SOURCE: OpEdNews

January 6, 2010

Maggie Mahar Untangles Health Care Legislation For OpEdNews

By Joan Brunwasser

Maggie Mahar is a Century Foundation fellow and expert on American health care. She is the author of the ground-breaking book, Money-Driven Medicine: The Real Reason Health Care Costs So Much. Welcome to OpEdNews, Maggie. Well, the Senate finally managed to pass a health care bill on Christmas Eve. How should we regard it? Is it a holiday gift or another boondoggle masquerading as meaningful, far-reaching reform?

This bill is a start. Over the next three years, there will be amendements and more legislation. This is not the final word on reform. For low-income people and people suffering from pre-existing conditions, this legislation offers much-needed help. This is important. But healthcare will remain too expensive for most of us unless the Independent Medicare Advisory Board (formerly called the Independent Medicare Advisory Council -- or IMAC) is given the power to change what Medicare (and other payers) pay for, and how they pay for it.

Some hospitals are overpaid -- they are being rewarded for being inefficient. In hospitals where more patients contract infections or fall victim to medical errors, they stay longer and undergo more procedures. As a result, Medicare winds up paying those hospitals more. Medicare needs to begin using financial sticks to encourage hospitals to pay more attention to patient safety. Medicare can also use financial carrots to reward hospitals with good safety records.

We're also over-paying some specialists for some services that offer little benefit to patients. Medicare should cut those fees-- and raise fees for primary care and chronic disease management. But none of this will happen unless the Independent Medicare Advisory Board has teeth, is protected from Congress, and begins its work as soon as possible.

Right now the law says that the Board cannot change reimbursements to hospitals for 10 years. By then, it will be too late. An amendment sponsored by Jay Rockefeller, Joe Lieberman and Sheldon Whitehouse would give the Board the clout it needs. Watch what happens with that amendment.

How does this legislation look for small business owners and the vast but shrinking middle class?

I haven't looked into the details of what this means for small business; I've been focusing on what it will mean for patients. But I would say that for small business owners, the bill is a mixed bag. Some will benefit, others won't. Much depends on how many employees they have and their profit margins. "Small businesses" is such a varied group that you almost need to assess the effect of the bill industry by industry.

For the middle-class, those in the lower half of the statistical middle class (households with joint income of, say $30,000 to $50,000) will generally get subsidies. For those at the owner-end, the subsidies should be generous enough to make insurance affordable. Caps on out-of-pocket payments (co-pays and deductibles) and there again, lower-middle-class families should be okay. Those who don't have employer-based insurance will finally have access to comprehensive care.

But for those on the upper edges of the statistical middle class (people with joint household income of $50,000 to $65,000) as well as the upper middle-class, (people with joint income of say, $65,000 to $90,000) insurance is going to be expensive and most will not be getting subsidies. (Everything depends on the size of the household. A family of four earning $65,000 would get a subsidy.)

Federal Employee Health Benefits plans are expensive; the Office of Personnel Management has not done a particularly good job of negotiating rates. But the government pays a very large share of the premium, so federal employees are generally okay (though many have very high deductibles, which means they can't always afford to use the insurance).

Upper-middle-class households in the Exchange who don't qualify for subsidies, (because they earn more than 400% of the federal poverty level for a family of their size) are going to be paying the entire premium themselves. In many cases, they will also have pretty high co-pays and deductibles. We are going to have to bring down the cost of care itself, or they are not going to be able to afford health care.

When I say bring down the cost of care, I mean that we have to stop over-paying inefficient hospitals. We have to cut what we pay some specialists for very lucrative tests and treaments that provide little benefit to the patient. We have to lower the cost of drugs -- either by importing drugs from other countries, or by letting the government negotiate with drug-makers for better prices. (This is what other countries do.) Finally, we have to begin paying for value, not volume. Today, by paying fee-for-service, we encourage providers to do more. We need to reward them when they provide for higher quality and better outcomes at a lower price.

Finally, I'm very concerned about older, middle-class Americans. Under the Senate bill, insurers can charge them three times as much as they charge younger Americans. This will make comprehensive insurance with reasonable co-pays and deductibles unaffordable for many middle-aged, middle-class and upper-middle class Americans. And people in their late 50s and early 60s are at a stage in life when they need care.

But we have three to four years to take a closer look at costs and amend the law. I hope Medicare uses those years to begin to rein in spending.

As a middle-aged, middle-class American myself, I'm also quite concerned about this legislation. Do you want to comment on the fact that, according to John Nichols in the Nation, the Democratic leadership seems to be planning to avoid the traditional conference process of reconciling the two bills? This may shut out the Republicans but it will also shut out Progressives.

At this point, it appears that Democrats will skip the conference process and let the Senate bill become the template for final legislation. I understand why they are doing this; the 60 vote coalition of moderate and liberal Senate Democrats is so fragile. In conference, it could easily break.

But I am very disappointed that so many strong elements of the House bill will probably never see the light of day. For example, the House proposed rolling out reform in 2013. By pushing the date back to 2014, the Senate leaves open the very real possibility that if conservatives win the White House in 2012, and Republicans have a majority in Congress, they could repeal reform before it ever becomes a reality. (If reform was scheduled to begin on Janaury 1, 2013, a new conservative administration would only have two months to try to undo the legislation before taking office.)

In addition, the lack of a public option makes it less likely that insurance will be affordable. And the fact that, under Senate legislation, the states will be regulating insurers means that regulation will be spotty, at best. The House bill raised fees for primary care physicians who treat Medicaid patients to Medicare levels. TheSenate bill does not. Today, those doctors are paid 30% less than they would be paid if providing the same services to Medicare patients. This is why Medicaid patients often have a hard time finding doctors . . .

At this point, we can only hope that over the next three years, new legislation will be introduced, and that the current bill will be strengthened and amended. Much will depend on what happens outside of Washington. We need a reform movement on the ground -- something comparable to the civil rights movement.

I would call on physicians, nurses, and other health care professionals, including hospital administrators, to set their self-interest aside, step back, take a look at what we need to do to create an affordable, sustainable, high-quality, patient-centered health care system. There is a consensus among those who have studied the problem: we over-treat and we over-pay for too many products and services that provide relatively little benefit to the patient. At the same time, we under-pay for the most important services: preventive care and management of chronic diseases.

Most patients don't fully understand what is wrong with our system. They assume that more care -- and more advanced, high-tech care and more diagnostic testing -- is always better care. But patients trust doctors. Physicians need to speak out and begin a long process of education, explaining that in health care, higher quality and lower costs go hand in hand. Any reform movement is, at bottom, a "teach-in". To paraphrase Marshall Ganz, reform is a matter of moving minds from where they are now to where they could be.

People will better understand the problems inherent in our current health care system after reading your 2006 book, Money-Driven Medicine: The Real Reason Health Care Costs So Much. Or, they can watch the documentary (by the same name) based on your book that was shown on Bill Moyers' Journal in September. Moyers says, "Money-Driven Medicine is one of the strongest documentaries I have seen in years and could not be more timely." Anything you'd like to add, Maggie?

(If your readers want to know more, they should check out my three posts about the legislation titled "The Glass Half-Empty, Half-Full"-- parts 1, 2, and 3 on www.healthbeatblog.org.

We'll look to your website for updates on the evolving legislation. And, thank you so much for talking with me, Maggie. It was a pleasure.

Author's Bio: Joan Brunwasser is a co-founder of Citizens for Election Reform (CER) which exists for the sole purpose of raising the public awareness of the critical need for election reform. We aim to restore fair, accurate, transparent, secure elections where votes are cast in private and counted in public. Electronic (computerized) voting systems are simply antithetical to democratic principles.

CER set up a lending library to achieve the widespread distribution of the DVD Invisible Ballots: A temptation for electronic vote fraud. Within eighteen months, the project had distributed over 3200 copies across the country and beyond. CER now concentrates on group showings, OpEd pieces, articles, reviews, interviews, discussion sessions, networking, conferences, anything that promotes awareness of this critical problem. Joan has been Election Integrity Editor for OpEdNews since December, 2005. Her articles also appear at RepublicMedia.TV and Scoop.co.nz.