"Repeal And Replace" With...What?...

Okay, The New Majority has had its fun...

In a largely partisan vote, members of The New Majority in the U.S. House have kept faith with the people who elected them by passing the "Repeal The Job-Killing Health Care Law" Act (in a gesture of The New Civility, House Speaker Boehner referred to the bill as the "Repeal the Job-Destroying Health Care Law" Act...a nicety perhaps too subtle for us here in the grass roots of America).

There will be no action on the bill in the Senate, where Democrats hold a narrow majority.

So...NOW what happens?...

The New Majority has set itself on a course to block key funding provisions related to Obamacare...but that, too, faces the prospect of a pesky Senate .

In reality, the stage is set for establishing "Reforming Health Reform" as a plank in the Republican platform for 2012.

Now, I'm not a Washington insider, but it would seem to me that the Republican strategy would have a little more...intellectual and political heft...if they were a little more forthcoming about what they're FOR.

It's not like we haven't been here before. Republican Congresses have been responsible for the last two quixotic attempts at "health reform:" The enactment of HIPAA in the mid '90's was supposed to increase access to health coverage for small businesses and individuals, as well as reduce the rapid rise in health insurance costs; it did neither, largely because the law and attendant regulations were written by insurers. And of course, there was that exercise in fiscal irresponsibility known as Medicare Part D.

So let's stipulate for the moment that the republican party has not recently demonstrated either much fiscal restraint of any particular expertise in health system reform.

And let's pretend that there really IS a desire on the part of The New Majority to do something constructive...to fix parts of the new law which are broken(or easily breakable) while not messing about quite so much in the private market...and creating incentives for people voluntarily to sign up for health insurance.

First, let's recognize a fact: In Medicare, Medicaid, The Veterans Administration and other programs, government is the biggest purchaser of health care services in our country. If I were advising The New Majority, I'd place priority #1 on improving the clinical and administrative efficiencies produced by the health plans currently under the direct oversight of the Congress.

Second, let's recognize that the private health insurance market is currently four markets: the market for large, self-insured employers (which have been quite aggressive in seeking exemptions from some of the plan design provisions of the new law, primarily to enable them to continue offering high-deductible health plans to their employees); and within the fully-insured market, companies with more than 50 employees; companies with 2-50 employees, and individuals and the self-employed, who are currently precluded by federal law (and most state laws) from obtaining group coverage.

Because large self-insured employers' health plans are currently regulated by the federal government under ERISA, it's appropriate for Congress to reinforce its oversight of these plans.

For the rest, Congress needs to own up to the fact that federal "assistance" in the fully-insured market has largely exacerbated problems faced by small employers and individuals in obtaining affordable coverage (there are a few exceptions, in my opinion...although many of the "consumer protections" being touted in the new law are actually statutory attempts to UNdo some the provisions under HIPAA which have created problems in the non-group market). So here, perhaps the key for Republicans is to do less, not more.

A key element of the Republicans' health reform platform for many years has been to repeal all tax preferences for the purchase of health coverage. That ain't going to happen. Instead, let's go the other way, and make sure that the tax preference follows whoever the purchaser is. Make health insurance premiums fully deductible for both companies and individuals.

There seems to be agreement that even Republican leaders are reluctant to do away with the health insurance exchanges incorporated into the new law. But there are some legitimate concerns that exchanges could adversely affect competition in the small group and individual markets. That's largely due to the fact that the new law tied new subsidies for premium costs exclusively to participation in the new exchanges.

So once again, let's go the other way, and create incentives for the formation of private Small Business Health Plans. This would enable small employers and individuals to band together in the private sector, in the voluntary marketplace, to purchase health coverage jointly. Give these private entities access to the same subsidies as are available through the exchanges, encourage them to use IT and other tools to increase administrative efficiencies, and create powerful private entities, governed by purchasers, to compete with public exchanges.

And put the mandate off till way, way in the future. Only two constituencies support a mandate: health policy wonks who believe, but can't prove, that mandating the purchase of health coverage will somehow subsidize the cost of coverage for those currently excluded for health reasons; and insurers, who both see the opportunity to capture a few million new customers, and know that once a mandate is enacted, there won't be any further need to worry about cost controls, because you'll have to buy coverage, no matter what it costs.

Throw in some tort reform, and you've got yourself a "replacement" for Obamacare.

Both the benefit and the problem with this approach is that many of these ideas have been part of the Republican playbook for a couple of decades, and even when they held firm majorities in Congress and control of The White House, the ideas have gone nowhere.

This is why it's highly unlikely you'll see a real "replacement" bill introduced in this Congress. Because for a couple of decades, Republicans have proved themselves unwilling to take much of a lead in health reform. It'll be much more fun to holler about liberty, obstruct the proceedings, and wait till 2012...

What Difference Does A Mandate Make, Really? The Numbers Don't Add Up...

Opponents of "Obamacare" were popping champagne corks just before Christmas, when a federal judge in Virginia rules that the individual mandate, a central element of the legislation, exceeded the regulatory authority granted to Congress under the Commerce Clause.

Supporters of the plan were predictably dismissive, though they warned that, absent a mandate, an insufficient number of new, young, healthy people would be brought into the insurance system, there could be little prospect for keeping insurance costs under control in the Brave New World.

I have preached against the imposition of mandates for many years, but not out of any cockeyed notion of individual liberty. I believe that a mandate would not achieve the stated policy goal of the plan's advocates, and would, in the long run, have the opposite effect, leading to acceleration of health insurance costs and even less emphasis on quality than is the case in the current morass we call a system.

Because I don't think the numbers add up. I'm not an actuary, so maybe somebody out there smarter than I am will correct my mere layman's understanding.

Let's assume for a moment that the total number of Americans lacking health care coverage is about 50 million (an increase of about 30% from the "37 million uninsured" which led to the enactment of HIPAA, which was supposed to "fix" the markets for small group and individual insurance...And how did THAT work out?...).

For about half that group, "uninsuredness" is not a permanent state. For about 25 million uninsured Americans, the condition is transitory, lasting six months or less, because they're between jobs. So they have some short-term exposure, but the market will take care of them.

That leaves 25 million.

It's estimated that a third of that group consists of "young invincibles," workers under age 30 who have not purchased coverage, either because they think they don't need it or because they can't afford coverage; often they can't afford coverage because pre-existing health conditions have made coverage for them very expensive, if they can get it at all. Theoretically, these are the people whom policymakers want in the system, on the notion that, in general, they'll use less in medical services that they'll pay for in premiums.

Getting them into the health insurance system might easily be accomplished through health insurance exchanges, with subsidies to make coverage more affordable (Note: community rating has a big effect on these young folks' premiums. In Ohio, a healthy 25-year old can purchase coverage for about $150 per month, because of age-based underwriting. In New York the cost is about triple that).


That leaves 16-17 million people.

About half that number represents working families who currently earn too much to qualify for coverage under Medicaid, but not enough to afford insurance premiums. I think that expansion of children's health coverage, and the institution of premium subsidies, help these families get into the system.

That leaves 8-9 million people who currently can't obtain coverage at any price because of pre-existing health conditions. They've had a helluva time finding coverage, but it's not as if they're not trying. A study by the Commonwealth Fund concluded that only about nine percent of those applying for health coverage in the individual market are able to obtain it, because their health conditions either render them uninsurable, or because they rates they're offered are out of reach.

Aren't we making pre-existing conditions go away, and extending premium subsidies to these individuals through exchanges, as well?

Most of the folks I know in this category are either desperate to acquire coverage, or struggling to obtain it.

So who's left? Where are the millions of slackers who refuse to purchase coverage, even when it's available to them at a relatively affordable price?

Is it reasonable to expect that premiums generated by bringing in the "young invincibles" will come anywhere near offsetting the cost of bringing in the 7-8 million older, sicker people who now can't purchase coverage at any price?

Then there's the matter of price...or more precisely, the contention that mandating participation by everyone has the long-term effect of bringing costs down for everyone. I think this contention is nonsense. There's no evidence to support it, and in the few instances where evidence exists, it would seem to support the contrary position.

Many years ago, I had the chance to debate The Lion Of The Senate, Ted Kennedy, on the subject of making health coverage mandatory. As we discussed the issue, I asked him, "Pretend for a moment that everyone in America was required to purchase a Cadillac Sedan DeVille? Not just a car, but a big old Cadillac with all the options. What do you think would happen to the price of Cadillacs?"

The Senator answered that he thought the price would go down, because there would be so many more of them.

I suggested the contrary: not only would the price not go down, but there'd be no limit on the price of Cadillacs, because regardless of price, the government said you had to have one. And it wouldn't matter how well your Cadillac worked; the government didn't say your Cadillac had to work great, only that you had to buy one. Oh, and by the way, other carmakers? Competition in the car market? It would cease to exist.

That's the last time we spoke personally.

There is one state, Hawaii, which mandates that all citizens have health coverage. It's essentially a holdover from Hawaii's plantation days. In the early '70's, state government required that all health plans offer chiropractic services. In the ten years following enactment of the mandate, the number of chiropractors in Hawaii doubled, and the cost of chiropractic services tripled.

Think heath care costs are accelerating in hyper-drive now?...Wait till you have no choice but to buy a standard health plan, courtesy of Our Friends In Government.

I'm perfectly happy to be proved wrong. It just ain't happened yet...

End-Of-Life Counseling and Health Care Rationing: Enough With The "Death Panels" Lie

The Obama Administration announced just before Christmas that it would use its Executive Order authority to enact regulations allowing physicians to be reimbursed for providing end-of-life counseling to patients and their families.

Predictably, conservative talking heads once again took up the cry of government interference in life-or-death decisions via the formation of "death panels", and of the slippery slope toward rationing of health care services.

Puh-leez...

It was a mark of the President's relative inexperience with hard-ball politics which led him to lose control of the debate over end-of-life counseling in the spring of 2010. And his unwillingness to engage with his opponents over the issue led to one of the key mistakes committed by novice politicians: letting your opponent define the terms of the debate.

It would seem the President and his minions are a little better prepared to pick up that fight again. And it would be good for the country if he succeeds. Here's why.

First, the new rule simply enables physicians to be paid for what most of them and their clinical and nursing staffs already do: assist patients and their families in weighing the pros and cons of treatment or palliative care options toward the end of life...whether it be the life of an aged and infirm relative, a traumatically injured younger person, or even a severely ill premature infant.

If you've ever been in a position to make such a decision, you know how difficult it is. Rarely are even the best-educated individuals capable of thinking straight when someone they love is teetering on the brink of death. And for many, clinical efficacy (whether or not a treatment will cure the patient) is rarely the first consideration.

And that leads to the most important reason that end-of-life counseling makes sense: it can lead to dramatic reductions in hospital and physician costs.

Over half...by some accounts, as much of 70%...of hospital costs are directed toward individuals in their last three months of life. Much of those costs come from providing high-technology supportive services to patients who have no hope of surviving. Many physicians will say privately that, when facing a hopeless clinical situation, they will often accede to family members' demands to spare no expense, or to try anything, to extend their suffering loved one's life, even if such efforts are obviously futile, to avoid possible legal action.

The ability to educate patients and families about the possible benefits of hospice, for example, could have a dramatic effect on health care expenditures for private insurance, and especially for Medicare. So to the extent that health care spending reductions, and deficit reduction, are supposedly objectives of meaningful health care reform, such a policy makes sense.

Where are the "death panels?" Nowhere. Nowhere is it even suggested that anyone's going to insist that "the plug be pulled on Grandma." That's just a rather spurious lie, as anyone who's read the rule, or even the original legislative language, can tell you for certain. I know many of the Republican members of Congress who've taken up this banner. They're smart. They KNOW they're perpetuating a Big Lie. It's apparently in their political self-interest to do so. They should be ashamed of themselves...if they're capable of feeling shame.

Does such a rule lead inevitably to "rationing" health care services? Depends on your definition of rationing. At its foundation, "rationing" is all about the rational allocation of unlimited resources, whether food or, in this case, money (in the form of services). So literally, one can NOT engage in rationing only if resources are unlimited.

Up till now, for most patients, end-of-life care is "rationed" based on the lifetime maximum of their health insurance policies. Providers have often thrown a bunch of technology at patients until they reach their lifetime max; then they're sent home, or into hospice care.

With the elimination of lifetime maximums on most fully-insured health plans, that form of rationing goes out the window. Absent more patient involvement in critical decision-making, hospitals will no longer have even THAT incentive to shut down their treatments for critically- or terminally-ill patients.

One would think that those advocates for "patient empowerment" out there would celebrate this rule as a potential benefit to patients, their families, and the overall system of care. One can only assume that the REAL opposition to the imposition of such a rule would be hospitals, whose revenues could suffer if more patients and families actually begin making educated choices.

And that may be what's REALLY at the root of this furor. As is usually the case with insurers, it's also true for hospitals that an uninformed patient is often their best (and most profitable) customer.