I’ve been on vacation since a few days before Christmas, and am taking a break from writing the blog. I hope you’ve enjoyed the posts I wrote and scheduled to go up all this week, but the next week or so are going to be marked by radio silence. I’m actually contemplating a move to a different blogging platform for the new year. Stay tuned for details and enjoy the rest of 2011 and the start of 2012!
Monthly Archives: December 2011
By now, it’s old news that Republican Congressman Paul Ryan has worked with Democratic Senator Ron Wyden to draft a bipartisan plan to “fix” the Medicare program. What is being proposed, essentially, is a system of “premium support”–the federal government would make fixed contributions to offset the costs of seniors purchasing insurance from an exchange of private plans, while the traditional Medicare fee-for-service program would remain an option for those who wanted to remain in it.
If this sounds a lot like the Affordable Care Act with a public option included, it’s because it is. If that didn’t fly before, why would it be seen as the ideal way forward for saving Medicare? It’s simple, the Democrats envisioned such a plan as a way of moving the health care system towards a system of managed competition or even single payer, while the GOP sees this as a way of moving Medicare away from single payer to a system of managed competition or even traditional private coverage. The problem is that, while it may mask some of the problem, it won’t solve it.
In Western medicine, there seems to be much more emphasis on treating symptoms rather than preventing or curing disease, and this, in my opinion, is the same approach taken by Ryan-Wyden. In theory, injecting competition into the Medicare market should treat the symptom of high health care costs. The problem, however, is that it won’t work. The symptom is a result of the underlying design of the health care system, by which I mean “fee-for-service reimbursement by third-party payers.” There is a mountain of evidence pointing to the fact that a single-payer system, in which the payer has no intention of generating a profit, is the least expensive option for the design of a health care system. Moreover, there is ample evidence that capitation or global budgeting is far less costly than fee-for-service. Those are the elements that need to be introduced into the health care system to start cutting health care costs. Moving Medicare from single-payer towards an exchange of private payers will make it more, not less, difficult to make those changes. Without addressing the underlying “disease,” we will have no choice but to seek out new compromises in an attempt to treat the “symptoms” or else be left to suffer with them.
When will we ever be free of the dreaded “R” word in health care? Will we ever accept that we can’t have our cake and eat it too? I’ve written about rationing many times before. Today, I want to share with you the words of Dr. Don Berwick, outgoing director of the Centers for Medicare and Medicaid Services. In a speech at the Institute for Healthcare Improvement National Forum on December 7, 2011, Dr. Berwick had this to say:
“Inscribed on the wall of the great hall at the entrance to the Hubert Humphrey Building, the HHS Headquarters in Washington where my office was, is a quotation from Senator Humphrey at the building’s dedication ceremony on November 4, 1977. It says: ‘The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped.’
I believe that. Indeed, I think that Senator Humphrey described the moral test, not just of government, but of a nation. This is a time of great strain in America; uncertainty abounds. With uncertainty comes fear, and with fear comes withdrawal. We can climb into our bunkers, each separately, and bar the door. But, remember, millions of Americans don’t have a bunker to climb into–they have no place to hide. For many of them, indeed, the crisis of economic security that we all dread now is no crisis at all–it is their status quo. The Great Recession is just their normal life….
Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys….If you really want to talk about ‘death panels,’ let’s think about what happens if we cut back programs of needed, life-saving care for Medicaid beneficiaries and other poor people in America. What happens in a nation willing to say to a senior citizen of marginal income, ‘I am sorry you cannot afford your medicines, but you are on your own?’ What happens if we choose to defund our nation’s investments in preventive medicine and community health, condemning a generation to avoidable risks and unseen toxins? Maybe a real death panel is a group of people who tell health care insurers that it is OK to take insurance away from people because they are sick or are at risk for becoming sick….
And, while we are at it, what about ‘rationing?’ The distorted and demagogic use of that term is another travesty in our public debate….The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry ‘foul’ about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people–elders, the poor, the disabled–who are least able to bear them. When the 17 million American children who live in poverty cannot get the immunizations and blood tests they need, that is rationing. When disabled Americans lack the help to keep them out of institutions and in their homes and living independently, that is rationing. When tens of thousands of Medicaid beneficiaries are thrown out of coverage, and when millions of seniors are threatened with the withdrawal of preventive care or cannot afford their medications, and when every single one of us lives under the Sword of Damocles that, if we get sick, we lose health insurance, that is rationing. And it is beneath us as a great nation to allow that to happen.”
Why don’t you ponder that over the next few days, and have a Merry Christmas!
The last Health Wonk Review of 2011 is up at the blog “Health News Watchdog.” It’s their first time hosting, and they did a great job. (And I’m not just saying that because my post is included.) Here’s the link.
When the Census Bureau released the latest numbers on insurance coverage, I wrote a post to highlight that nearly 500,000 young adults went from being uninsured to having insurance. An excerpt from that post actually got picked up by Jonathan Cohn at TNR. Now there’s more evidence that ObamaCare is working for both young and old Americans. The Department of Health and Human Services recently announced that, in fact, more than 2.5 million Americans between the ages of 19 and 25 were covered by their parents’ health insurance in the first half of 2011. That’s not surprising given that the Affordable Care Act included a provision that allows those under age 26 to remain on their parents’ coverage.
And the good news isn’t just for twenty-somethings. Early data show that America’s seniors are also benefiting from the Affordable Care Act. How you ask? Well, one of the first provisions enacted targeted the Medicare Part D “donut hole.” Part D is the program that provides prescription drug coverage for Medicare beneficiaries, and it was designed with a giant gap in coverage right where people needed it most. (As an aside, that was done for purely political reasons, to keep the price tag a little lower on the legislation when it was being debated on Capitol Hill.) Well, ObamaCare didn’t completely eliminate the donut hole, but it did shrink it, by reducing the proportion of costs the beneficiary is responsible for. The result? Nearly 2.7 million older Americans saved an average of $569 each on their prescription drugs through October 2011. Moreover, some 24 million Medicare beneficiaries received free preventive care. This is good news served with a side of good news.
It’s true that health reform is still very much in the process of being implemented. My glasses are not so rose-colored as to expect that every element of the law will be a success. Some things won’t work, and will need to be retooled or abandoned. But some things, as these developments underscore, will be successful, and when that happens, it should be roundly acknowledged.
Americans seem to have a problem with fractions. As in, they don’t appear to grasp how they work. That’s the conclusion I’ve finally reached after noticing a striking trend among public opinion polls in which Americans like the parts of something, but dislike the whole. The only way that one can hold such a position, it seems to me, is if one is unclear that the parts together compose the whole. With fractions, we understand that 2/8 + 1/4 + 1/2 = 1, but the logic doesn’t appear to hold elsewhere.
For example, consider the Affordable Care Act. When polled, the public strongly supported the individual components of the law. Asked to consider the law as a whole, though, and supported dropped off significantly. It’s a bit confusing, isn’t it? They might as well say “I love crust, cheese, tomato sauce, and pepperoni, but don’t you go putting it all together and trying to shove a slice of pizza down my throat.”
We see the same hard to reconcile pattern in Congressional approval ratings. The current approval rating for Congress is the lowest it’s ever been at an abysmal 13%. Asked to consider whether most incumbents deserved to be re-elected, the answer was another all-time-low: 20% said yes. In other words, very few of us approve of Congress as a whole. But the parts? Well that’s a different story. Asked to consider whether the incumbent in their district deserved to be re-elected, the answer was much higher: 53% said yes. Folks, those numbers just don’t add up. It’s time we realized that it’s impossible for everyone to be above average.
The parts necessarily make up the whole. That’s why fractions have denominators. If you, and more than half of everyone else, thinks that your (or their) member of Congress deserves to be re-elected, then the chances are pretty good that they will be. This explains why we keep voting the same people to another term, and yet we act surprised when the result is more polarization and less progress. It’s why we like all of the provisions of health reform, but oppose the law that would implement them, and then wonder why we continue to pay more and more for our health care. We need to understand the part we play in the way things are. If we don’t like the big picture, we need to stop assuming that we’re not the problem, and start figuring out how to fix it.
Peter Bach is a physician with a recent op-ed appearing in the New York Times. Dr. Bach’s piece about whether or not end-of-life health care spending is wasteful is compelling. I recommend you read his essay, but I want to hit some of the high points.
The first is that we may be making an error based on hindsight. Precisely because hindsight is 20/20, we can fall into the trap of evaluating health care decisions after the outcome is known, which is not how health care decisions are actually made. So, as Dr. Bach stresses, a tremendous amount of health care spending may be deemed warranted if it saves the life of the patient, but the same spending would be labeled wasteful if the patient dies. This is an excellent point.
Other points Dr. Bach makes relate to supposed sources of bias. For example, sick people need more health care (which costs more money) and are also more likely to die. Ergo, the link between health care spending and death is likely to be positive, but the reality is that health status is the common denominator. He also laments the fact that data on end-of-life spending is much more readily available than data on other types of health care spending. That’s also a pretty accurate assertion.
It’s in his concluding remarks that Dr. Bach gets to the real matter at hand: We don’t know who is going to benefit and who isn’t. In his essay, he describes how he saved someone’s life. As it turns out, the condition that person had is fatal in about 1 of every 8 cases. In other words, paying to intervene for that condition seems like a good bet. If, on the other hand, only 1 out of 8 people with the condition survived, it might be a tougher sell. Of course, what that scenario underscores is that the overall costs and benefits are important to understand, but so are the individual risks and benefits. For example, if you have the condition, you are probably hoping that you are the 1 person who will survive after receiving the intervention, not counting on your being 1 of the other 7.
Research that can help us understand not only which procedures are generally more effective than others, but also who the 1 person who loses or benefits (given the two scenarios above) will be, are the next frontier in improving the health care system–cutting costs without harming quality. Of course, this type of research will bring accusations of “death panels” back out of the woodwork. I just hope few people will actually take such things seriously, so that the necessary work can proceed. Without it, I’m not sure that there’s much hope.