Healthcare Reform Thread II

[Dinner]

The bill is a complete turd sandwich.

It does not cover everyone.

It does not control costs.

Therefore, it does nothing to effect change in the two biggest failings of our health care system.

You can thank the conservative blue dog corporatist Democrats for that. Well, them and the Republican Party which so stedfastly refused to assist in any meaningful reform.

[SlowwHand]

So blame everyone. That's a safe position.

[Dinner]

It may not cover everyone, but it will cover millions more people who are currently not covered.

Yes, it covers them by forcing them to buy into the our ****ty current insurance system. Great job.

Indeed. It's the worst of both world's and the Dems won't even grab their balls and force a decent compromise during reconciliation. Republicans did it all the time but Dems? Nope, not enough balls to do something so logical and so against the desires of Washington's second largest lobbying group.

Shoot them all.

[Drake Tungsten]

Nelson Caved for This?
Douglas Holtz-Eakin

I’m sitting here digesting the news of Ben Nelson’s caving to the pressure and the Dems passing the Reid bill. I don’t get it. Honestly. I realize that passing a health care bill has become a political imperative. But I don’t understand why this bill meets the need.

To begin, it is extremely unpopular. Sixty four percent of Americans don’t think it meets their priorities for reform. And it will be even more unpopular in 2010, 2011, 2012, and 2013 — years in which the harsh medicine of higher taxes and regulatory takeover will produce sharp premium increases and less satisfactory care. Only in 2014 does the massive redistribution start, and Dems might get some relief from their purchased constituencies.

On top of that, the schedule is now such that they will have to go back to the House in early 2010 and deal with a likely revolt against the absence of a “public plan” and the tax on “Cadillac” plans. So, just at the time when Obama is going to need Dems to close ranks and support him on Afghanistan, the ranks will be splitting. Why pass a bill that will create more problems for the divided party?

Finally, it is now clear that the pressure is rising over the massive spending and deficits. Obama will clearly want to devote substantial rhetorical effort on this front in the State of the Union speech, and put out a budget that has at least cosmetic fiscal courage. To do this at the same time he might be signing a budget-busting $2.5 trillion health-spending bill will make a mockery of the effort.

So, count me disappointed that we didn’t get real reform. But count me baffled as to why we got this.

http://corner.nationalreview.com/post/?q=NDhmYzgzOWY5OGRjMTI4N2QxOTMwNWQ0NWRmNjM5MGI=

[Wezil]

Obama seems to have the reverse Midas touch.

What's next on his agenda?

[Ramo]

And you are making me agree with Ramo

(but not the stupid reconciliation argument... the problem with reconciliation is that it can't allow for horse trading, meaning it may even be more difficult to pass, in addition to the temporary nature of reconciliation bills, etc).

Horse trading? What the hell is that supposed to mean? And "temporary" entitlement programs have way of becoming permanent.

The real problem with reconciliation is that the Parliamentarian could rule parts of the bill ineligible. But since these aspects are the least controversial parts of reform (i.e. the regulation and the exchanges) that can be separated from the original bill and be passed under regular order fairly easily.

In fact, this bill will allow Congress to go back to health care under reconciliation rules every session to make it better (i.e. improving subsidies).

[Ramo]

Yes, this will not end up like RomneyCare because of the laughable cost-controlling measures that won't actually be implemented and wouldn't make a significant difference even if they were.

Let's suppose Congress was planning on serious cost control under a universal, more than catastrophic, health care framework. What do you suppose it would look like?

[Ramo]

Gawande has an excellent article on cost control in the Senate bill:

[A lengthy analogy to pilot programs in farming]

There are, in human affairs, two kinds of problems: those which are amenable to a technical solution and those which are not. Universal health-care coverage belongs to the first category: you can pick one of several possible solutions, pass a bill, and (allowing for some tinkering around the edges) it will happen. Problems of the second kind, by contrast, are never solved, exactly; they are managed. Reforming the agricultural system so that it serves the country’s needs has been a process, involving millions of farmers pursuing their individual interests. This could not happen by fiat. There was no one-time fix. The same goes for reforming the health-care system so that it serves the country’s needs. No nation has escaped the cost problem: the expenditure curves have outpaced inflation around the world. Nobody has found a master switch that you can flip to make the problem go away. If we want to start solving it, we first need to recognize that there is no technical solution.

Much like farming, medicine involves hundreds of thousands of local entities across the country—hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers. They provide complex services for the thousands of diseases, conditions, and injuries that afflict us. They want to provide good care, but they also measure their success by the amount of revenue they take in, and, as each pursues its individual interests, the net result has been disastrous. Our fee-for-service system, doling out separate payments for everything and everyone involved in a patient’s care, has all the wrong incentives: it rewards doing more over doing right, it increases paperwork and the duplication of efforts, and it discourages clinicians from working together for the best possible results. Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive. And the best way to fix all this is—well, plenty of people have plenty of ideas. It’s just that nobody knows for sure.

The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front. Government has a crucial role to play here—not running the system but guiding it, by looking for the best strategies and practices and finding ways to get them adopted, county by county. Transforming health care everywhere starts with transforming it somewhere. But how?

We have our models, to be sure. There are places like the Mayo Clinic, in Minnesota; Intermountain Healthcare, in Utah; the Kaiser Permanente health-care system in California; and Scott & White Healthcare, in Texas, that reliably deliver higher quality for lower costs than elsewhere. Yet they have had years to develop their organizations and institutional cultures. We don’t yet know how to replicate what they do. Even they have difficulties. Kaiser Permanente has struggled to bring California-calibre results to North Carolina, for instance. Each area has its own history and traditions, its own gaps in infrastructure, and its own distinctive patient population. To figure out how to transform medical communities, with all their diversity and complexity, is going to involve trial and error. And this will require pilot programs—a lot of them.

Pick up the Senate health-care bill—yes, all 2,074 pages—and leaf through it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be.

The bill tests, for instance, a number of ways that federal insurers could pay for care. Medicare and Medicaid currently pay clinicians the same amount regardless of results. But there is a pilot program to increase payments for doctors who deliver high-quality care at lower cost, while reducing payments for those who deliver low-quality care at higher cost. There’s a program that would pay bonuses to hospitals that improve patient results after heart failure, pneumonia, and surgery. There’s a program that would impose financial penalties on institutions with high rates of infections transmitted by health-care workers. Still another would test a system of penalties and rewards scaled to the quality of home health and rehabilitation care.

Other experiments try moving medicine away from fee-for-service payment altogether. A bundled-payment provision would pay medical teams just one thirty-day fee for all the outpatient and inpatient services related to, say, an operation. This would give clinicians an incentive to work together to smooth care and reduce complications. One pilot would go even further, encouraging clinicians to band together into “Accountable Care Organizations” that take responsibility for all their patients’ needs, including prevention—so that fewer patients need operations in the first place. These groups would be permitted to keep part of the savings they generate, as long as they meet quality and service thresholds.

The bill has ideas for changes in other parts of the system, too. Some provisions attempt to improve efficiency through administrative reforms, by, for example, requiring insurance companies to create a single standardized form for insurance reimbursement, to alleviate the clerical burden on clinicians. There are tests of various kinds of community wellness programs. The legislation also continues a stimulus-package program that funds comparative-effectiveness research—testing existing treatments for a condition against one another—because fewer treatment failures should mean lower costs.

There are hundreds of pages of these programs, almost all of which appear in the House bill as well. But the Senate reform package goes a few U.S.D.A.-like steps further. It creates a center to generate innovations in paying for and organizing care. It creates an independent Medicare advisory commission, which would sort through all the pilot results and make recommendations that would automatically take effect unless Congress blocks them. It also takes a decisive step in changing how insurance companies deal with the costs of health care. In the nineteen-eighties, H.M.O.s tried to control costs by directly overruling doctors’ recommendations (through requiring pre-authorization and denying payment); the backlash taught them that it was far easier to avoid sicker patients and pass along cost increases to employers. Both the House and the Senate bills prevent insurance companies from excluding patients. But the Senate plan also imposes an excise tax on the most expensive, “Cadillac” insurance plans. This pushes private insurers to make the same efforts that public insurers will make to test incentives and programs that encourage clinicians to keep costs down.

Which of these programs will work? We can’t know. That’s why the Congressional Budget Office doesn’t credit any of them with substantial savings. The package relies on taxes and short-term payment cuts to providers in order to pay for subsidies. But, in the end, it contains a test of almost every approach that leading health-care experts have suggested. (The only one missing is malpractice reform. This is where the Republicans could be helpful.) None of this is as satisfying as a master plan. But there can’t be a master plan. That’s a crucial lesson of our agricultural experience. And there’s another: with problems that don’t have technical solutions, the struggle never ends.

http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?currentPage=all

[HalfLotus]

Obama seems to have the reverse Midas touch.

What's next on his agenda?

Iran, probably.

[Wezil]

Oh geez. That should be fun.

[DinoDoc]

I hope your happy Boomers! You're robbing your Great-Great Grandchildren to pay for your damn Botox treatments.

[MrFun]

I'm going to use your quote and mean it to include a few people.

It was brought up to take steps towards an answer, in addition to Mr. Fun's observation.
If this is truly the way to go, why not do it right? Measure twice, cut once.
So what if it doesn't happen next year? It's open to study. Do it right.
Doing it right, in part, means including everyone uniformly. Why leave more people behind in something else so important?

Republicans opposed doing it the right way, the first time (passing true, universal health care).

[KrazyHorse]

I hope your happy Boomers!

[Drake Tungsten]

I, like Keith Olbermann, am going to refuse to buy sub-standard health insurance. Civil disobedience!

[Asher]

I hope your happy Boomers! You're robbing your Great-Great Grandchildren to pay for your damn Botox treatments.

It surely won't be any more wasteful than unnecessary wars. At least health care saves lives and doesn't send young Americans out to foreign soil to die with nothing to show for it.