But I thought you wanted to reduce spending, Mr. Boehner!

Maybe you haven't heard, but the majority party in the House of Representatives has already introduced a bill to repeal the Patient Protection and Access to Care Act (i.e., "Obamacare"). The very same week, the very same party changed House rules to require that any bill introduced to that legislative body must pay for every additional dollar of cost by cutting an existing dollar in the budget.
Except for the resolution to repeal PPACA. The non-partisan Congressional Budget Office released a preliminary review of the bill (the CBO hasn't had time to do a full review yet), estimating that repeal of the health reform bill will add $230 billion to the federal budget deficit from 2012 to 2021 (cf. Robert Lowes, Medscape Medical News, Jan. 6, 2011).
Since the health care bill was projected by the CBO to reduce the deficit by $143 billion over 10 years, the true effect of repealing it approaches $370 billion.
So which is it, Speaker Boehner? Do you want to cut spending, or do you want to play politics with our health care? Because if you were serious about cutting spending, you would follow your own newly minted rule and dig up $230 billion on alternative budget cuts in order to repeal the health care reform bill.
Oh, wait a minute! This is politics. We don't have to be consistent, or rational, or for that matter truthful. Republicans are complaining that the "tax-and-spend" Democrats have run up the deficit to such heights that they are destroying our economy, not to mention the labor market. Then why do they introduce a bill entitled, "Repealing the Job-Killing Health Care Law Act (emphasis mine)" when, by the very act of repealing PPACA, the Republicans would increase the deficit even more, which by their own machinations would kill even more jobs?
Truth is the newly empowered Republicans are continuing to play cynical politics. It's an easy stand for them to take to assuage their Tea-Party upstarts, because the bill will never pass a Democratic-controlled Senate. And if by some miracle it did, President Obama would surely veto the bill.
I have a better suggestion. Keep PPACA, and begin to amend it brick by brick, introducing incremental improvements to what is in actuality NOT a wholesale restructuring of our health care system, but, in fact an incremental one. The truth is, ObamaCare is probably not drastic enough to save the sinking ship of American health care. But to repeal the only meaningful advance we have made in thirty years to fix the system is like drilling another hole in the bottom of a sinking ship.

Can't We All Just Get Along?

Thank you, Rodney King.

The election of Mass. Sen.-elect Scott Brown (Republican for the People) is a good thing. Without a supermajority, the Democrats can't push through their agenda with impunity. Heck, they couldn't push it through WITH a supermajority! Conversely, the Republicans can't play the role of helpless victims, because they now hold the power to - if nothing else - filibuster.
So now is the time to re-approach health care reform. Not that it will happen. That would require Democrats to grow backbones, and we all know that evolution doesn't happen that fast. The President was right to chide his colleagues and tell them not to head for the hills. If you didn't know better, you'd think the Republicans had taken back the House and Senate. They got one little ol' senate seat, for God's sake. The Democrats still hold 57 seats. They remind me of the French, ready to surrender at the drop of a hat.

As I said, NOW is the time to tackle health care reform again. Why? Because now the Republicans have to actually respond. Either they have to collaborate with the Democrats, or they have to put up roadblocks. And now that they'll need Republican support to pass a reform bill, the Democrats will have to play nice in the sandbox and be willing to compromise on some of their issues.

For the Republicans' part, they will have to either cooperate or obfuscate. Which means, ultimately, if the Democrats can push a more conciliatory bill through, the Republicans will be forced to filibuster. And if that bill is more palatable to the American people (as it'll have to be even to get on the floor again), the Republicans will be perceived as anti- working class American, and anti-small business, if they prevent a bill from passing.

The question is whether President Obama has the wherewithal to persuade his party to get back on the horse. If he can do that, he is the consummate politician of our age.

Pooch is still a virgin: Senate passes HCR bill

OK. I was wrong. I predicted in this space that the Senate would fail to pass a meaningful health care reform bill. But in fact Harry Reid (with the President's help) was able to cobble together a supermajority and pass a health care reform bill. It was not without compromise, and a lot of political hay was made about the bacon that got fried to get the bill passed.
Nebraska won't have to pay for any of the cost of expanding Medicaid coverage in that state. One New England medical school hospital will get an extra $100 million. And a handful of other bribes. The Republicans are disingenuous to point the finger at the deal-making, since this is the way Congress has operated from its inception (remember the reason we have two houses of Congress was to get the small states to vote for the Constitution in the first place).
Conservative wingers and liberal wingers ("fringe" is a more appropriate term) would have been happier - or would have felt morally superior - if they had been able to defeat this bill: the left because it was too watered-down - a sell-out - and the right because it portended the inexorable march of socialism across our land. Thankfully, both fringes were unsucccessful.
Not that the Senate bill is the panacea. It is riddled with flaws and weaknesses. But it's a far sight better than the status quo, as is the House bill, as well. We simply could not continue on the road we were on. The truth is that, whatever compromise we end up with passing both houses will reduce the rate of spending growth and will eventually reduce the deficit, as well.
The right thing to do for the American people is to hammer out a bill in conference committee that can pass into law. It won't be perfect. Far from it. But, as I said above, it'll be better than where we would have ended up without a bill. Once the bill becomes law, Congress can begin the work of hammering out the dents and improving the law brick by brick.

Senate smothers the life out of health care reform

I shouldn't be surprised. Mark Twain himself once said, "Imagine that you are a senator. Now imagine that you are an idiot. But I repeat myself." (or something like that). Why did I think that the Senate would produce a health care reform bill that would accomplish what President Obama set out to do?

I hope I am wrong in predicting that the Senate will fail to pass meaningful health care reform legislation this year. But here's why I think I'll be proved right:

1. The Republican bloc has chosen to derail health care reform, rather than to work to bring to a vote a package that they could live with. Their motivation can be only short-term political gain, and their act is one of destruction, rather than edification. The Republican bloc is not acting on behalf of American citizens, but on their own political behalf. For that reason, every one of them should be voted out of office at the very next possible chance.
2. Liberal Democrats have been surprisingly willing to compromise, but I suspect that they're tired of (in their eyes) selling out and will soon tire of compromise and will return to demanding more socially inclined legislation, led by their party chairman Howard Dean, who is now publicly calling for the current Senate bill to be thrown out.
3. Joe Lieberman is becoming drunk with the delusion of power, and will insist on his way, which in summary is to defeat any and every idea and amendment offered by the liberal Democrats.

The result will be a compromise that nobody is happy with.

Here's what I would be happy with: a private health care plan chartered and managed by the Office of Personnel Management and priced by market forces. Subsidies will be awarded to purchasers based on their income level. Don't expand Medicaid. Don't offer Medicare to persons aged 55-64. Instead, put all of these folks in the OPM-managed health plan. While ostensibly more expensive than the Medicare and Medicaid options, it would in fact end up being more affordable, because both government insurance plans (Medicare and Medicaid) are priced on misconceptions and are not adjusted by the market.

Without a "semi-public" option, as some are calling this, the private sector will not deliver affordable health plans for the currently uninsured. And without some form of public option, the bill won't pass the Senate.

But, for the sake of argument, let's say the Senate does pull itself together and passes a health care reform bill. Whatever squeaks out of the Senate will be a far cry from what the House generated, and the Conference Committee will have a herculean task pulling a mash-up out of these two disparate pieces of legislation.

President Obama, may I make a suggestion? While the clowns of Congress are performing on the current three-ring circus, bring your staff together in the West Wing and write a Health Care Reform Bill that accomplishes what you set out to do. As soon as the current effort flops, bring your bill to both houses, and commence twisting arms until they break or pull off. You won't have to water it down like the current bills because you'll be able to leverage Congress' failure to empower your negotiating position.

The pundits say that your presidency will live or die by the success or failure of health care reform. Pundits are stupid. They said the same thing about Bill Clinton, and his presidency, though sullied by failing to reform health care, was nonetheless very successful. BUT, if the pundits are right, and health care reform will define your presidency, wouldn't you rather be responsible for what ultimately passes?

First amendment to pass, first to fail

First I must apologize for not having yet read the Senate bill. I've been busy reading the 669 pages of the Federal Register that updates the Medicare outpatient prospective payment system for hospitals for calendar year 2010. Since this piece of executive rulemaking has direct impact on my everyday job, it had to take precedence. It took me a long time to read because I kept it at my bedside. Best sleep I've gotten in years.

The Baltimore Sun reported today that the Senate passed the first amendment to the health care reform bill currently on the floor, that amendment requiring all insurers to cover women's preventative health and screening tests with no copay. I suspect the impetus for this amendment arose from the backlash to the US Preventive Services Task Force's recent publication of relaxed breast cancer screening recommendations in the Journal of the American Medical Association.

Truth is, the amendment, as I understand it, won't really prevent any deleterious changes to insurance coverage arising from such research. What it will do, however, is increase access to diagnostic services, hopefully allowing us to find cancers earlier and thereby decrease mortality from these diseases. At least that's the conventional wisdom. Ironically, what the USPSTF discovered is that screening women in their 40s by mammography doesn't have an impact on breast cancer mortality.

Overall, though, I think it's a good thing to improve access to preventive care and screening. In fact, in my experience, most insurance plans are migrating to coverage of preventive care and early detection and exempting these interventions from patient financial responsibility. The reason: it's good business. Insurance companies have already discovered that they save money by treating disease earlier.

The other amendment - the one that failed - was sponsored by John McCain and attempted to restore funding to Medicare that was being shifted to expand coverage to the 31 million or so uninsured the bill proposes to cover. Those of us on the provider side would have loved for that amendment to pass. It would mean little or no money being taken out of our pockets. It means we're going to have to figure out how to be good business operators, reducing waste and spurring innovation in order to adapt to the significant financial hit we're going to take when the bill passes.

If you look at this from another angle, however, you realize that the provider community isn't losing as much as it initially seems. Even though we'll lose some Medicare reimbursement, we'll offset that by significant reductions in unreimbursed care provided to the uninsured. If the math works out as it should, two-thirds of folks who currently do not have insurance will be covered when the bill passes.

Tonight I'll start reading the Senate Bill, so that I can speak half-way intelligently about it. Don't expect me to be blogging by the weekend. The bill is 2,074 pages. And judging by my experience with the Federal Register, I'll be sleeping like a baby until the New Year comes.

HCR, once stuck in the mud, is moving down the tracks again

As I predicted in my last column, the Senate Finance version of health care reform will form the core of whatever ultimately passes both houses of congress. The Republican minority attempted to derail reform, only to reveal to the Democrats that they can pass reform without Republican support. The opposition party comes off looking merely obstructionist, with the exception of Olympia Snowe.

The Public Option, once on life support, is making a remarkable recovery. Still in all, I am not a big fan of the public option because it will artificially depress the market. The reason is that supporters of the public option intend to set initial pricing at current Medicare rates, which are already below market value. Many older primary care physicians, whose patients have aged along with them into the Medicare universe, are retiring early because they can't afford to keep their practices operating at the rates Medicare pays. If the public option is implemented at those same rates, physicians will opt out, either immediately, or after trying to make it work for several months.

If this is indeed the turn of events, the public option, rather than tempering the rates charged by commercial insurers for individual and small group plans, will simply devolve into an empty shell, much like the Competitive Acquisition Program that CMS attempted to launch several years ago. For most of you, who have never heard of the CAP, it was an attempt to knock physicians out of the drug reselling business, where oncologists, for instance, earned most of their profits. CMS sought to control costs by enticing a handful of drug distributers to bid for the government's business. These few companies, in turn would have in effect an oligopoly (except without the ability to artificially prop up prices, which is the main purpose of oligopolies). These companies would then develop extensive drug delivery and retailing pipelines, with the oncologists serving as consignment shops.

The drug distribution industry saw the hook in the worm and didn't bite. Neither did the oncologists. The CAP never came to be.

Now here is how the public option can - and should - work: First of all, don't implement the public option right away. Instead, save it and use it as a threatening storm on the horizon, triggering its operation only if the commercial insurance market cannot provide affordable plans to individuals and small groups. Second, if the public option is enacted, set the pricing at 110% to 115% of Medicare rates. That's on the low end of what HMOs will pay for health services, but maybe high enough to entice the most efficient and well-run providers into opting in. From there the market should dictate which way the rates go.

Which brings me to a point regarding Medicare that many folks don't know, and I can't believe I'm about to say this because it'll make me sound like Milton Friedman, God rest his soul:

In a free market, supply and demand are inversely proportional, such that when supply is high and demand is low, prices drop, and vice versa. As the Baby Boomers age into Medicare, the demand for services will rise dramatically. At the same time, we are facing an impending shortage of physicians, as well as most other medical professionals. The result, in a free market economy, would be a significant increase in price commanded for health services.

Medicare works the opposite way. It wants to maintain budget neutrality. CMS, or more accurately, Congress, wants to pay only a certain aggregate amount for health services. So when demand goes up, and quantity supplied increases to meet the demand, Congress will reduce the price paid per unit in order to contain health care costs in the aggregate. What will be the effect of this? More physicians will retire early. Fewer college graduates will enter medical school. Nurses will leave hospital inpatient units in droves. The rate of consolidation in the health care sector will increase.

Medicare and Medicaid beneficiaries will be most vulnerable to these changes, because health care providers will simply stop offering services that are utilized disproportionately by these patients.

Here's a specific prediction: if CMS continues to reduce payments for cancer care - for instance chemotherapy treatments - medical oncologists will stop treating patients in their offices, because they'll lose money on the drugs. They'll begin sending government-insured patients to the hospitals for chemotherapy. However, since hospitals will be hit with a disproportionate number of underpaying patients (the physicians keeping the well-insured patients for themselves), the hospitals will simply shutter their chemotherapy infusion suites. Medicare patients will have to go to the few safety-net hospitals to get their treatments, and they'll have to wait in line, because the demand will far exceed supply.

The same chilling effect will be felt in other sectors of health care where the majority of patients are insured by the government.

Unfortunately, I'm not foretelling a future full of doom. These reductions in services are already occurring. In the large metropolitan market where I work, several community hospitals have already either closed or greatly restricted their outpatient infusion services because they can no longer afford to treat the number of uninsured and underinsured patients seeking chemotherapy at their facilities. And by underinsured, I mean to include Medicaid patients and Medicare patients who don't have a MediGap supplemental policy.

Maybe cancer care is an anomaly. Or maybe it's the canary in the mineshaft.

Rational thoughts on health care reform

I have hesitated to start this blog. Who cares what I think about health care reform, anyway? Who am I to opine on the subject? And so I've been sitting on my hands.
Day after day, however, I've been inundated by so many other writers, and pundits, and self-styled experts on health care reform, reporting not facts or statistics, but hysteria, misinformation, or just plain ignorance.
In Journalism School I learned the importance of checking facts, of using corroborating sources, of showing as much objectivity as it is possible for a human to have. That's a lot of work! Who has time for that? I have a life (well, sort of), with real responsibilities, and demands on my time. But then I've been reading and listening to so many so-called journalists who clearly aren't following the responsible route of reporting. From Ann Coulter, who wrote the most inane column on health care and the free market, to the Regular Guys, a couple of syndicated shock jocks who ramble audaciously about completely false concepts such as forced euthanasia in the health care reform bill. Hell, I thought, I'm not any stupider than these guys!

I can't fault Fox News or Clear Channel for airing these morons and allowing them to spread misinformation on the public airwaves. After all, as the parent of a severely developmentally disabled child, I've always been a proponent of hiring the handicapped. But if I'm going to complain, then I have to offer a responsible alternative. So I have decided to jump into the fray with this blog: Miranda Writes about Health Care Reform (if I have to explain the pun in the title, then you should probably stop reading now and turn on Fox News).

What are my qualifications to discuss health care reform? Well, I'm no Uwe Reinhart, but I do have some street cred. I earned an MBA with a concentration in health care in 1999. I have worked for 17 years in a not-for-profit community hospital, concentrating on cancer care. I consume the Wall Street Journal daily - which, by the way, is absolutely the best health care reporting in the country. I have immersed myself in source documents published on the CMS website, making me somewhat of a local expert on government-run health care.

So that's me, and that's why I believe I have something to say about health care reform. In the coming days and weeks, I will talk about different aspects of health care reform, including, but not limited to, the current bills moving through the House and Senate. I'll also talk about concepts that may or may not be included in the current debate, but have been presented and discussed in recent years and hold merit for today's discussion.
I welcome your thoughts, your responses, your disagreements, your ideas. But you have to promise to consider the facts and alternative views before making up your mind. If you've already made up your mind, then don't waste your time reading this, and don't waste space responding.