So Obama, after letting the Democratic caucuses flounder around for a year, has put his own proposal on his table. Nothing much new here. It tinkers with the Senate’s passed bill but in modest ways. The Wonk Room has a chart comparing the options.
It lacks any sort of public option in the form of new offerings or expansion of current government-as-payee offerings. It lacks even the national exchange. And of course it misses tort reform.
Kent Bottles has a good summary of media coverage of why cost control is so difficult. I know plenty of pundits find him easy to disparage but I’m with Dr. Uwe Reinhardt on this. As Bottles’ quotes from a linked NY Times piece,
[R]eaders should replace the term ‘cost control’ in their minds with ‘constraining and possibly reducing the future incomes of doctors, hospitals, pharmaceutical companies, medical device companies and so on.’” He goes on to say that given our system of governance where political contributions mean so much, “the task of constraining or reducing the incomes of American health care providers will be a long and arduous battle with powerful, moneyed interest groups.
Only a global budget eases the political situation enough to allow for lower reimbursements and in turn reduced costs. Only a global budget can affect rationing in a sustainable way. Only a global budget can contain costs long term. Only cost containment on the order offered by a single payer or socialized system will allow the expansion of access to care enough to term it universal. Otherwise, forget that goal…at least not long term.
Medicare is the payee for healthcare services for more than 40 million Americans. It accounts for more than 30% of practice revenue by Center for Studying Health System Change measures.
And it’s fee schedule sucks and the proposal to freeze it, as in 2007, sucks; especially for primary care physicians. But even as MedPAC surveys find better than a quarter of Medicare recipients complain they have trouble finding physicians who accept Medicare, I continue to assert that a catastrophic access problem for those >65 is hard to imagine.
The possibility of a 5-year Medicare pay freeze is the latest twist in recent congressional efforts to fix the SGR problem. The current battle over healthcare reform legislation — and how to get federal spending under control — has made that job complicated.
[I]nternists…depend on Medicare for 44% of their revenue. In some ophthalmology practices, 80% of the patients are Medicare recipients, said Kristen Hedstrom, assistant director of legislative affairs for the American College of Surgeons.
Physicians who derive most of their revenue from Medicare can hardly afford to back out of the program, noted Ms. Hedstrom. For all practical purposes, they would not have a patient base anymore.
A single payer insuring 40 million; generating nearly half of all revenue for primary care. Unless primary care physicians are actively losing money, and I admit some of them are, where are the plurality of them going to go to create an access crisis?
As long as the vast majority of primary care physicians are at least breaking even on medicare where is this exodus going to come from?
And yet organized medicine and average docs continue to pretend they have a stick in the coming fight over the proposed freeze or in the fight to fix the SGR. We hear it from groups like The Heritage Foundation or in op/eds or even in New York Times pieces. Yeah, physicians will leave Medicare and we’ll hear the anecdote about the grandmother who can’t find a medicare physician in the middle of midtown Manhattan. But physicians fleeing on a scale large enough to cause outrage? To cause panic at the AARP? To force restitution and continued cost of living increases in the fee schedule?
Nah.
If organized medicine staves off the freeze and, God willing, the SGR mandated cuts it’ll be because they greased the wheels appropriately and sold the above story. And truly I’m with them in trying to do that. But you don’t have to buy the hoopla yourself to try to sell it.
Their options are few, and extremely complex, mostly involving legislative tactics that would be difficult to pull off in the best of circumstances, let alone at a time when members are worried they could be the next Martha Coakley – a seeming Democratic shoo-in laid low, in part, by health reform.
And already Tuesday night, Democrats were being forced to come to terms with the prospect that their decades-long goal of health reform might once again fall short, despite getting closer to becoming law than ever before.
Since the initial shock of the loss things have not significantly improved. That’s a stunning admission, that Democratic majorities in the House and Senate may not come through to muster anything of health care reform. Their options are well spelled out across the blogosphere but essentially include the House passing the Senate bill as is, reconciliation or scaling down health care reform to something that could attract a bipartisan vote in the Senate.
Pelosi has been public and clear that she does not think she has the votes in the House for the Senate bill.
That in and of itself should be stunning and dismaying to Democrats and liberals. When history is finally written the political story of my generation is going to be the indecisiveness, incohesiveness and just plain terrible political game played by the Democratic Congressional caucus. In power and out of it Democratic Congressional leadership has been a sham. Gentleman Sam, who?
The fact a generational President, who stepped in with broad support and a Speaker who led her party to historic gains in the House can’t coerce groups like the Blue Dogs and Stupak’s gang into support what is, at least percieved, as once in a lifetime legislation is nothing short of political failure.
Even as the horror of the loss of Kennedy’s former seat wears off the Democrats remain divided and confused and generally thunderstruck. From the DCCC chair to Senator Dodd to comments from Republicans (mp3), there shouldn’t be a lot of hope from liberals.
As John Stewart says, “See, it’s not that the Democrats are playing checkers and the Republicans are playing chess. It’s that the Republicans are playing chess and the Democrats are in the nurse’s office because once again they glued their balls to their thighs.”
Democrats have to elect some actual politicians to leadership roles.
I continue to be of the mindset that meaningful reform was dead long ago. The Senate bill doesn’t offer a lot of hope for cost containment, and thus in the long run, improving access to care. That’s for another post however. I’m merely perpetually surprised the Democrats can’t even get the minimum the Senate managed to squeeze out onto the books.
It goes beyond the Capitol, to Democratic allies who have done just a terrible job with the message to the public.
I’m hardly crying over such; I don’t support reform. But I’m surprised I’m getting my wish.
I think just about anything should be able to be marketed to us, through any commercial medium. That’s not a terribly popular opinion however. The United States is one of the few in the world where direct to consumer marketing of drugs and medical devices is prominent. And you find medication adds all over the television and publications and even sometimes on display media. Increasingly your finding direct to consumer advertising of pharmaceuticals online as well. Like all advertising online advertising is regulated by the FDA. However, some of the online marketing opportunities fall into highly grey areas, as you might imagine as new technologies are utilized to pitch you drugs.
The FDA is holding a public meeting today about online and social media use by big pharma and medical device makers. Here’s the WSJ Health Blog describing the goals of the meeting.
The FDA says its holding the meeting this week to get input on “making policy decisions on the promotion” of drugs and medical devices on “the Internet and social media tools.”
Those schedule to speak at the meeting include people from trade groups (AdvaMed and PhRMA); Internet companies (Yahoo, Google); drug makers (Pfizer, J&J, among others); and assorted ad agencies, consumer advocates and the like.
As you might imagine whenever an internet and social media-saavy group is engaged, the commentary on the meeting has been real time and copious. You can find threads on Twitter or numerous blog posts detailing what went down during day #1 of the public hearing. Eye on FDA has some commentary on the conflicting agendas of various groups who have been given voice at the meeting.
There’s no doubt that American physicians earn more than the rest of the western world. Even when you factor in the cost of medical education in the United States (and it is substantial) a medical degree remains something of a better investment in this country than essentially anywhere else. This is largely because doctors has far more control over their earnings in this country than do those in other western countries. As physicians here in the U.S. we’re largely fee based and not salaried.
Now physician income, likely, tallies somewhere between 10 and 20% of all health care spending in America. Depending on who you talk to that’s either substantial or it’s not. But the fact is that even when physicians don’t earn directly they drive health care costs with incentives, even if not financial, to promote health care spending in the form of tests/procedures/referrals.
As you might imagine, health care reform likely foreshadows changes to physician reimbursement in this country…at least in the long term.
Both NPR and the NY Times have recent articles on physician earnings under the shadow of healthcare reform.
Doctors who choose to work in nonprofit clinics seem to view their professions more as a calling than as a job. There is evidence that when medicine was less adversarial than it is now, American doctors were both happier and more respected, even though their incomes were much lower. Doctors elsewhere also remain satisfied and respected, though they are paid less than their American counterparts.
In time, medical schools will be able to attract plenty of talented people willing to accept positions under the Mayo model, where they would spend more time healing patients and less time fighting insurers. Any of the current health reform bills would help start this transition.
I’m not saying that physicians earn too much in America. They don’t. Indeed most healthcare systems undervalue physician services. I know much economic work goes towards valuing human life, which is always questionable, but I have hard time believing anyone would truly value the life of a loved one when it comes to health care services. Especially acute care services where mortality or severe morbidity are on the line there is essentially topless value to the services provided by physicians and the rest of the healthcare professions.
Despite that healthcare reform MUST eventually level off physician reimbursement in order to control healthcare costs. It is coming, whether it is fair or not, so get ready for it.
The House bill has some key points. It has both a limited individual and an employer mandate. It sets up a national health insurance exchange. It has a public option, without an opt out clause; the public option exists as a free standing market institution (it must survive on its premiums alone) within the exchange and has no eligibility levels although no employer is required to offer the public option. It severely limits insurance companies, including when/if they can cancel policies and the maximum allowable out of pocket costs/yearly for anyone covered. It places a 5.4% tax on individuals earning at least $500,000 and families earning at least $1,000,000 to help fund the bill. It lacks an SGR fix, which makes it a surprise the AMA supported it. Here is a fine plain language summary of the bill. The WSJ has a summary as well about how the Bill plays to various staked groups in healthcare.
Pelosi lost nearly 40 Democrats and gained a single Republican in passing the bill. The New York Times has a great interactive graphic looking at the Democrats who opposed the bill.
This is a big step, no doubt but if reform is to happen much remains.
The path ahead remains shaky – for the bill and for many of the Democrats who voted to approve it. Party leaders need to mend the bruised feelings that will linger from this debate before they can address whatever legislation the Senate can produce.
And in the Senate, Majority Leader Harry Reid is still struggling to find 60 votes for Senate legislation and made clear he might not meet the White House’s Christmas deadline to pass a bill. Obama said in his statement, however, that he expects to sign a bill this year.
I don’t know what to make of the Senate situation. I’m not even sure the people in the know know what to make of the Senate situation. Certainly all the pressure is now on Reid.
Even before Saturday’s House vote, senators had begun to question why Reid suddenly embraced a public health insurance option – one that he didn’t yet have the 60 votes to pass.
In the process, the Senate debate over health-care has stopped dead, raising the possibility the Senate won’t even begin floor debate until after Thanksgiving. Reid himself recently left open the chance the final bill could slip until early next year.
That remark earned him a visit from White House Chief of Staff Rahm Emanuel, who showed up in the majority leader’s office a day later to press him on the urgency of the Christmas deadline, according to two Senate aides.
But it’s not just timing. Reid’s first task is finding a way to bridge the divide in his caucus between liberals pushing for a public option and moderates who have resisted the most ambitious version of that plan.
I’ll refrain from making a prediction that Reid will never get a full fledged public option, as appears in the House bill. Not after declaring the public option, in any form, dead earlier and being shown up. But obviously it isn’t likely that the Senate is liberal enough for such a public option. Even if Reid gets some form of the public option, such as with the opt out provision, it remains to be seen what happens when the Senate and House try to reconcile their bills; how far the Senate pulls the public option to the right.
We’ll see I suppose. My bet: A public option with an opt out, the tax increase is killed and Reid gets it passed sometime between Thanksgiving and Christimas. And the conference committee puts something out that looks a lot more like the Senate bill than the House bill.
I wasn’t old enough to vote when Joe Lieberman appeared on a ballot in Texas. I’ll be honest I doubt the Gore-Lieberman ticket would’ve gotten my vote at that point in my life. I was a Texan and George Bush hadn’t quite risen to the mediocrity he eventually would.
ZD YouTube FLV Player
But to imagine how close Joe Lieberman was to the presidency has become an increasingly scary thought. I don’t think anyone who has watched Lieberman’s personal persona can think that his aspirations were to something less than the White House. I can think of few Senators further from it now.
He’s, of latest, manifest his bizarre behavior in reference to the debate on health care. Whatever you think about the debate, Lieberman’s continued threats to personally filibuster the public option seem beyond reason. Here’s Nate Silver putting it in words better than I can,
[T]he usual things that serve to motivate a Congressman don’t seem to motivate Joe Lieberman.
Would voting to filibuster the Democrats’ health care bill (if it contains a decent public option) endear Lieberman to his constituents? No; Connecticutians favor the public option 64-31.
Would it make his path to re-election easier? No, because it would virtually assure that Lieberman faces a vigorous and well-funded challenge from a credible, capital-D Democrat, and polls show him losing such a match-up badly.
Would it buy him more power in the Senate? No, because Democrats would have every reason to strip him of his chairmanship of the Homeland Security Committee.
Are there any particular compromises or concessions he wants in the bill? He hasn’t stipulated any, at least not publicly.
What Joe Lieberman wants, in all probability, is attention. He wants Harry Reid to have to stand up and say things like : “I don’t have anyone that I’ve worked harder with, have more respect for, in the Senate than Joe Lieberman.” He wants face time on Meet the Press. He wants to make liberals feel some pain — especially those who tried to get Ned Lamont elected in his place. He wants everyone to know how maverick-y he is.
Personally I’m okay with Joe being Joe obviously. Everyday he continues to pull this shit it makes the opt out option more tenuous. I feel almost certain he’ll cave, but in the off chance he doesn’t good for him. But really I’m cheering on someone with something of a personality disorder. There’s no order to what Lieberman is doing. Attempts to attribute some far reaching strategy to Lieberman’s actions are misplaced. The man has borderline tendencies. There’s nothing more to Lieberman than him demanding attention. Next he makes a suicidal gesture on the Senate floor.
p.s.
Here’s Slate on the issue, “[o]r maybe Lieberman is making all of this up as he goes along.”
I’ll be honest, I’ve declared off this blog and with full confidence that the ‘public option’ was dead. Even with all the hope for reconciliation I just did not think the Democrats had the cohesiveness or that Harry Reid commanded the authority to muster his conservative wing for the vote. Comments like this stirred me to that belief,
U.S. Sen. Blanche Lincoln said today she opposes a public health insurance option because it would be too expensive.
“For some in my caucus, when they talk about a public option they’re talking about another entitlement program, and we can’t afford that right now as a nation,” Lincoln said in a speech to the Elder Law Task Force at the University of Arkansas for Medical Sciences.
Reid’s efforts got a boost Friday when two key Senate moderates signaled that that they were not inclined to block him.
“I conveyed to Leader Reid that a number of moderates still were extremely concerned about a government-run, taxpayer-funded, national public plan,” Sen. Mary Landrieu (D-La.) said in a statement after meeting with Reid. “However, I am encouraged that the conversations taking place over the past week among Senators who back different versions of a public option could potentially lead to a compromise. I believe this compromise should happen sooner, rather than later, so we can get to work on other critical aspects of heath care reform.”
An aide to Sen. Joseph Lieberman (I-Conn.) said that, while the senator does not favor a public option with a state exemption, he was “inclined” to vote for a motion to proceed. This would put Reid closer to the 60-vote threshold.
I don’t support a public option or any government involvement in health care. But it is hard to deny that if your goal is to control costs then a global budget system is the way to go. A public option is, without a doubt, a backdoor to a single payer system in a decade or so.
It will save money if simply because of economy of scale. There might be some cost savings in the efficiency of how it functions as compared to the private insurers but the real savings will be as the public option narrows the market. If you thought health insurance was a monopoly in some areas already, it will get even less competitive. But as competition dries up, what the insurers and the public option are willing to pay for health care will as well. The entire cost of the operation will go down as providers are dictated less reimbursement for care.
Indeed I would argue a ‘public option’, and eventually a global budget system, is the only long term viable way to control costs.
Without a ‘public option’ any “health care reform” the Democrats achieve will be laughable.
If Harry Reid pulls this off in the Senate it will be impressive, even if I don’t support it. Like I said, I thought the public option was dead for sure.
The Sustainable Growth Rate is a Medicare formula under which when Medicare goals over annual budget (virtually guaranteed every year) physicians reimbursements are automatically reduced the next fiscal year to bring Medicare expenditures back in line. In 2010 physician fees are to be cut 21.5% across the board under the SGR formula.
Every year, with significant prodding, Congress forestalls the cuts due to take place under the SGR formula. But they do it merely on a year to year basis.
Proposals to scrap the SGR formula have come and gone, without success, through the Congress under Republican leadership.
“In the Senate’s first vote on health care spending this year, a bipartisan majority rejected the Democrat leadership’s attempt to add another quarter trillion dollars to the national credit card without any plan to pay for it,” Mr. McConnell said in a statement. “With a record deficit and a ballooning national debt, the American people are saying enough is enough. Today’s vote shows that this message is finally starting to get through to Congress. Hopefully it’s a sign of things to come in the health care debate ahead.”
