close!)

The term Kabuki theater when used to describe the Health Care Summit, however, was pejoratively meant to describe grandstanding and rhetoric–political posturing not substance. Essentially, Republicans were warning that the air of bipartisanship being proposed by the President was an illusion, designed only to trade talking points in hopes of making Republicans look bad on national television with no actual aspirations of compromise.

While I think the President’s effort paid off as intended, many others disagree. In fact, as soon as the Summit concluded, the analysis of winners and losers began and commentary from bloggers of all stripes has been plentiful. What is perhaps most evident is that all of the questions leading up to the Summit have been replaced by a host of new questions in its wake. This edition of HWR brings you a sample of what people are talking about now as the future of health care reform remains undecided.

Almost as if it were planned by Democratic strategists as a lead-in to the Summit, Wellpoint subsidiary Anthem Blue Cross of California announced a proposed 39% increase in premiums. It was all over the news and even elicited a strong response from DHHS Secretary Kathleen Sebelius and a report on cost growth from the agency. Dr. Roy Poses of the Health Care Renewal blog digs deeper by asking what lies beneath the increase. His conclusion is that the organization suffers from governance and leadership woes, but he doesn’t think that that’s an excuse. In fact, he thinks addressing such issues should be a central part of health reform. Louise, of the Colorado Health Insurance Insider, agrees, citing the Wellpoint premium increase as all the evidence that is needed for America to pass an individual mandate for insurance coverage. The logic is simple: Guaranteed issue without an individual mandate will make 39% premium increases the norm rather than the exception.

So, how does Congress keep that from happening? Jason Shafrin of The Healthcare Economist provides a summary of the many bad and few good ideas to emerge from the Summit. Chief among his list of bad ideas: Starting over. He writes “If you don’t like the current proposals, say what you don’t like about them. If you have suggestions on how to do it better, say them. Suggesting a ‘do over’ is not helpful.” He makes a good point.

As for good ideas, Shafrin says we need sweeping reform, not incrementalism. Mad Kane’s Political Madness author Madeleine Kane agrees, and takes Sen. Lamar Alexander to task in limerick form for even suggesting an incremental approach.

It’s clear that obstructionist politics aren’t going away any time soon. As the opponents of reform keep up their efforts to derail the process, they continue to appeal to the public’s fears. First it was “death panels” and “socialized medicine.” Now, as Gary Kaplan of Managing Disputes points out, there is talk of the increase in frivolous litigation that health reform will produce. Kaplan says that opposing reform because of the potential for future lawsuits is akin to closing hospitals to save electricity. In other words, it’s hugely counterproductive.

And while we’re on the subject of topics that are misconstrued for political gain, we can’t ignore comparative effectiveness research (CER). CER is one of the more divisive issues in the debate. Democrats tout it as a means to achieving a more efficient health care system. Many Republicans decry it as yet more government-run medicine with bureaucrats getting between you and your doctor. In a post written for the blog of the Robert Wood Johnson Foundation, Bob Berenson of the Urban Institute and Beth Docteur of the Center for Studying Health Systems Change underscore once again the valuable uses of CER. The problem, they assert, is that people don’t understand it, and their default response is to expect the worst-case scenario. On the whole, they present CER as just another useful tool for improving our health care system–it is in their opinion neither all good or all bad.

Fortunately, although Republicans and Democrats didn’t find much to agree on during the Summit, that hasn’t stopped many of my colleagues from investigating other alternatives ranging from value-based insurance to state-based reforms.

While there’s still room for negotiation, Austin Frakt takes up the topic of value-based insurance over at The Incidental Economist. His post summarizes the findings of a study by Michael Chernew and colleagues that value-based insurance–“the reduction of copayments for some services (e.g. some drugs) for individuals with specified conditions to promote their use and obviate other types of care”–which finds that this strategy might actually have the potential to lower health care costs. As if we needed one more thing to confuse people! But it does sound like a promising strategy. The study appears in Health Affairs and you can access it here (subscription required).

Others are interested in the feasibility of state-based reforms. Writing at the Health Business Blog, David Williams takes issue with the notion that the states could possibly pick up the reform ball and run with it. He makes his case by agreeing with–while also critiquing–the arguments put forward by Sara Rosenbaum in a recent issue of the New England Journal of Medicine. The biggest obstacle (and one Prof. Rosenbaum missed) says Williams, is the enormous role played by the Medicare program, which establishes benefit and financing precedents, and over which states have no authority.

Williams isn’t the only one batting around the idea of “letting the states do it.” Jaan Sidorov of the Disease Management Care Blog read Prof. Rosenbaum’s article in the NEJM, too, and he isn’t having any of it. In fact, he wishes that the journal came with a mute button that would allow readers to cut through what he calls “faux hard science” to examine the underlying “subjective policy preferences.” Maybe Mr. Williams and Dr. Sidorov need to hold their own summit to compromise on the proper role of the states in reform.

When it comes to the role of the states, one of the major ideas to emerge from the right is increasing competition by allowing the sale of health insurance across state lines (which is currently prohibited by law). It’s a good idea in many ways, but there is reason to be concerned that insurers would choose to locate in states with the most lenient insurance regulations, undermining consumer protections that exist today. If you want an idea of what these consumer protections are like, Anthony Wright of the Health Access WeBlog has an excellent overview of the situation unfolding in California, where state lawmakers are already attempting to eliminate them.

In a slightly different take on the idea of consumer protections, over at the Workers Comp Insider, Julie Ferguson urges employers to re-examine their return-to-work policies and programs in light of a record workers comp related ADA payout being made by Sears to more than 200 former employees who alleged that they were kept off the job after suffering injuries and other health problems. The bottom line here: We need to stop discriminating against people on the basis of their health–an idea that was widely discussed during the President’s Health Care Summit.

Of course, in closing out this edition, we must remember that all of this regrouping only became necessary when Republican Scott Brown won the Massachusetts Senate race. One wonders just exactly where he falls on the spectrum as a conservative from one of America’s most liberal states. The Boston Health News‘ Tinker Ready writes a post entitled “Still wondering about Scott Brown and health reform.” Of course Scott Brown campaigned on his opposition to the Senate bill, she says, but what exactly–if anything–does he plan to do about our ailing health care system? Might Sen. Brown make a name for himself by refusing to go along in lock-step with the GOP and supporting the legacy of Massachusetts’ longest serving Senator? Unfortunately, it’s hard to predict, because as Ready writes, “…we know what he’s against. It would be nice to know what he’s for.”

And so, another act of the play comes to an end. After all the high drama, are we any closer to seeing meaningful health reform passed in this country? It’s hard to say. Reconciliation is there if Congress finds the resolve to use it, but the conclusion is far from certain.

Perhaps we’ll know more in a couple of weeks when Minna Jung at The Users’ Guide to the Health Reform Galaxy hosts the next edition of Health Wonk Review.

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Posted by on March 4, 2010 in Uncategorized


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