My good deed for this fine Friday is to alert you to the posting of a new edition of the Health Wonk Review. This edition is hosted by Joe Colucci of the New Health Dialogue Blog, and his theme is Muppets. Check it out!
Monthly Archives: September 2011
This week has been notable in the world of health reform implementation. First, on Monday, the Obama administration made a decision with big implications for the future of reform when it decided against asking the federal appeals court in Atlanta to revisit its decision on the constitutionality of the individual mandate. At issue was whether the Justice Department should request an “en banc” review. For those of us non-lawyers, court of appeals cases are often heard and ruled upon by a three-judge panel, even though the full court consists of 11 judges. An “en banc” review involves hearing the case anew in front of all 11 judges. Think of it as a way of getting a second opinion.
The decision was a strategic one on the part of the Obama administration, because it had the potential to speed up or slow down the judicial process as the Affordable Care Act weaves its way through the courts. Most agree that this case is going to the Supreme Court, but asking for another review along the way is a way to draw things out until 2013 or beyond, while forgoing said review paves the way for the Supreme Court to hear the case next summer.
According to Washington Post reporter, Sarah Kliff, the move was likely motivated by three things. First, it guarantees that the case will be handled by the Obama administration. The idea of a Republican administration arguing in support of “ObamaCare” is absurd on its face. Second, it avoided the embarrassment of the appeals court denying the en banc request or, worse, ruling the individual mandate unconstitutional twice in a row, both of which would weaken the Obama administration’s position. Finally, it makes the Obama administration look confident in its defense of health reform. With everyone fully expecting a Supreme Court case over the individual mandate, buying time looks a lot like uncertainty, while welcoming the case suggests that they think they can and will win.
Legal issues aside, the other major development this week was the announcement that health insurance costs rose dramatically over the last year. According to a Kaiser Family Foundation study, costs went up by 9%, with the average family plan costing more than $15,000 in annual premiums. The question is why, especially during this economic downturn, we are seeing such a big jump. Critics of the Affordable Care Act will assert that this is proof that “ObamaCare” isn’t working, but is, in fact, making things worse. There’s really no way to prove that right now, but for all intents and purposes it doesn’t matter, because whether he wants to or not, President Obama has no choice but to claim the health care system right now. Its successes or failures are his successes or failures. It doesn’t make much sense for insurers to artificially inflate prices, because once reform is fully implemented, they will have to spend at least 80 cents of every premium dollar on benefits, or refund the difference. I almost suspect that this is a price-gouging effort to generate additional revenue while they can, before reform makes them clean up their act. The bad economy and the floundering stock market in which insurance companies make their money may also have driven them to offset losses by increasing premiums. Again, there aren’t data that I know of to support this, but I think it’s compelling.
At any rate, these are the sorts of stories that will continue to unfold as time goes by. Numerous questions will emerge about the success or failure of reform, and a lot of interesting research should come out of this whole thing, both for legal scholars and social scientists. We are all, in some sense, subjects in the Nation’s grand experiment. Some of us are simultaneously fortunate enough to be investigators as well.
“Things just aren’t working out between us.” That’s what some doctors are saying to the practice of medicine as the federal government marches forward with implementation of the Affordable Care Act. Over at the National Journal, Megan McCarthy takes a look at how a number of physicians–faced with the prospect of being held accountable for the job they do–are thinking about calling it quits. They don’t want to spend a bunch of time documenting the quality of care they provide, only to find that the quality of that care is suboptimal and have their paychecks docked because of it.
Hey, listen, I understand. If I were accustomed to doing just about whatever I wanted and getting paid for it, I’d be reluctant to embrace the change. But this actually tells me that some real change is about to happen in our health care system. Sure, the prospect of physicians leaving the practice of medicine in droves and exacerbating current workforce shortages is alarming, but I choose to look at the glass as half-full rather than half-empty. For me, the fact that the rules of the game are about to change significantly enough to make some people think about no longer playing is a great sign. There will be others who want to practice medicine. I say let them do it. Let the market principles we abide by do their thing.
Who will leave? Most likely it will be older practitioners, or those who–for a variety of reasons–were already considering leaving the field before the ACA. Who will stay? Physicians who provide high quality care. Sure, there will still be plenty of variation from doc to doc, but a system that rewards good outcomes and punishes bad ones should, over time, improve the overall quality of our providers and our health care system. If we could just solve the access problem, that’d be something we could all benefit from.
I and others write frequently about Massachusetts because of the state’s bold experiment in health reform. Back in 2006, when Mitt Romney signed the state’s health reform legislation into law, there was great anticipation about what would be achieved by requiring residents to purchase health insurance or pay a penalty. After five years, the results are in, and while the news is generally favorable, it’s not all good news.
Yes, Massachusetts has the lowest uninsured rate in the nation. No, health care costs there have not fallen. Yes, access to care has improved. Unfortunately, disparities in coverage and access persist. The latter is the finding of a new study by James Maxwell and colleagues that appears in the September issue of Health Affairs. The authors report that, while insurance coverage has increased among all groups, it has lagged behind for Hispanics–with a particularly troubling lack of progress seen among the Spanish-speaking population.
Non-Hispanic whites were doing well to begin with. Approximately 91 percent of them were insured before the law took effect, and by 2009, that number had reached 96 percent. There’s not much more room for improvement. During the same time period, Hispanics went from an insured rate of 68 percent to nearly 79 percent. Yes, that’s a bigger gain, but there’s a lot of ground to be made up before things are equitable.
The aggregate Hispanic numbers are misleading, though, because language is an important obstacle to navigating the system. Breaking Hispanics into English-speaking and Spanish-speaking groups shows that not speaking English has really made it difficult for people to obtain health insurance. In 2005, 78 percent of English-speaking Hispanics had coverage, compared to just 51 percent of Spanish-speaking Hispanics. Three years after health reform was enacted, those numbers improved to 88 percent for English-speaking Hispanics and 67 percent for Spanish-speaking Hispanics. That’s right. The Spanish-speaking Hispanics are doing worse after health reform than their English-speaking counterparts were doing before reform. Suffice it to say, if Massachusetts still has this much work to do, the rest of the country faces a monumental task.
A recent article I was reading began like this: “Americans don’t think health care reform is working, and they are especially dubious of government priorities, according to a survey released on Monday by the Deloitte Center for Health Solutions.”
A lot of folks stop reading right there–or at least stop thinking right there. In fact, many probably don’t get beyond the phrase “American’s don’t think health care reform is working.” Period. End of sentence. Such tendencies are especially strong in a world besieged by endless streams of nearly instantaneous information. We don’t have (or don’t take) the time to think critically about the information presented to us. It is unfortunate to say the least.
The phrase “Americans don’t think health care reform is working” seems to suggest that all Americans espouse that view. In fact, however, you have to keep reading to find that 49% consider the ACA a good start, while 30% consider it “a step in the wrong direction.” That’s a lot more mixed than the opening sentence would suggest. Indeed, the same survey finds that 76% of consumers do not have a strong understanding of how the health care system works. I could, if I chose, use that result to amend the original headline: “More than 75% of Americans don’t understand how the health care system works, but know ‘Obamacare’ won’t fix it.” Framing matters, and that starts with the polling firm. Ask yourself: Who actually conducted the poll? Do they have a known bias? Were they paid on behalf of an organization with a political agenda?
Ultimately, you need to go directly to the poll itself. Here you’ll find not only the data (hopefully), but the instruments used to collect that data. The data is important for the simple reason that figures can be misleading. For example, percentages may look impressive, but may be trivial in nominal terms, or vice versa. Just as important, however, is question wording. The public rarely scrutinizes polls at this level, but the way in which questions are worded can have a profound effect on how people answer the question. Ask people if government should define marriage as an act between a man and a woman, and you’ll get a much more favorable response than you will if you ask whether they believe government should make it illegal for two persons of the same sex to marry each other. The first instance presents a generally favorable idea being supported by government. The second instance asks the same thing in a negative light by focusing on government limiting individuals’ rights. These framing effects are well known, and they often lead to polling results being oversold.
David Grande, Sarah Gollust, and David Asch, all of the University of Pennsylvania, have a wonderful article out in the latest issue of Health Affairs that looks at the various ways in which polls about health reform worded questions pertaining to the individual mandate and the public option. They found what polling experts have long known: How you ask the question matters. Their conclusion–looking across all the different polls–was that “Americans support an expanded role for government in health care that provides more choices and makes insurance more affordable. However, Americans do not want to see the government assume a more prominent role as a dictator of individual decisions.” I think their synthesis of a wide variety of polling data effectively hits the nail on the head, and tells us far more about the American public’s views than any single poll taken as a snapshot of the gospel.
The way in which John Boehner and other members of Congress essentially held the government hostage during the debt ceiling debate marks a new era in American politics. Never before had Congress said “Unless we get our way on issues X, Y, and Z, we’re going to let the country default on its loans.” It would be like a husband saying to his wife, “Unless I get to watch football all day on Saturday and Sunday, I’m not paying the mortgage!” While it doesn’t make much sense, it is nevertheless the world we now inhabit.
The thing is, it at least partially worked, and that means that this style of deficit and debt politics–using budget debates to make otherwise unattainable policy demands come true–is here to stay. That, in turn, means that the entire budgetary process is about to get a whole lot tougher. Everything will be accounted for, and many of the old tricks will no longer be viable means of finding small pockets of funding for special projects–or even paying for larger programs, like Medicare and Social Security.
As Jon Oberlander writes, this new style of politics is likely to have serious repercussions for the health care industry. In short, when balancing the budget becomes essential, the rules enforce a zero sum game. Unless we raise revenues, we’re going to have cut spending, and health care is one of the most expensive things we purchase. The health care industry then faces a choice: Support tax increases or face the very real possibility of cuts to their bottom line.
By all accounts, Texas Governor Rick Perry is the leading candidate in the GOP field. There’s still plenty of time for that to change, and I hope it does. Here’s why: The man can’t seem to make up his mind on the important issue of personal liberty. This, from my understanding, is a key element of the Tea Party movement and the Libertarian party among others. Government should be smaller, because it doesn’t need to spend so much time and money on telling people what they can and can’t do. The mantra seems to be something like: As long as my actions don’t harm someone else, I should be completely free to do whatever I wish (e.g., in the privacy of my own home).
That’s a sentiment that, while not without some failings, I can understand. Heck, in many instances, I wholeheartedly support it. Perry, however, has decided to waffle on this issue. In fact, he downright contradicts his own ideology. The two competing points are these: On the one hand, Perry cries out against health reform and calls the individual mandate “unconstitutional.” That makes sense if you are of the small government, personal liberty and individual responsibility camp. Well, at least insofar you don’t acknowledge the ways in which others may be harmed by your choice to forgo insurance and seek free care later. On the other hand, Perry issued an executive order mandating that all young girls in Texas be given the HPV vaccine, which can protect against cervical cancer. That, from the liberty and personal responsibility stance, makes no sense. Shouldn’t the girls–or their parents or legal guardians–be the ones to make that choice? Perry says he passed the HPV vaccine mandate to save lives and cut cancer treatment costs, but saving lives and cutting costs is precisely what health reform–through the individual mandate–is designed to do. Curious, no?
Note: This post was inspired by an excellent article written by Slate’s William Saletan. That article–which I recommend–is located here.
David Leonhardt writes for the New York Times‘ Economix blog regularly. Recently, he authored a piece on the incidence of physician malpractice in the U.S. It contained a nifty chart, which I am sharing with you here. The things to take away from this are: Malpractice claims vary widely by physician specialty and malpractice claims rarely result in a payment of any kind (either a settlement or a judgment). That doesn’t mean we don’t need malpractice reform. We do. But it does put a limit on how much cost-savings such reform will generate.
The wonkiest people on the internet have come together again in the latest Health Wonk Review. My post looking at the example of Medicare to show how the popularity of “ObamaCare” may improve over time is included. Check it all out for yourself here.
When the Affordable Care Act was enacted, there was immediate and enormous uncertainty about how the law would be implemented, whether or not it would be successful, and how its success or failure would be recognized. Proponents pointed to economic theory and Romneycare in Massachusetts, suggesting that we’d see a decrease in the number of uninsured initially, followed–hopefully–by a reduction in the rate of health care spending growth. Opponents, meanwhile, shook their collective heads and began filing lawsuits over the constitutionality of the individual mandate, and those cases are still winding their way through the courts.
While the ACA is still in its infancy, with numerous provisions of the law yet to be implemented, there is now evidence that health reform is doing its job. To be sure, a tremendous amount of uncertainty remains, but the latest data from the U.S. Census Bureau shows that the number of uninsured Americans remains unchanged between 2009 and 2010. Though health reform critics might like to jump on that statistic and proclaim that the ACA has failed to cover more Americans, history proves otherwise.
The U.S. economy–while supposedly no longer in a recession–is far from robust. Historically, economic downturns coincide with increases in the number of uninsured, as people lose their jobs and, thanks to the design of our health care system, their insurance coverage. So, the unchanged number of uninsured masks what actually happened: Roughly 810,000 middle-aged adults, those ages 45 to 64, were likely let go from their jobs, didn’t yet qualify for Medicare, and ended up uninsured. Meanwhile, some 494,000 young adults, those ages 18 to 25, gained coverage, which seems to point to the ACA provision allowing children to stay on their parents’ plans until age 26 that went into effect in the fall of 2010. Of course, there may be other explanations, but the simplest explanation is likely the right one.
Assuming that the ACA continues to reduce the number of uninsured, the bigger question is what happens to costs after it is fully implemented. A large part of this will hinge on consumer behavior, and the news here is mixed. There is emerging evidence that uninsured patients don’t dramatically alter their care-seeking after gaining coverage. In some cases, this is a good thing. For example, in Massachusetts, the uninsured being served by community health centers continued to seek care there even after they were insured. That’s good news for the health centers, which would otherwise be left with an even heavier burden of uncompensated care than they currently face, and it’s good news for the health care system, because health centers are widely recognized as high quality, cost effective primary care providers. Expanding that model could help to bend the cost curve.
At the same, however, there is evidence from the University of Pennsylvania’s Dan Polsky and colleagues that the uninsured who become Medicare eligible don’t change their behavior either. In particular, they continue to have lower rates of physician office-visits and higher rates of emergency room and hospital outpatient department use. That’s bad news, because those sources of care are notoriously more expensive and present an obstacle to continuity of care.
Consequently, the future is uncertain. The promise of the ACA to reduce the number of uninsured remains intact, but what happens to health care costs will be determined largely by the actions of tens of millions of newly insured persons. If ever there was a time to help patients make informed decisions regarding their use of the health care system, that time is now.