Saturday, February 27, 2010

Democrats have a bad plan; Republicans have no plan

Sen. Lamar Alexander of Tennessee, chosen to be the Republican “point man” at President Obama’s health care summit presumably because he doesn’t come off like the meanest scold in the school the way Minority Leader Mitch McConnell of Kentucky does, told us afterwards that while his party supported almost nothing in the President’s health care proposal (including those aspects that they formerly championed) they had “better ideas”. This is a good thing, since they have no policy proposal. Those ideas being not on display at the meeting, where they spent their time sniping at the President’s proposal, I went to the Op-Ed in New York Times of February 22, 2010 where 5 prominent Republicans not currently in Congress discussed “How the G.O.P. Can Fix Health Care”.

Some of these are not bad ideas at all. Bill Frist, a heart transplant surgeon and former Senate Majority Leader (when the Republicans controlled both houses of Congress and the Presidency and did not do health care reform), although he cannot resist saying that the power to change is “…just not in the Democratic leaders’ DNA,” because they oppose markets, tells us that “Transforming health care to slow the growth of spending requires a radical restructuring of how health services are paid for. . The most powerful way to reduce costs (and make room to expand coverage) is to shift away from ‘volume-based’ reimbursement (the more you do, the more money you make) to 'value-based' reimbursement.” I agree and think I am on record as advocating that. “Reward value, not volume,” he says, “Medicare and private insurance companies should reimburse providers not for each discrete service they provide but for managing a patient’s condition over an entire episode of care… Health care providers could then compete on the basis of efficiency and success.” He also says, demonstrating more faith than evidence based on past performance, that at the local level waste would “most likely” be eliminated, and that “markets work”. It is a shame that Frist didn’t try to implement any of these changes when he had so much power. He also addresses not at all the other major issue of health reform, which is providing access to care for the poor, uninsured, and underinsured. Maybe not surprising from one who is not only a super-subspecialist doctor but a member of the family that created and owns Hospital Corporation of America (HCA), a huge for-profit chain that has never concerned itself about caring for the underserved.

Mark McClellan, the former head of the Center for Medicare and Medicaid Services (CMS) under President Bush, and now at the Brookings Institution, also has suggestions for saving money, though not as radical as Dr. Frist’s, and also completely avoids the coverage of those who are currently unable to access adequate health care. James Pinkerton, of the New America Foundation and a former advisor to Presidents Reagan and GHW Bush, does begin to address health care, not just money. He says Americans want more medical care but that they should also be able to get better health. I’m all for the better health part, but am not convinced by any evidence that more medical care overall is needed, though certainly some people need more than they are getting. Unfortunately, Pinkerton’s piece is entirely platitudes; while he doesn’t say he thinks we need more medical care, he offers no suggestions that would lead to better health, or (surprise!) even mention the problem of how to cover the uninsured. Another former policy advisor to President GHW Bush and president of the “nonpartisan” Committee for Economic Development, Charles Kolb, begins to get to the issue of coverage, saying both Medicare and the current private insurance market don’t work and we need a plan like the one for federal employees to compete with private insurance companies. He actually mentions the word “uninsured” and tells us that the way to fund coverage for them is to eliminate the tax deduction for employer based health care contributions. This might help but there would require a lot of other money. And this one will increase the costs to those already insured, as businesses will pass them on to their employees.

Finally, we have the distinguished Newt Gingrich, the former Speaker of the House whose caucus derailed President Clinton’s efforts at health care reform, as well as every other progressive idea that might help the American people, while posturing as a social conservative family-values guy and leaving his wife – who had cancer – for another woman. Not the first, but certainly not the last of incredible hypocrites wearing the Republican colors. And yes, I know about Eliot Spitzer, but you can’t beat the Republicans for sanctimonious words that are violated by their actions. (Kind of like all the GW Bush “hawks” from Cheney on down who never served in the military but were willing to paint as soft those who had, not only Al Gore but John Kerry and Max Cleland, who lost two legs and an arm in Vietnam, for goodness sakes!) Anyway, Newt is also against wasteful spending, and tells us that we can save $600 billion a year if we eliminate unnecessary care. This is presumably much of the same care that the majority of the people in the study cited by Charles Kolb want more of, but no matter. Gingrich is absolutely right on the need to control unnecessary care, most of it done by sub-sub-specialists (like Frist) and not primary care physicians, but how much is unclear; we do waste money, but most efforts to save Medicare from “fraud” seem to look like across-the-board witch hunts in which a set amount is to be recouped (e.g., we won’t pay for care that is a certain amount, like more than one or two standard deviations above the mean) rather than looking at the need for that care in that patient. And, of course, Gingrich doesn’t advocate using the savings for covering the uninsured, though at least he has “provided” the money. Again, something that he never did when in office, and his successors currently in office are not advocating.

So what do we have? Some reasonable ideas for saving money and controlling costs from Republicans who used to have power in government, but nothing concrete at all being offered up by those who are now in Congress. We have a virtually complete ignoring by these NY Times Op-Ed writers of the fact that there are 45 million uninsured and another 30 million underinsured in this country, a number that is growing , and that increasing large numbers of insured can’t afford it and can’t get the care that they need, while the insurance companies (see “Anthem Blue Cross of California”) are trying their best to seem as voracious and evil as the bankers and financiers who ruined the world’s economy for everyone. (And both, the financiers and the insurance companies, are making out like, well, the bandits that they are!) We have Republicans in Congress who can only oppose and snipe, and fear mainly that the Democrats, who have a large majority in both houses, may actually use it to pass a kind of (weak) health reform by using the budget reconciliation process. That part is ok; it still requires a majority and in contradiction to the conscious outright lying by the Republicans is the way most health legislation has been passed. For example, COBRA, that allows you to buy insurance coverage from your former employer when you lose your job, gets its name from the Consolidated Omnibus Budget and Reconciliation Act of 1986, SOBRA (Sixth OBRA of 1986), the State Children’s Health Insurance Program (S-CHIP) and the creation of Medicare Advantage plans (1991) – see Firedog Lake. Also both Bush tax cuts of 2001 and 2003 were implemented by Republican use of the budget reconciliation process.

And a terrible Democratic plan, that, in an apparent effort to garner either Republican or conservative Democratic support, is a huge giveaway to the insurance industry. See the great comments of Dr. Don McCanne, and the Reuters February 25, 2010 article by Drs. Steffie Woolhandler and David Himmelsten. But at least it will eliminate discrimination for pre-existing conditions and cover more people (maybe 30 million; why is covering only 30 million of the uninsured ok?). But given that the best Republican ideas don’t cover more than 3 million of the current uninsured, the answer to getting a better idea is never going to come from that side of the aisle.

A single-payer, Medicare for All, plan, would cover everyone, save a huge amount of money initially and provide the mechanism for future cost savings and controls, and is apparently off both the Democratic and Republican tables. It would “take” the money from the for-profit insurance companies who offer little value and run up our costs and wastes in an effort to make their profits. Call the President and your Senators and Congressman and demand single payer. Every day.

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