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.

Between the Republicans and Nancy Pelosi, there must be a rational middle!

The Republican Party finally wised up, although perhaps too late, and announced that they will present a Republican alternative to the various, Democratic-driven health care reform plans being pushed through Congress. Perhaps Karl Rove has come out of retirement to advise the party, which heretofore behaved like spoilers, bent only on derailing health care reform without offering something better.

The problem: it has been reported (in the WSJ, of course, and elsewhere) that the Republican alternative won't raise taxes (at least, not on the rich); won't force individuals to purchase insurance or small businesses to cover their employees; won't include a public option to compete with private health plans; won't expand Medicaid or cut Medicare . . . so what exactly are they reforming? It sounds, to the untrained ear, like the Republican version of health care reform is status quo.

On the other extreme, Nancy Pelosi has upped the ante as both houses prepare to pass final versions of their internal bills prior to sending them to conference committee. I suspect that she has proposed her bill as a political maneuver, to give her more leverage when negotiating compromises with the conservative wing. But there are significant problems with Pelosi's proposal; specifically, it costs way too much (over $1 trillion); but it also pays for itself. That's a bad thing because it means a significant increase in taxes on the rich coupled with overly drastic cuts to Medicare in order to balance the budget on reform.

Not that I'm ever going to be in danger of paying the surtax, but a 5% burden added to folks already in the highest tax bracket is an overwhelming shock. I think a 1.5% to 2% surtax would be more palatable.

Pelosi is also in the camp that thinks Medicare is a generous payer, and that there is an abundance of fat to cut out of the system. I'm the first to agree that there is waste and economic profit in various pockets within Medicare, but I don't think there is overall excess. What needs to happen with Medicare is not overall cuts, but rebalancing of payments (e.g., the proposal to shift reimbursement to primary care physicians from specialists).

The System is Working (even if inefficiently)

Liberals and conservatives should take a short vacation from wallowing in fear and panic and take note that the system actually works! Yes, it's a good bit inefficient, and the pendulum swings could be a little less volatile. But overall, our system of government is actually working, with regard to health care reform. Different groups with different perspectives are pushing legislation that benefits them. These proposals are being whittled and reshaped through conflict with other parties who have other needs. After all the head butting and name calling is done, we'll have a final product that resembles what most of us want. Or at least will settle for.

And we'll know when we've arrived at a suitable compromise, because the fringes on either side of the middle will be screaming about the injustice and irresponsibility of final bill. Beware a final bill that is blessed by either the far right or the far left!

Illegals seeking wellness

I should save this for another column, because (1) this one is getting too long; and (2) this is a whole 'nother subject. But I can't let this issue pass without comment. The issue: some conservative Democrats and (do I even need to say it?) most Republicans are concerned that undocumented workers will be able to purchase insurance from the Public Option (even though they are barred from receiving government subsidies).

These congresspersons want to prohibit these "aliens" from purchasing Public Option coverage. Are they crazy? Why would we NOT allow them to PURCHASE insurance? Who cares if it's a government-managed plan, if these undocumented immigrants are paying in full for the coverage? At least, then, when they seek medical attention, it will be paid for with privately paid premiums, rather than tax dollars.

If we refuse to allow these immigrants to purchase insurance, based on some misguided jingoistic principle, when they do require urgent medical care, as eventually some will (remember, many of them do the jobs that are too dangerous, or low paying, or back-breaking, for red-blooded Americans to perform), these undocumented workers will show up in the already strained emergency rooms of our hospitals, and we will treat them, because federal law requires that we treat them (EMTALA . . . we can't turn away true emergencies, regardless of any circumstances, including citizenship and ability to pay). And, because we didn't allow them to purchase insurance, YOU will pay for their care, with your tax dollars (Emergency Medical Assistance, or EMA Medicaid), or with higher prices and higher insurance premiums (cost-shifting by providers to cover uncompensated care).

Not only as a matter of fairness, but also economic common sense, we should enthusiastically allow undocumented aliens to purchase the Public Option plan. If it's a matter of nationalistic principle, then deport them all and "Hire American!" to build houses and buss tables. But if we're going to exploit their work ethic, the least we can do is allow them the opportunity to be healthy.

Is Health Care a Right or a Privilege? A Christian Ethical Perspective

One of the basic sources of conflict in our society regarding the direction that health care reform should take stems from a deep division among our populace as to whether health care is a basic human or civil right. If health care is a right, then government has an obligation to provide it, regardless of the individual's ability to pay for it. If it is a civil right, then this coverage must be extended to all lawful citizens. If it is a human right, then it must also be extended to criminals, non-resident aliens and illegal immigrants.

If, however, we do not have a right to health care, then there is no obligation for the government to provide health services to individuals within our society. There is no obligation to stem infant mortality, or control the spread of communicable diseases, or develop better treatments for cancer. That is not to say that these are not worthwhile goals; merely, that it is not the government's responsibility to provide these benefits. It is up to the market to provide these services if they are profitable, and to charities to provide them otherwise.

It seems that some of the most verbal opponents of government-supported health services are committed, believing Christians. I find this counter-intuitive. I cannot mount a competent secular ethical argument for a human or civil right to health care. But I can make a case from a Christian ethical perspective. And I invite commentary from readers of other religious traditions regarding the ethical imperatives arising from their traditions with respect to health care.

Christianity as a religion grew from Judaic roots, and is founded upon the belief that an historical human being who lived in Palestine around 2,000 years ago, Jesus of Nazareth, was in fact the incarnation (the "fleshing out") of God. Consequently, the words and actions of Jesus are perhaps the most authoritative reference for Christian life and practice. Jesus was crystal clear about the individual's responsibility for the welfare of his/her neighbor. In Luke 4 he quotes from the Hebrew prophet Isaiah to define his mission:

"The Spirit of the Lord is on me,

because he has anointed me
to preach good news to the poor.
He has sent me to proclaim freedom for the prisoners
and recovery of sight for the blind (emphasis added),
to release the oppressed,
to proclaim the year of the Lord's favor."

In chapter 11 of the same book, Jesus tells the story of the Good Samaritan, the man who spent his own money to bind the wounds of an injured man (providing emergency services) and put him up at an inn for his recuperation (hospitalization). Defining this as "neighborly" behavior, Jesus commanded, "Go and do likewise."

There are many, many more examples, but I'll give just one more: In Matthew 25, Jesus describes the final judgement of the nations (Greek ethnos, which means cultures or peoples, the concept of nation state having not yet developed). Those who are judged righteous and rewarded with eternal life are those who carried out specific behaviors, and those who were judged evil and condemned for eternity failed to perform these same behaviors:

"I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I naked and you clothed me, I was sick and you looked after me (emphasis added), I was in prison and you came to visit me."

Jesus goes on to say that whenever we treat the least of our neighbors (i.e. the marginalized of society) in this way, it is as if we are literally caring for him.

At this point, the Christian who is inclined to disagree with me will quote Jesus (John 18) telling Pilate, "My Kingdom is not of this world," and follow this with quotes from Paul (Romans 13: submit yourself to the governing authority) and I Peter (submit yourselves to the king), to make the case that how we live our faith is a separate issue from how the government orders our society. I counter with the consistent message of the Hebrew prophets, and offer this one example from Isaiah 10:

Woe to those who make unjust laws,

to those who issue oppressive decrees,

to deprive the poor of their rights

and withhold justice

from the oppressed of my people,

making widows their prey

and robbing the fatherless.

What will you do on the day of reckoning,

when disaster comes from afar?

To whom will you run for help?

Where will you leave your riches?

When the New Testament was written, the Roman Empire was not a Christian state. In fact, Christians were persecuted and killed by Rome. On top of that, Christians were convinced that the end of the world was near, and therefore they were not concerned with temporal matters like social justice, nor were they in a position to influence these matters.

Israel, on the other hand, was a theocracy of sorts. The King and the Temple cult were inextricably tied. Temple worship was the "state religion." It was in this context that Isaiah prophesied against the religious and political leadership of Jerusalem. This context is more congruent with current American society, which is still not yet post-Christian. Christians who believe the American myth of a country founded on Judeo-Christian principles (and I'm using myth in the technical sense here, NOT as a synonym for fable) are violating their own integrity when they adopt the economic conservative stance that we have no societal or political obligation to provide at least a basic level of health care for our nation's citizens.

I therefore call on Christians to put their money where their mouth is. If we believe the United Sates is a Christian (or Judeo-Christian) nation, then we need to be intellectually and ethically consistent and support a more socialized model of medical care. OR, we need to be honest about what we really believe about the authority of Scripture (or, in this case, the lack thereof).

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.

Senate Finance bill will become the centerpiece of reform

The health care reform bill being crafted in the Senate Finance committee, chaired by Sen. Max Baucus, will become the core of whatever bill ultimately passes both houses of Congress. We will all need to read the bill (I haven't started yet) so that we know for ourselves what the bill puts forth, rather than trusting the pundits to explain it for us.

By now everyone should realize that virtually everyone has an axe to grind when it comes to health care reform. You're not going to get a straight presentation from any major information outlet. So read the bill for yourself.

What I have picked up from reading the Wall Street Journal (still, in my mind, the most objective and accurate reporting on health care reform), as well as other news sources, is that the Finance bill has effectively killed the public option. As I have said before, I think that's a good thing, because the public option was going to start at Medicare payment rates. Most physicians aren't very good businessmen, but those who are will undoubtedly have refused to contract with the public option plan. They are already losing money on Medicare patients and can't afford higher volumes of patients at those payment rates.

Hospitals are even less adept at business than physicians, so most of them probably would have signed on with the public option. The hospital where I work is losing money on Medicare patients. For every dollar we spend to care for a Medicare beneficiary, the government is reimbursing us 90 cents. We can't afford more health insurance plans that pay at Medicare's rates.

Nancy Pelosi and other liberal Democrats will raise cain over the Senate's rejection of the public option, but in the end they will not be able to reverse the direction that Congress is moving.

There is a moderate possibility that the public option will be retained as a "trigger" option; that is, the public option will be retained in reserve and will be activated if the market fails to provide an acceptable level of coverage at a reasonable price for lower income individuals. I would support using the public option as a "poison pill" of sorts. Without the threat of austere action, the players in the health care market will not be sufficiently incentivized to produce the necessary reductions in cost (and economic profit) required to bring health care spending in line.

Let me be so bold as to suggest that you write your senators and ask them to support a delayed public option health plan to be activated only upon the failure of the market to generate the necessary reforms.