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Retired Steelworkers and single payer advocates rest after a long day rallying and lobbying for health care on June 25, 2009.

The Senate and House are preparing to reconcile two modestly different approaches to health care reform.  Charges and counter charges continue to swirl around like New Year’s Eve confetti.  Are we on the verge of an historic breakthrough on health care reform?

What lessons have we learned about ourselves and our government?  Let me suggest six.

1.            America matters more to some than Americans.

The target of health care reform is Americans who are in the margins of our workforce.  They earn too much money to qualify for health care programs for the poor – state Medicaid and Children’s Health Insurance Programs (CHIP).  They work for small businesses who cannot or do not provide health insurance coverage.

As a society we have already agreed to provide health care to the poor, the old and those who work full time for profitable companies.  Why is it so difficult to fill the remaining cracks in the system?

Yet opponents of reform frame their arguments as a classic American struggle against big government.  The stories of very real Americans facing death by neglect or medical bankruptcy don’t seem to resonate as much as the conjured images of America challenged by fictional tyrannical death panels and giant government databases.

2.            I got mine – go get your own.

Very few people with health insurance pay anywhere close to the full cost of health insurance.  Less than 10% of adults under 65 obtain their health insurance in the individual market where they have to pay the full price.  73% of those who tried to buy individual insurance gave up either because it was not available to them or it was too expensive, according to a study by the Commonwealth Fund.  For the rest of us, our employer pays the majority share, or the government for those on Medicare and those on Medicaid.

Yet extending the same helping hand to those who may need health insurance to continue to participate in the workforce is tantamount to terrorism or tyranny, according to certain news commentators.  That may be an extreme view, but the noise it generates is dead weight that drags the center of political discourse away from constructive and meaningful reform.

3.            Money talks

Despite the clamor from the right, polls consistently show strong support for health care reform and even for the “controversial” public option.  Recently, I described how opinion pools show strong support for a single payer system.

So why are Democratic politicians having such a hard time getting “on board” with health care reform.  Countless stories have documented the amount of money the health care industry has spent on lobbying members of Congress.  One is reminded of my home town’s favorite son, Simon Cameron, Lincoln’s first Secretary of War, who once said, “An honest politician is one who when bought, stays bought.”  Only when some politicians began to realize that actual voters are behind those poll numbers did the public option begin to show renewed life.

Sadly, the Senate result reinforces the impression that money talks.

4.            Symbols matter

There is not a whole lot of evidence that the public option by itself will make a meaningful dent in the number of uninsured or in medical cost inflation.  But it is a powerful symbol reflecting one’s viewpoint about who should be the intermediary between the patient and the health care system – a government or quasi-governmental organization, or a private health insurance company.  There is clearly little appetite or political will to take on the insurance companies directly with the kind of strong and consistent regulation found in other countries.  The best that Democrats can offer is the threat of weak-kneed competition.

5.            Why do simple when complex is so – complex?

There is much ado about the nearly 2,000 pages of the health care bill.  When Congress tries to fix 1/6 of the American economy, it can’t be easy.  An analogy can be made to taking your tired old clunker to the repair shop.  It is too expensive.  It can’t haul nearly as many people as it was supposed to.  But you love it to death.  Your favorite repairman could hand you a ten-page estimate and tell you it will still be expensive and still won’t carry the all the passengers you would like.  Or he could hand you a one-page invoice for a new car.  HR 676, the “Medicare for All” legislation and beloved of single payer advocates, is 27 pages long.

6.            Who does Congress love most?  Not you and me.

Do you doubt the devotion of Congress to the insurance industry?  If so, the provision in both the House and Senate proposals to require an 85% medical loss ratio should say it all.  The law requires that at least 85% of premium income be used to pay for medical claims of covered participants.  Even the most conservative estimates put Medicare’s loss ration in excess of 90%, some argue in excess of 95%.  If the government can spend premium income more efficiently why let the private insurers in?

What next?

It’s no longer a safe bet that health insurance legislation will succeed (It does not deserve to be called health care legislation).  It is criticized from the right and from the left.

As feeble as it is, it will be a significant achievement given the long record of historical (and hysterical) opposition. Calling it reform will be the challenge of the spin-doctors.  Already there are estimates that it will leave a significant number of people still uninsured.  It doesn’t do enough to manage costs.  And there will undoubtedly be a backlash for a variety of reasons, some of them legitimate.  The question will be, how soon before Congress will have to revisit this issue?

Photo by JL McGee

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When reason fails shouting prevails.

From Senator Max Baucus, “We need more police.”

Voics from the back of the room

And more voices from behind the table.

Margaret Flowers, MD & Katie Robbins, Healthcare-NOW

Carol Paris, MD, PNHP

Adam Schneider from Health Care for the Homeless

Russell Mokhiber, Single Payer Action

Thanks to the brave organizers of this event!

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In discussing the nation’s health care system, “broken” is the most common descriptive term.  Almost all stakeholders seem to agree on the adjective.  Not Mr. Tevi Troy, writing recently for the Weekly Standard.

Health Care Reform Can be a Stimulus

I have argued that a major overhaul of health care would be a significant stimulus to the economy by leveling the competitive playing field for both employers and workers – those currently working, those out of work and those working on the margins.  In the long term, it would free up capital, both the monetary kind and the human kind, for more productive investments.

It does not surprise me that Congress might see things differently.  The major health care provisions in the stimulus package that will be approved by the Senate have very little to do with stimulus and everything to do with safety net.  Support for state Medicaid programs and provisions related to COBRA.  There are two small provisions in the package that do attempt to push the reform agenda a tiny fraction of an inch.

There is a provision in both House and Senate versions of the bill for for further development of electronic medical records and there is money for “comparative effectiveness research”.

These are hardly earth shaking provisions, unless you are listening to the likes of Mr. Tevi Troy.  To Mr. Troy and his ilk, these measures are the Ft. Sumter of the liberal war on the US health care system.

What planet to these people live on?

Electronic Medical Records

The Institute of Medicine has demonstrated that tens of thousands people die each year from prescription errors, many of which could be avoided with legible prescriptions.  One sure way to improve that simple process would be a script printed by a computer.  Errors could be avoided if doctors knew what other drugs the patient was taking.  That information can be provided by an electronic medical record.

Yet Mr. Troy and other right wing fear mongers describes the stimulus as a “threat to American health care.”

But as Dr. David Brailer points out in a Health Affairs blog post, the stimulus for electronic medical records will only be successful if it focuses less on the technology and more on the organizational and human impediments to its widespread adoption.

Effectiveness Research

Likewise, the defenders of the broken status quo react even more vociferously to the “comparative effectiveness research” calling it a “federal infrastructure that could be used as a tool for government rationing.”

Again according to the Institute for Medicine, one hundred thousand people a year die from hospital acquired infections.  Only 50% of people receive care in accordance with recognized best medical practice.  And yet research on the effectiveness of medical treatments is a threat?

I used to work for the Pennsylvania Health Care Cost Containment Council (PHC4), a state agency on the leading edge of public reporting on the outcomes of health care.  The PHC4 has demonstrated repeatedly that there are wide unexplained variations in the quality of care and in the practice of care.

The United States pays more for health care than any other country in the world.  And not just a little bit more.  We spend almost fifty percent more than the next most expensive country – Switzerland.  We pay more in taxes for health care than countries with tax supported health care systems and yet almost 90 million people had some period during 2006-2007 when they went without health insurance.  The United States does not rank among the top twenty nations in life expectancy or infant mortality.  This should be an embarrassment.

Investments to improve the delivery of care are long overdue.

Yet if the reactions of the out-of-touch to these modest patches to the status quo are a gauge, we are in for a noisy debate when real reform gets center stage.

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Since November 4th, interest in health reform proposals has understandably intensified.  I like to flatter myself that this blog might make a small contribution.  But I do have a day job and so the horn I blow here only has one note; if we simplify the system we can find the money we need to cover the people without health insurance and increase product satisfaction among all stakeholders.  

I am not a policy wonk who views the health care system wonderfully distilled through the glorious abstraction of statistics; nor am I encumbered by practical politics.   I view the system from the bottom looking up.  I have a stake in the present system, but that stake is poorly represented in these musings.  I am a gatekeeper to the health care maze.  In my ideal world there would be far less need for the work I am doing.

I know from daily encounters just how daunting that maze is for people needing care.  I tend to demonize piece rate physicians who are too quick to deny care rather than trust the maze.

So when I read others who write about health care reform I look for my theme.  On Sunday, November 23, 2008, the Washington Post published an opinion piece by Shannon Brownlee and Ezekiel Emanuel, 5 Myths About Our Ailing Health-Care System.  The authors are right on target with four of the five myths that they debunk.  They drive home the point that we are paying a lot of money for our health care, that we are paying a lot of money for not particularly good health care, that we really are paying the price through premiums, taxes, and lost wages, and that Americans are ready for a change.

I take issue with myth #3 – we would save a lot of money if we could cut the administrative waste of private insurance.  The authors don’t think much of that notion.  Since administrative complexity, and consequently costs, is my central theme, I need to take issue with the authors on this one.  The authors argue that if the private sector were to spend on administration what Canada spends, the potential savings is only $120 billion.  That’s not enough to cover the cost of covering the uninsured, they assert.  In addition, it would only be a one-time savings. 

First, $120 million is well within the cost range most often cited to cover the uninsured.  If not enough, it is certainly close enough.  Covering the uninsured is a major motivation for politicians.  There may be lots of reasons to reform health care, but only this one will move politicians to act.  If there is savings to pay for that coverage, that is additional motivation for political decision makers.

Second, the savings is not a one-time savings.  The savings recurs with every health service that is now billed to a private payer.  I fail to see how the authors can argue otherwise, unless they fail to understand just how duplicative the current bureaucratic maze is.

The authors’ argue that administrative costs are not a major driver of health cost inflation.  True, but those costs pay for administrative services that add little value to population health and add considerably to the inflation of frustration experienced by both patient and provider alike.  

My real beef is that they limit themselves to administrative savings from private insurance.  They ignore the savings from government programs.  Government programs do tend to have much lower administrative costs than the private sector, even lower than the benchmark 15% number used to generate the $120 million administrative savings mentioned earlier.

There are just too many government programs.  And the government programs intersect with the private programs and other government programs in too many confusing and complex ways.  See, for example, my discussion of our program’s encounter with the Veteran’s Administration.

The authors argue rightly on myth #4 – health care reform is going to cost a bundle – that a better organized delivery system will produce greater savings than any administrative savings.  But to achieve the long-term benefits of a better organized health care delivery system, we need better organized patient delivery systems and better organized payment delivery systems.  

The ideal is a system that enrolls people once and payment flows from a single source to those delivering care.  That is admittedly an ideal, but meaningful reform proposals need to keep that target in mind and not layer even more programs, regulations and bureaucracies over top of the current system.

So, to Ms. Brownlee and Dr. Emanuel I maintain that cutting administrative waste to save money is not a myth; it is a necessary first step toward a more efficient delivery system.