The birth of the bill was anything but pretty with infighting, favors, legislative slights-of-hand, enticements, and even threats occurring, but like a difficult breech birth, it still brought forth our new legislative baby. We have learned much from the bill's gestation:
First, our legislators in Washington rarely read complicated bills before them. Sound bites carry the day when important policy is at stake.Yet here we are.
Second, the people have felt too disenfranchised and disempowered for too long. They are tired of feeling powerless to the ever-increasing costs in health care, yet still insist on the new, the shiny, the whizbang. This cultural disconnect will continue to plague our policy makers moving forward.
Third, we have watched the centralization of power and money in health care cede decisions to our Big Box retail-purveyors of health care delivery in favor of the local physician and the patient. Now with government regulators and oversight committees and health czars, a new world order is now upon us. Will it be better? Hard to know. But costs concerns will take precedence over health concerns from time to time, and America is going to have a hard time adjusting to this new paradigm. For doctors, there will be a push for greater efficiencies to care for the greater volume of patients yet paradoxically, taking one's time and being inefficient is usually synonymous with patient satisfaction.
Fourth, despite the outcome of the vote in the House of Representatives, the government isn't perfect either. Like the Big Box retailers they aim to regulate, the government is also centralized, oversized, disorganized, and slovenly yet affects every corner of our country. Whether you're a Southern Baptist or Jewish Rabbi, better get ready for what the government's health board says, because their decision we be the same for all of us. God forbid they get it wrong: as we've seen, changing things takes a while. Still, it's here, we're all going to have to chew on it this legislation, digest it, and expel the parts that stink.
Perhaps more than anything is that the war has begun that pits the power of our current health care "stakeholders" and our government. It is sad that it's come to this - that we could not collectively determine a simpler way to provide health care to our populace with local self-determination that preserves innovation and economies of scale over central oversight of issues affecting our most personal health decisions.
Like King Pyrrhus of Epirus, whose army suffered irreplaceable casualties in defeating the Romans during the Pyrrhic War, the President, the Speaker, and our Congress has set us on a new course.
Hail to the victors.
Let's just hope their victory was worth it.
-Wes
The great irony is that Government has caused the increasing crisis in healthcare, and is now claiming that only more Government intervention can solve that crisis.
ReplyDeleteThe least destructive way to subsidize healthcare is to give vouchers to the needy. But, the high cost is or would be politically unpopular. So, that cost is hidden by underpaying for medical services, resulting in an a tax on insured patients through cost shifting. This distorts the entire market, producing unrealistic prices and a web of special deals.
On top of this, the Government makes employer-provided healthcare tax-free, but taxes all other means of purchase.
- -
Do Smart People Run The Market?
"The market" usually refers to economic exchange, but here it applies even more strongly to health care delivery. How do we best solve the complex problems in healthcare?
Academics and politicians routinely pose a question: Do you want us to provide rational, insightful, far-seeing management of your life and resources, or do you want to leave this to the unregulated, unplanned, hit-or-miss results of the market? They are smug in their belief that there is only one smart answer, that rational planning has to beat random action every time.
Of course, they spin the question to get their desired answer. The better question is: Which do you choose as the primary way of finding solutions to the problems of life?
The choice is not between government planning or market non-planning.
The choice is between:
(1) government planning by the few through politics, or
(2) market planning by millions with the knowledge and resources to create more value than they use up.
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The Political Distribution of Wheat
This is a short analogy to what is happening in the market for medical services. What does a market for wheat have to do with healthcare? It is easier to understand.
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The Medicare Tomato Market
This is a very readable, longer analogy and explanation of Medicare economics.
Say that tomatoes were declared vital to life and made available free through the Medicare National Tomato Bank. The story of the healthcare market is translated to the tomato market.
Medicare/Medicaid spending is currently 1/2 of healthcare. Government underpays; doctors and hospitals stay in business by shifing the unpaid costs onto the insured patients, the ones who can pay and don't see the bills.
I was wondering if you were in mourning over the past few days!
ReplyDeleteObama said it best; this is only the start of change in our health care system as we have known it. It will continue to be a work in progress that will require refinements over time.
I fail to see why you remain so convinced that this is some goverment centralization and command control. Show me the elements of this bill that exert this central influence!
People will still be free to determine where they obtain their insurance and I see no restraint on choice of providers. There will be 30 million plus people who did not have health insurance previously; how can doctors consider that a bad thing if they truly are interested in the public health.
No longer do we need to be concernd about what diagnosis we tag our patients with for fear they will no longer be able to obtain health insurance. No longer will we need to worry about our childrn going without health insurance. Choice will be more readily availble in insurance pools that have only been previously availible to federal employees.
I think you have been listening to Fox News too much with the talking heads likening this to a communist takeover. This says alot about how far right the Republican party has tilted over the past several years that an attempt to offer the same access to health care that seniors enjoy is described as Armmegedon by the house minority leader. This bill recognises nearly all (I'll concede Obama chickened out on tort reform) the problems with our present system and attempts to fix them.
Time for that change you can believe in!
"sad to say it has come to this?" Jeez, what have the republicans been doing for the last 8 years, and the two Reagan admins, and the Bush I admin? And what's with the "war" term while your words seem to want us all to work together?
ReplyDeleteI don't know how it all is going to work out, but this much is true: some folks are going to live that would have died, and 30 million Americans are going to have access to health care.
Keith-
ReplyDeleteI fail to see why you remain so convinced that this is some goverment centralization and command control. Show me the elements of this bill that exert this central influence!
For those not familiar, Disproportionate Share Hospital (DSH) adjustment payments provide additional help to those hospitals that serve a significantly disproportionate number of low-income patients; eligible hospitals are referred to as DSH hospitals. States receive an annual DSH allotment to cover the costs of DSH hospitals that provide care to low-income patients that are not paid by other payers, such as Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) or other health insurance.
So now, quoting from one of the Amendments to the bill signed by the President:
"(7) MEDICAID DSH REDUCTIONS.
(A)REDUCTIONS.
(i)IN GENERAL. Fore each of fiscal years 2014 through 2020 the Secretary shall effect the following reductions:
(I)REDUCTION IN DSH ALLOTMENTS. The Secretary shall reduce DSH allotments to States in the amount specified under the DSH health reform methodology under subparagraph (B) for the State for the fiscal year.
(II)REDUCTIONS IN PAYMENTS. The Secretary shall reduce payments to States under section 1903(a) for each calendar quarter in the fiscal year, in the manner specified in clause (iii), in an amount equal to of the DSH allotment reduction under subclause (I) for the State for the fiscal year.
(ii)AGGREGATE REDUCTIONS. The aggregate reductions in DSH allotments for all States under clause (i)(I) shall be equal to
(I)$500,000,000 for fiscal year 2014;
(II)$600,000,000 for fiscal year 2015;
(III)$600,000,000 for fiscal year 2016;
(IV)$1,800,000,000 for fiscal year 2017;
(V)$5,000,000,000 for fiscal year 2018;
(VI)$5,600,000 for fiscal year 2019; and
(VII)$4,000,000,000 for fiscal year 2020."
Now, aren't we expanding Medicaid coverage with this bill? And don't the Senators have to sign this bill into law as is? Might there be a little typo on the number of digits in section VI above? Or is 2019 a special year because it cuts the payments only 5.6 million rather than $5.6 billion? Either way, these are pretty dramatic cuts projected to hospitals caring for the disadvantaged.
Yep, there's some change (and typos?) our disadvantaged can believe in, Keith!
Anony 09:12-
I agree with you about the Republican's inaction on this issue.
The "war" I'm referring to is one waged between the interests of the government to control costs versus the needs of the health care giants to remain profitable, provide jobs, and innovate to improve patient's health. Whether more government will truly control costs (given their track record with two other entitlement programs) remains to be seen, but seems unlikely.
Wes,
ReplyDeleteReally, really good. Impressed.
I linked your story.
JMM
what happened to the public will have 5 days to review any bill before this president signs it?
ReplyDeleteor the executive order re:abortion used to buy the votes?
unfortunately,the healthcare reform legislation provides $10,000,000,000 per year to hire and pay the estimated 16,000 new IRS employees to enforce the new taxes. yikes!
I work in a safety net hospital. We are already bursting our budget with the number of Mediaid and no insur patients. If millions more get mediaid that not many doctors take and the DSH for such hosspitals is cut we will struggle and probably shut down.
ReplyDeleteExcuse me Andrew, but is this not what the new health care plan does to a great degree? It provides for subsidies so people can buy health insurance from buying co-ops for many of the middle class now priced out of the market.
ReplyDeleteIf you refer to Medicaid, I agree that the inequities that were created years ago should be done away with, but in our infinite wisdom as a collective country, we decided years ago that poor people were less deserving of the same medical benefit as seniors. To do so would have likely made the whole health care plan a net monetary loser over 10 years and given its critics the opportunity to brand it as another spending orgy by the democrats.
Wes,
As to your contention that hospitals will have their DSM cut, you seemingly forget there will be 15 million new insured patients under the Medicaid program. Although hospitals squak about underpayments from Medicare and Medicaid, the real problems for many hospitals are they have expanded the cost side of the equation with building of new hospitals and highly compensated administrators that make it impossible for that equation to ever reconcile. There is a group of hospitals that are engaged in internecine warfare to attract the well insured customers with ever expanding facilities, glitzy advertising, and concierge service that often is not important to the delivery of health care, but serves the current buisiness model for making a healthy profit. This is what has driven up prices in the private insurance market year after year. Hospitals that deliver disproportionate indigent care do not have these big lobbys with waterfalls, and their administrators are less generously paid, so they have learned to adjust to the re imbursement and still do the task that they are chartered to do (I do remember that most of these are so called non profit institutions with a mission to serve their communities, not their bottom line).
Instead of free care, these hospitals will now get some compensation for their care that will remove the need for these subsidies. It may not be generous enough to certainly cover the overhead at the place you work at, but for many, it will pay the bills and keep the lights on. It is basically moving toward a fairer payment system for hospitals. In fact the AHA supported the bill!
This to me represents a good action to move the ball in the direction of a fairer payment system for all. The next step would be to equalize the payments for Medicare and Medicaid so that we do not continue this concept of poor people being less deserving of health care than the elderly. But then we would have that dreaded Europeanization of health care, and we know how miserably the French, English, and Germans have been suffering with their current health care systems. I see how often we see massive protests in these countries calling for their health care systems to be dismantled and for their goverments to emulate the ideal system we have in our country.
God bless the land of the free and the home of the brave!
If you will permit me to be a little off topic and ignore the typos, the tomato market, and the spin...
ReplyDeleteRegarding the states that will challenge the law in court, I find myself wondering if we might let them reject the reforms with the understanding that they reject ALL federal support of their health care services with the exception of medicare as their citizens agree that that is a program that they want to continue. My tax dollars don't go to Virginia to support their health care and they don't send payments to Washington that would be used for the nation's health care. And for the purposes of this daydream, let's forget that this challenge was settled by the Civil War. How long and how well do you suppose those health care systems will be able to function? I'd appreciate your usual careful analysis of this "Modest Proposal". Please don't forget to include what services will be provided to those citizens who have no insurance, no SChip, no medicaid, no NHI services, no CDC services, no flu vaccines.
I haven't read the 2300-page law yet, nor any of the thousands more pages of administrative rules that will follow.
ReplyDeleteBut this much I know for sure:
When government expands its power, individual freedom nearly always diminishes.
And that's not good, on balance.
But this is what modern Americans want, apparently.
-Steve
To Keith,
ReplyDeleteI favor vouchers to buy insurance or pay for care in a less regulated market for health care.
ObamaCare tries to hide its costs and taxes by coercing everyone. The costs will show up as increasing insurance premiums and runaway utilization of "free" healthcare.
The analogy is providing food stamps so that the needy can buy groceries from ordinary food markets.
Compare that to the analogous ObamaCare action of regulating food markets, requiring them to accept Government rules on what they can charge and which foods they can sell, and wanting to open government markets to "compete" with private food markets.
ObamaCare is already a net monetary loser. It increases costs by more than $1 trillion, and claims to reduce the deficit by increasing taxes even more. It doesn't "save" anything.
Andrew,
ReplyDeleteI still maintain that people will buy their insurance from the private insurance market under this bill, so I fail to see how your analogy to food stamps differs from that of food stamps?!
Public option was not included in the bill and the only peopl with no option will be those in poverty that will need to obtain Meidcaid.
Steve,
I would naimtain that pople will have more fredom under this legislation. They will no longer be tethered to their jobs as a condition of affordable insurance for one. They will no longer have to sell the farm, the house, and empty out the bank account if one of thier family has a major illness. You hosnestly think this current system allows freedom? Only the walthy have freedom under our current system!
Good regulation can control the abuses of private buisiness and it has been shown time and again that laws must be created to reign in the worse abuses. I presume you do not see any need for financial reform either after our major banks nearly took down the whole country with their greedy and self serving buisiness practices. Rmebr the S&L crisis (bailed out by goverment). Remember the dot com bust? Granted they broke no laws, but they certainly took advantage of the past years of goverment deregulation brought about by this atitude of goverment being evil that has been propagated by some (tea party wackos, Glenn Beck and his Fox News breathren and what remains of the Republican party).
To Keith,
ReplyDeleteOK. You don't see a difference between subsidizing a customer and taking over the business.
The business in this case is the insurance company, the hospitals, and the doctors.
Keith - Pages 148 - 149 of the health care bill:
ReplyDeleteBeginning on January 1, 2015, a qualified health plan may contract with—
(B) a health care provider only if such provider implements such mechanisms to improve health care quality as the Secretary may by regulation require.
First, how many health insurance plans in the exchange will be deemed by the government to be "qualified health plans" - all of them or they don't make it into the exchange.
So insurers and doctors cannot contract together if the physician does not follow the health care quality regulations established by "the Secretary". You can interpret that as great, because the government is going to define your quality for you. But, you don't even know what they will be considering "quality" health care at this point. Nobody does, and that definition is wide open for decades of alterations by a government body. "Quality" for them revolves more around "cost effective" than what is the best choice for that patient at that time.
I will concede, maybe you really trust the government to make decisions for your practice, but most doctors do not. EXHIBIT A is the example of CMS protocols for pneumonia. How are those government "order sets" better for patients. How are they better for doctors? That is not "safer" for patients, it usurps physician judgment, and it drives up costs and spending. Yet doctors are forced to do it because of some government bureaucrat who hasn't even stepped into their office to actually visualize the current patient sitting across from them, let alone dig through their medical history and signs and symptoms in that specific circumstance.
Second, YOU may know that there is a big difference between making bedside decisions and blanket assumptions about large populations of people, but that does not automatically translate into the government acknowledging that difference - again, exhibit A is the CMS pneumonia protocol. If the government understood that difference, would they be forcing doctors to order unnecessary blood cultures?
If medical science were black and white, and what worked for one group of one million people also worked for another, then government regulation this way would make sense. The assumption that blanket standards and protocols by a government body are safer for patients, is absolutely terrifying in my opinion.
Keith - Pages 148 - 149 of the health care bill:
ReplyDeleteBeginning on January 1, 2015, a qualified health plan may contract with—
(B) a health care provider only if such provider implements such mechanisms to improve health care quality as the Secretary may by regulation require.
How many health insurance plans in the exchange will be deemed by the government to be "qualified health plans" - all of them or they don't make it into the exchange.
So insurers and doctors cannot contract together if the physician does not follow the health care quality regulations established by "the Secretary". You can interpret that as great, because you like that the government is going to define your quality for you. But, you don't even know what they will be considering "quality" health care at this point. Nobody does, and that definition is wide open for decades of alterations by a government body. "Quality" for them revolves more around "cost effective" than what is the best choice for that patient at that time.
I will concede, maybe you really trust the government to make decisions for your practice, but most doctors do not. EXHIBIT A is the example of CMS protocols for pneumonia (must order blood cultures in 4 hours, abx in 6 hours with any signs of pneumonia, even if against physician judgment and is penalized with financial penalty).
How are those government "order sets" better for patients. How are they better for doctors? Those are not reflections of higher quality for patients, it usurps physician judgment, and it drives up costs and spending. Yet doctors are forced to do it because of some government bureaucrat who hasn't even stepped into their office to actually visualize the current patient sitting across from them, let alone dig through their medical history and signs and symptoms in that specific circumstance.
If medical science were black and white, and what worked for one group of one million people also worked for another, then government regulation this way would make sense. The assumption that blanket standards and protocols by a government body are safer for patients, is absolutely terrifying in my opinion.
I may have more from the bill, stay tuned....
Keith,
ReplyDeleteFirst CMS says more than half of the newly insured will be on Medicaid. Second, how will more people be buying private insurance policies than government when, according to the CBO (and the Massachusetts example), private insurance premiums are set to increase even more because of this bill, not decrease. The penalty will be more affordable than the private policies.
Here is what Richard Foster, Chief Actuary of CMS said about the Senate bill:
“"Of the additional 33 million people who are estimated to be insured in 2019 as a result of the PPACA, a little more than one-half (18 million) would receive Medicaid coverage due to the expansion of eligibility to those adults under 133 percent of the FPL. "
"However, a number of workers who currently have employer coverage would likely become enrolled in the expanded Medicaid program...For example, some smaller employers would be inclined to terminate their existing coverage, and companies with low average salaries might find it to their-and their employees'-advantage to end their plans..."
Link:
http://www.samhsa.gov/Financing/post/Estimated-Financial-Effects-of-the-Patient-Protection-and-Affordable-Care-Act-of-2009-as-Proposed-by-the-Senate-Majority-Leader-on-November-18-2009.aspx
And surely you have read the CBO reports on premiums with this bill.
Juxtapose that with what has been happening in Massachusetts:
“Embedded within the heavily subsidized program are several perverse incentives affecting firms and individuals. First, the program unintentionally gives incentives for smaller firms to discontinue health insurance so that their employees can sign up for cheaper state-subsidized care. Second, it gives incentives for employed individuals to earn less in order to qualify for higher benefits.”
Link:
www.cato.org/pubs/journal/cj29n2/cj29n2-7.pdf
I am still working on the health care bill to find things to report…stay tuned.
Keith,
ReplyDeleteFirst, CMS says more than half of the newly insured will be on Medicaid. Second, how will more people be buying private insurance policies than government when, according to the CBO (and the Massachusetts example), private insurance premiums are set to increase even more because of this bill, not decrease. The penalty will be more affordable than the private policies.
Here is what Richard Foster, Chief Actuary of CMS said about the Senate bill:
"Of the additional 33 million people who are estimated to be insured in 2019 as a result of the PPACA, a little more than one-half (18 million) would receive Medicaid coverage due to the expansion of eligibility to those adults under 133 percent of the FPL. "
"However, a number of workers who currently have employer coverage would likely become enrolled in the expanded Medicaid program...For example, some smaller employers would be inclined to terminate their existing coverage, and companies with low average salaries might find it to their-and their employees'-advantage to end their plans..."
Link:
http://www.samhsa.gov/Financing/post/Estimated-Financial-Effects-of-the-Patient-Protection-and-Affordable-Care-Act-of-2009-as-Proposed-by-the-Senate-Majority-Leader-on-November-18-2009.aspx
And surely you have read the CBO reports on premiums either rising or not being lowered because of this bill.
Juxtapose that with what has been happening in Massachusetts:
“Embedded within the heavily subsidized program are several perverse incentives affecting firms and individuals. First, the program unintentionally gives incentives for smaller firms to discontinue health insurance so that their employees can sign up for cheaper state-subsidized care. Second, it gives incentives for employed individuals to earn less in order to qualify for higher benefits.”
Link:
www.cato.org/pubs/journal/cj29n2/cj29n2-7.pdf
I am still working on the health care bill to find things to report…stay tuned.
-Jodi
Keith,
ReplyDeleteStarting page 621, PART I—LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM:
Page 627
‘‘(3) PERFORMANCE STANDARDS.—
‘‘(A) ESTABLISHMENT.—The Secretary shall establish performance standards with respect to measures selected under paragraph (2) for a performance period for a fiscal year (as established under paragraph (4)).
‘‘(B) ACHIEVEMENT AND IMPROVEMENT
.—The performance standards established under subparagraph (A) shall include levels of achievement and improvement.
‘‘(C) TIMING.—The Secretary shall establish and announce the performance standards under subparagraph (A) not later than 60 days prior to the beginning of the performance period for the fiscal year involved.
‘‘(5) HOSPITALPERFORMANCESCORE.—
‘‘(A) IN GENERAL.—Subject to subparagraph
(B), the Secretary shall develop a methodology for assessing the total performance of each hospital based on performance standards with respect to the measures selected under paragraph
(2) for a performance period (as established under paragraph (4)). Using such methodology, the Secretary shall provide for an assessment (in this subsection referred to as the ‘hospital performance score’) for each hospital for each performance period.
That’s just some of it, more to come.
Or, you could just go through and count how many times the bill says, “The Secretary shall”. But given there are SOOO many, it would way too long.
-Jodi
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ReplyDelete