SOMETIMES YOU HAVE TO HAVE A SENSE OF
HUMOR ABOUT THINGS, R-E-A-L-L-Y,
INCLUDING POLITICS...AND GETTING OLDER...
Editorial Nov. 1, 2009
Interesting
"discussion" by NYTIMES readers...part of a
continuing series by The New York Times that is providing
a comprehensive examination of the policy challenges and politics
behind the debate over health care reform. You can read all of these
articles at: nytimes.com/healthcare2009
A
man goes to the doctor for a check up.
As
he sits in the examining room, a Labrador Retriever comes in and
sniffs him in a few places, and goes away. Then a cat comes in
and jumps up on the examining table and stares for a bit, then
leaves.
The
doctor comes in and in a few minutes of examination declares the
man in fine condition.
Two
weeks later, the man gets a $1000 bill for the visit. He
calls the office and complains about the extra charges for service not
received. "But didn't you get a Lab test and a Cat scan?" the
office business manager asks.
Dec.
5, 2011 evaluation in CT;
this
is no joke...we begin this
sub-page with news of some Presidential appointments, post-Daschle
withdrawal, cyber-war up in air?
HEALTH
CARE ISSUES; AND WHAT ABOUT SOCIAL SECURITY? HEALTH CARE
CHANGES ARTICLE CT MIRROR...HUNGER IN AMERICA.
Contents:
Weston
High School graduate's
website: http://keithhennessey.com
The Provider Will See You Now
NYTIMES
By DANIELLE OFRI, M.D.
December 29, 2011, 11:35 am
I can’t quite remember when the term “provider” slipped into the
hospital lexicon. It was perhaps 10 years ago, when our hospital
started hiring physician assistants and nurse practitioners to share
the clinical load. In contrast to the regular staff nurses, who cared
for the patients in conjunction with the doctors, physician assistants
and nurse practitioners would see patients independently, the way the
rest of the doctors did. So there needed to be a term that would
include all three groups – physician assistants, nurse practitioners
and doctors — who could have primary responsibility for patients.
“Health care provider” came into vogue as the catchall phrase and was
quickly truncated to just “provider.” The term does have its upside,
helping to minimize hierarchy. History has shown us that medical
hierarchy usually serves more to stomp on underlings than to provide
leadership. In fact, physician assistants, nurse practitioners and
doctors have more similarities than differences in their day-to-day
interactions with patients, even as they come from unique backgrounds
and bring different strengths to the table.
Still, the term “provider” has never stopped irritating me. Every time
I hear it — and it comes only from administrators, never patients — I
cringe. To me it always elicits a vision of the hospital staff as
working at Burger King, all of us wearing those paper hats as someone
barks: “Two burgers, three Cokes, two statins and a colonoscopy on the
side.”
The other term that makes my skin crawl is “hospitalist.” Whenever I do
full-time inpatient work (in contrast to outpatient clinic work), I’m
called a hospitalist. What the heck is a hospitalist — someone whose
specialty is taking care of hospitals? In my mind I see a car repair
shop, with the entire hospital building hoisted on the lift, and all
the — ahem — providers underneath with wrenches, drills and oilcans in
our upraised arms.
I always thought my annoyance with these terms was just my personal pet
peeve, something that allowed my mind to wander off to fast food and
auto mechanics during dry administrative meetings. So I was grateful to
come across an essay on this topic by Dr. Pamela Hartzband and Dr.
Jerome Groopman in The New England Journal of Medicine.
The authors put their finger on what is so grating about these terms.
They note that the term “provider” has a deliberate sterility to it
that wrings out any sense of humanity, and connotes a widgetlike
framework for that which is being “provided.” It makes us feel like a
vending machine pushing out hermetically sealed bags of “health care”
after the “consumer’s” dollar bill is slurped eerily in.
But the most profound unease created by generic terms like “provider,”
the authors point out, is the sense that medicine is turning into a
corporate entity. Buzzwords like “provider,” “consumer,” “quality,”
“productivity,” “synergy” — all are just that, buzzwords. They come
from the corporate world and carry a plastic blandness with them, even
if the concepts they embody do have some validity for medicine.
Oh, it’s easy to achieve perfect efficiency between consumer and
provider, with maximum productivity. Type your symptoms into a
computer, pause for 0.15 second while it scans its superior database,
then get your diagnosis and a printout of your prescription. This would
indeed be the most efficient health care delivery system. But it would
be hard to call this medical care.
Perhaps “care” is the key word. Medicine — as opposed to fast food
joints, auto body shops or investment firms — involves care. This is
intrinsically human and cannot be commoditized the way burgers,
carburetors or mortgage-backed securities can be.
Medicine certainly has inefficiencies and poor practices that can and
must be fixed. The corporate perspective has offered some helpful
insights into where we can improve. The corporate analogy, however, can
go only so far. Medicine cannot be automated in the same way a factory
can.
Sure, some parts of medical care can truly benefit from the widget
approach — pre-operative check-lists, drug interaction databases,
electronic medical records. But the essence of medicine — how we make
use of science to care for patients — cannot be codified to fit neatly
into a shareholder’s report. The “consumers” who fall ill are human
beings, and the “providers” to whom they turn for care are human beings
also. The “transactions” between them are so much more than packets of
“health care.”
So yes, maybe it’s splitting hairs to want to be called a doctor,
rather than a provider. Yes, maybe there is a hint of paternalism in
preferring “patient” over “consumer” or “customer.” And yes, there are
probably grander problems in medicine that require urgent attention.
But words do influence us. In a world that is increasingly
depersonalized, it is ever more critical to maintain protected spheres
of human interaction. When my children fall ill, I will be so relieved
when a nurse or doctor or physician assistant — a human being — enters
the room. It is a signal that my children — the patients — will be
cared for. I can always take them to Burger King later for provisions.
Insurance exchange unlikely to lower health plan costs, consultant says
Arielle Levin Becker, CT MIRROR
December 5, 2011
The state's health insurance exchange, a key part of federal health
reform, is intended to give individuals and small businesses more
options for buying insurance. But for many people in Connecticut, the
new marketplace might not bring affordable coverage options when it
launches in 2014, according to a consultant to the board developing the
exchange.
That's because according to data from Connecticut insurers, the
majority of health plans sold to individuals and small businesses
provide less generous coverage -- most likely, at a lower cost -- than
plans sold on the exchange will be required to provide.
The analysis suggests that people buying insurance through the exchange
could get plans that offer more coverage with lower out-of-pocket
costs, but they would likely have to pay more for them.
"It's going to be very difficult for the exchange to compete in the
marketplace based on price," Paul Grady, a partner with the consulting
firm Mercer, said during a presentation to the exchange board last
week. He added that small businesses and the uninsured tend to be very
sensitive to the price of coverage, which will likely be a driving
force in their insurance selections.
But Grady added that the exchange could compete in other ways, such as
by offering innovative health plans that can reduce costs by improving
health, or by targeting employers that don't provide any coverage to
their workers.
Four levels of coverage
Health reform requires plans sold on the exchange to be offered at four
different levels of "actuarial value," which refers to how much of the
benefits the plan pays. A plan with a higher actuarial value covers
more of the costs of health care, with the member responsible for fewer
out-of-pocket costs like copayments or deductibles, while a plan with a
lower actuarial value would leave more to the member to pay. Generally,
those with higher actuarial values have higher premiums, while those
that leave the members to pay more out-of-pocket have lower premiums.
Under the health reform law, plans sold on the exchange must come at
four levels -- bronze, silver, gold and platinum. The minimum, bronze,
must have an actuarial value of 60, meaning the plan would cover an
average of 60 percent of a member's health care costs and the member
would be responsible for the other 40 percent.
But in Connecticut, a large swath of the population that could buy
coverage through the exchanges currently have plans that fall below the
bronze level of coverage, the Mercer analysis found.
Among people who buy coverage for themselves, rather than getting it
through an employer, 72 percent have plans that fall below the bronze
level of coverage required of exchange plans. Another 22 percent would
be considered to have bronze plans.
Half of employers with fewer than 50 workers provide coverage below the
minimum that an exchange plan would provide. (One caution: The
actuarial value in the analysis is based on plan design, without
accounting for employer contributions. So a plan designed with a bronze
actuarial value could actually require lower out-of-pocket costs for
the member if the employer helps cover some of the costs.)
Larger companies are more likely to offer plans with higher actuarial
values -- known as "richer" plans; only 7 percent of companies with 50
to 99 workers provide "below-bronze" coverage, as do 5 percent of
companies with between 100 and 499 workers.
'A voice for change'
But that's not the exchange's target market. When the exchange gets
started in 2014, it will only be required to cover people who buy
coverage on their own and employers with 50 or fewer workers. The board
governing the exchange could elect to expand eligibility to companies
with 100 or fewer workers.
If the exchange isn't likely to be able to compete with the rest of the
insurance market based on price, Grady said, it could still have an
important role.
He noted that larger employers, who tend to have more control over
their insurance plan designs, have been able to contain their health
care costs without shifting costs to employees by using innovative plan
designs, such as by encouraging the use of preventive care or managing
chronic conditions.
Small businesses tend to buy their coverage from insurers, rather than
designing their own plans, and Grady said products that mirror what
large employers do have not been developed for the small employer
market. The exchange board could play a role in encouraging them, he
said.
"You can be a voice for change and innovation, and I think that would
be really helpful," he said.
Doing so might not directly benefit the exchange itself, he added. If
the exchange manages to get insurance carriers to offer innovative
products, the insurers will likely also offer them outside the
exchange. That won't necessarily lead to more people buying coverage on
the exchange.
"But it's going to be beneficial to the people that are participating
in the exchange and outside of the exchange, who are going to benefit
from some of that information," he said.
In addition, Grady said, the exchange has an opportunity to reach small
employers who don't offer insurance to their workers now, and who don't
understand how the insurance marketplace works.
Board member Mary Fox suggested another niche.
"Since we can't compete on price, we could compete on elements like
transparency and consumer education and making sure that we have simple
products, simply and well explained to the consumer," she said.
"Because I think one of the things that would be attractive would be to
kind of reduce the complexity in the overall insurance marketplace."
Fox also asked if data exists on the health quality of the people who
buy plans of different actuarial values, such as whether people who buy
bronze plans have poorer or better health.
State Healthcare Advocate Victoria Veltri echoed the question, saying
that it's important to look at health outcomes for people who do or
don't have insurance to cover their visits to the doctor and whether
people with bronze plans are getting the care they need.
William Van Deventer, a senior associate at Mercer, said that in
general, people who have more health risks and need more medical
services are going to be attracted to gold or platinum plans that
require fewer out-of-pocket costs for getting care, while people who
are healthier would tend toward bronze plans.
But Veltri said that while she agreed with the general rule, it also
depends on whether people can afford the premiums of a gold plan.
Grady said he had not seen recent studies, but that old studies
indicated that as people's out-of-pocket costs increase, they are less
likely to get the medical services they need.
Federal health reform requires health plans to cover the full cost of
preventive services, with no out-of-pocket costs to members, he noted.
"But the people aren't going to get those preventive services because
they're worried if they get to there and they find out that there's
something wrong with them, they're not going to be able to afford the
care that's necessary," he said.
Challenges for exchanges
Grady also spoke of the difficulty of operating a health insurance
exchange. Massachusetts has one, known as the Massachusetts Connector,
but it has limited options for small businesses; none of the major
insurance carriers in the state offer products for small businesses on
the exchange, and only about 4,000 small businesses participate.
By contrast, Grady said, Connecticut already has an effective exchange,
run by the Connecticut Business and Industry Association, or CBIA. It
has about 75,000 members and covers about a third of the small employer
market, with a choice of 25 plans.
But Grady noted that the actuarial value of the plans offered is
unclear.
Ellen Andrews, executive director of the Connecticut Health Policy
Project, said she's not primarily concerned with how many people get
coverage through the exchange, as long as they get insurance. And
people with plans with low actuarial values still have insurance, she
noted.
"There's plenty of market for just the uninsured in the state," she
said.
Study finds confusion about medical home concept
CT MIRROR
Arielle Levin Becker
October 12, 2011
State officials are developing plans for Medicaid recipients to be
cared for in "medical homes" beginning in January, but they might want
to start with a marketing campaign: In focus groups conducted on behalf
of the Department of Social Services, many people said they were
unfamiliar with the concept--or worse.
Upon hearing the term "medical home," some people said it sounded like
a place you go to die, said Meryl Price, a consultant working with DSS
to design the medical home program. Other participants said it sounded
like an institution, a place where you go and don't get out.
"That was a pretty intense finding," Price said Wednesday during a
meeting on the medical home plan.
The focus groups were meant to gather information from Medicaid
recipients that would inform the design of the medical home program.
Although participants were unfamiliar with medical homes, many of the
problems they identified--a lack of coordination between primary care
providers and specialists, long wait times for services, not being
given test results, even when they ask--are things the medical home
model aims to address.
Despite what the name might imply, a medical home is not a nursing home
or institution; it's not a physical location at all. Instead, it's a
way of running a medical practice in which the health care providers
take a more active role in meeting patients' needs. There's no single
definition, but the concept involves a medical practice serving as a
patient's regular source of care--hence the word "home"--and
coordinating the care patients get from specialists. To ensure that
patients can access care when they need it, many practices that serve
as medical homes offer extended hours or give patients the option of
communicating with providers by telephone or email.
The model is frequently called a patient centered medical home, but DSS
is calling its program a person centered medical home in recognition of
people with disabilities who are sensitive to the term "patient."
Although most health care providers in Connecticut currently don't meet
the medical home standards set by multiple accrediting groups, DSS
hopes the model will become common enough that all Medicaid recipients
will have access to a medical home within a few years.
The focus groups included people recruited by community organizations
and DSS, and included a range of Medicaid clients--low-income adults,
adolescents, people with disabilities, pregnant women, mothers of
newborns, parents of children with special health care needs, and
people with behavioral health needs.
Most participants reported that they had had a relationship with a
primary care provider for more than a year, and that their doctor
treated them like a "whole person," not a patient or a disease.
But participants raised concerns about accessing specialists, care
coordination and the way they get treated when they go to the doctor.
People in the focus groups said their health care providers should be
more proactive in ensuring that they get all the information they need,
and said they need more help identifying specialists that accept
Medicaid and in arranging transportation to get there. Many also
reported coordination problems between their primary care provider and
specialists, with gaps including being asked to repeat information,
having trouble getting their medical records, being asked for details
about their medical conditions that might not be clear to people who
are not health care professionals, and variation in treatment between
providers.
Many participants also described less-than-ideal experiences visiting
their doctors. Medicaid clients believe that the front desk staff at
their doctors' offices are rude, and attribute it to discrimination,
Price said.
"People perceived the problem as more with the front desk staff and not
the doctors and the rest of the staff," she said.
Participants were also bothered by doctors interrupting them or leaving
the room, and by front desk staff dismissing their concerns. "I think
that happens to everybody everywhere," Price added.
Many focus group participants said they felt they had faced
discrimination because they are covered by public insurance, getting
rude and disrespectful treatment from staff and poorer treatment from
their doctors.
Price noted that one participant, referring to the state-run Charter
Oak Health Plan, said, "When they find out you have Charter Oak or
whatever, your appointment is six months out."
Participants also reported that they felt they were discriminated
against or had received poor treatment from office staff because of
their socioeconomic status or their race. Participants with behavioral
health needs reported discrimination or poor treatment and said
providers dismissed their opinions or concerns after learning about
their psychiatric disability.
Price made several recommendations based on the finding, pointing to
the need for practices to increase efficiency and the desire among
participants to do business with their doctors by phone. Patients also
need better access to specialty care and to appointments on short
notice.
She noted that DSS is embarking on a major project with the Connecticut
Health Foundation to address health disparities, and suggested looking
for ways to improve communication between patients and providers,
including sensitivity training for providers and office staff, and
making sure providers explain things in layman's terms.
Price also pointed to the need to make sure that consumers are educated
about what a medical home is, and to use the term consistently. She
noted that some focus group participants have children with special
health care needs whose care is delivered in medical home practices,
but even they were not familiar with the term. Price asked what they
thought of their medical home and they replied, "What's that?"
Alicia Woodsby, public policy director of the National Alliance on
Mental Illness, Connecticut, said she was struck by the responses. She
said it hadn't occurred to her that people would think medical homes
were institutions, but that it made sense, particularly for people with
disabilities. It's important to work on the marketing of the concept,
she said.
"People might not think this is a great thing if we don't work on
that," she said.
Six Ways the Supreme Court Could Rule on Obamacare
Jeffrey H. Anderson, Weekly Standard
October 3, 2011 9:01 AM
The majority of the 50 states claim that Obamacare is unconstitutional,
the Obama administration claims that it's not, and both sides have now
asked the U.S. Supreme Court to decide the question on appeal from a
3-judge panel of the 11th Circuit Court. In August, the panel (made up
of two Clinton appointees and one George H. W. Bush appointee) ruled
that Obamacare’s individual mandate — its requirement that essentially
every American buy government-approved health insurance under penalty
of law — is unconstitutional but that the rest of the legislation
should be allowed to stand. The 26 states that filed suit in the case
have appealed, arguing that the individual mandate is so central to the
legislation as a whole that to void the mandate, while retaining the
rest, is to leave something in place that’s unworkable and which
Congress almost certainly never would have passed. The Obama
administration also has appealed, arguing that the powers vested in
Congress by the Constitution authorize its passage of all aspects of
the 2,700-page legislation.
The Court could presumably rule in any one of six ways:
1. It could decide not to strike down any part of the legislation,
ruling that Congress was authorized to pass the individual mandate
under its power “To regulate Commerce...among the several States.” (Not
striking down legislation should not be confused with declaring it to
be “constitutional.” The Court’s proper role is to void
legislation if it violates “the manifest tenor” (the obvious meaning)
of the Constitution — it should no more declare a law “constitutional”
than a jury should declare a defendant “innocent”). Such a ruling would
reverse the lower court’s ruling on the individual mandate.
If the Court does indeed rule in this manner, it will have stretched
the commerce clause to establish, for the first time, that Congress can
force Americans to buy a particular commercial good — and can dictate
what form of that good they must buy. At the very least, this would be
true for all goods that every American partakes of in some way, such as
food.
2. It could decide not to strike down any part of the legislation,
ruling that the individual mandate is not really a mandate but rather
is a new tax (on those who don’t have insurance), which Congress was
authorized to institute under its power “To lay and collect
Taxes...to...provide for the...general Welfare.” The problem with this
is that President Obama emphatically insisted on national television
that the individual mandate “is absolutely not a tax increase.”
Moreover, Obamacare’s text doesn’t refer to the mandate as a tax. As
the 11th Circuit Court panel put it, “[T]he individual mandate...was
not enacted pursuant to Congress’s tax power” and therefore cannot be
sustained on those grounds.
3. It could affirm the lower court’s ruling, by holding that the
individual mandate is unconstitutional and allowing the rest of the
legislation to stand. The problem with this is that — as the Obama
administration itself has argued — without the individual mandate, the
legislation would become “cost prohibitive.” In fact, because of the
legislation’s requirement that insurers cover those with preexisting
conditions at the same premiums that healthier people pay, the White
House says that “the only way to keep people from gaming the system and
raising costs on everyone else is to ensure that everyone takes
responsibility for their own health insurance” — and the way that the
legislation achieves this is through the individual mandate.
In light of these White House comments, it seems somewhat farfetched to
believe that a bill that overcame a filibuster with no votes to spare
in the Senate, and which passed by only 7 votes in the House, would
have passed either chamber with the individual mandate removed and
everything else left in place.
4. The Supreme Court could declare the individual mandate
unconstitutional and also void the law’s “guaranteed issue” and
“community rating” provisions (provisions that, in tandem, would
require insurers to cover all applicants without charging higher
premiums to those with expensive preexisting conditions), while
upholding the rest of the legislation. No court has yet taken this
position, but it would seem to be a tenable one. In the drafting of the
legislation, these mandates were inextricably linked. Without the
individual mandate, the requirement that insurers cover everyone with
expensive preexisting conditions — without charging them higher
premiums — would simply lead to people waiting until they are already
ill or injured before signing up for “insurance” to pay for their care.
Again, this point has been made quite well by the White House: “If
insurance companies can no longer deny coverage to anyone who applies
for insurance — especially those who have health problems and are
potentially more expensive to cover — then there is nothing stopping
someone from waiting until they’re sick or injured to apply for
coverage since insurance companies can’t say no. That would lead to
double digit premiums increases — up to 20% — for everyone with
insurance, and would significantly increase the cost [of] health care
spending nationwide.”
It would seem that if the individual mandate is struck down, then the
mandates requiring coverage of those with preexisting conditions
(“guaranteed issue”) at the same premiums as everyone else (“community
rating”) must be struck down as well.
5. It could strike down the individual mandate and the rest of the
legislation along with it. U.S. District Court judge Roger Vinson ruled
in this manner, arguing that since the individual mandate is “the
keystone or lynchpin of the entire health reform effort,” upon its
removal the entire act must be invalidated. Vinson wrote,
“[T]his Act has been analogized to a finely crafted watch, and that
seems to fit. It has approximately 450 separate pieces, but one
essential piece (the individual mandate) is defective and must be
removed. It cannot function as originally designed. There are simply
too many moving parts in the Act and too many provisions dependent
(directly and indirectly) on the individual mandate and other health
insurance provisions — which...were the chief engines that drove the
entire legislative effort — for me to try and dissect out the proper
from the improper, and the able-to-stand-alone from the
unable-to-stand-alone. Such a quasi-legislative undertaking would be
particularly inappropriate in light of the fact that any statute that
might conceivably be left over after this analysis is complete would
plainly not serve Congress’ main purpose and primary objective in
passing the Act.”
6. It could decide that the states lack legal standing to bring the
suit at this time, thereby postponing challenges to Obamacare’s
constitutionality until after the election and likely until after its
full implementation (in January of 2014) — if it’s not repealed first.
Whichever way the Court rules, and by whatever vote, three things are
important to remember:
First, while the justices have the final say on whether Obamacare will
be treated as being unconstitutional or not, and while their judgment
should be respected and observed, they have no claim to infallibility.
In other words, no private citizen should feel compelled to yield to
the rightness of the justices’ decision, only to its authority — an
important distinction that Lincoln made clear in response to Dred
Scott.
Second, as Chief Justice John Marshall said in McCulloch v. Maryland,
“The peculiar circumstances of the moment may render a measure more or
less wise, but cannot render it more or less constitutional.” In other
words, the wisdom and the constitutionality of legislation are two
distinctly different things, and Obamacare is an unprecedented threat
to Americans’ liberty, the nation’s fiscal solvency, and the basic
relationship between the government and the people — regardless of
whether the Court rules that it is also unconstitutional.
Third, all but one of the six possible holdings by the Court (#5 —
striking down the legislation in full) would still require a political
resolution. In all likelihood, therefore, the fate of Obamacare will be
determined not by a decision of the Court, but by the success or
failure of the repeal movement — which in turn will likely be decided
by the presidential election.
In CT, "E.T.
call home" not exactly a clear message...
Report: There's no consensus on what
constitutes 'medical homes'
Arielle Levin Becker, CT MIRROR
August 16, 2011
The number of physician practices officially considered "patient
centered medical homes" has grown dramatically in the past six months,
helped along when the state's largest group of primary care practices
earned the designation last week.
The proliferation mirrors a widespread national push toward the model,
which encourages care coordination and making it easier for patients to
access care. Private insurers are sponsoring pilots to test the model,
and it's being used in state Medicaid programs, Medicare, and the
military's TRICARE health plan, which has a goal of having 2 million
beneficiaries enrolled in medical homes by the end of the year.
Connecticut has a medical home pilot program for state employees and
retirees, and is developing plans to encourage health care providers to
serve as medical homes for Medicaid patients. Six months ago, just 21
practices and clinicians in the state had been recognized as medical
homes by the National Committee for Quality Assurance, one of several
accrediting organizations. After the 70 practices of ProHealth
Physicians achieved recognition last week, the number was up to 412.
But despite the broad-based support for the concept, there is no broad
agreement on what a medical practice must do to be considered a medical
home, and no solid evidence about what pieces are required to improve
care and reduce costs, a report released this month warned.
"The medical home model does have the potential to transform the way
health care is delivered--but potential is the key word here," wrote
the report's authors, Dr. Robert A. Berenson, Kelly J. Devers and
Rachel A. Burton of the Urban Institute. "The danger posed by the
current enthusiasm for the concept is that it could lead to the
adoption of unproven models on a wide scale nationwide before
evaluations of existing pilots can show us what works in what
situations, and what levels of reimbursement are needed to get
providers to engage in all the new activities encompassed by the
medical home model." Full story here.
Where Wisdom Lives
NYTIMES
By DAVID BROOKS
June 6, 2011
Sometimes life presents you with a basic philosophical
choice. Americans are going to have to confront a giant one over the
next several years.
It starts in the wonky world of Medicare. As presently constructed,
Medicare is based on an open-ended fee-for-service system. The
government pays providers each time they deliver a service. The more
services they provide, the more money they get.
The fee-for-service system is incredibly popular. Recipients don’t have
to think about the costs of their treatment, and they get lots of free
money. The average 56-year-old couple pays about $140,000 into the
Medicare system over a lifetime and receives about $430,000 in benefits
back. The program is also completely unaffordable. Medicare has
unfinanced liabilities of more than $30 trillion. The Medicare trustees
say the program is about a decade from insolvency.
Some Democrats simply want to do nothing as Medicare careens toward
bankruptcy. Last Sunday on “Face the Nation,” for example, Nancy Pelosi
said, “I could never support any arrangement that reduced benefits for
Medicare.”
Fortunately, more responsible Democrats are looking for ways to save
the system. This is where the philosophical issues come in. They
involve questions like: Who should make the crucial decisions? Where
does wisdom reside?
Democrats tend to be skeptical that dispersed consumers can get enough
information to make smart decisions. Health care is phenomenally
complicated. Providers have much more information than consumers.
Insurance companies are rapacious and are not in the business of
optimizing care.
Given these limitations, Democrats generally seek to concentrate
decision-making and cost-control power in the hands of centralized
experts. Under the Obama health care law, a team of 15 officials will
be created to discover best practices and come up with cost-cutting
measures. There will also be a Center for Medicare and Medicaid
Innovation in Washington to organize medical innovation. Centralized
officials will decide how to set national reimbursement rates.
Republicans at their best are skeptical about top-down decision-making.
They are skeptical that centralized experts can accurately predict
costs. In 1967, the House Ways and Means Committee projected that
Medicare would cost $12 billion by 1990. It actually cost $110 billion.
They are skeptical that centralized experts can predict human behavior
accurately enough to socially engineer new programs. Medicare’s chief
actuary predicted that 400,000 people would sign up for the new health
care law’s high-risk pools. In fact, only 18,000 have.
They are skeptical that political authorities can, in the long run,
resist pressure to hand out free goodies. They are also skeptical that
planners can control the unintended effects of their decisions.
Republicans point out that Medicare has tried to control costs
centrally for decades with terrible results. They argue that a
decentralized process of trial and error will work better, as long as
the underlying incentives are right. They suggest replacing the
fee-for-service with a premium support system. Seniors would select
from a menu of insurance plans. Their consumer choices would drive a
continual, bottom-up process of innovation. Providers could use local
knowledge to meet specific circumstances.
Representative Paul Ryan’s Republican plan is controversial because of
the amount of public money he would dedicate to his premium support
plan, but the basic architecture of the plan has been around for
decades. In less rigidly ideological times, many Democrats supported
variations of this basic approach.
Advocates, like Alain Enthoven of Stanford, point out that
competition-based plans have improved outcomes in many places. Such
plans cover employees of the University of California and state
employees in California, Wisconsin and Minnesota. They also note that
the Medicare prescription drug benefit also uses a competition model.
Consumers have been adept at negotiating a complex marketplace, and
costs are 41 percent below expectations.
The fact is, there is no dispositive empirical proof about which method
is best — the centralized technocratic one or the decentralized
market-based one. Politicians wave studies, but they’re really just
reflecting their overall worldviews. Democrats have much greater faith
in centralized expertise. Republicans (at least the most honest among
them) believe that the world is too complicated, knowledge is too
imperfect. They have much greater faith in the decentralized discovery
process of the market.
I’d only add two things. This basic debate will define the identities
of the two parties for decades. In the age of the Internet and
open-source technology, the Democrats are mad to define themselves as
the party of top-down centralized planning. Moreover, if 15
Washington-based experts really can save a system as vast as Medicare
through a process of top-down control, then this will be the only realm
of human endeavor where that sort of engineering actually works.
Federal officials wrestle with long-term insurance under health reform
Deirdre Shesgreen, CT MIRROR
February 7, 2011
WASHINGTON--Top federal health officials are designing a new insurance
program aimed at increasing the health care options for people with
disabilities--and helping them avoid the financial collapse that often
comes with severe medical crises.
If successful, the program could also provide much-needed fiscal relief
to states like Connecticut, where the Medicaid program, which pays for
long-term care for the poor and disabled, is a significant element of
the busted budget.
Proponents say the new insurance initiative, created under the federal
health reform law, is potentially transformative. But critics say it is
seriously flawed and will almost certainly fail. And even as interest
groups line up to influence the parameters of the program--the
premiums, benefits, and other components--Republicans in Congress have
targeted it for repeal.
At issue is the so-called CLASS Act, short for Community Living
Assistance Services and Supports.
It seeks to address everyone's worst medical nightmare: being diagnosed
with a debilitating, chronic condition that regular private insurance
will not cover over the long term.
Whether it's multiple sclerosis, Alzheimer's disease, or a stroke that
limits mobility, such conditions can be financially devastating.
"How does the prospect of living in a nursing home at age 50 and beyond
after a stroke sound to you?" asked William Minnix, president of
LeadingAge, an advocacy group that represents non-profit nursing homes,
assisted living residences, and other facilities. "And then after you
deplete your assets and sell your house, to leave nothing to your
children?"
More and more Americans are facing this desperate situation. Currently
there are 10 million Americans who require long-term support services.
"As America ages, that number is steadily rising," Health and Human
Services Secretary Kathleen Sebelius said at a forum on long-term care
on Monday.
"By 2020, it's expected 15 million Americans will need some kind of
long-term care services," she said. "We know that 1 of every 6 who
reach the age of 65 will spend more than $100,000 a year on long-term
care."
And yet right now, Sebelius added, those who want to plan for those
needs have very few options.
Patients can pay out of pocket, but nursing homes costs about $75,000 a
year, and home health aides run an average of $18 an hour. Individuals
can purchase private long-term care insurance, but premiums are
expensive and few insurance companies even offer such policies anymore.
The third option, which is all-too-typical for many middle-class
families, is that they burn through their personal savings until almost
nothing is left. Then they're poor enough to qualify for Medicaid, and
the cost of their care is picked up jointly by the state and federal
government.
"We have a looming needs situation," Sebelius said at Monday's forum,
sponsored by the Kaiser Family Foundation. "If nothing changes, we'll
see more and more of [these patients] either forced into a dependent
living situation against their wishes or forced to clear out their
savings to afford the services and supports they need to live
independently."
Neither is sustainable. Medicaid now spends one-third of its
budget--more than $100 billion annually--on long-term care services.
That price tag is a particularly tough sell in this current fiscal
climate, as governors across the country try to close gaping budget
holes.
Enter the CLASS Act, which proponents tout as a revolutionary
initiative and detractors say is another federal entitlement in the
making.
Under the CLASS Act, which was part of health reform, HHS is now
working to establish a federal long-term insurance option-a voluntary
program open to working adults, who will pay premiums set by HHS. If
they become disabled, the program will pay out a small daily benefit,
based on their needs, to cover support services that will allow them to
stay in their community.
With lower premiums than a private insurance plan, proponents argue, it
will make long-term insurance more attractive to the sick and healthy
alike. The benefits will be more flexible than Medicaid, because the
consumer controls the spending and can therefore opt for home health
services rather moving into a nursing home.
"It's a long overdue national mechanism that we can use to plan for the
future," said Mercedes Witowsky, a New Jersey advocate for the disabled
whose daughter had a massive stroke when she was 16 years old.
Witowsky's private insurance covered her daughter's hospital care and
some rehabilitation immediately after her stroke. But it would not
cover the long-term expenses of having a home health aide help her get
dressed, bathed, and through each day. Now 21 and in college, her
daughter relies on Medicaid for that care.
Like many, Witowsky, who also spoke at Monday's Kaiser forum, never
imagined she would need long-term health insurance for herself, let
alone for her teenage daughter. Only about 7 million Americans
currently have private long-term care insurance.
"They either don't want to think about it or they think 'I've got
insurance' or 'I've got Medicare'," Minnix said. "People don't realize
the limits of current coverage."
Medicare doesn't cover long-term nursing home services. And private
insurance usually doesn't either. Nor does either generally pay for
in-home care to help a disabled individual live independently. Even
Medicaid is seriously restrictive in its coverage of long-term care.
Minnix calls the CLASS program "one of the most revolutionary" elements
of health reform. "More and more families are recognizing that this
could happen to anybody and therefore it's something that's logical to
insure against," he said.
But critics say the program is poorly designed and will end up costing
taxpayers billions of dollars.
"Design problem No. 1 is it will be most attractive to those who need
the benefit," said Douglas Holtz-Eakin, a former director of the
Congressional Budget Office and now president of the conservative
American Action Network Forum.
If only the sick or disabled buy into the programs, he said, the
premiums will not cover the costs of care. He's also worried that HHS
will set the premiums too low to entice participation, therefore
shortchanging the insurance fund before it even gets going.
And finally, he said that as participants begin to realize how small
the benefits are, Congress "will be tempted to pump up" the program and
create a whopping new entitlement program.
Holtz-Eakin doesn't dispute that there's a problem. But he said that
what's needed is a more robust private long-term insurance market.
Right now, he argues, Medicaid "crowds out" private competitors.
He conceded that there are no easy solutions and the problem is only
going to become more acute.
"The bulk of long term care services are donated at this point,
typically by family members, mostly woman," he noted. "And given the
demographics--that more elderly are living longer and more women are
working--this problem is going to get worse before it gets better."
He and others are urging Republicans in Congress to target the CLASS
Act for repeal, and there are already bills in the legislative hopper
to do so.
Howard Gleckman, a resident fellow at the Urban Institute and author of
the book, "Caring for Our Parents," agrees that the CLASS program is
not well crafted.
"I worry that relatively few healthy people will enroll, and if that
happens that will drive up the premiums," he said, creating a "death
spiral" where only people who know they need it will purchase it,
making it "a system that's entirely unaffordable."
But repealing the measure is not the way to go, he said, "because then
what you are left with is the Medicaid system, which is unsustainable."
He said that while flawed, the program is a good first step. And if
done correctly and improved upon, it will help solve the looming
long-term care crisis. For example, he said, if there are incentives
for employers to get their workers enrolled, that would be a good way
to expand the insurance pool.
In her remarks Monday, Sebelius acknowledged those concerns and said
CLASS is "far from perfect." But as HHS officials begin to set up the
program, she said, the agency will use the "ample flexibility" in the
law to make sure it's successful and solvent.
If they don't, she said, "countless Americans will have to clean out
their savings" to get the care they need.
WOLF: Lies, damn lies and death panels
Obamacare was for them before it was against them (and back again)
The Washington Times
By Dr. Milton R. Wolf
5:39 p.m., Thursday, December 30, 2010
Those death panels that the White House first promised were never a
part of Obamacare and then promised had been removed from Obamacare are
back in Obamacare, but the White House promises us it's nothing new. If
this doesn't trouble you, I'll make a promise of my own: When your
mother gets caught in the cross hairs, it will.
The liberal intelligentsia, prisoners of their own conditioned reflex
response, mocked Sarah Palin when she warned America in a Facebook post
of the Obamacare death panels. The excitable Keith Olbermann even
crowned it a 2009 "Lie of the Year." Specifically, the ex-governor of
Alaska referred to the Advance Care Planning Consultation provision in
the Affordable Care Act, Section 1233 of H.R. 3200, which specifically
called to pay doctors to discuss - some say encourage - withholding
end-of-life care with their elderly patients once every five years. The
White House denied impropriety but removed the provision when fellow
Democrats balked. Only then did the bill pass by a single vote.
The liberal talking class continued to mock Mrs. Palin and her
supposedly mythical death panels, that is, until liberal icon and
former Enron adviser Paul Krugman let the cat out of the bag that death
panels are indeed a reality and, in his ghoulish vision, killing off
senior citizens and taxing the survivors is a solution to America's
debt problem: "Some years down the pike, we're going to get the real
solution, which is going to be a combination of death panels and sales
taxes." This gives a chilling new meaning to death and taxes. Suddenly
the inharmonious left fell silent.
So what is a death panel exactly? Nowhere will you find that term in
the Patient Protection and Affordable Care Act, but then again, neither
will a word search of the Constitution find the right to abortion or
the separation of church and state. Admittedly, the term is
provocative, but then again, so is the disquieting notion that a
Washington panel should decide who lives and who dies. And make no
mistake, when a nameless, faceless bureaucrat decides what treatments
will and won't be made available to your mother, that is precisely what
is happening.
The Federal Coordinating Council for Comparative Effectiveness
Research, in fact, was sneaked into the American Recovery and
Reinvestment Act - the stimulus bill, of all places. It empowered the
government to decide what conditions were hopeless and therefore would
be left untreated. (Gee, I sure hope your mom doesn't get one of
those.) Obamacare gives even wider latitude to the Center for Medicare
and Medicaid Services, the Department of Health and Human Services and
even the Food and Drug Administration (FDA) to determine what care will
be made available.
Speaker of the House Nancy Pelosi, California Democrat, famously said
of Obamacare that "we have to pass the bill so that you can find out
what is in it," and sadly, she was right because most of the
implementation rules were left unwritten at the time. Some estimate
that the 2,700-page law will generate another 100,000 pages of rules
written by bureaucrats - try to imagine - in the ultimate end run of
Congress and the American people. Obamacare, if allowed to stand, will
usher in a new crushing era of heavy-handed, European-style
social-welfare bureaucracy.
As if on cue, Dr. Donald Berwick, President Obama's choice as Medicare
chief, in a profoundly arrogant move, reinstated, effective this week,
the very end-of-life provision that Congress rejected, but with an
accelerated payment scheme that effectively will result in even more
elderly Americans being nudged to forgo medical care. Sidestepping
Americans and their representatives in Congress is nothing new for Dr.
Berwick. You'll recall, he enjoyed a recess appointment, which allowed
him to avoid congressional hearings that would have forced him to
defend his deeply troubling statements: He's "romantic" about the
British government-run health system, he explicitly favors health care
rationing, he thinks it's the role of the health care system to
redistribute wealth, and, perhaps most troubling of all, he thinks the
once inviolable doctor-patient relationship is "no longer tenable"
without government control.
To be sure, there is nothing certainly inappropriate about discussing
end-of-life care with patients so long as the patient and their family
can maintain complete trust that their doctor is providing caring - and
this is crucial - uncoerced advice. Quite the contrary, it absolutely
should be done, but it's a far too important part of the doctor-patient
relationship to permit the government to determine how and when. These
difficult decisions are undermined unless they are made freely by the
patient and his or her family, grounded in the unassailable trust the
patient has in the doctor to provide caring and - this is crucial -
uncoerced advice. Sadly, this administration already has shown a
willingness to undermine patients' trust in their doctors by falsely
claiming surgeons will amputate legs or remove tonsils just to make a
quick buck. Not only have I, as a physician, counseled many families in
these trying end-of-life times - a heart-rending and life-changing
experience for all of us involved - but I learned firsthand of their
importance when my father, himself a physician, made his own wishes
known to us in the final months of his life. If ever a family's
decision should be held sacred from the government, this is it.
Just as troubling, death panels exist elsewhere. The FDA's role in
pharmaceuticals was limited initially to safety, but expanded decades
ago to policing efficacy, a move that delayed and prohibited lifesaving
pharmaceutical approval with, quite literally, incalculable resultant
deaths and suffering. And now FDA has gone even further, crossing an
alarming moral line. For the first time in our history, the government
has banned the use of a cancer drug based not on its safety or even
efficacy, but on its financial cost. Just this month, the FDA revoked
approval of Avastin to late-stage breast-cancer patients, dashing many
women's final and desperate hope for life.
Obamacare's unkeepable promises just keep mounting, which doesn't bode
well for the veracity of the administration's other key life-issue
claim: that no taxpayer dollars would fund abortions. This was yet
another promise without which Obamacare would not have passed.
Promises from the White House notwithstanding, Mrs. Palin indeed was
right. Death panels are all too real, and no family deserves to be
caught up in them. Granted, some may find the term "death panel"
unnecessarily provocative, but then again, what exactly should we call
a panel whose decisions result in death? Perhaps Mr. Krugman can
suggest a more palatable name that embodies his lofty death-panel
desires, but he had better hurry. The first deaths are about to occur.
Dr. Milton R. Wolf is a radiologist
in Kansas and President Obama's second cousin once removed. He blogs at
miltonwolf.com.
© Copyright 2010 The Washington Times, LLC. Click here for reprint
permission.
Suing ObamaCare
NYPOST
By BETSY McCAUGHEY
Last Updated: 4:07 AM, October 15, 2010
Posted: 10:42 PM, October 14, 2010
Yesterday, in a federal courtroom far from the noise of town-hall meet
ings, Tea Parties and talk shows, Judge Roger Vinson quietly compelled
the Obama administration to show why the new health law, enacted on
March 23, does not trample the Constitution. The ruling is a
victory for the cause of freedom and limited government.
Vinson reminded the nation that even in the face of a perceived crisis,
such as the number of uninsured and rising health costs, it isn't
enough that a law be wise or expedient. That law must also respect the
limits imposed by the US Constitution. Those limits are not merely
"formalistic," he said; they protect liberty. Vinson rejected
many of the administration's arguments for throwing out constitutional
challenges brought by 40 percent of all the states in the nation:
Florida, South Carolina, Nebraska, Texas, Utah, Louisiana, Alabama,
Michigan, Colorado, Pennsylvania, Washington, Idaho, South Dakota,
Indiana, North Dakota, Mississippi, Arizona, Nevada, Georgia and Alaska.
The ruling paves the way for a trial to begin in Florida in December,
with appeals expected all the way to the Supreme Court. The final word
from the nine justices would likely come late in 2012, before the
presidential election.
This is the second legal defeat for the administration. On Aug. 2,
another federal judge ruled against the administration's motion to
dismiss a separate lawsuit by Virginia. That judge noted that it was
far from certain that Congress had the authority to compel Americans to
buy insurance or penalize those who don't. Virginia Attorney
General Ken Cuccinelli said that his state's challenge was "about
liberty, not health care." David Rivkin, the lead attorney for the
20-state challenge, calls that case "the most important of my lifetime."
If ObamaCare's insurance mandate law is ruled unconstitutional, the
whole law could collapse. Most complex legislation contains a
boilerplate statement that if one part of the law is struck down, other
parts remain enforceable. But the authors of the Obama health law
removed that statement, suggesting that the whole scheme was unworkable
without compulsion. The administration's lawyers claim that the
Commerce Clause gives the federal government the authority to mandate
coverage. They cite two cases in which the Supreme Court stretched the
meaning of interstate commerce like a rubber band.
In Wickard v. Filburn (1942), the court ruled that the federal
government could limit how much wheat a farmer can grow to feed his own
animals. Similarly, in Gonzalez v. Raich (2005), the court found that
the federal government could bar a sick person from cultivating a mere
six stalks of marijuana, even where state law allows it. Growing
something for personal use doesn't seem like interstate commerce, said
the justices, but individual decisions in the aggregate could impact
national markets.
Yet the administration wants to stretch the definition of interstate
commerce even farther, to include an individual's decision not to do
something -- in this case not to buy insurance. Judge Vinson expressed
skepticism: "The government has never required people to buy any good
or service as a condition of lawful residence in the United States," he
noted.
"If the federal government can do this," Rivkin cautioned, "there is no
limit to what the federal government can do."
The judge also ruled that another issue must get its day in court --
ObamaCare's vast expansion of Medicaid. Each state has always
decided who is eligible for Medicaid and what benefits they get,
depending on what the state budget can handle. The federal government
has paid roughly half the cost. But the ObamaCare law strips the
states of control over Medicaid, imposing a one-size-fits-all benefit
package and raising the income limit so high that some 85 million
people are projected to be on Medicaid in 2014.
The feds would pay the full cost for those millions of new Medicaid
cases only for the first two years. After 2016, states must raise taxes
or cut other spending to come up with extra Medicaid funds.
Yet the Supreme Court has ruled that Medicaid is a "cooperative
venture" -- and that the federal government can't coerce the states
into an unaffordable deal. (Harris v. McRae, 1980). Judge Vinson says
the states are making a "plausible claim" that ObamaCare is doing just
that. If the 20 states prevail on either challenge -- compulsory
insurance or the Medicaid expansion -- Rivkin predicts that they will
ask to stop the clock on ObamaCare until the Supreme Court rules. That
will spare states from having to spend billions of dollars on a law
that may never go into effect.
And it will give members of Congress time to read the Constitution they
have sworn to uphold.
ObamaCare's
redistribution of health
NYPOST
By BETSY McCAUGHEY
Last Updated: 4:31 AM, September 27, 2010
Posted: 11:43 PM, September 26, 2010
New projections from the federal Cen ters for Medicare and Medicaid
paint a stark picture of the impact of the ObamaCare law: We're in for
a massive redistribution of health resources.
When the projections were released this month, news reports stressed
that the president's "reform" utterly fails to slow the growth of
health-care spending. Every year through 2019, employers and consumers
will face higher premiums than if the law hadn't passed.
But worse news is how radically the Obama law spreads the health wealth
around.
In 2014, a staggering 85.2 million people -- 31 percent of all
nonelderly Americans -- will be on Medicaid and CHIP (the Medicaid-like
children's health program). This accounts for the majority of those
who'd gain health coverage. Amazingly, only 3 percent more people will
have private insurance.
President Obama pledged to reduce the number of uninsured by making
health plans affordable -- but that's not how his law actually does it.
Rather, it loosens Medicaid eligibility by raising the income ceiling
and barring asset tests.
In short, it pushes our country toward a welfare state.
Often, workers put up with low salaries to get good health benefits for
their families. But the new law stipulates that Medicaid recipients get
the same benefits that employers are required to provide workers. That
will diminish the incentive to work -- another step toward reversing
welfare reform. Why stick it out on the job if the benefits are just as
good in Medicaid?
ObamaCare is the health component of an overall move to make more
people dependent on government. In the last two years, we've seen a
breathtaking expansion of food stamps, Medicaid, welfare and housing
programs. One in six Americans depends on them.
That's partly due to the recession -- but the Obama administration
projects roughly doubling spending on these programs by 2018, even in
years it predicts the economy will be booming.
Two fundamental American sentiments get trampled in the process: our
culture of hard work and self-sufficiency and our commitment to stand
by the generation that nurtured us.
To expand Medicaid, the Obama law eviscerates Medicare. It's like
robbing Peter to pay Paul, only it's robbing grandma and grandpa. The
new projections show that in 2019, for example, ObamaCare cuts Medicare
funding by $86.4 billion -- which works out to $1, 428 less for each
elderly patient that year. Baby boomers will face difficulties
accessing care that seniors now get. Richard Foster, chief actuary for
Medicare, has spoken with brave bluntness about the possible impact,
warning that some hospitals might stop taking Medicare. Where will
seniors go?
Figures don't lie. The projections from the Obama administration's own
agency, the Centers for Medicare and Medicaid, depict the truth in
stark terms.
Higher premiums are bad enough, but to see the older generation
victimized in order to expand a welfare culture is a total reversal of
American values.
Now we know department...
Carter says Kennedy
delayed health care years ago
YAHOO
By ANDREW MIGA, Associated Press Writer
16 September 2010
WASHINGTON – Former President Jimmy Carter says Americans could have
had comprehensive health care coverage decades ago if Sen. Edward M.
Kennedy hadn't blocked a plan Carter had proposed.
Carter revisited the old spat in an interview with CBS' "60 Minutes" to
be aired Sunday. Portions of the interview, prompted by the publication
of his White House diary, were posted on the program's website Thursday.
"The fact is that we would have had comprehensive health care now, had
it not been for Ted Kennedy's deliberately blocking the legislation
that I proposed," Carter said in the interview. "It was his fault. Ted
Kennedy killed the bill."
Carter cast his Democratic rival as spiteful. "He did not want to see
me have a major success in that realm of life," Carter said.
The Massachusetts senator unsuccessfully challenged Carter for the 1980
Democratic presidential nomination. Carter then lost to Republican
Ronald Reagan. Kennedy, who made health care reform a prized
cause,
died in August 2009 from brain cancer. The disagreement over
health
care is noted in Carter's latest book, "White House Diary." According
to a "60 Minutes" statement, Carter wrote at the time: "Kennedy
continuing his irresponsible and abusive attitude, immediately
condemning our health plan. He couldnt get five votes for his plan."
Kennedy and Carter had competing health care reform plans while Carter
was president. Kennedy favored a more comprehensive approach that would
have insured all Americans against health care costs regardless of age
or income. Carter backed a more moderate proposal that would have been
phased in over several years.
In his 2009 memoir, "True Compass," Kennedy blamed Carter for dragging
his feet on health care and wrote that Carter viewed his health care
efforts as a platform to challenge his presidency.
"If that's why he slowed things down, then he made a poor political
calculation," Kennedy wrote. "If we had passed comprehensive national
health insurance together, it would have been a huge victory for
Carter."
When asked in interviews about his biggest regret as a senator, Kennedy
often recalled his failure to make a deal to pass President Richard
Nixon's sweeping health care proposal in the early 1970s. Kennedy said
that at the time he did not think it went far enough.
The animals now want government healthcare
The social security sacred cow
NYPOST
By JACOB SULLUM
Last Updated: 1:32 AM, September 1, 2010
Posted: 1:14 AM, September 1, 2010
Alan Simpson violated a taboo last week when he likened Social Security
to “a milk cow with 310 million tits.” But contrary to the
dictionary-deprived critics who accused him of sexist vulgarity, the
former Wyoming senator’s transgression had nothing to do with his use
of a perfectly acceptable synonym for teat. Simpson’s real sin was
“belittling a bedrock program,” as the AARP put it — i.e., showing
insufficient reverence for a sacred cow...full article
here.
We just noticed this article
UConn’s
Dempsey Hospital Off The Charts In Controversial “Double CT Scan” Use
New Haven Independent
by Lisa Chedekel | Jan 7, 2011 6:32 am
Sent: Jan 8, 2011 11:48 am
Nationally, when a patient shows up at a hospital for medical imaging
for a chest or abdominal malady, the chances that he or she will need a
“combination” CT scan, which entails an excess radiation risk, are
slim: 5 percent in the case of chest scans, and 19 percent for
abdominal scans.
Not so at UConn’s John Dempsey Hospital, where 48 percent of all
patients who received CT scans of the chest were subjected to
combination scans—nearly 10 times the national average—according to
data collected by the federal Centers for Medicare & Medicaid
Services [CMS]. And more than 72 percent of patients who were sent for
CT scans of the abdomen received double scans. The data, from 2008, is
the most recent available.
Combination scans have come under scrutiny because they may
unnecessarily expose patients to excess radiation. Standards of quality
care say that most patients who get a CT scan of the chest should be
given a single CT scan, rather than a double study. “Combination scans
are usually not appropriate for the chest,” CMS guidelines say.
Similarly, with abdominal scans, a rate of double scans that is higher
than the national average – 4 times higher, in Dempsey’s case – may
indicate that “too many patients are being given a double scan when a
single scan is all they need,” CMS says. “Combination scans involve
additional radiation exposure and risks associated with use of
contrast.”
Combination CT scans mean that a patient gets two scans – one regular
scan, and a second with a substance called “contrast” that is put into
the patient’s body before the scan begins, to help make parts of the
body stand out more clearly on the x-rays.
For chest scans, a patient’s radiation exposure from a double scan is
700 times higher than from a simple chest X-ray. For abdominal scans,
the radiation dose is comparable to that of approximately 400 chest
X-rays.
The data collected by CMS’ “Hospital Compare” system shows that
Dempsey, part of the UConn Health Center, has the highest rate of
double chest and abdomen scans among all hospitals in the state, most
of which are in line or have lower rates than national averages.
Dr. Douglas Fellows, chair of radiology at the UConn Health Center,
said this week that he was “absolutely staggered” by the rates recorded
by the federal government. “To be 10 times higher than the national
average is astounding,” he said.
But he said his own internal review last year had flagged a high
incidence of the multiple scans – a trend that the hospital is now
addressing through a number of steps. Clinicians with expertise in
abdominal and chest imaging are working with physicians to encourage
single scans, he said. And in cases where outpatients come to Dempsey
with orders for double scans, Fellows’ staff is contacting doctors to
push for single scans.
Also, when double scans are clearly warranted, Dempsey radiologists are
using a lower-dose radiation on the initial non-contrast study, Fellows
said.
“Radiation safety is very high on our list of concerns,” he said.
“We’re working very hard on this, in terms of changing policies and
talking to physicians to reduce the orders for double scans.”
Statewide, most hospitals—including Bristol, Danbury, Stamford,
Waterbury, St. Francis in Hartford and St. Raphael in New Haven—are
well-below the national average for combination scans. Only Hartford
Hospital, Norwalk Hospital and Charlotte Hungerford in Torrington are
higher than national average for double chest scans; only MidState
Medical Center in Meriden and Bridgeport and St. Vincent hospitals are
higher for abdominal scans. But all are significantly lower than
Dempsey in both categories.
Overall, the state’s average for double scans is lower than the
national average.
A report to the state Office of Health Care Access filed by Dempsey
shows the hospital did more than 17,000 CT scans in the 2009 fiscal
year, up 3 percent over the prior year. Double scans are more expensive
than single scans – nearly 60 percent higher in cost, according to
average Medicare reimbursement rates.
Questions about the double scans come as state officials grapple with
news that the UConn Health Center won’t be receiving a much-anticipated
$100 million federal grant that officials were counting on to help pay
for a massive renovation and improvement project. The Center, including
the hospital, has faced financial trouble in recent years and has
required millions of dollars in state bailouts. But the hospital also
has been recognized in recent years with several quality and patient
care awards.
While CT scans are a steady revenue source for hospitals, a number of
recent studies have pointed to potential risks from radiation exposure.
A November study published in the journal Radiology found that
emergency department use of CT scans had increased nearly six-fold
since 1995 and showed no signs of tapering off.
In 2007, the scans were used in 16.2 million emergency room visits—a
huge increase from 1995’s figure of 2.7 million. By the end of the
study period, the top complaints among those who underwent CT scans
were abdominal pain, headache, and chest pain.
The study noted that CT scans to investigate abdominal pain carry a
higher radiation dose than CT exams used to determine the cause of a
headache. The study found that overall, the use of scans that typically
involve a higher radiation dose grew faster than those with a lower
radiation dose. In 1995, a patient visiting the emergency room with
chest pains rarely received a CT exam. But by 2007, chest pain was the
third most common complaint in the ER associated with CT imaging,
according to the study.
The American College of Radiology [ACR], with more than 30,000 members,
has expressed concerns about the unnecessary use of scans. The group
recommends that hospitals adopt “decision support systems” for
clinicians, using a set of clinical findings to produce a list of
possible diagnoses and evaluation measures – a step that the ACR
believes could cut down on unnecessary scans.
“We do feel that there’s unnecessary scanning being done out there, and
we would like to see steps being taken to address that,” said Shawn
Farley, a spokesman for the ACR.
Other studies also have sparked concerns about the technology’s
possible overuse and the resulting radiation exposure and significant
costs. Two recent reports in the Archives of Internal Medicine found
that doses of radiation from the commonly performed procedure vary
widely and may contribute to tens of thousands of future cancer cases.
“While CT scans can provide great medical benefits, there is concern
about potential future cancer risks because they involve much higher
radiation doses than conventional diagnostic X-rays,” the authors of
one report wrote.
Last year, the FDA took up the issue, announcing an initiative to
reduce unnecessary CT scans and limit patients’ exposure to “radiation
that can increase a person’s lifetime cancer risk.” The agency said it
wants to ensure that safeguards are built into the design of the
machines, that practitioners are appropriately trained, and that
patients are better informed about their radiation exposure and risks.
The “Hospital Compare” database compiled by CMS also includes a measure
that looks at whether hospitals perform unnecessary MRI (magnetic
resonance imaging) tests on patients complaining of lower back pain. In
most cases, the pain resolves on its own and does not require an MRI
for diagnosis, Medicare officials say. The MRI scans can be expensive
and stressful, but do not expose the patient to radiation.
In its data, CMS looked at the percentage of patients with back pain
who probably did not need an MRI but got one before trying other
treatments. The national average is 33 percent.
Two Connecticut hospitals—New Milford and Windham Community – exceeded
the national average on such MRIs. Some other hospitals also had
high rates, but the patient count was not large enough to be sure how
well the hospitals were performing. Dempsey’s rate for unnecessary
MRI’s was lower than the state and national averages.
Americans
get most radiation from medical scans
YAHOO
By MARILYNN MARCHIONE, AP Medical Writer
Mon Jun 14, 4:53 am ET
We fret about airport scanners, power lines, cell phones and even
microwaves. It's true that we get too much radiation. But it's not from
those sources — it's from too many medical tests.
Americans get the most medical radiation in the world, even more than
folks in other rich countries. The U.S. accounts for half of the most
advanced procedures that use radiation, and the average American's dose
has grown sixfold over the last couple of decades.
Too much radiation raises the risk of cancer. That risk is growing
because people in everyday situations are getting imaging tests far too
often. Like the New Hampshire teen who was about to get a CT scan to
check for kidney stones until a radiologist, Dr. Steven Birnbaum,
discovered he'd already had 14 of these powerful X-rays for previous
episodes. Adding up the total dose, "I was horrified" at the cancer
risk it posed, Birnbaum said.
After his own daughter, Molly, was given too many scans following a car
accident, Birnbaum took action: He asked the two hospitals where he
works to watch for any patients who had had 10 or more CT scans, or
patients under 40 who had had five — clearly dangerous amounts. They
found 50 people over a three-year period, including a young woman with
31 abdominal scans.
When other radiologists tell him they've never found such a case,
Birnbaum replies: "That tells me you haven't looked."
Of the many ways Americans are overtested and overtreated, imaging is
one of the most common and insidious. CT scans — "super X-rays" that
give fast, extremely detailed images — have soared in use over the last
decade, often replacing tests that don't require radiation, such as
ultrasound and MRI, or magnetic resonance imaging.
Radiation is a hidden danger — you don't feel it when you get it, and
any damage usually doesn't show up for years. Taken individually, tests
that use radiation pose little risk. Over time, though, the dose
accumulates.
Doctors don't keep track of radiation given their patients — they order
a test, not a dose. Except for mammograms, there are no federal rules
on radiation dose. Children and young women, who are most vulnerable to
radiation harm, sometimes get too much at busy imaging centers that
don't adjust doses for each patient's size.
That may soon change. In interviews with The Associated Press, U.S.
Food and Drug Administration officials described steps in the works,
including possibly requiring device makers to print the radiation dose
on each X-ray or other image so patients and doctors can see how much
was given.
The FDA also is pushing industry and doctors to set standard doses for
common tests such as CT scans.
"We are considering requirements and guidelines for record-keeping of
dose and other technical parameters of the imaging exam," said Sean
Boyd, chief of the FDA's diagnostic devices branch.
A near-term goal: developing a "radiation medical record" to track dose
from cradle to grave.
"One of the ways we could improve care is if we had a running sort of
Geiger counter" that a doctor checked before ordering a test, said Dr.
Prashant Kaul of Duke University.
He led an eye-opening study that found that U.S. heart attack patients
get the radiation equivalent of 850 chest X-rays over the first few
days they are in the hospital — much of it for repeat tests that may
not have been needed.
How much radiation is risky?
It's hard to say. The best guess is based on the 1986 Chernobyl nuclear
power plant accident and studies of Japanese atomic bomb survivors who
had excess cancer risk after exposures of 50 to 150 millisieverts (a
measure of dose) of radiation.
A chest or abdominal CT scan involves 10 to 20 millisieverts, versus
0.01 to 0.1 for an ordinary chest X-ray, less than 1 for a mammogram,
and as little as 0.005 for a dental X-ray. Natural radiation from the
sun and soil accounts for about 2 millisieverts a year.
A big study last year estimated that 4 million Americans get more than
20 millisieverts a year from medical imaging. Two percent of people in
the study had high exposure — 20 to 50 millisieverts.
Another study by Columbia University researchers, published in 2007,
estimated that in a few decades, as many as 2 percent of all cancers in
the U.S. might be due to radiation from CT scans given now. Since
previous studies suggest that a third of all tests are unnecessary, 20
million adults and more than 1 million children are needlessly being
put at risk, they concluded.
Just because a scan didn't find anything wrong doesn't mean a test
wasn't needed. Scans are useful for many diagnoses. But many studies
suggest people are getting too much imaging now. For example, Mayo
Clinic researchers reviewed the medical records of 251 people given
heart scans in 2007 and found that only a quarter of them were clearly
appropriate.
Reasons for overuse:
_Accuracy and ease of use. Scans have become a crutch for doctors
afraid of using exams and judgment to make a diagnosis. Some think a
picture tells more than it does. Imaging that shows arthritis in a knee
or back problems doesn't reveal how to make it better, said Dr. Richard
Baron, a primary care doctor in Philadelphia.
"Physical therapy for an orthopedic injury is always the first choice,"
yet doctors rush to order tests, he said. "The question you should be
asking when you do sophisticated imaging is, 'Is there something I can
fix with an operation?'"
_Malpractice fear. A missed heart attack or a burst appendix could be
devastating for a patient — and mean a lawsuit.
"I have great sympathy for the ER physicians because of the
responsibility placed in their hands with strangers that come in off
the street," said Louis Wagner, chief physicist at the University of
Texas in Houston. "They have to make a decision that could mean life or
death for a patient, and the fastest way to find out is CT."
_Patient pressure. People urge doctors to "do something" to figure out
what's wrong, and "often, doctors feel that the way to demonstrate that
they're doing something is to order tests," said Dr. Christopher
Cassady, a radiologist at Texas Childrens Hospital and the American
Academy of Pediatrics' expert on this topic.
At his hospital, doctors first do an ultrasound on suspected
appendicitis cases instead of rushing into a CT scan. Ultrasounds
require no radiation.
_Health care chaos. One doctor may not know that another has ordered
the same test. If a patient is referred to a specialist, "it's often
easier for him to order another study than to figure out how to get the
one that was done somewhere else," Baron said.
_Insurance issues. X-rays often are required by insurers to prove
health, or for students to study abroad.
_Availability. Rural hospitals may not have an ultrasound technologist
on duty in the wee hours, but imaging machines are always there.
_Treatment choice. A quick fix for chest pain — artery-opening
angioplasty — requires far more imaging and radiation than bypass
surgery does. The same is true of "virtual colonoscopy" instead of the
standard version.
Which tests are overused? A scientific group, the International
Commission on Radiological Protection, cites routine chest X-rays when
people are admitted to a hospital or before surgery; imaging tests on
car crash victims who don't show signs of head or abdominal injuries;
and low-back X-rays in older people with degenerative, but stable,
spine conditions.
Even when tests are justified, they often include more views than
needed and too much radiation. Top offender: chest CT scans looking for
clogged arteries and heart problems. Cardiologists are increasingly
aware of this risk and are seeking solutions.
At Columbia University, a study on dummies by Dr. Andrew Jeffrey
Einstein found two dose-modifying techniques could lower the needed
radiation dose by 90 percent without harming image quality.
Another cardiologist and radiation safety expert, Dr. Gilbert Raff,
showed the same in real life. A study he led of nearly 5,000 patients
at 15 imaging centers in Michigan found that radiation dose could be
cut by two-thirds with no loss of quality.
What should patients do?
"You should question everything — what's the dose, why am I getting it?
You should be an informed consumer," said Dr. Fred Mettler, radiology
chief in the New Mexico Veterans Administration health care system. He
led a study of health effects after the Chernobyl accident and is a
U.S. representative to the United Nations on radiation safety.
He advised challenging "big ticket" tests like CT scans that deliver a
lot of radiation to the chest and abdomen — places where cancer is
likely to develop. "You shouldn't get too excited about feet and knee
X-rays," Mettler said.
Questions to ask about radiation scans:
_Is it truly needed? How will it change my care?
_Have you or another doctor done this test on me before?
_Are there alternatives like ultrasound or MRI?
_How many scans will be done? Could one or two be enough?
_Will the dose be adjusted for my gender, age and size? Will lead
shields be used to keep radiation away from places it can do harm?
_Do you have a financial stake in the machines that will be used?
_Can I have a copy of the image and information on the dose?
Mettler suggests bringing a blank CD or thumb drive with you.
"You should have all of your stuff digitally on something," he said. "I
keep mine on my laptop."
The despicable 'duty to
die'
NYPOST
By THOMAS SOWELL
Last Updated: 4:19 AM, May 15, 2010
Posted: 12:14 AM, May 15, 2010
One fashionable notion among some of the intel ligentsia is that old
people have "a duty to die," rather than become a burden to others.
This is more than just an idea discussed around a seminar table.
Already Britain's government-run medical system is restricting what
medications or treatments it will authorize for the elderly. It seems
almost certain that similar attempts to contain runaway costs will lead
to similar policies when US medical care is taken over by the
government.
Make no mistake: Letting old people die is a lot cheaper than spending
the kind of money required to keep them alive and well. If a
government-run medical system is going to save any serious amount of
money, it is almost certain to do so by sacrificing the elderly.
There was a time when some desperately poor societies had to abandon
old people to their fate, because there was just not enough margin for
everyone to survive. Sometimes the elderly would simply go off to face
their fate alone.
But is that where we are today?
Talk about "a duty to die" made me think back to my early childhood in
the South, during the Great Depression. One day, I was told that an
older lady -- a relative -- was going to come and stay with us for a
while, and I was told how to be polite and considerate toward her.
"Aunt" Nance Ann had no home of her own. But she moved around from
relative to relative, not spending enough time in any one home to be a
real burden.
At that time, we didn't have things like electricity or central heating
or hot running water. But we had a roof over our heads and food on the
table -- and Aunt Nance Ann was welcome to both.
Poor as we were, I never heard anybody say, or even intimate, that Aunt
Nance Ann had "a duty to die." I only began to hear that kind of talk
decades later, from educated people in an age when even most families
living below poverty level owned a car and had air-conditioning.
It is today, in an age when homes have flat-paneled TVs, and most
families eat in restaurants regularly or have pizzas and other meals
delivered to their homes, that the elites -- rather than the masses --
have begun talking about "a duty to die."
Back in the days of Aunt Nance Ann, nobody in our family had ever gone
to college. Indeed, none had gone beyond elementary school. Apparently
you need a lot of expensive education, sometimes including courses on
ethics, before you can start talking about "a duty to die."
Many years later, while going through a divorce, I told a friend that I
was considering contesting child custody. She urged me not to do it.
Why? Because raising a child would interfere with my career.
But my son didn't have a career. He was just a child who needed
someone. I ended up with custody of my son and, although he was not a
demanding child, raising him could not help impeding my career a
little. But do you just abandon a child when it is inconvenient to
raise him?
The lady who gave me this advice had a degree from the Harvard Law
School. She had more years of education than my whole family had, back
in the days of Aunt Nance Ann.
Much of what is taught in our schools and colleges today seeks to break
down traditional values, and replace them with more fancy and
fashionable notions, of which "a duty to die" is just one.
These efforts used to be called "values clarification," though the name
has changed over the years, as more and more parents caught on to what
was going on and objected. The values that supposedly needed
"clarification" had been clear enough to last for generations and
nobody asked the schools and colleges for this "clarification."
Nor are we better people because of it.
Connecticut Dems back new tack on prescription drugs
By Mary E. O’Leary, New Haven Register Topics Editor
Tuesday, April 13, 2010
HARTFORD — Democrats and municipal officials got behind a proposal
Monday that would allow cities and towns to benefit from the large
purchasing power of the state in covering prescriptions for their
employees.
The plan was discussed the same day Democrats said they and Gov. M.
Jodi Rell have negotiated a way to close the $371 million deficit
facing the state this year.
House Speaker Christopher Donovan, D-Meriden, said he was 99.9 percent
sure the deal will fly in a House vote today. He said there will be no
increase in taxes to do it. Rell dropped a proposal to cut $45 million
in aid to municipalities, and both sides reconciled differences over
where to cut.
“Tomorrow is good,” Donovan said.
This includes no changes in the estate tax, although Democrats could
push that again for 2011; there is no hospital gross receipts tax for
this year, but that also remains open. The governor submitted a plan to
Democrats last week that is the basis of negotiations.
The larger issue of what to securitize in 2011 to bring in $1.3 billion
remains a moving target, with Rep. Steven Fontana, D-North Haven,
saying it depends on what can be negotiated with Rell.
He is recommending other things be looked at to save money, such as
certain sales tax exemptions.
Rell is interested in borrowing against keno gambling, while Democrats
opted for securitizing an electric charge that was due to expire, which
was suggested as an option by Rell’s budget chief, but which Rell has
threatened to veto. “Discussions are happening,” Donovan said.
On the prescription issue, Fontana said if the municipalities
self-insure prescription riders, they can save money by taking
advantage of the state’s cheaper drug costs.
Right now, the plan, which is expected to be voted on Wednesday, is to
make the benefit available to towns, school boards and libraries.
“Any time we offer choices and offer the potential for improved
benefits is a good day at the Capitol,” said Rep. Betsy Ritter,
D-Waterford, co-chairwoman of the Public Health Committee.
Matt O’Connor, communications director for the Service Employees
International Union, Local 2001, which represents school and town
workers, in addition to state workers, favors opening up the drug
prescription coverage to municipalities as a way to save money and jobs.
“The skyrocketing costs of all health care ... are enormous on both the
employer and the town, the board of education and our members,”
O’Connor said. “We see this as a triple win.”
SEIU:
Non-industrial unions in 21st century???
Organized labor's agenda hits
roadblock; what now?
YAHOO
By SAM HANANEL, Associated Press Writer
Sat Feb 27, 7:35 pm ET
WASHINGTON – Labor's high hopes for major gains under President Barack
Obama and a Democratic Congress have dimmed, raising fresh doubts about
union leverage even in the best of political times.
Prospects for a health overhaul have faded. Even slimmer are the
chances of achieving labor's chief goal, passage of a bill making it
easier for unions to organize workers. A bipartisan jobs bill passed
this week by the Senate drew tepid praise from the AFL-CIO president,
Richard Trumka, who called it a "Band-Aid on an amputated limb" — far
short of what unions wanted.
This wasn't what unions expected a year ago after spending more than
$400 million to help elect Obama and increase the size of Democratic
majorities in the Senate and House. Leaders of labor's largest
federation will try to figure out how to refocus their political agenda
when they begin their annual meeting in Orlando, Fla., on Monday.
Another setback came in January when two Senate Democrats joined
Republicans in blocking the appointment of labor lawyer Craig Becker to
the National Labor Relations Board. Becker has worked for the AFL-CIO
and Service Employees International Union (SEIU).
Republicans have said they fear Becker would push the board to require
companies to recognize unions if they can get a simple majority of
employees to sign union cards — the same "card check" measure that's
stalled in Congress. Labor leaders were counting on Obama put
Becker
in the post when Congress was out of session. They were disappointed
when Obama said he wouldn't do it anytime soon.
"Enough is enough," Trumka said in an e-mail to labor activists. He
urged union members to call the White House and "demand that President
Obama fight Republican obstructionism" on Becker's nomination.
Some labor experts say unions have come up flat in mounting an
effective liberal response to "tea party" activists who helped
Republican Scott Brown win the special Senate election in Washington to
succeed Democrat Edward M. Kennedy, who died last year. An AFL-CIO poll
showed that 49 percent of union households supported Brown.
"There's been no indication that there's muscle behind their money,"
said Leon Fink, a labor historian at the University of Illinois at
Chicago. "There was no equivalent mobilization for public works or for
a progressive health care measure."
Even more troubling for unions, their membership in the private sector
fell 10 percent during Obama's first year in office to a historic low
of 7.2 percent. A poll this past week from the Pew Research Center for
the People & the Press found that 41 percent of those surveyed have
a favorable view of unions, compared with 58 percent in a similar
survey in 2007.
"I think that everyone is frustrated literally, but it's important to
understand who we have to be frustrated with," said United Steelworkers
president Leo Gerard.
Gerard said unions are angry about Republican tactics they view as
obstructionist and a few conservative Senate Democrats who are making
it tough for Obama to push through his agenda. Gerard said that
Democrats may not count on the usual support they expect from union
members in this fall's elections.
"If we don't have clear progress and clear attempts at progress, we're
going to have a hard time motivating our folks," he said.
AFL-CIO spokesman Eddie Vale said union members have been more hopeful
in recent days about Congress pushing some version of health care
reform in the process known as reconciliation. They also believe Obama
will direct more bailout money to community banks, infrastructure
repair and development of green jobs. "One of the things we want to
talk about is how we can build upon our existing grass roots structure
to make it bigger, more effective and get more results moving forward,"
Vale said.
Unions have fared much better with Obama than under Republican
President George W. Bush. Obama helped save thousands of union jobs
through federal bailouts of General Motors and Chrysler and by propping
up state governments through the stimulus bill. Also, SEIU's president,
Andy Stern, is one of the most frequent White House guests.
But the window seems to have shut on labor's top goal — a vote on the
card check bill before Democrats lost their 60-vote majority in the
Senate that could help keep GOP stalling tactics at bay. Unions believe
changing the law is the only way for them to "level the playing field"
with companies that have had an easier time stifling union organizing
drives.
"Obama said health care had to go first (before card check) and stuck
to that," said Gerald McEntee, president of the American Federation of
State, County and Municipal Employees. "We thought we were going to go
bang right off the bat and it didn't happen that way."
Amy Dean, a former AFL-CIO organizer who has written a book about the
future of the labor movement, said unions made the mistake of waiting
for an agenda "and as a result, got rolled."
"The lesson from the Clinton years is you can't wait for the White
House, you have to have your own political strategy," Dean said.
Sex robot focuses on appealing to the
mind
By PETER SVENSSON, AP Technology Writer
Sun Jan 10, 2:25 pm ET
LAS VEGAS – A New Jersey company says it has developed "the world's
first sex robot," a life-size rubber doll that's designed to engage the
owner with conversation rather than lifelike movement.
At a demonstration at the Adult Entertainment Expo in Las Vegas on
Saturday, the dark-haired, negligee-clad robot said "I love holding
hands with you" when it sensed that its creator touched its hand.
Another action, this one unprintable, elicited a different vocal
response from Roxxxy the robot. The level of sophistication
demonstrated was not beyond that of a child's talking toy, but Roxxxy
has a lot more brains than that — there's a laptop connected to cables
coming out of its back. It has touch sensors at strategic locations and
can sense when it's being moved. But it can't move on its own, not even
to turn its head or move its lips. The sound comes out of an internal
loudspeaker.
Douglas Hines, founder of Lincoln Park, N.J.-based True Companion LLC,
said Roxxxy can carry on simple conversations. The real aim, he said,
is to make the doll someone the owner can talk to and relate to.
"Sex only goes so far — then you want to be able to talk to the
person," Hines said.
The phrases that were demonstrated were prerecorded, but the robot will
also be able to synthesize phrases out of prerecorded words and sounds,
Hines said. The laptop will receive updates over the Internet to expand
the robot's capabilities and vocabulary. Since Hines is a soccer fan,
it can already discuss Manchester United, he said. It snores, too.
Owners will also be able to select different personalities for Roxxxy,
from "Wild Wendy" to "Frigid Farrah," Hines said. He's charging
somewhere from $7,000 to $9,000 for the robot, including the laptop,
and expects to start shipping in a few months.
A Japanese company, Honey Dolls, makes life-size sex dolls that can
play recorded sounds, but Roxxxy's sensors and speech capabilities
appear to be more sophisticated. Hines' goals are certainly more
far-reaching.
An engineer, Hines said he was inspired to create the robot after a
friend died in the Sept. 11, 2001, terror attacks. That got him
thinking about preserving his friend's personality, to give his
children a chance to interact with him as they're growing up. Looking
around for commercial applications for artificial personalities, he
initially thought he might create a home health care aide for the
elderly.
"But there was tremendous regulatory and bureaucratic paperwork to get
through. We were stuck," Hines said. "So I looked at other markets."
The broader goal of the company is still to take artificial
personalities into the mainstream, beyond sex toys, Hines said.
"The sex robot thing is marketing — it's really about making a
companion," he said.
In a 2007 book, "Love and Sex with Robots," British chess player and
artificial intelligence expert David Levy argues that robots will
become significant sexual partners for humans, answering needs that
other people are unable or unwilling to satisfy.
How Obama's routing the recovery
NYPOST
By CHARLES GASPARINO
Last Updated: 6:32 AM, January 11, 2010
Posted: 1:56 AM, January 11, 2010
So, despite all the money spent on stimulus, the economy continues to
lose jobs and unemployment remains at a staggering 10 percent. That
grim news appeared to catch the Obama administration by surprise last
week -- but it shouldn't have.
The number-crunchers at the Treasury Department have been celebrating
what appears to be the end of the Great Recession as told through
rising GDP, higher business profits and a buoyant stock market. But
owners of small businesses -- the usual engines of economic growth --
are still refusing to hire back workers as they normally do when the
economy turns up from a sharp decline.
Talk to them, and they'll gladly tell you why: Having weathered the
recession, they now fear the administration will choke off the nascent
recovery and increase their costs through higher taxes to pay for the
myriad of programs President Obama has in store for us, including the
hyperexpensive health-care overhaul.
If the president wasn't so busy looking to score cheap political points
when he met with the heads of the big banks last month, he'd have
listened to their warnings on this very issue. At one point, JP Morgan
CEO Jamie Dimon politely interrupted Obama's monologue on how the banks
should be lending more to small businesses to explain that many
businesses simply don't want to borrow to expand their operations and
hire more workers.
"Jamie basically said the demand for loans is way down because
businesses, particularly those that are making money and can qualify
for loans, simply don't want to borrow," said one person with direct
knowledge of the conversation.
And they're not borrowing because they don't know just how high their
tax bills will be when the president gets done implementing all his
"hope" and "change."
That's what stock analyst Peter Sidoti is discovering. Sidoti's firm
supplies research on so-called small-cap companies, ones the stock
market values at $300 million to $2 billion. With typical payrolls of
100 to 2,000 employees, these are the very definition of the "small
businesses" that provide many if not most of the nation's new jobs.
Of the 600 companies Sidoti and his team cover, "There hasn't been one
bankruptcy," he tells me. How did they survive the recession? By
cutting costs and hoarding cash, not expanding their business and
hiring more people, even as the economy now is starting to recover.
During other recoveries, Sidoti says, firms like these would be hiring
workers in droves as demand picks up for goods and services. This time
around, they're not -- because "they don't know what their costs are
going to be." And those costs are, of course, higher taxes.
He recalls a conversation with the CEO of one company he covers, Monroe
Muffler, who said his average cost per worker is $35,000 a year, but he
isn't going to expand his workforce much more if he has to pay another
$8,000 a year in higher taxes, thanks to the new health-care plan and
other government initiatives.
"This is a huge problem," Sidoti explains. "Unemployment is at 10
percent and all these businesses see are higher costs in the future
from health care and other policies -- so they are hoarding cash.
They're making money, but why logically would any businessman use this
money to expand if he doesn't know what all his costs will be because
of the expansion of these government programs?"
The issue is strikingly similar to what the banks face. As we're all
aware, the banks are making big money and waiting to pay out bonuses in
the coming days. But the cash isn't coming from lending the money out.
Instead, the banks are cutting costs, hoarding cash and investing some
of it in low-risk bonds.
Businesses are doing the same even if the economy "grows" according to
official statistics. Why risk expanding operations and hiring workers
amid a wild boom in government that will lead to massive tax hikes when
you can make money simply by doing nothing or laying people off?
All of which translates into a jobless recovery -- the economy
appearing to grow while unemployment remains unnaturally high -- unless
of course, you work in government.
Teresa
Heinz has breast cancer
Washington Times
ASSOCIATED PRESS
Wednesday, December
23, 2009
BOSTON (AP) -- Teresa Heinz says she is being treated for breast cancer
discovered through mammography and argues that younger women should
continue undergoing the tests despite a federal panel's recent
recommendation to reduce their frequency. The 71-year-old wife of
the 2004 Democratic presidential nominee, Sen. John Kerry, of
Massachusetts, told The Associated Press that the cost of mammography
is far lower than the physical and personal tolls women ages 40 to 60
face if their cancer goes undetected early and they later have to be
treated with aggressive chemotherapy.
"Chemotherapy is serious. It also costs a lot of money. It's very
painful. And it's very destructive of people's -- most people's --
lives for a while, anyway. So why put people through that instead of
just having a test that's done, and it's done?" Heinz told the AP
during an interview this week. "So that's why I was so upset about that
decision of this panel."
She recalled nurses in a hospital where she was receiving a magnetic
resonance imaging procedure, or MRI, being "so livid" when they heard
the U.S. Preventive Services Task Force recommend last month that women
start receiving mammograms at age 50, rather than the long-standing
practice of 40.
"They said, 'We've taken all these years to teach women to do
preventive mammograms, and now look at this,'" Heinz said.
President Barack Obama's administration later backed off the
recommendation amid criticism from many medical and women's groups. It
said the government's policies "remain unchanged."
Kerry helped launch Obama on the national political stage by giving the
then-Illinois senator the keynote speaking role at the 2004 Democratic
National Convention. Heinz -- the widow of Sen. John Heinz, heir
to the Heinz ketchup fortune -- said she found out in late September
that she had cancer in her left breast after having her annual
mammogram. In early October, she underwent lumpectomies on both
breasts at a Washington hospital after doctors also discovered what
they thought was a benign growth on her right breast.
That diagnosis was initially confirmed in postoperative pathology, but
two other doctors later found it to be malignant. In November, Heinz
had another pair of lumpectomies performed at Massachusetts General
Hospital. Doctors also inserted titanium clips in the tissue of
both breasts during the operations, and next month she will receive
five days of targeted radiation aimed at improving her odds of a
successful treatment to 95 percent.
Heinz said she is undecided about follow-up medicinal treatments that
could raise her survival odds to 99 percent, given her age and the
potential side effects.
Her surgeon at Massachusetts General Hospital was the one she
recommended to Elizabeth Edwards, who found out she had breast cancer
just as her husband, former Sen. John Edwards, of North Carolina, was
concluding his stint as Kerry's vice presidential running mate.
Heinz said she has not spoken with Elizabeth Edwards about her own
cancer bout.
Healthcare shares rise as reform bill progresses
YAHOO
Dec. 21, 2009
BOSTON (Reuters) – Healthcare shares rose on Monday as a bill to reform
healthcare passed the first critical test in the Senate, without many
of the provisions, such as a government-run health insurance option,
that investors most feared would hurt profits.
The S&P Healthcare Index (.GSPA) rose 1.4 percent, while the Morgan
Stanley Healthcare Payor stock index (.HMO) rose 3.6 percent. The
S&P Managed Health Care index (.GSPHMO) rose 4.6 percent.
"All in all, relative to the last version of health reform issued by
the Senate, things have turned out pretty well for the health insurance
industry," said Carl McDonald, an analyst at Oppenheimer. "In
particular, all versions of a government-run health plan have largely
been eliminated."
The original Senate bill taxed the health insurance industry a fixed
$6.7 billion a year. Under the new proposal, the industry would face a
$2 billion tax in 2011, with increases over time to $10 billion in 2017.
Analysts said the new proposal would allow insurers time to factor the
tax into pricing.
The bill would require most Americans to have insurance, expanding the
membership rolls for health insurers. At the same time, it replaces a
proposed government-run public insurance option with less onerous
exchanges to cover those who are not covered through their employment.
Matthew Borsch, an analyst at Goldman Sachs & Co., said Cigna Corp
(CI.N) remains his favorite among health insurers.
"Aside from reform, the important backdrop to our sector view is
fundamentals, which are decidedly mixed but with the key being that
downside risk to commercial margins is mitigated by firming of industry
pricing," he said in a research note.
Shares of Cigna rose 5.3 percent to $37.69. Shares of Aetna Inc (AET.N)
rose 5.84 percent to $34.41. Humana Inc (HUM.N) rose 3.79 percent to
$45.17 and United Health Group Inc (UNH.N) rose 5 percent to $33.14.
Shares of Wellpoint Inc (WLP.N) rose 3.8 percent to $60.51.
Shares of pharmacy benefit managers Medco Health Solutions Inc (MHS.N)
rose 3.84 percent to $65.51 and Express Scripts (ESRX.O) rose 5.2
percent to $88.77 as concern eased that an industry tax could be added
to the bill in the final days leading up to the vote.
"Based on discussions with our political consultant in Washington, we
believe that a PBM tax is now not part of the final Senate bill," said
Steven Valiquette, an analyst at UBS Securities.
Shares of Allergan Inc (AGN.N), maker of the anti-wrinkle treatment
Botox, rose 1.7 percent to $61.68 after it dodged a bullet that would
have placed a 5 percent tax on cosmetic surgery, wrinkle-filling
injections and similar procedures. Instead, a 10 percent tax would be
placed on indoor tanning salons.
The bill's revisions delayed a tax on medical device manufacturers
until 2011. The total tax on the industry would be unchanged at nearly
$20 billion.
Shares of St. Jude Medical Inc (STJ.N) rose 1 percent to $37.18; shares
of Stryker Corp (SYK.N) rose 0.6 percent to $50.78 while shares of
Zimmer Holdings Inc (ZMH.N) rose 0.9 percent to $58.97. Shares of
Medtronic Inc (MDT.N) slipped 3 cents to $43.19.
Think back to
1990's, when "managed care" was the silver bullet - what did you do
then? Your doctor's not in the HMO approved list? We paid
our GP in cash!!!
ObamaCare: No Exit
By
SCOTT GOTTLIEB
Last Updated: 7:32 AM, December 21, 2009
Posted: 2:17 AM, December 21, 2009
Perhaps the most common question I'm asked about ObamaCare is: "Will I
be able to buy my way out of it?" The answer is: "Not unless you're
very rich."
The plan before the Senate creates a set of 50 state-based insurance
"exchanges" that are established as markets for health plans. Consumers
must buy policies from their employers or through the exchanges — but,
either way, their choice of coverage is limited to one of four basic
insurance plans that the government sanctions.
Private insurers will still compete to offer policies but must model
their coverage on one of these four templates. In short, the Senate
bill explicitly standardizes health benefits and then establishes
elaborate mechanisms (including subsidies and penalties) to pay for
them.
Here's the rub: While these four plans vary from low- to high-cost
options, the benefits offered under them are pretty much the same. The
difference between the cheaper and pricier plans is mostly the amount
of cost sharing (e.g., you pay less for insurance if your co-pays are
higher).
In effect, the plan creates a single national health-insurance policy.
Consumers' only real option is to trade higher co-pays for lower
premiums. But we'll all get the same package of benefits established by
a series of new agencies and an "insurance czar" seated in Washington.
Once the exchanges are in place, the individual market — the ability to
go directly to an insurer and buy a health-care policy — will
disappear. You'll have only two places to buy insurance, in the
exchanges or through your workplace.
As for health plans offered by employers, "no health-insurance policies
could be issued (other than grandfathered plans) that don't meet the
actuarial standards set for these plans" sold in the exchanges. The
government will "define the essential health benefits" that all plans
must eventually offer, not only those sold in the exchanges but also
plans offered by employers. But like other elements of today's private
coverage, the grandfathered plans also disappear in short time. While
the bill allows some employer plans to continue as they are today,
that's only so long as the policy doesn't change — and natural market
forces will ensure that most such policies must change within a few
years after the bill becomes law.
All of which brings us to the question of whether you'll be able to
spend extra money to add benefits that exceed the government's basic
package or opt out of that plan entirely. The bill doesn't address this
question directly — yet I can say with great confidence that it will be
costly and in some cases impossible.
The bill leaves these issues in the hands of the bureaucracies that
will write the law's enabling regulations. And it's clear both what the
spirit of the Obama plan and the habits of these bureaucracies will
produce.
The overriding goal of this reform is to turn health insurance into a
more "egalitarian" benefit that's the same for everyone, regardless of
income, personal preference or need. So rules written under President
Obama to implement the Obama plan are a sure bet to intentionally
curtail anyone's ability to wrap around this national coverage with a
supplemental policy or to contract privately with doctors to pay your
way out of its limitations.
This is exactly what the bureaucracy's done with Medicare. Doctors
accepting Medicare can't contract privately with Medicare patients to
bill for services that Medicare doesn't cover. Nor can patients buy
added coverage to help plug Medicare's gaps. (The "Medigap" that many
seniors now buy are tightly regulated by the government to limit how
much they expand on Medicare's basic benefits; they mostly just help
defray co-pays.)
In short, beneficiaries are trapped inside the Medicare insurance
scheme, just as they'll soon be trapped inside the ObamaCare exchanges.
Doctors can't offer benefits not covered by the government plans, and
patients can't buy extra insurance to make up for many gaps.
These restrictions were designed into Medicare for a reason:
Progressives don't want it to be easy for rich seniors to buy their
out; they fear that if the well-off can leave the federal plan, it will
become a lower-end benefit. That is, it will wind up like Medicaid,
whose enormous problems are largely ignored by politicians because poor
Americans don't have the political power to force improvements.
The very rich, of course, will be able to buy their way out of
ObamaCare. Many of the best doctors will go cash only, opting entirely
out of the Obama program, to cater to a wealthy clientele. But only the
truly affluent will have the cash to escape.
The vast rest of us will be locked inside the new system — stuck with
the same collection of government-decreed medical benefits.
Testing, Testing: The health-care bill has no master plan for curbing
costs. Is that a bad thing?
by Atul Gawande
December 14, 2009
Cost is the spectre haunting health reform. For many decades, the great
flaw in the American health-care system was its unconscionable gaps in
coverage. Those gaps have widened to become graves—resulting in an
estimated forty-five thousand premature deaths each year—and have
forced more than a million people into bankruptcy. The emerging
health-reform package has a master plan for this problem. By
establishing insurance exchanges, mandates, and tax credits, it would
guarantee that at least ninety-four per cent of Americans had decent
medical coverage. This is historic, and it is necessary. But the
legislation has no master plan for dealing with the problem of soaring
medical costs. And this is a source of deep unease.
Health-care costs are strangling our country. Medical care now absorbs
eighteen per cent of every dollar we earn. Between 1999 and 2009, the
average annual premium for employer-sponsored family insurance coverage
rose from $5,800 to $13,400, and the average cost per Medicare
beneficiary went from $5,500 to $11,900. The costs of our dysfunctional
health-care system have already helped sink our auto industry, are
draining state and federal coffers, and could ultimately imperil our
ability to sustain universal coverage.
What have we gained by paying more than twice as much for medical care
as we did a decade ago? The health-care sector certainly employs more
people and more machines than it did. But there have been no great
strides in service. In Western Europe, most primary-care practices now
use electronic health records and offer after-hours care; in the United
States, most don’t. Improvement in demonstrated medical outcomes has
been modest in most fields. The reason the system is a money drain is
not that it’s so successful but that it’s fragmented, disorganized, and
inconsistent; it’s neglectful of low-profit services like mental-health
care, geriatrics, and primary care, and almost giddy in its overuse of
high-cost technologies such as radiology imaging, brand-name drugs, and
many elective procedures.
At the current rate of increase, the cost of family insurance will
reach twenty-seven thousand dollars or more in a decade, taking more
than a fifth of every dollar that people earn. Businesses will see
their health-coverage expenses rise from ten per cent of total labor
costs to seventeen per cent. Health-care spending will essentially
devour all our future wage increases and economic growth. State budget
costs for health care will more than double, and Medicare will run out
of money in just eight years. The cost problem, people have come to
realize, threatens not just our prosperity but our solvency.
So what does the reform package do about it? Turn to page 621 of the
Senate version, the section entitled “Transforming the Health Care
Delivery System,” and start reading. Does the bill end medicine’s
destructive piecemeal payment system? Does it replace paying for
quantity with paying for quality? Does it institute nationwide
structural changes that curb costs and raise quality? It does not.
Instead, what it offers is . . . pilot programs.
This has provided a soft target for critics. “Two thousand seventy-four
pages and trillions of dollars later,” Mitch McConnell, the Senate
Minority Leader, said recently, “this bill doesn’t even meet the basic
goal that the American people had in mind and what they thought this
debate was all about: to lower costs.” According to the Congressional
Budget Office, the bill makes no significant long-term cost reductions.
Even Democrats have become nervous. For many, the hope of reform was to
re-form the health-care system. If nothing is done, the United States
is on track to spend an unimaginable ten trillion dollars more on
health care in the next decade than it currently spends, hobbling
government, growth, and employment. Where we crave sweeping
transformation, however, all the current bill offers is those pilot
programs, a battery of small-scale experiments. The strategy seems
hopelessly inadequate to solve a problem of this magnitude. And
yet—here’s the interesting thing—history suggests otherwise.
At the start of the twentieth century, another indispensable but
unmanageably costly sector was strangling the country: agriculture. In
1900, more than forty per cent of a family’s income went to paying for
food. At the same time, farming was hugely labor-intensive, tying up
almost half the American workforce. We were, partly as a result, still
a poor nation. Only by improving the productivity of farming could we
raise our standard of living and emerge as an industrial power. We had
to reduce food costs, so that families could spend money on other
goods, and resources could flow to other economic sectors. And we had
to make farming less labor-dependent, so that more of the population
could enter non-farming occupations and support economic growth and
development.
America’s agricultural crisis gave rise to deep national frustration.
The inefficiency of farms meant low crop yields, high prices, limited
choice, and uneven quality. The agricultural system was fragmented and
disorganized, and ignored evidence showing how things could be done
better. Shallow plowing, no crop rotation, inadequate seedbeds, and
other habits sustained by lore and tradition resulted in poor
production and soil exhaustion. And lack of coördination led to
local shortages of many crops and overproduction of others.
You might think that the invisible hand of market competition would
have solved these problems, that the prospect of higher income from
improved practices would have encouraged change. But laissez-faire had
not worked. Farmers relied so much on human muscle because it was cheap
and didn’t require the long-term investment that animal power and
machinery did. The fact that land, too, was cheap encouraged extensive,
almost careless cultivation. When the soil became exhausted, farmers
simply moved; most tracts of farmland were occupied for five years or
less. Those who didn’t move tended to be tenant farmers, who paid rent
to their landlords in either cash or crops, which also discouraged
long-term investment. And there was a deep-seated fear of risk and the
uncertainties of change; many farmers dismissed new ideas as “book
farming.”
Things were no better elsewhere in the world. For industrializing
nations in the first half of the twentieth century, food was the
fundamental problem. The desire for a once-and-for-all fix led
Communist governments to take over and run vast “scientific” farms and
collectives. We know what that led to: widespread famines and tens of
millions of deaths.
The United States did not seek a grand solution. Private farms
remained, along with the considerable advantages of individual
initiative. Still, government was enlisted to help millions of farmers
change the way they worked. The approach succeeded almost shockingly
well. The resulting abundance of goods in our grocery stores and the
leaps in our standard of living became the greatest argument for
America around the world. And, as the agricultural historian Roy V.
Scott recounted, four decades ago, in his remarkable study “The
Reluctant Farmer,” it all started with a pilot program.
In February, 1903, Seaman Knapp arrived in the East Texas town of
Terrell to talk to the local farmers. He was what we’d today deride as
a government bureaucrat; he worked for the United States Department of
Agriculture. Earlier in his life, he had been a farmer himself and a
professor of agriculture at Iowa State College. He had also been a
pastor, a bank president, and an entrepreneur, who once brought
twenty-five thousand settlers to southwest Louisiana to farm for an
English company that had bought a million and a half acres of land
there. Then he got a position at the U.S.D.A. as an “agricultural
explorer,” travelling across Asia and collecting seeds for everything
from alfalfa to persimmons, not to mention a variety of rice that
proved more productive than any that we’d had. The U.S.D.A. now wanted
him to get farmers to farm differently. And he had an idea.
Knapp knew that the local farmers were not going to trust some outsider
who told them to adopt a “better” way of doing their jobs. So he asked
Terrell’s leaders to find just one farmer who would be willing to try
some “scientific” methods and see what happened. The group chose Walter
C. Porter, and he volunteered seventy acres of land where he had grown
only cotton or corn for twenty-eight years, applied no fertilizer, and
almost completely depleted the humus layer. Knapp gave him a list of
simple innovations to follow—things like deeper plowing and better soil
preparation, the use of only the best seed, the liberal application of
fertilizer, and more thorough cultivation to remove weeds and aerate
the soil around the plants. The local leaders stopped by periodically
to confirm that he was able to do what he had been asked to.
The year 1903 proved to be the most disastrous for cotton in a quarter
century, because of the spread of the boll weevil. Nonetheless, at the
end of the season Porter reported a substantial increase in profit,
clearing an extra seven hundred dollars. He announced that he would
apply the lessons he had learned to his entire, eight-hundred-acre
property, and many other farmers did the same. Knapp had discovered a
simple but critical rule for gaining coöperation: “What a man
hears he may doubt, what he sees he may possibly doubt, but what he
does himself he cannot doubt.”
The following year, the U.S.D.A. got funding to ramp up his activities.
Knapp appointed thirty-three “extension agents” to set up similar
demonstration farms across Texas and into Louisiana. The agents
provided farmers with technical assistance and information, including
comparative data on what they and others were achieving. As experience
accrued, Knapp revised and refined his list of recommended practices
for an expanding range of crops and livestock. The approach proved just
as successful on a larger scale.
The program had no shortage of critics. Southern Farm Magazine
denounced it as government control of agriculture. But, in 1914, after
two years of stiff opposition, Congress passed the Smith-Lever Act,
establishing the U.S.D.A. Cooperative Extension Service. By 1920, there
were seven thousand federal extension agents, working in almost every
county in the nation, and by 1930 they had set up more than seven
hundred and fifty thousand demonstration farms.
As Daniel Carpenter, a professor of government at Harvard, points out,
the demonstration-farm program was just one of a hodgepodge of
successful U.S.D.A. initiatives that began as pilots. Another was
devoted to comparative-effectiveness research: experimental stations
were established—eventually, in every state—that set about determining
the most productive methods for growing plants and raising livestock.
There was a pilot investigation program, which, among other things,
traced a 1904 fruit-decay crisis in California to cuts in the fruit
from stem clippers and the fingernails of handlers (and, along the way,
introduced modern packing methods industry-wide). The U.S.D.A.’s
scientific capabilities grew into the world’s greatest
biological-discovery machine of the time.
The department invested heavily in providing timely data to farmers, so
that they could make more rational planting decisions. It ran the
country’s weather-forecasting system. And its statistics service
adopted crop-reporting systems from Europe that allowed it to provide
independent crop forecasts—forecasts that, among other things,
dramatically reduced speculation bubbles. (In 1927, Republicans,
prompted by aggrieved New York speculators, managed to prohibit the
U.S.D.A. from releasing the forecasts; the program was reinstituted
three years later, following an outcry from farmers.) The department
continuously updated its storehouse of technical assistance, so that
when new technologies arrived—new hybrid varieties, new kinds of
fertilizer, new forms of mechanization—farmers were able to make use of
them more swiftly and effectively. The U.S.D.A. established an
information-broadcasting service. A hundred and seventeen commercial
and forty-six military radio stations carried crop reports; printed
reports were distributed to fifteen million farmers a year. It also
introduced a grading system for food—meat, eggs, dairy products, and
fresh fruits and vegetables—to flag and discourage substandard quality.
What seemed like a hodgepodge eventually cohered into a whole. The
government never took over agriculture, but the government didn’t leave
it alone, either. It shaped a feedback loop of experiment and learning
and encouragement for farmers across the country. The results were
beyond what anyone could have imagined. Productivity went way up,
outpacing that of other Western countries. Prices fell by half. By
1930, food absorbed just twenty-four per cent of family spending and
twenty per cent of the workforce. Today, food accounts for just eight
per cent of household income and two per cent of the labor force. It is
produced on no more land than was devoted to it a century ago, and with
far greater variety and abundance than ever before in history.
This transformation, though critical to America’s rise as a superpower,
involved some painful dislocations: farms were consolidated;
unproductive farmers were winnowed out. As the historian Sally Clarke,
of the University of Texas at Austin, has pointed out, it’s astonishing
that the revolution took place without vast numbers of farm
foreclosures and social unrest. We cushioned the impact of the
transformation—with, for instance, price supports that smoothed out the
price decline and avoided wholesale bankruptcies. There were
compromises and concessions and wrong turns. But the strategy worked,
because United States agencies were allowed to proceed by trial and
error, continually adjusting their policies over time in response not
to ideology but to hard measurement of the results against societal
goals. Could something like this happen with health care?
There are, in human affairs, two kinds of problems: those which are
amenable to a technical solution and those which are not. Universal
health-care coverage belongs to the first category: you can pick one of
several possible solutions, pass a bill, and (allowing for some
tinkering around the edges) it will happen. Problems of the second
kind, by contrast, are never solved, exactly; they are managed.
Reforming the agricultural system so that it serves the country’s needs
has been a process, involving millions of farmers pursuing their
individual interests. This could not happen by fiat. There was no
one-time fix. The same goes for reforming the health-care system so
that it serves the country’s needs. No nation has escaped the cost
problem: the expenditure curves have outpaced inflation around the
world. Nobody has found a master switch that you can flip to make the
problem go away. If we want to start solving it, we first need to
recognize that there is no technical solution.
Much like farming, medicine involves hundreds of thousands of local
entities across the country—hospitals, clinics, pharmacies, home-health
agencies, drug and device suppliers. They provide complex services for
the thousands of diseases, conditions, and injuries that afflict us.
They want to provide good care, but they also measure their success by
the amount of revenue they take in, and, as each pursues its individual
interests, the net result has been disastrous. Our fee-for-service
system, doling out separate payments for everything and everyone
involved in a patient’s care, has all the wrong incentives: it rewards
doing more over doing right, it increases paperwork and the duplication
of efforts, and it discourages clinicians from working together for the
best possible results. Knowledge diffuses too slowly. Our information
systems are primitive. The malpractice system is wasteful and
counterproductive. And the best way to fix all this is—well, plenty of
people have plenty of ideas. It’s just that nobody knows for sure.
The history of American agriculture suggests that you can have
transformation without a master plan, without knowing all the answers
up front. Government has a crucial role to play here—not running the
system but guiding it, by looking for the best strategies and practices
and finding ways to get them adopted, county by county. Transforming
health care everywhere starts with transforming it somewhere. But how?
We have our models, to be sure. There are places like the Mayo Clinic,
in Minnesota; Intermountain Healthcare, in Utah; the Kaiser Permanente
health-care system in California; and Scott & White Healthcare, in
Texas, that reliably deliver higher quality for lower costs than
elsewhere. Yet they have had years to develop their organizations and
institutional cultures. We don’t yet know how to replicate what they
do. Even they have difficulties. Kaiser Permanente has struggled to
bring California-calibre results to North Carolina, for instance. Each
area has its own history and traditions, its own gaps in
infrastructure, and its own distinctive patient population. To figure
out how to transform medical communities, with all their diversity and
complexity, is going to involve trial and error. And this will require
pilot programs—a lot of them.
Pick up the Senate health-care bill—yes, all 2,074 pages—and leaf
through it. Almost half of it is devoted to programs that would test
various ways to curb costs and increase quality. The bill is a
hodgepodge. And it should be.
The bill tests, for instance, a number of ways that federal insurers
could pay for care. Medicare and Medicaid currently pay clinicians the
same amount regardless of results. But there is a pilot program to
increase payments for doctors who deliver high-quality care at lower
cost, while reducing payments for those who deliver low-quality care at
higher cost. There’s a program that would pay bonuses to hospitals that
improve patient results after heart failure, pneumonia, and surgery.
There’s a program that would impose financial penalties on institutions
with high rates of infections transmitted by health-care workers. Still
another would test a system of penalties and rewards scaled to the
quality of home health and rehabilitation care.
Other experiments try moving medicine away from fee-for-service payment
altogether. A bundled-payment provision would pay medical teams just
one thirty-day fee for all the outpatient and inpatient services
related to, say, an operation. This would give clinicians an incentive
to work together to smooth care and reduce complications. One pilot
would go even further, encouraging clinicians to band together into
“Accountable Care Organizations” that take responsibility for all their
patients’ needs, including prevention—so that fewer patients need
operations in the first place. These groups would be permitted to keep
part of the savings they generate, as long as they meet quality and
service thresholds.
The bill has ideas for changes in other parts of the system, too. Some
provisions attempt to improve efficiency through administrative
reforms, by, for example, requiring insurance companies to create a
single standardized form for insurance reimbursement, to alleviate the
clerical burden on clinicians. There are tests of various kinds of
community wellness programs. The legislation also continues a
stimulus-package program that funds comparative-effectiveness
research—testing existing treatments for a condition against one
another—because fewer treatment failures should mean lower costs.
There are hundreds of pages of these programs, almost all of which
appear in the House bill as well. But the Senate reform package goes a
few U.S.D.A.-like steps further. It creates a center to generate
innovations in paying for and organizing care. It creates an
independent Medicare advisory commission, which would sort through all
the pilot results and make recommendations that would automatically
take effect unless Congress blocks them. It also takes a decisive step
in changing how insurance companies deal with the costs of health care.
In the nineteen-eighties, H.M.O.s tried to control costs by directly
overruling doctors’ recommendations (through requiring
pre-authorization and denying payment); the backlash taught them that
it was far easier to avoid sicker patients and pass along cost
increases to employers. Both the House and the Senate bills prevent
insurance companies from excluding patients. But the Senate plan also
imposes an excise tax on the most expensive, “Cadillac” insurance
plans. This pushes private insurers to make the same efforts that
public insurers will make to test incentives and programs that
encourage clinicians to keep costs down.
Which of these programs will work? We can’t know. That’s why the
Congressional Budget Office doesn’t credit any of them with substantial
savings. The package relies on taxes and short-term payment cuts to
providers in order to pay for subsidies. But, in the end, it contains a
test of almost every approach that leading health-care experts have
suggested. (The only one missing is malpractice reform. This is where
the Republicans could be helpful.) None of this is as satisfying as a
master plan. But there can’t be a master plan. That’s a crucial lesson
of our agricultural experience. And there’s another: with problems that
don’t have technical solutions, the struggle never ends.
Recently, I spoke with the agricultural extension agent for my home
town, Athens, Ohio. His name is Rory Lewandowski. He is fifty-one and
has been the extension agent there for nine years. He grew up on a
Minnesota dairy farm, and got a bachelor’s degree in animal science and
agronomy from the University of Minnesota and a master’s degree in
agronomy from the University of Wisconsin. He spent most of his career
in farm education, including eight years in Bolivia, where, as a
volunteer for the Mennonite Central Committee, he created demonstration
farms in an area where the mining economy had collapsed.
I had a vague childhood memory of the extension office, on West Union
Street, near downtown Athens; kids in my school used to go to 4-H
meetings there. But I had no idea what the agent really did. So I asked
Lewandowski. “I just try to help make farming better in Athens County,”
he said.
Athens is a green, hilly county at the edge of the Appalachian
Mountains, and the farms there are small—an average of a hundred and
fifty acres, Lewandowski said. There are six hundred and sixty of them,
with, he estimated, as many as a hundred kinds of produce and
livestock. His primary task is to help farmers improve the productivity
and quality of their farms and to reduce environmental harm. A hundred
years after Seaman Knapp, the difficulties have changed but they
haven’t gone away.
I’d caught Lewandowski in his office on a Saturday. He routinely puts
in sixty-five to eighty hours a week at his job. He has a five-week
small-ruminant course for sheep and goat producers; a ten-week
master-gardener course; and a grazing school. His wife, Marcia, who has
written two knitting books, handles registration at the door. He sends
out a monthly newsletter. He speaks with about half the farmers in the
county in the course of a year.
Mostly, the farmers come to him—for guidance and troubleshooting. He
told me about a desperate message that a farmer left him the other day.
The man’s spinach plants had been afflicted with downy mildew and were
collapsing. “He said he was going to lose his whole crop by the weekend
and all the markets that he depended on,” Lewandowski said. He called
the farmer back and explained that the disease gets started with cooler
temperatures and high humidity. Had the farmer been using overhead
watering?
Yes, he said, but he had poked around the Internet and was thinking
about switching to misting.
Not a good idea. “That still leaves too much moisture on the leaf,”
Lewandowski said. He recommended that the farmer switch to drip
irrigation, and get some fans in his greenhouse, too.
The farmer said that he’d thought about fans but worried that they
would spread the spores around.
They will, Lewandowski said. “But you need wetness on the leaves for
four to six hours to get penetration through the leaf cuticle,” he
explained. If the plants were dried out, it wouldn’t be a problem.
“You’ve got to understand the biology of this,” he said to me.
He doesn’t always understand the biology himself. He told me about a
beef farmer who had been offered distiller’s grain from a microbrewery,
and wanted to know whether he could feed it to his cows. Lewandowski
had no idea, but he called the program’s beef extension expert and got
the answer. (Yes, with some limits on how much he put in a ration.) A
large organic farm called with questions about growing vegetables in
high tunnels, a relatively new innovation that the farm had adopted to
extend its growing season. Lewandowski had no experience with this, but
an extension agent in Wooster, Ohio, was able to supply information on
what had worked best elsewhere.
“You have to be able to say, ‘I don’t know, but I can figure that out
for you,’ ” Lewandowski said.
If he could change one thing about farming in Athens, I asked, what
would it be? “Grazing management,” he said. “Think about how the grass
grows in your lawn. A grass plant needs at least a few days after a
mowing to grow.” If you mowed your lawn every day, the grass would
become thin and patchy. That’s what happens when farmers leave their
animals out in one big pasture—which is what most small farmers do—or
rotate them too slowly. In his grazing school and in demonstrations, he
asks farmers to keep their animals in a given area for only a few days,
then move them to a section where the grass is eight inches tall and
has reached its highest nutrient value. This way, the pastures won’t
erode, and the cattle will grow better, yielding higher-quality meat
and more of it. The technique requires discipline, though, and extra
work, and farmers have been slow to give it a try.
I asked him if he has had any victories. All the time, he said. But he
had no illusions: his job will never end.
Cynicism about government can seem ingrained in the American character.
It was, ironically, in a speech to the Future Farmers of America that
President Ronald Reagan said, “The ten most dangerous words in the
English language are ‘Hi, I’m from the government, and I’m here to
help.’ ” Well, Lewandowski is from the government, and he’s here to
help. And small farms in Athens County are surviving because of him.
What he does involves continual improvisation and education; problems
keep changing, and better methods of managing them keep emerging—as in
medicine.
In fact, when I spoke with Lewandowski about farming in Athens, I was
struck by how much it’s like the health-care system there. Doctors
typically work in small offices, with only a few colleagues, as in most
of the country. The hospital in Athens has less than a tenth the number
of beds that my hospital in Boston has. The county’s clinicians could
do much more to control costs and improve quality of care, and they
will have to. But it will be an ongoing struggle.
My parents recently retired from medical practice in Athens. My mother
was a pediatrician and my father was a urologist. I tried to imagine
what it would be like for them if they were still practicing. They
would be asked to switch from paper to electronic medical records, to
organize with other doctors to reduce medical complications and
unnecessary costs, to try to arrive at a package price for a child with
asthma or a man with kidney stones. These are the kinds of changes that
everyone in medicine has to start making. And I have no idea how my
parents would do it.
I work in an academic medical group in Boston with more than a thousand
doctors and a vastly greater infrastructure of support, and we don’t
know the answers to half these questions, either. Recently, I had a
conversation with a few of my colleagues about whether we could accept
a bundled payment for patients with thyroid cancer, one of the cancers
I commonly treat in my practice as a surgeon. It seemed feasible until
we started thinking about patients who wanted to get their imaging or
radiation done elsewhere. There was also the matter of how we’d divide
the money among the surgeons, endocrinologists, radiologists, and
others involved. “Maybe we’d have to switch to salaries,” someone said.
Things were getting thorny. Then I went off to do an operation in which
we opened up about a thousand dollars’ worth of disposable materials
that we never used.
Surely we can solve such problems; the reform bill sets out to find
ways that we can. And, in the next several years, as the knowledge
accumulates, I suspect that we’ll need our own Seaman Knapps and Rory
Lewandowskis to help spread these practices county by county.
We’ll also need data, if we’re going to know what is succeeding. Among
the most important, and least noticed, provisions in the reform
legislation is one in the House bill to expand our ability to collect
national health statistics. The poverty of our health-care information
is an embarrassment. At the end of each month, we have county-by-county
data on unemployment, and we have prompt and detailed data on the price
of goods and commodities; we can use these indicators to guide our
economic policies. But try to look up information on your community’s
medical costs and utilization—or simply try to find out how many people
died from heart attacks or pneumonia or surgical complications—and you
will discover that the most recent data are at least three years old,
if they exist at all, and aren’t broken down to a county level that
communities can learn from. It’s like driving a car with a speedometer
that tells you only how fast all cars were driving, on average, three
years ago. We have better information about crops and cows than we do
about patients. If health-care reform is to succeed, the final
legislation must do something about this.
Getting our medical communities, town by town, to improve care and
control costs isn’t a task that we’ve asked government to take on
before. But we have no choice. At this point, we can’t afford any
illusions: the system won’t fix itself, and there’s no piece of
legislation that will have all the answers, either. The task will
require dedicated and talented people in government agencies and in
communities who recognize that the country’s future depends on their
sidestepping the ideological battles, encouraging local change, and
following the results. But if we’re willing to accept an arduous,
messy, and continuous process we can come to grips with a problem even
of this immensity. We’ve done it before. ♦
Read more:
http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?printable=true#ixzz0ZbpBzAQB
An
esspecially important issue for the Northeast...
Suburbs See a Challenge as
Residents Grow Older
NYTIMES
By LIZETTE ALVAREZ
December 6, 2009
HAMILTON, N.J.
THE trash talk on the boccie court at the Hamilton Township Senior
Center was heating up.
“What’s the matter, you can’t bend down?” Natale Gigliotti, 71, shouted
to an opposing player who lunged as he tossed the ball. “Corto, corto”
— short, short — Mr. Gigliotti said as the ball landed. “That’s a
boo-boo.”
“Ohhhh, they love to talk,” said Ray Fink, 79, Mr. Gigliotti’s boccie
partner and a regular at the center’s billiard tables and boccie court.
Hamilton, in Mercer County, is a pleasant suburban town, not far from
Trenton, with a smattering of historic homes, the requisite big-box
stores and a pre-Revolutionary pedigree. It also has more residents who
are 65 and older than many other towns in New Jersey — 15 percent of
its nearly 94,000 people, while in some towns the proportion is 5
percent or less — and that demographic fact has forced Hamilton to pay
close attention to the needs of its elderly.
This is not to say that other towns and counties are far behind.
In just two years, baby boomers will start to retire, and by 2030 the
number of America’s elderly is expected to reach 72 million, more than
double the number in 2000. Demographers expect the suburbs to age
particularly quickly, as residents retire close to home, or as those
who have already moved to the Sun Belt return to live near relatives as
they grow frail. Some towns are already feeling these effects:
Twenty percent of Glen Cove, in Nassau County, is 65 and older, for
instance, as is 23 percent of Somers, in Westchester County.
This increase in the number of elderly will place unparalleled strains
on many suburbs’ services.
“In the Northeast, we have to look at it as if the clock is ticking,”
said Brian M. Hughes, the Mercer County executive. “We have an aging
housing stock and a population that is not increasing as much as the
rest of the country. We need to figure out how we’re going to provide
more services with a smaller tax base.”
Mercer County, with its grayer population, offers a peek at the future
in terms of preparing for its aging residents.
On the housing front, the county has seen a sharp rise in developments
for people 55 and over. These adult communities, some with house prices
reaching $500,000, pay homage to the retirement villages of Florida,
only on a smaller scale. They offer gardens, large clubhouses and
swimming pools, games and a built-in social life. An estimated 13
such adult communities have been built in Mercer County since 2002 — a
much brisker pace than in previous years. Almost all their homes,
usually one story and requiring little yardwork, are tailor-made for
the aging.
The county has also seen a boom in assisted-living facilities, said
Sherrill Senter, a real estate agent with the Keller Williams Hamilton
firm, who added that builders are planning for older people even in the
general housing market. Many newer houses, she says, have a bedroom on
the first floor or a study that can easily be converted into a bedroom
for an aging parent. Real estate agents, eager to learn of plans
that will affect them, now attend meetings between nonprofit groups and
the Mercer County Office on Aging.
The county has also supplemented its network of shuttle vans for the
elderly by arranging to use other vans, borrowed from the Association
of Retarded Citizens and other groups, when available. And the Hamilton
senior center is offering its own transportation service — something
such centers do not often do.
“As the population ages, we have to find a way to get them mobile,”
said Kathleen Fitzgerald, a nurse and the supervisor of senior services
at the center.
Last year, also with its eye on a grayer future, Mercer Community
College started to offer a certificate in gerontology for health care
providers, social workers, caregivers and others. The required courses
include such subjects as the aging process, memory loss and a holistic
approach to aging.
Eileen Doremus, executive director of the county’s Office on Aging,
said that a gerontology certificate would become essential to doing
business. “It doesn’t matter what realm you work in and live in,” she
said. “You will be interacting with people who are older, be it in real
estate, health care, retail.”
Local governments like Mercer County are not alone in their efforts.
Over the past two years, the state of New Jersey has instructed 400
chronic disease health managers in training the elderly to avoid costly
trips to hospitals. Trainers teach the elderly how to keep tabs on
their ailments and cope with pain and frustration. Senior centers
are another important aspect of elderly care, and so it is in Mercer
County. As he took a break from one of his regular billiards games, Mr.
Fink — Mr. Gigliotti’s boccie partner — explained how he ended up at
the Hamilton senior center.
“I didn’t want to move into the city; I have always lived in the
suburbs,” said Mr. Fink, a former quality control manager for an
electronics manufacturer. He also wanted to be near his son, who lived
in Hamilton. Then, he said, “I met a couple who told me about Mercer
County and said they had the best senior center. I’m very active.”
The senior center moved to a spacious building in 2001. To be
successful, such facilities must shake off their stigma as depressing
places where the elderly come just to eat a hot meal and shuffle about.
In Hamilton, that stigma remains, but less so every year, Ms.
Fitzgerald said.
The center, which is publicly financed and has a hard-to-get national
certification by the National Council on Aging, provides the requisite
lunch, health checks and help with paperwork. But visitors can also sit
down at computer banks to learn how to design Web pages or post photos
online; they do the cha-cha with a dance instructor; sing in choral
groups and on karaoke night; swim in the small pool; smack down
dominoes and stage plays.
There are even a few younger patrons, whose needs differ from those of
older ones. One example is Paula and Jack Beiger, who practiced the
rumba one morning, keeping impeccable time to the music.
“Some people our age are almost embarrassed to come to the senior
center,” said Ms. Beiger, 54, who is allowed in only with her
63-year-old husband (members must live in Hamilton and be at least 60).
“We come just for the dancing and have such a good time.”
As for Mr. Fink, he does not plan to leave Hamilton Township. But he
does worry about the aging of the baby boomers. He waited a year and a
half for his current apartment — in a subsidized building for the
elderly called Pond Run — and that was before the rising tide.
“As a nation, we have to set up more volunteer programs to support
these people,” Mr. Fink said. “There will be so many of them.”
Op-Ed Contributors
Trading Women’s Rights for Political Power
By KATE MICHELMAN and FRANCES KISSLING
November 12, 2009
Washington
A GRIM reality sits behind the joyful press statements from Washington
Democrats. To secure passage of health care legislation in the House,
the party chose a course that risks the well-being of millions of women
for generations to come.
House Democrats voted to expand the current ban on public financing for
abortion and to effectively prohibit women who participate in the
proposed health system from obtaining private insurance that covers the
full range of reproductive health options. Political calculation aside,
the House Democrats reinforced the principle that a minority view on
the morality of abortion can determine reproductive health policy for
American women.
Many House members who support abortion rights decided reluctantly to
accept this ban, which is embodied in the Stupak-Pitts amendment. They
say the tradeoff was necessary to advance the right to guaranteed
health care. They say they will fight another day for a woman’s right
to choose.
Perhaps. But they can’t ignore the underlying shift that has taken
place in recent years. The Democratic majority has abandoned its
platform and subordinated women’s health to short-term political
success. In doing so, these so-called friends of women’s rights have
arguably done more to undermine reproductive rights than some of
abortion’s staunchest foes. That Senate Democrats are poised to allow
similar anti-abortion language in their bill simply underscores the
degree of the damage that has been done.
Many women — ourselves included — warned the Democratic Party in 2004
that it was a mistake to build a Congressional majority by recruiting
and electing candidates opposed to the party’s commitment to legal
abortion and to public financing for the procedure. Instead, the lust
for power yielded to misguided, self-serving poll analysis by
operatives with no experience in the fight for these principles. They
mistakenly believed that giving leadership roles to a small minority of
anti-abortion Democrats would solve the party’s image problems with
“values voters” and answer critics who claimed Democrats were hostile
to religion.
Democrats were told to stop talking about abortion as a moral and legal
right and to focus instead on comforting language about reducing the
number of abortions. In this regard, President Obama was right on
message when he declared in his health care speech to Congress in
September that “under our plan, no federal dollars will be used to fund
abortions” — as if this happened to be a good and moral thing. (The
tone of his statement made the point even more sharply than his words.)
The party has distanced itself from the abortion-rights movement in
other ways. It has taken to calling Democrats who oppose a woman’s
right to choose “pro-life” (and not “anti-choice”). The group Democrats
for Life of America, whose Congressional members ultimately led the
battle to exclude private insurance companies that cover abortions from
health insurance exchanges, was invited to hold a press conference in
Democratic Party offices. The party has promoted “pro-life
progressives” like Sojourners, Catholics United and Catholics in
Alliance for the Common Good, organizations whose leaders have stated
that abortions should be made “more difficult to get.”
This, then, is where we stand as party leaders celebrate passage of the
House bill. When it comes to abortion, they seem to think all positions
are of equal value so long as the party maintains a majority. But the
party will eventually reap what it has sown. If Democrats do not commit
themselves to defeating the amendment, then they will face an
uncompromising effort by Democratic women to defeat them, regardless of
the cost to the party’s precious majority.
In the meantime, the victims of their folly will be the millions of
women who once could count on the Democratic Party to protect them from
those who would sacrifice their rights for political gains.
Democrats
Raise Alarms Over Costs of Health Bills
NYTIMES
By SHERYL GAY STOLBERG
November 10, 2009
WASHINGTON — As health care legislation moves toward a crucial airing
in the Senate, the White House is facing a growing revolt from some
Democrats and analysts who say the bills Congress is considering do not
fulfill President Obama’s promise to slow the runaway rise in health
care spending.
Mr. Obama has made cost containment a centerpiece of his health reform
agenda, and in May he stood up at the White House with industry groups
who pledged voluntary efforts to trim the growth of health care
spending by 1.5 percent, or $2 trillion, over the next decade.
But health economists say it is impossible to know whether the bills,
including one passed by the House on Saturday night, would meet that
goal, and many are skeptical that they even come close.
Experts — including some who have consulted closely with the White
House, like Dr. Denis A. Cortese, chief executive of the Mayo Clinic —
say the measures take only baby steps toward revamping the current
fee-for-service system, which drives up costs by paying health
providers for each visit or procedure performed. Some senators are also
dissatisfied.
“My assessment at this point,” said Senator Ron Wyden, Democrat of
Oregon and a member of the Finance Committee, “is that the legislation
is heavy on health and light on reform.”
There are a variety of ideas for attacking cost increases more
aggressively, including setting Medicare reimbursement rates for
doctors and hospitals more rigorously and discouraging workers and
employers from buying expensive health insurance policies that mask the
true costs of treatment.
Among other innovations being considered is a cost-cutting method known
as bundling, in which health providers receive a lump sum to care for a
patient with a particular medical condition, say, diabetes or heart
disease. The House bill calls for the administration to develop a plan
for bundling, while the Senate Finance Committee version of the bill
gives it until 2013 to create a pilot program.
Some experts would like to see such changes adopted more quickly, and
senators of both parties say they will press for more aggressive
cost-cutting measures when the bill comes up for debate. But drastic
changes in the health care reimbursement system could cost the White
House the support of doctors and hospital groups, who have signed onto
the legislation and are lobbying hard to keep the current
fee-for-service system from being phased out too quickly.
The debate underscores a fundamental tension inside the White House
between cost-containment idealists and pragmatists.
The first group includes officials like Peter R. Orszag, the budget
director, and Dr. Ezekiel J. Emanuel, the medical ethicist whose
brother Rahm is the chief of staff. The second includes Rahm Emanuel
and Nancy-Ann DeParle, the director of the Office of Health Reform, who
must contend with the realities of getting legislation passed.
“Let’s be honest,” Rahm Emanuel said in a recent interview. “The goal
isn’t to see whether I can pass this through the executive board of the
Brookings Institution. I’m passing it through the United States
Congress with people who represent constituents.”
He went on: “I’m sure there are a lot of people sitting in the shade at
the Aspen Institute — my brother being one of them — who will tell you
what the ideal plan is. Great, fascinating. You have the art of the
possible measured against the ideal.”
Mr. Orszag would not be interviewed. But in an e-mail message sent
through a spokesman, he said the current legislation “lays the
foundation” for cost-cutting over the long-term, adding: “Will more
need to be done in the future? Absolutely.”
Senator Susan Collins, the Maine Republican whose vote the
administration is courting, convened a news conference on Monday with
Senator Lamar Alexander of Tennessee, a member of the Republican
leadership, to spotlight her concerns over cost containment. Ms.
Collins said she had been meeting with a group of moderate Democrats
who shared her views.
“I don’t believe we need more pilot projects to show us that health
care delivery reforms are necessary,” she said in an interview. She
added, “I think people are much more upset over the cost of care than
the administration is acknowledging.”
Both the House and the Senate are proposing cost-saving measures. The
House bill projects $440 billion in Medicare savings over 10 years; the
Senate Finance Committee bill projects about $420 billion. White House
officials say there will be additional, substantial savings in the
private sector, as well. But how much is not clear.
Still, it is one thing to wring savings out of a bloated system, quite
another to change the way that system does business.
Experts agree that the Senate Finance bill does more to put systemic
changes in place. That is because the bill includes two measures that
health economists favor: a tax on high-value “Cadillac” health plans,
and an independent commission that would make binding recommendations
on how to cut Medicare costs.
House Democrats strongly oppose the Cadillac tax, which would hurt,
among other people, union workers with generous benefit plans. But Ms.
DeParle said in an interview that she sensed fresh interest in the
House in adopting the Medicare commission idea. “There is a lot of
support for cost containment,” she said.
Dr. Cortese, of the Mayo Clinic, said the bills could do more to reward
quality care over quantity. He said he had met with Mr. Orszag and
others at the White House and had proposed legislative language that
would give Medicare three years to begin rewarding hospitals that are
delivering better care at lower cost.
“Our position has been focusing on paying for value,” he said, adding,
“My take is there are people in the White House who understand exactly
what I’m saying.”
Yet a deal the White House made with the hospital industry could make
it difficult to cut costs too deeply.
The White House and the Senate Finance Committee chairman, Max Baucus
of Montana, agreed to limit hospitals’ payment reductions to $155
billion over 10 years. Those savings will come almost exclusively from
“an agreement to squeeze the prices a little bit across the board,
rather than reforming the way payments work,” said Mark McClellan, who
ran Medicare under President George W. Bush.
House
Dems say Sat. vote on health care may slip
YAHOO
By ERICA WERNER and RICARDO ALONSO-ZALDIVAR, Associated Press Writers
November 6, 2009
WASHINGTON – House Democrats acknowledged they don't yet have the votes
to pass a sweeping overhaul of the nation's health care system, and
signaled they may push back the vote until Sunday or early next
week. Majority Leader Steny Hoyer, D-Md., told reporters in a
conference call Friday that the make-or-break vote on President Barack
Obama's push to make health coverage part of the social safety net
could face delay. Democrats were originally hoping to pass the bill on
Saturday_and officially, that's still the plan.
But Democrats have yet to resolve a intraparty disputes over abortion
funding and illegal immigrants' access to medical coverage. They
cleared one hurdle Friday when liberals supporting a government-run
Medicare-for-all system withdrew their demand for a floor vote. Hoyer
sought to pin the blame for any possible slippage on delaying tactics
expected from Republicans, who unanimously oppose the health care
remake.
"Nice try Rep. Hoyer, but you can't blame Republicans when the fact is
you just don't have the votes," said Antonia Ferrier, spokeswoman for
House Republican Leader John Boehner of Ohio. Republicans could stall
the bill by demanding roll-call votes on parliamentary matters.
Hoyer acknowledged that Democrats are still short of the 218 votes they
need to pass the bill. "There are many people who are still trying to
get a comfort level that this is the right thing to do," he said.
"We're very close."
While Hoyer said he still expects a vote Saturday evening, he said he
has put lawmakers on notice they may be called to the House floor
Sunday afternoon, or even Monday or Tuesday. The White House
issued a formal endorsement of the House bill Friday, and said Obama
plans to go to Capitol Hill on Saturday to rally Democrats. House
passage of the 10-year, $1.2 trillion legislation that extends health
coverage to tens of millions of uninsured Americans and puts tough new
restrictions on insurance companies would be a breakthrough for his
agenda.
A moderate Democrat, South Dakota Rep. Stephanie Herseth Sandlin,
announced Friday she would not vote for the House bill — but held out
the possibility she could support final passage of the legislation,
after compromises with the Senate. Sandlin said she fears the House
bill could diminish access to health care in her state.
Action on health legislation was slowed as senators waited for the
Congressional Budget Office to weigh in on a bill written by Majority
Leader Harry Reid in consultation with the White House and key
committee chairmen. Senate votes could slip until next year, but in the
House Democratic leaders pressed forward. They expressed optimism
that when it came time to vote, they'd have the majority needed to
prevail in the 435-seat House.
Asked Thursday if she had the votes, Speaker Nancy Pelosi replied: "We
will."
Pelosi and other Democratic leaders were finalizing language to bar
federal funding of abortion and resolving a flare-up over the treatment
of illegal immigrants in the legislation that had Hispanic lawmakers up
in arms. Members of the Congressional Hispanic Caucus object to a
provision in the Senate legislation — backed by the White House — that
bars illegal immigrants from buying health insurance within a proposed
new marketplace, or exchange, even if they use their own money to buy
from private companies. Illegal immigrants can buy private health
insurance now, so some lawmakers say the White House position goes too
far.
Democrats were trying to toughen prohibitions in the bill against
federal funding for abortions in a way that would satisfy enough
anti-abortion Democrats. The U.S. Conference of Catholic Bishops was
involved in the talks, but the issue was still unresolved Friday
morning.
Federal law now bars government funds from being used to pay for
abortion except in cases of rape, incest, or to save the life of the
mother. The health care bill would create a new stream of federal money
to subsidize medical insurance premiums, and the dispute is over how to
apply the abortion restrictions to those funds. Abortion
opponents say language now in the bill is inadequate to ensure that
only private dollars — not federal funds — can be used to pay for the
procedure. Abortion rights supporters say if the bill gets much more
restrictive, it would deny women access to a procedure now covered by
many private insurance plans.
Hoyer said Democratic leaders want the health care bill "to keep the
situation neutral," not shift the government's policy on abortion
funding in one direction or another. But activists on both sides of the
issue disagree on what it would take to meet that goal. The House
effort picked up two major endorsements Thursday, from the powerful
seniors' lobby AARP and the American Medical Association.
The bill would cover 96 percent of Americans, providing government
subsidies beginning in 2013 to extend coverage to millions who now lack
it. Self-employed people and small businesses could buy coverage
through the new exchanges, either from a private insurer or a new
government plan that would compete. All the plans sold through the
exchange would have to follow basic consumer protection rules.
For the
first time, almost all individuals would be required to purchase
insurance or pay a fine, and employers would be required to insure
their employees. Insurance companies would be barred from denying
coverage to people with pre-existing medical conditions or charging
much higher rates to older people.
Obama’s fumbles on ‘Monday Night Football’
NYPOST
By KYLE SMITH
Last Updated: 4:53 AM, October 18, 2009
Posted: 12:06 AM, October 18, 2009
Remember that time President Bush interrupted the Emmy telecast to tell
people we should support reform of Social Security before it bankrupted
the country?
Neither do I. Yet when I tuned in to watch "Monday Night Football" this
week to check out the Miami Dolphins’ Wildcat offense, I didn’t expect
to see President Obama taking the direct snap and trying to pound his
political message into the end zone.
Where’s the flag for illegal procedure? The president is popping up
everywhere but Cialis commercials. How long before we have to watch him
and Michelle holding hands in matching bathtubs as they lecture us
about executive compensation schemes?
With the full blessing of the media, Obama is still in election mode,
and I say: If elections persist more than 24 months, it’s a problem.
Especially when the networks are giving him free time to air what
amount to campaign commercials.
A pre-taped intro from Obama opened the Oct. 12 "MNF" telecast. This
was at least his third appearance there in the last three years. That
means he’s on more than the Arizona Cardinals.
The ostensible purpose was to tell us it was Hispanic Heritage Month. I
thought it was Columbus Day, thus more of an occasion to celebrate
Italian heritage, but poor Columbus went unmentioned — by a man who
graduated from a university named after him and currently lives in a
district named after him.
The real point of Obama’s cameo, though, was to slip in a little
political appeal.
Obama told us, "Our nation faces extraordinary challenges right now,
and our ability to tackle them will depend on our willingness to
recognize that we’re all in this together, that we each have an
obligation to give back to our communities, and we all have a stake in
the future of this country. Because in the end todos somos Americanos —
we are all Americans."
As National Review’s Jay Nordlinger put it, in a piece about
sportswriters who make anti-Bush cracks, this was a "Safe-Zone
Violation." Sports are supposed to be insulated from such intrusions of
reality. Does the pigskin have to be turned into a political football?
Do we have to pause and give our attention to a liberal president even
during a red-state sport (to date, the Nebraska Cornhuskers have never
lost a game to Wellesley)?
Liberals don’t like safe-zone violations either, supposedly. Remember
the outrage on the left in 2004, when Al Michaels made a joke at John
Kerry’s expense? After two consecutive turnovers at a game hosted in
Massachusetts by the New England Patriots, John Madden said "This is
what you call a flip-flop." Michaels quipped, "You’re in the right
state for that."
At least what Michaels said had the virtue of being funny. Comedy
counts as entertainment. Then-Senator Obama was (almost) funny when he
first appeared on "MNF" in 2006 and, in a joke about the speculation at
the time about whether he would run for president, said, "I am ready .
. . [pause, put on Bears cap] for the Bears to go all the way, baby!"
Like I said, almost funny (but mainly just free publicity).
Michaels was evidently given a dressing-down by his bosses, because in
his next broadcast following the Kerry jibe, he mentioned that
Condoleezza Rice, who had expressed interest in being NFL commissioner,
was in the stadium. But then he backtracked, saying, "But we’re not
supposed to talk anything besides football, so, sorry."
The Kerry joke led to James Carville fuming, "These announcers are
getting to think they’re some kind of political commentators or
pontificators. But the football fans watch football to hear about
football. If Al Michaels wants to give his political opinions, tell him
to come on ‘Crossfire.’"
Ding. Give James Carville a prize. Football fans want to hear about
football.
Now consider the substance of what Obama said. Anyone but the network
executives who approved the speech can see it was hardly neutral. It
wasn’t "stay in school and study hard." It laid down a partisan
political philosophy.
"We’re all in this together"? No, we aren’t. Mostly, we’re competing
with each other. If your company goes out of business, maybe my company
can pick up your assets cheap and add your customers. Your foreclosure?
My new house.
America isn’t like a sports team, except when it comes to war. But I
doubt that Obama was talking about the special exception of wartime
deprivation, given his lack of interest in the Afghanistan war, the one
that inspired the president’s top men to castigate his own handpicked
commander for talking about it too much.
Worse: Obama says, "We each have an obligation to give back to our
communities." I suppose that’s true in a literal sense. I’m not going
to argue that I’m not obliged to pay taxes, although that strategy
didn’t work out so badly for Wesley Snipes. (Three years in prison in
exchange for escaping taxes on $13 million? Plaxico Burress, call
Wesley’s lawyer.)
But Obama wasn’t talking about a literal legal obligation, because
there would be no need to remind us of that. He never feels the need to
remind us we’re obligated not to steal one another’s cars. Nor was he
talking about volunteerism: Not an obligation. It’s kind of in the
definition.
No, by "our nation faces extraordinary challenges" and "we’re all in
this together" and "we all have an obligation to give back" he was
saying: Tough times mean we all need to march to the same tune, and
it’s the one playing on my iPod. "Please don’t blame me for the
unemployment increases my stimulus was supposed to avert." "Please
understand I know what’s best for you." "Please support my healthcare
tax-and-spendapalooza."
Civic "obligation" does not run from individuals to the "community,"
i.e., the government. If anything, the truth is the opposite: The
government is supposed to provide you with things like security and
freedom and order, and if it offers to "provide" you with new things
like a revamp of health care, you can ask whether you as an individual
will come out better, not just blindly accept it for the supposed
greater good of "the community." Obama is carrying the ball the wrong
way down the field. Why does he expect us to cheer?
Killing Marcus Welby
NYPOST
By SCOTT GOTTLIEB
Last Updated: 5:19 AM, October 18, 2010
Posted: 10:18 PM, October 17, 2010
If ObamaCare really called for the creation of "death panels," the
first victim of these in vented tribunals would have been Marcus Welby
MD, the character in the hit 1960s television show that followed the
daily dramas of a small-town family doctor.
The health legislation doesn't call on government tribunals to
euthanize seniors, as some fanciful critics claim, but the bill does
kill off private-practice medicine.
ObamaCare envisions that doctors will fold their private offices to
become salaried hospital employees, making it easier for the federal
government to regulate them and centrally manage the costly medical
services they prescribe. To get this control, ObamaCare creates
"Accountable Care Organizations," which are basically hospitals coupled
with local doctor networks that the hospital owns.
Under ObamaCare, an ACO is supposed to take "accountability" for local
Medicare patients, who in turn get most care from providers working
inside the ACO's network. To encourage efficiency and cost-cutting, an
ACO can share in the savings it achieves from more closely managing its
assigned pool of patients. The idea is to give doctors a financial
incentive to better coordinate care and reduce their use of costly
medical services.
The ACO concept was coined in 2006 by the same Dartmouth health
researchers who famously found that higher Medicare spending doesn't
correlate with better medical outcomes. Their data was controversial.
Some experts refuted the findings. Even so, it became the intellectual
foundation for ObamaCare's vision of "bending the cost curve" -- that
you can improve medical outcomes by cutting Medicare spending. The ACOs
have become Washington's most fashionable vehicle for pursuing that
prophecy.
In many ways, the ACO concept builds on the 1990s approach to
"capitation," in which health-maintenance organizations gave doctors a
lump sum to care for a group of patients. This arrangement put a
financial onus on doctors to cut costs. The concept lowered spending
but was unpopular with patients, leading to a backlash against managed
care.
Even if the Obama team dresses up the same concepts in a new acronym,
their regulatory impulse to tightly manage how these organizations
operate tilts the ACOs into the hands of hospitals. It forces doctors
to sell their medical practices to these networks if the physicians
want to maintain what they're paid by Medicare.
Obama's health-care czar, Nancy Ann DeParle, laid bare this financial
coercion. Writing recently in the "Annals of Internal Medicine," she
said that "the economic forces put in motion by [the Obama health-care
plan] are likely to lead to vertical organization of providers and
accelerate physician employment by hospitals and aggregation into
larger physician groups." Physicians, she said, "that accept the
challenge will be rewarded in the future payment system" as ObamaCare
"reforms" how doctors are paid under Medicare.
The Obama plan contains other economic forces that will drive such
"vertical integration" in which doctors become employees of hospitals
and health plans. For one, under ObamaCare, health plans will see their
revenue (premiums) and costs (medical benefits) largely fixed by
government regulation. So the only way health plans can improve their
profits is by cheapening the product that they provide, in other words,
holding down the cost of the health coverage that they offer.
In turn, the only way to cheapen health coverage is to control the
medical services consumers can access. The only way to tightly control
the use of medical services is to exert more leverage over the doctors
who order the tests and treatments. That means health plans will need
to maintain tight networks of providers to exert more control over
doctors -- or else own the physicians outright. So expect to see health
plans doing their own "vertical integration" -- buying out medical
practices, just like hospitals are doing.
According to a recent survey of health executives, 74 percent said
their hospitals or health systems plan to employ more physicians over
the next 3 years, and 61 percent plan to acquire medical groups. The
doctor-recruitment firm Merritt Hawkins said that 45 percent of
physician job searches last year were for direct employment of a doctor
by a hospital, up from 23 percent in 2005.
In 2005, more than two-thirds of medical practices were doctor-owned, a
share that was largely constant for many years. By next year, the share
of practices owned by physicians will probably drop below 40 percent,
according to data from the Medical Group Management Association.
Hospitals or health plans will own the balance of doctor practices.
So the next time you see your doctor, it may be far from home, in an
office park built by your nearest hospital. Thanks to ObamaCare, Marcus
Welby is taking down his shingle. He's becoming an employee of General
Hospital.
Scott Gottlieb, a physician and
American Enterprise Institute resi dent fellow, is a partner in a firm
that invests in health-care companies.
Geography makes difference in health coverage
YAHOO
By MIKE SCHNEIDER, Associated Press Writer Mike Schneider, Associated
Press
September 24, 2009
ORLANDO, Fla. – Where someone lives makes a difference in whether or
not that person has health insurance.
Census data released this week shows a vast geographic inequality in
the uninsured that has been shaped by an area's state laws, population
makeup and jobs. Residents in vast swaths of the Southwest are many
times more likely to lack health insurance than residents in pockets of
the Northeast and upper Midwest.
"Depending on who you are and where you work, you can be very unlucky
and not get covered," said Dr. Bruce Siegel, director of the Center for
Health Care Quality at George Washington University. "It's a completely
fragmented system."
Of the nation's 435 congressional districts, Texas districts topped the
list with the highest percentage of uninsured residents, while the
lowest percentage of the uninsured were in congressional districts in
Massachusetts, which in 2006 legislated near-universal health insurance.
The extremes range from Democratic U.S. Rep. Gene Green's congressional
district in Houston, where 40.1 percent of the population is uninsured,
to Democratic Rep. Jim McGovern's district around Worcester, Mass.,
where only 3.4 percent of the population has no coverage.
McGovern's district is helped by the state's mandatory health-insurance
requirement and having the University of Massachusetts Medical School
and UMass Memorial Medical Center as two of the area's largest
employers.
Green attributed the large numbers of uninsured in his inner-city
district to low-paying jobs where employers don't provide insurance,
and even if they do, employees often can't afford the high co-payments.
"We've been trying to hold a finger in the dike," Green said.
In between these extremes are the San Francisco congressional district
of House Speaker Nancy Pelosi, where more than 11 percent of the
residents are uninsured, and the South Carolina district of Republican
U.S. Rep. Joe Wilson, where almost 15 percent of residents have no
health insurance. Wilson gained fame for his outburst of "You lie!"
during President Barack Obama's speech to Congress on health care
reform.
The reasons for the geographic disparities boil down to state policies,
types of jobs and demographics.
Eligibility for Medicaid, the federal health program for poor families
managed by states, varies between states: Some are more generous than
others. In Massachusetts' case, lawmakers mandated that virtually
everyone in the state be insured or face steadily increasing fines,
dropping the percentage of uninsured to 4.1 percent.
An Associated Press statistical analysis showed that a county's
percentage of residents without health insurance was influenced by its
percentage of Hispanics; the percentage of residents ages 20 to 24 and
60 to 64; and the percentage of residents working in farming, fishing,
hunting, mining, construction, real estate, support positions such as
secretary or janitor and hotel and food service workers.
Salaries matter too, as well as the presence of government and union
jobs.
While more than 90 percent of the nation's highest-wage earners had
access to health insurance, that was true for little more than a
quarter of the nation's lowest wage-earners. Just under three-quarters
of the nation's workers had access to health insurance, but the access
rate jumped to 88 percent for government workers, according to the
Bureau of Labor Statistics.
Construction workers in heavily unionized areas of the United States,
such as the Northeast, Chicago and California, are more likely to have
health coverage than in right-to-work states in the South and
Southwest, said Jacob Hay, a spokesman for the Laborers' International
Union of North America. Workers in right-to-work states can't be forced
to join a union as a condition of employment.
Indeed, BLS data showed that 80 percent of union workers in private
industry had health insurance benefits in 2006, while only 49 percent
of nonunion workers did.
"A solution we would point to is that when workers are able to come
together in a union, they're able to fight for better jobs, and part of
that includes fighting for and negotiating health care benefits," Hay
said.
The four states with the highest concentrations of the uninsured —
Texas, New Mexico, Nevada and Florida — also have some of the nation's
largest Hispanic populations.
"Much of the explanation lies in the kinds of jobs they have," said
Jill Quadagno, a Florida State University sociology professor. "Fewer
are in state employment compared to blacks and more are in agricultural
employment, often migrant labor, which does not provide health
insurance."
With the age groups, people between ages 20 and 24 may be least likely
to have health insurance because they don't have jobs, have jobs that
don't include health insurance or have aged-out of their parents'
health insurance coverage.
Some people in the 60 to 64 age group may be making too much money to
qualify for public insurance but they can't afford private insurance.
Others may be early retirees whose company didn't provide health
insurance in retirement but they're too young to qualify for Medicare,
the federal program which provides health insurance for people age 65
and older, Siegel said.
Next to Massachusetts, the states
with the least uninsured residents were Hawaii (6.7 percent), Minnesota
(8.7 percent) and Connecticut (9 percent).
Behind Texas, the states with the largest percentage of uninsured
residents were New Mexico (21.4 percent), Nevada (21.3 percent) and
Florida (20.8 percent), where 41-year-old Tanya Cheaney lives.
When Cheaney lost her customer service job earlier this year at an
Orlando cabinet maker, she not only lost her health insurance but her
ability to pay for the $400-a-month in anti-seizure and blood pressure
drugs she needs every day. She now faces the choice of going without
the medication or putting off her car insurance payments so she can buy
the drugs.
"We're going to have to rob Peter to pay Paul," Cheaney said.
NOT EXACTLY THE AVERAGE
POPULATION...
Op-Ed Contributors
A Public Option That Works
NYTIMES
By WILLIAM H. DOW, ARINDRAJIT DUBE and CARRIE HOVERMAN COLLA
August 22, 2009
TWO burning questions are at the center of America’s health care
debate. First, should employers be required to pay for their employees’
health insurance? And second, should there be a “public option” that
competes with private insurance?
Answers might be found in San Francisco, where ambitious health care
legislation went into effect early last year. San Francisco and
Massachusetts now offer the only near-universal health care programs in
the United States.
The early results are in. Today, almost all residents in the city have
affordable access to a comprehensive health care delivery system
through the Healthy San Francisco program. Covered services include the
use of a so-called “medical home” that coordinates care at approved
clinics and hospitals within San Francisco, with both public and
private facilities. Although not formally insurance, the program is
tantamount to a public option of comprehensive health insurance, with
the caveat that services are covered only in the city of San Francisco.
Enrollees with incomes under 300 percent of the federal poverty level
have heavily subsidized access, and those with higher incomes may buy
into the public program at rates substantially lower than what they
would pay for an individual policy in the private-insurance market.
To pay for this, San Francisco put into effect an
employer-health-spending requirement, akin to the “pay or play”
employer insurance mandates being considered in Congress. Businesses
with 100 or more employees must spend $1.85 an hour toward health care
for each employee. Businesses with 20 to 99 employees pay $1.23 an
hour, and businesses with 19 or fewer employees are exempt. These are
much higher spending levels than mandated in Massachusetts, and more
stringent than any of the plans currently under consideration in
Congress. Businesses can meet the requirement by paying for private
insurance, by paying into medical-reimbursement accounts or by paying
into the city’s Healthy San Francisco public option.
There has been great demand for this plan. Thus far, around 45,000
adults have enrolled, compared to an estimated 60,000 who were
previously uninsured. Among covered businesses, roughly 20 percent have
chosen to use the city’s public option for at least some of their
employees. But interestingly, in a recent survey of the city’s
businesses, very few (less than 5 percent) of the employers who chose
the public option are thinking about dropping existing (private market)
insurance coverage. The public option has been used largely to cover
previously uninsured workers and to supplement private-coverage options.
Through our experience working on health-care-reform efforts in
California and Washington (one of us worked for President George W.
Bush’s Council of Economic Advisers), we have seen how concern over
employer costs can be a sticking point in the health care debate, even
in the absence of persuasive evidence that increased costs would
seriously harm businesses. San Francisco’s example should put some of
those fears to rest. Many businesses there had to raise their health
spending substantially to meet the new requirements, but so far the
plan has not hurt jobs.
As of December 2008, there was no indication that San Francisco’s
employment grew more slowly after the enactment of the
employer-spending requirement than did employment in surrounding areas
in San Mateo and Alameda counties. If anything, employment trends were
slightly better in San Francisco. This is true whether you consider
overall employment or employment in sectors most affected by the
employer mandate, like retail businesses and restaurants.
So how have employers adjusted to the higher costs, if not by cutting
jobs? More than 25 percent of restaurants, for example, have instituted
a “surcharge” — about 4 percent of the bill for most establishments —
to pay for the additional costs. Local service businesses can add this
surcharge (or raise prices) without risking their competitive position,
since their competitors will be required to take similar measures.
Furthermore, some of the costs may be passed on to employees in the
form of smaller pay raises, which could help ward off the possibility
of job losses. Over the longer term, if more widespread coverage allows
people to choose jobs based on their skills and not out of fear of
losing health insurance from one specific employer, increased
productivity will help pay for some of the costs of the mandate.
The San Francisco experiment has demonstrated that requiring a
shared-responsibility model — in which employers pay to help achieve
universal coverage — has not led to the kind of job losses many fear.
The public option has also passed the market test, while not crowding
out private options. The positive changes in San Francisco provide a
glimpse of what the future might look like if Washington passes
substantial health reform this year.
William H. Dow, who was a senior
economist for President George W. Bush’s Council of Economic Advisers,
is a professor of health economics at the University of California,
Berkeley, where Arindrajit Dube is an economist at the Institute for
Research on Labor and Employment and Carrie Hoverman Colla is a
doctoral student in health economics.
NOTE:
The author of this op-ed is not close to 85, and his parents are no
longer alive...our guess.
Op-Ed Contributor
Health Care’s Generation Gap
NYTIMES
By RICHARD DOOLING
August 17, 2009
IN the 1980s, I worked as a respiratory therapist in intensive-care
units in the Midwest, taking care of elderly, dying patients on
ventilators. I remember marveling, along with the young doctors and
nurses I worked with, over how many millions of dollars were spent
performing insanely expensive procedures, scans and tests on patients
who would never regain consciousness or leave the hospital.
When the insurance ran out, or Medicare stopped paying, patients and
their families gave the hospital liens on their homes to pay for this
care. Families spent their entire savings so Grandma could make yet
another trip to the surgical suite on the slim-to-none chance that
bypass surgery, a thoracotomy, an endoscopy or kidney dialysis might
get her off the ventilator and out of the hospital in time for her 88th
birthday.
That was back in the mid-’80s, when the nation was spending around 8
percent of its gross domestic product on health care. I and other
health care workers solemnly agreed that the spending spree could not
continue. Taxpayers and insurance companies would eventually revolt and
refuse to pay for such end-of-life care. Somebody would surely expose
the ruse for what it was: an enormous transfer of wealth based on the
pretense that getting old and dying is a medical emergency requiring
high-tech intensive-care intervention and armies of specialists, which
could cost $10,000 or more per day. (Europeans have so far resisted
this delusion, one reason they spend much less than we do on health
care, with far better results.)
But we were wrong. Health care spending has since doubled, to around 16
percent of our gross domestic product, and in the next 25 years or so
is projected to reach 31 percent of G.D.P. Despite having those figures
in hand, Congress might still pass legislation calling for spending
more, not less, on health care, even though we’ve been told for decades
that what we spend has almost nothing to do with the quality of care we
receive.
In fact, expensive care is often worse care, because it snowballs into
what some are calling an “epidemic of overtreatment,” in which
unnecessary procedures, tests and medications all spawn more tests,
more meds (to treat the side effects of the first batch) and more
follow-up scans and procedures (in stand-alone clinics owned by the
same doctors prescribing the tests, scans and procedures).
With so much evidence of wasteful and even harmful treatment, shouldn’t
we instantly cut some of the money spent on exorbitant intensive-care
medicine for dying, elderly people and redirect it to pediatricians and
obstetricians offering preventive care for children and mothers? Sadly,
we are very far from this goal. A cynic would argue that this can’t
happen because children can’t vote (even if their parents can), whereas
members of AARP and the American Medical Association not only vote but
can also hire lobbyists to keep the money flowing.
One thing’s for sure: Our health care system has failed. Generational
spending wars loom on the horizon. Rationing of health care is
imminent. But given the political inertia, we could soon find ourselves
in a triage situation in which there is no time or money to create
medical-review boards to ponder cost-containment issues or rationing
schemes. We’ll be forced to implement quick-and-dirty rules based on
something simple, sensible and easily verifiable. Like age. As in: No
federal funds to be spent on intensive-care medicine for anyone over 85.
I am not, of course, talking about euthanasia. I’m just wondering why
the nation continues incurring enormous debt to pay for bypass surgery
and titanium-knee replacements for octogenarians and nonagenarians,
when for just a small fraction of those costs we could provide children
with preventive health care and nutrition. Eight million children have
no health insurance, but their parents pay 3 percent of their salaries
to Medicare to make sure that seniors get the very best money can buy
in prescription drugs for everything from restless leg syndrome to
erectile dysfunction, scooters and end-of-life intensive care.
Sir William Osler, widely revered as the father of modern medicine,
said, “One of the first duties of the physician is to educate the
masses not to take medicine.” Perhaps the second duty should be to
administer an ounce of prevention instead of a pound of cure.
Richard Dooling is the author of
“Critical Care,” a novel.
Tax Intake In
Biggest Drop Since Depression; Total revenues on track to plunge
DAY
By Stephen Ohlemacher, Associated Press
Published on 8/4/2009
Washington — The recession is starving the government of tax revenue,
just as the president and Congress are piling a major expansion of
health care and other programs on the nation's plate and struggling to
find money to pay the tab.
The numbers could hardly be more stark: Tax receipts are on pace to
drop 18 percent this year, the biggest single-year decline since the
Great Depression, while the federal deficit balloons to a record $1.8
trillion.
Other figures in an Associated Press analysis underscore the
recession's impact: Individual income tax receipts are down 22 percent
from a year ago. Corporate income taxes are down 57 percent. Social
Security tax receipts could drop for only the second time since 1940,
and Medicare taxes are on pace to drop for only the third time ever.
The last time the government's revenues were this bleak, the year was
1932 in the midst of the Depression.
“Our tax system is already inadequate to support the promises our
government has made,” said Eugene Steuerle, a former Treasury
Department official in the Reagan administration who is now vice
president of the Peter G. Peterson Foundation. “This just adds to the
problem.”
While much of Washington is focused on how to pay for new programs such
as overhauling health care — at a cost of $1 trillion over the next
decade — existing programs are feeling the pinch, too.
Social Security is in danger of running out of money earlier than the
government projected just a few month ago. Highway, mass transit and
airport projects are at risk because fuel and industry taxes are
declining.
The national debt already exceeds $11 trillion. And bills just
completed by the House would boost domestic agencies' spending by 11
percent in 2010 and military spending by 4 percent.
For this report, the AP analyzed annual tax receipts dating back to the
inception of the federal income tax in 1913. Tax receipts for the 2009
budget year were available through June. They were compared to the same
period last year. The budget year runs from October to September,
meaning there will be three more months of receipts this year.
Is there a way out of the financial mess?
A key factor is the economy's health. The future of current programs —
not to mention the new ones Obama is proposing — will depend largely on
how fast the economy recovers from the recession, said William Gale,
co-director of the Tax Policy Center.
“The numbers for 2009 are striking, head-snapping. But what really
matters is what happens next,” said Gale, who previously taught
economics at UCLA and was an adviser to President George H.W. Bush's
Council of Economic Advisers.
“If it's just one year, then it's a remarkable thing, but it's totally
manageable. If the economy doesn't recover soon, it doesn't matter what
your social, economic and political agenda is. There's not going to be
any revenue to pay for it.”
A small part of the drop in tax receipts can be attributed to new tax
credits for individuals and corporations enacted in February as part of
the $787 billion economic stimulus package. The sheer magnitude of the
tax decline, however, points to the deep recession that is reducing
incomes, wiping out corporate profits and straining government programs.
Social Security tax receipts are down less than a percentage point from
last year, but in May the government had been projecting a slight
increase. At the time, the government's best estimate was that Social
Security would start to pay out more money than it receives in taxes in
2016, and that the fund would be depleted in 2037 unless changes are
enacted.
Some experts think the sour economy has made those numbers outdated.
“You could easily move that number up three or four years, then you're
talking about 2013, and that's not very far off,” said Kent Smetters,
associate professor of insurance and risk management at the University
of Pennsylvania.
The government's projections included best- and worst-case scenarios.
Under the worst, Social Security would start to pay out more money than
it received in taxes in 2013, and the fund would be depleted in 2029.
The fund's trustees are still confident the solvency dates are within
the range of the worst-case scenario, said Jason Fichtner, the Social
Security Administration's acting deputy commissioner.
“We're not outside our boundaries yet,” Fichtner said. “As the recovery
comes, we'll see how that plays out.”
The recession's toll on Social Security makes it even more urgent for
Congress to address the fund's long-term solvency, said Sen. Herb Kohl,
D-Wis., chairman of the Senate Aging Committee.
“Over the past year, millions of older Americans have watched their
retirement savings crumble, making the guaranteed income of Social
Security more important than ever,” Kohl said.
President Barack Obama has said he wants to tackle Social Security next
year, after he clears an already crowded agenda that includes
overhauling health care, addressing climate change and imposing new
regulations on financial companies.
Medicare tax receipts are also down less than a percentage point for
the year, pretty close to government projections. Medicare started
paying out more money than it received last year.
Meanwhile, the recession is taking a toll on fuel and industry excise
taxes that pay for highway, mass transit and airport projects. Fuel
taxes that support road construction and mass transit projects are on
pace to fall for the second straight year. Receipts from taxes on jet
fuel and airline tickets are also dropping, meaning Congress will have
to borrow more money to fund airport projects and the Federal Aviation
Administration.
Last week, Congress voted to spend $7 billion to replenish the highway
fund, which would otherwise run out of money in August. Congress spent
$8 billion to replenish the fund last year.
Rep. Richard Neal, D-Mass., chairman of the House subcommittee that
oversees fuel taxes, is working on a package to make the fund more
self-sufficient. The U.S. Chamber of Commerce, which doesn't back many
tax increases, supports increasing the federal gasoline tax, currently
18.4 cents per gallon.
Neal said he hasn't endorsed a specific plan. But, he added, “You can't
keep going back to the general fund.”
Op-Ed Columnist
Kill the Rhinos!
NYTIMES
By DAVID BROOKS
July 24, 2009
Forget the wonkery. Let’s get primeval. Rising health care costs are a
stampede of big ugly rhinos. They are trampling your crops, stomping on
your children’s play areas and spoiling your hunting grounds.
President Obama wasn’t exaggerating when he said this cost onslaught is
unsustainable. The rhinos have been roaming unchecked for a generation.
We’ve thrown research projects, legislative and corporate reforms at
them, all in an effort to tamp down health care inflation. But the
rhinos keep coming. They are ubiquitous, powerful, protean and
inexorable.
They feed on fuel sources deep in our system: expensive technological
progress, the self-interest of the millions of people who make their
living off the system, the public’s desire to get the best care for
nothing, the fee-for-service payment system and so on.
The rhinos are closing off your future. As the White House folks say,
health care premiums have doubled over the last decade. The government
is saddled with $36 trillion in unfunded liabilities.
So your only question should be: Where do you find a tool or weapon big
enough to stop the rhino stampedes? You know the problem is big, and
you figure the response had better be gigantic.
Then you look on Capitol Hill and you see a bunch of popguns. The
politicians describe these big ugly problems, but when it comes time to
talk about their remedies they tell you: Don’t worry. Nothing’s going
to change. In other words, we’re going to eliminate the biggest,
hairiest, most entrenched problem in the country without fundamentally
changing the system and without asking for sacrifice from anybody.
Good luck.
Then you talk to the health care experts promoting the bills and they
are very honest: We don’t know exactly how to slow health care
inflation. But we think we have some good ideas. We’re going to put
some innovations, information clearinghouses and pilot projects in this
legislation, and over the next 10 years we will see what works to
really bring down costs. We’re going to go on a voyage of discovery to
learn about rhino eradication.
And, indeed, some of the ideas do sound good: more information
technology, comparative effectiveness research, conducting experiments
to bundle hospital payments so they are based on outcomes. Some of the
providers that do things right, like the Mayo Clinic, really are
getting results.
But some of these ideas have been watered down in the legislation. And
you’re not a complete idiot. You know there is a big difference between
finding islands of excellence and creating a national system based on
them.
Besides, you’ve got a bunch of big, evil rhinos stomping around! You
want more than some promising ideas to pinpoint waste, fraud and abuse.
You want some big heavy hammers to clock those suckers in the head.
Now that the first wave of legislation is bogging down, you want to
take the seeds of cost control and you want to do more. You want to
eliminate or cap the tax exemption on employee health benefits. This is
a big way to crush one of the core drivers of health care inflation.
You’re willing to give MedPAC-style technocrats a chance to take
control of Medicare spending away from Congressional spendthrifts.
You want to loosen federal regulations so that states have more room to
experiment — not tighten them, as the current legislation does, so that
states have less. You want reforms throughout the system that will cut
down on first-dollar reimbursement in exchange for catastrophic
protection. You want to tie Medicare subsidies to income. You want to
look at anything that will move us away from a fee-for-service model,
the core perversion in the system.
You want to change incentives at both ends. The legislators who drew up
the first bills want to change the provider’s incentives. But big cost
savings can also come if consumers have choices and incentives to hunt
for cheaper coverage. The Wyden-Bennett bill gives people a chance to
choose the best option, instead of imprisoning people in existing
coverage, as the current legislation does. The Medicare Part D reform
has produced impressive reductions by allowing consumers to pocket
prescription drug savings. Other proposals would give people tax
credits and allow them to go to any trusted community group — like AARP
or a union or a religious group — that wanted to compete to offer
coverage.
Not everything is compatible with everything else. But the point is
that you have rhinos at the door! You’ll try anything that works. You
want a political class that no longer perpetuates the myth that people
can get everything for nothing. You know that it was political
pandering that got us into this mess in the first place.
Obama is right. Things will be bad if we don’t tackle the problem this
year. Things will be worse if we add to the costs without beating the
rhinos.
Robin Hood Health Care?
Governors Join G.O.P. in
Concerns on Health Bill
NYTIMES
By BRIAN KNOWLTON
July 20, 2009
WASHINGTON — Despite President Barack Obama’s assurance that a
revamping of the United States health-care system would not swell the
federal deficit, his goal of quick congressional passage seemed to grow
a bit more tenuous on Sunday as Republicans dug in their heels while
governors in both parties raised concerns that they will be handed
costly new Medicaid obligations without the money to pay for them.
The states pay, on average, more than 40 percent of the cost of
Medicaid, so they bear a significant burden of any expansion of the
program to help more low-income Americans. At their annual summer
meeting, in Biloxi, Miss., the governors said that their concerns
dominated discussion, with striking levels of bipartisan hostility
voiced during a closed-door luncheon on the topic on Saturday.
And Congressional Republicans said on Sunday that Mr. Obama could
probably meet his deficit goal only by increasing taxes on the
wealthiest Americans and requiring small business owners, already
battered by the enduring recession, to assure coverage of their
employees.
The Senate’s top Republican, Mitch McConnell of Kentucky, said on NBC’s
“Meet the Press” that rising health-care costs, and the problem of
millions of Americans who lack insurance, could be resolved without a
costly revamping — estimates are that it could cost $1 trillion over a
decade — that he said would lead to inferior care and an outsized
government role.
Representative Charles Rangel of New York, who chairs the Ways and
Means Committee, was asked on CBS’s “Face the Nation” whether a
health-care revamping could be achieved without significantly raising
taxes. “Well, no,” said Mr. Rangel, a Democrat of New York, even though
he added that billions in savings would help reduce the tax impact.
Mr. Rangel said that the proposed surtax on the wealthy would affect
“less than 1 percent of the wealthiest people in the United States” and
would not have the impact on small businesses that critics say.
The White House budget director, Peter Orszag, spoke Sunday of Mr.
Obama’s target for passage of health-care legislation by early August,
when Congress begins its summer recess, as less a firm deadline than a
“goal.”
“It’s still the goal, we think we can make that, we’re working towards
that,” Mr. Orszag said on CNN’s “State of the Union.” The House begins
its summer recess on Aug. 3, the Senate on Aug. 7. Mr. Orszag also
sought to allay concerns that the new approach could weigh down an
already lagging economic recovery.
But he also opened the door to a new controversy by refusing to rule
out the possibility of government health-care funds being used to pay
for abortions.
Senator Judd Gregg, Republican of New Hampshire, hinted at how volatile
that could be. “No matter what your views are on abortion, you
shouldn’t ask people to use their tax dollars if they think that
abortion is taking a life,” he said on “Fox News Sunday.”
“I would hate to see the health care debate go down over that issue.”
Kathleen Sebelius, secretary of health and human services, at first
side-stepped questions on whether Mr. Obama specifically supported a
proposed surtax on the wealthy to pay for expanded health care.
“What the president supports is paying for this; he has said it will
not add a dime to the deficit,” she said, when asked about a surtax on
“Meet the Press.” But later she added: “I think the ideas are in play.
This is a very legitimate way to go forward.”
In his weekly radio address on Saturday, Mr. Obama said pointedly: “ I
will not sign on to any health plan that adds to our deficits over the
next decade. And by helping improve quality and efficiency, the reforms
we make will help bring our deficits under control in the long term.”
Mr. Orszag also defended the effectiveness of the administration’s $787
billion economic stimulus plan and the pace of recovery despite the
unemployment numbers.
“You can’t go from job losses of 700,000 a month, which is what was
happening in the months leading up to January, to job growth like that,
you know, just instantaneously,” he said. “It is going to take some
time.”
But Mr. Orszag’s suggested that the “sense of panic and fear in the
financial markets” felt late last year and early this year “has
dissipated to some degree.”
Mr. Obama’s effort to move quickly on health-care reform hit a
stumbling block last week when the director of the Congressional Budget
Office, Douglas Elmendorf, said that the bills working their way
through Congress would not bring health costs down over the next decade.
“Those were pretty damning words” and suggested the need to rethink the
legislation, said Mr. Gregg.
Mr. Obama sought to allay such fears on Saturday.
“The same folks who controlled the White House and Congress for the
past eight years as we ran up record deficits will argue — believe it
or not — that health reform will lead to record deficits,” he said.
“That’s simply not true.”
He argued that his proposals would cut “hundreds of billions of
dollars” in unnecessary spending and change incentives so health
providers “will give patients the best care, not just the most
expensive care.”
But Mr. McConnell declared that the United States already had the best
health care in the world and did not need an approach that would have
the country’s hospitals and doctors “working for the government.”
In fact, a study last year by an influential health policy research
group, the Commonwealth Fund, found that the United States had the most
expensive health care in the world, yet was in last place among
industrialized countries in preventing deaths through timely and
effective medical care.
Kevin Sack contributed reporting from
Biloxi, Miss., and Robert Pear and Sheryl Gay Stolberg from Washington.
Mass.
Panel Backs Radical Shift in
Health Payment
NYTIMES
By KEVIN SACK
July 17, 2009
BOSTON — A high-level state commission recommended Thursday that
Massachusetts radically restructure the way doctors and hospitals are
paid, kicking off the second phase of a health care overhaul that has
succeeded in covering nearly every resident but done little to slow the
relentless growth of health costs.
The recommendations, if taken up by the Legislature and Gov. Deval
Patrick, would make Massachusetts the first state to end the practice
of paying physicians, hospitals and other health care providers for
each office visit, laboratory test or procedure. Instead, providers
would group themselves into networks that would be responsible for a
patient’s well being and would be compensated with a flat monthly or
annual fee known as a “global payment.”
The existing “fee-for-service” system has been roundly criticized for
offering incentives that encourage doctors to provide more treatment
than is necessary, a significant contributor to the high cost of health
care. Global payments, it is thought, would reward health care
providers for keeping their patients well rather than for merely
treating their ailments. If the cost of treating a patient is less than
the global payment, the provider networks — called accountable care
organizations in the proposal — would keep the difference as profit.
Discussions about changing the payment system also have been central to
the national health care debate in Washington. Those discussions have
focused primarily on providing financial rewards to doctors who
consistently offer high-quality preventive care, and less on
demolishing the fee-for-service system.
Although state officials and lawmakers in Massachusetts said it would
be a political challenge to enact the proposals, they also said the
state’s circumstances demanded it. The commission recommended that its
plan be implemented over a five-year period.
“We are among the highest cost states and without intervention our
projections are that spending on a per-person basis could double by
2020,” said Sarah Iselin, commissioner of the state division of health
care finance and quality, and a co-chairwoman of the health care
payment commission.
Senator Richard T. Moore, co-chairman of a joint legislative committee
on health care financing, said he expected to hold hearings on the
recommendations this fall. Representative Harriett Stanley, the
committee’s other co-chair, said she did not expect consideration of a
bill until well into 2010.
“It’s going to be a very long haul, but it’s a trip worth taking,” she
said.
The commission, which was created by the Legislature last year, and
directed by two top policy advisors to the governor, included leaders
of the state’s medical, hospital and insurer associations, and they
joined in Thursday’s unanimous vote for the recommendations. As in
2006, when state leaders negotiated a plan to cover almost all of the
state’s residents, it was deemed politically vital to keep such
stakeholders at the payment reform table.
But while the doctors’ and hospitals’ representatives said their groups
endorsed the general principles behind changing the payment system,
they made it clear that their continuing support would depend on
details that were deferred by the commission.
Chief among them is how a new payment system would account for
variations among doctors and hospitals in the health conditions and
socioeconomic status of their patients. The commission recommended that
payments would have to be adjusted to recognize the insurance risks
posed by the sickest patients, but said it would leave the details to
an independent board that would be formed to oversee the process.
“Hospitals want to be part of this historic endeavor,” said Lynn
Nicholas, president of the Massachusetts Hospital Association. But she
added that “the success of moving to a global payment system is not a
foregone conclusion” and expressed concerns about how risks would be
adjusted and how start-up costs would be covered.
The president of the state medical society, Dr. Mario E. Motta, also
urged caution. “A big transition like this has never been done on such
a broad scale, so it must be done very carefully, deliberately and
thoughtfully,” he said.
The commission’s report stressed the importance of changing not only
the way that doctors and hospitals are paid by private insurers, but
also by the two large public insurance plans — Medicare and Medicaid.
That would require permission from the federal government.
The commission issued its recommendations three years after the state
enacted one of the most sweeping restructurings of health care in the
country’s history. By requiring nearly all residents to have health
insurance, and providing subsidies to those earning up to $66,150 for a
family of four, the state has succeeded in covering 97 percent of its
residents.
That is by far highest rate of any state, and elements of the plan have
been emulated by President Obama and congressional Democrats in their
proposals to restructure the national health care system.
But to maintain a fragile coalition of doctors, hospitals, insurers,
consumers and businesses, Massachusetts’ political leaders deliberately
deferred any serious discussion about how to control health costs. They
have continued to rise at what state leaders acknowledge is an
unsustainable rate, between 6 and 9 percent a year, well above the
national average.
The state has a tradition of heavy spending on health care. It has more
doctors per capita than any state, many of them specialists at Boston’s
expensive academic medical centers. The state’s most prominent
hospitals have been able to negotiate high reimbursement rates from
insurers, and a new state law requires comprehensive insurance
benefits, which drives up costs.
Although the state’s subsidized insurance program, Commonwealth Care,
has managed to keep a lid on premium increases, it is already straining
the state’s budget. Last year, it filled a shortfall in the program by
assessing insurers and hospitals, raising the penalty on businesses
that do not cover their workers, increasing premiums and co-payments,
and raising the state tobacco tax.
This year, the program is facing $250 million in reductions, including
cutting off coverage for legal immigrants, because the economy has both
drained revenues and boosted enrollment. And on Wednesday, one of this
city’s main safety net hospitals, Boston Medical Center, challenged the
state in a lawsuit for what it contends are unfairly damaging cuts in
payments for treating poor patients.
DIRECTOR,
White House Office for Health Reform
Nancy-Ann
DeParle is a partner at CCMP Capital, a private equity firm formed in
August 2006 by the buyout professionals of JPMorgan Partners, LLC. At
CCMP, she focuses on health care investments, and serves on the boards
of CareMore Health Plan, Legacy Hospital Partners, and Noble
Environmental Power, a wind energy production company. In addition, she
is a director of Boston Scientific, Cerner, and the Robert Wood Johnson
Foundation. From 2002-2008, she served as a member of the Medicare
Payment Advisory Commission (MedPAC), which advises Congress on
Medicare payment policy. From 1997-2000, DeParle served in the Clinton
Administration as Administrator of the Health Care Financing
Administration (HCFA, now called the Centers for Medicare &
Medicaid Services or CMS). A key health policy advisor to President
Clinton, she ran Medicare, Medicaid, and S-CHIP, which provide health
insurance for 74 million Americans at an annual cost of more than $600
billion. Before joining HHS, she served as Associate Director for
Health & Personnel at the White House Office of Management and
Budget (OMB).
Earlier
in her career, she served in
the Cabinet of Tennessee Governor Ned McWherter as Commissioner of
Human Services. She has also worked as a lawyer in private practice and
is an Adjunct Professor of Health Care Systems at the Wharton School of
the University of Pennsylvania. In 1994, Time selected her one of
“America’s 50 Most Promising Leaders Age 40 and Under.” DeParle
received a B.A. from the University of Tennessee, where she was Student
Body President, and a J.D. from Harvard Law School. She also received a
B.A. and M.A. from Balliol College of Oxford University, where she was
a Rhodes Scholar.
-----------------------------
Obama health 'czar' was chief of
legally troubled firms
Washington Times
Chuck Neubauer
December 8, 2009
Nancy-Ann DeParle, one of President Obama's chief advocates for the
health care reform bill wending its way through Congress, earned more
than $6.6 million as a paid director for health care firms, some of
which were targeted in government investigations or whistleblower
lawsuits on suspicions of billing fraud and other legal problems.
Five of the companies faced allegations ranging from overcharging
Medicare to failing to warn patients of the dangers of their products,
according to a study by the Investigative Reporting Workshop at
American University and a review by The Washington Times of U.S.
Securities and Exchange Commission (SEC) records and Mrs. DeParle's
financial disclosure statement.
Mrs. DeParle, a former top administrator for the agency that runs
Medicare and Medicaid, has resigned from her corporate directorships
and said she will remove herself from any matters directly involving
the companies. According to a handwritten note attached to her
financial-disclosure form by an ethics official in June, she also has
divested "all conflicting assets."
But a Washington watchdog group said it plans to monitor the pending
health care reform legislation to make sure her new job does not
conflict with her prior industry ties.
"We want to look at it to be sure there was no conflict," said Steve
Ellis, vice president of Taxpayers for Common Sense. "We need to look
at the end to see who wins and who loses."
Mrs. DeParle, named in March as director of the White House Office of
Health Reform, collected at least $6.6 million from the health care
companies since 2001, including directors' fees and the profits from
selling stock that she acquired through options or awards as a
director, according to American University's July study and a
subsequent review by The Times. Most of the companies are publicly
traded.
Nearly all the companies, whether they had legal troubles or not, have
a huge stake in the shape of the pending health care bill. Mrs. DeParle
is one of the administration's key officials helping to push through
the legislation.
Her spokeswoman, Linda Douglass, said there was no conflict between
Mrs. DeParle's involvement in health care reform and her past work as a
corporate director for the health care companies, where she was not
involved in day-to-day operations.
Mrs. Douglass described her boss as a dedicated public servant who sold
some of her stocks at a loss and took a pay cut to accept the
$158,500-a-year "health czar" job. She said that as a corporate
director, Mrs. DeParle pushed for the companies to comply with federal
and state regulations and investigations.
"Throughout her professional life, Nancy-Ann DeParle has been known for
her integrity, extraordinary hard work and meticulous adherence to
ethical guidelines," Mrs. Douglass said. "Now she is fighting to
implement the president's health insurance reform plan."
David Axelrod, a senior Obama adviser, also praised what he called Mrs.
DeParle's "honesty and integrity," saying that during health care
reform meetings the two attended, he never saw her "advocate for
industry at all" or "try to set policy."
Before she went into the private sector, Mrs. DeParle was a key health
care adviser to President Clinton, running Medicare and Medicaid as
administrator of the Health Care Financing Administration (HCFA) from
1997 to 2000. HCFA is now known as the Centers for Medicare and
Medicaid Services.
In March, Mr. Obama named Mrs. DeParle and Health and Human Services
Secretary Kathleen Sebelius to push his health care plan through
Congress after his original choice for both jobs, former Sen. Tom
Daschle, South Dakota Democrat, withdrew over questions about his
income taxes and his work for the health care industry.
Mrs. DeParle did not have to undergo the Senate confirmation process
that Mr. Daschle faced because she is a White House staffer, not a
Cabinet officer. She reported $2.3 million in income on her financial
disclosure form covering 2008 and through her May 13, 2009, filing.
The companies for which she served as a director include:
c DaVita, Inc., a Colorado firm with 1,513 outpatient kidney dialysis
centers in 43 states and Washington, D.C., with more than 117,000
patients, most on Medicare. From May 2001 to July 2008, Mrs. DeParle
received more than $1.64 million in directors' fees and profits from
the sale of stock she acquired as director through options and awards,
SEC records show.
The U.S. attorneys in Texas, New York, Georgia and Missouri have
subpoenaed records from DaVita since 2004 in civil and criminal
investigations, some of which involved how the company billed Medicare,
according to the SEC records. The inspector general's office at Health
and Human Services also subpoenaed the firm in December 2008 regarding
its billings of Medicare for drugs.
DaVita said in May that the U.S. attorney in New York had closed that
investigation without charges, but other inquiries are still pending,
according to records that the company filed in November with the SEC.
"DaVita always cooperates fully and assists the federal government in
all ongoing matters," said company spokesman Craig Handzlik.
While she was a board member, campaign disclosure records show, Mrs.
DeParle gave $15,000 to DaVita's political action committee, which
bankrolled the company's political friends.
c Boston Scientific, Corp., a developer, manufacturer and marketer of
medical equipment including heart devices such as stints and
defibrillators. Mrs. DeParle served as a director from April 2006 to
March 2009, earning more than $174,808 in directors' fees, according to
SEC records.
Boston Scientific said in an SEC filing that it received notice in 2008
of seven federal or state investigations into its practices. In a
separate inquiry, the U.S. Army requested information about the
company's "sales and marketing interactions" with doctors at an Army
medical center in Tacoma, Wash.
c Guidant Corp., a heart device manufacturer accused of concealing
flaws in some of its devices. Mrs. DeParle served as a director from
May 2001 until its sale in April 2006 to Boston Scientific, earning at
least $1.19 million in profits from the sale of stock she acquired
through awards and options, SEC records show. Most of the profits came
from cashing in her Guidant stock options when the company was
purchased by Boston Scientific.
In May 2005, Guidant acknowledged that it had not told doctors over a
three-year period that one of its defibrillators had a flaw causing it
to short-circuit in about two dozen cases - including one in which a
college student died. The company later recalled the product, and in
November 2005, the New York attorney general's office accused Guidant
of concealing safety problems with some of its defibrillators.
In November, Boston Scientific agreed to pay $296 million to settle a
Justice Department investigation into charges that Guidant failed to
properly report the problems with its defibrillators to the U.S. Food
and Drug Administration (FDA).
Although she was a director of the company, Mrs. DeParle was "not aware
of the defibrillator issue" until it was mentioned in a May 2005 New
York Times article, Mrs. Douglass said.
In July 2003, a Guidant subsidiary pleaded guilty to felony charges of
failing to report 2,628 incidents to the FDA in which one of its
cardiac devices malfunctioned - including a dozen cases in which the
patients died. The subsidiary agreed to pay $92 million to settle the
case, the largest amount ever paid by a defendant up to that time in a
case involving flawed medical equipment.
The total includes a $49 million payment to Medicare, Medicaid and the
Department of Veterans Affairs to settle claims that they had paid for
defective products.
Mrs. DeParle joined the Guidant board in 2001, a few days after the
company told the FDA about the malfunctions with its cardiac device.
She was involved as a director in trying to settle the issue, Mrs.
Douglass said.
c Specialty Laboratories, Inc., a California-based chain where Mrs.
DeParle served as a director from April 2001 to June 2004, earning an
estimated $66,000 in directors' fees, records show. In 2002, the
company was suspended for several months from receiving Medicare and
Medicaid reimbursements for violating state and federal law by using
unlicensed personnel in testing and as supervisors.
The company was cited for similar problems in 1999 by HCFA, which was
then headed by Mrs. DeParle.
c Medco Health Solutions Inc., the No. 1 firm in the pharmacy benefits
management business, where Mrs. DeParle began serving on the board of
directors in October 2008, earning $13,500 in fees. The company has
been the target of three federal whistleblower lawsuits, all of which
are under seal and predate her board appointment. The company has spent
nearly $2.6 million in federal lobbying, including on health care
reform, for the first nine months of this year.
"Nancy-Ann DeParle was a valued Medco board member during her limited
time of service," a Medco spokesman said in a statement.
c Cerner Corp., an information technology company that makes software
for health care firms and could benefit from the Obama administration's
plans to spend billions of dollars encouraging the use of electronic
medical records. Mrs. DeParle was a director from May 2001 through
March 2009, earning $970,900 in fees and profits from stock sales,
according to the SEC records.
In February, Congress approved $35 billion in incentives for health
care companies to modernize operations through the use of information
technology. Cerner reported in an SEC filing last summer that although
it did not expect an immediate boost from the technology provisions in
the bill, "the longer-term potential could be significant" and the
company was well-positioned to benefit from the incentives.
The legislation was passed before Mrs. DeParle became health care czar,
but while she was a Cerner director.
c Triad Hospitals Inc., one of the largest publicly owned hospital
companies in the U.S. with 54 facilities. Mrs. DeParle was a director
from July 2001 to July 2007, when the company merged with Community
Health System.
She earned $1.525 million in directors' fees and profits from stock and
stock options when the companies merged, according to SEC records.
c CCMP Capital, a private equity firm where Mrs. DeParle was a managing
director overseeing health care investments from August 2006 to her
federal appointment. Her personal financial disclosure form shows that
she received $1 million in salary and bonus from CCMP for 2008 and
early this year.
It could not be determined how much she made from the firm in 2006 and
2007 because CCMP is not a publicly traded company. As part of her
work, she served on the boards of two health care companies in which
CCMP had invested - Legacy Hospital Partners and CareMore Health Plan.
Although her appointment has drawn some criticism because of her ties
to the health care industry, others said she had established a record
of fighting Medicare abuse.
"She is the person who put the notion of eliminating fraud and abuse in
Medicare and Medicaid on the agenda at HCFA," said Dr. William L.
Roper, dean of the School of Medicine at the University of North
Carolina and one of Mrs. DeParle's predecessors at HCFA. "It should not
be a bar to government service because you served honorably in the
private sector."
Obama Introduces Sebelius as Choice for HHS
By THE ASSOCIATED PRESS
Filed at 1:02 p.m. ET
March 2, 2009
WASHINGTON (AP) -- President Barack Obama has introduced Kansas Gov.
Kathleen Sebelius as his choice to be secretary of health and human
services.
Obama on Monday also announced that he has selected Nancy-Ann DeParle
to be director of the White House Office for Health Reform.
At the announcement, Obama said health care premiums have grown four
times as fast as wages over the past eight years, and he called it
''one of the fastest growing expenses in the federal budget.''
Obama said ''there's no easy formula for fixing our health care
system.'' The president's announcement comes just days before he holds
a White House summit on health care.
Op-Ed Contributor
Obama’s Mixed Messages
NYTIMES
By R. GLENN HUBBARD
August 30, 2009
PRESIDENT OBAMA’S health care plan is in trouble. If he really wants to
accomplish reform, he might start by learning some lessons from the
past. I witnessed firsthand President George W. Bush’s attempt, and
unfortunate failure, to reform Social Security. Now, Mr. Obama is
making similar mistakes in his effort to fix our health care system.
One of the most important lessons is that words matter — maybe too
much. Mr. Bush allowed his unwavering emphasis on “personal accounts”
to derail a compromise that could have helped solve the larger problem
of restoring the fiscal sustainability of Social Security.
In his campaign for the presidency, George W. Bush rightly noted the
low rates of return that would be available to younger workers. He
proposed an alternative: Allow a portion of payroll taxes to be
invested in personal savings accounts. The idea was that at least some
of this money would be invested in the stock market, thus enabling
households to earn a higher rate of return on their contribution than
they would receive from traditional Social Security.
While many economists (including me) have supported personal accounts
as a better way to pre-finance Social Security benefits than government
investment in the private sector, personal accounts on their own do not
offer higher, risk-adjusted returns. Much of Social Security’s
projected lower returns to younger workers is a result of the high
returns received by current retirees, who will continue to be paid.
(Social Security is a pay-as-you-go system, in which current taxes go
principally to finance current benefits.) Furthermore, investing in
stocks, which over long periods can yield more than bonds, for example,
is no free lunch.
As the Council of Economic Advisers chairman in 2002, I tried to make
this very point to President Bush. In the Oval Office, I showed him two
$1 bills and asked: “If one of these dollars is invested in bonds and
the other in stocks, what is the present value of either today?” The
answer, I told him, is $1. The higher return on stocks reflects greater
risk than investments like bonds, and investors cannot be as confident
about the outcome of their investments.
The bigger problem for Social Security, then and now, is that the
present value of its unfinanced liabilities is in the trillions of
dollars. President Bush understood this, but his primary emphasis on
personal accounts sent a mixed message. After all, these accounts on
their own would not solve Social Security’s long-run financial
problems. Mr. Bush’s fixation thus dimmed prospects for the compromise
that was probably available to advance Social Security reform.
Many Democrats saw personal accounts as the thin end of a wedge to
dismantle traditional Social Security. Mr. Bush should have just
jettisoned the term “personal accounts” and offered add-on expanded
saving incentives — like letting individuals contribute more pretax
dollars to I.R.A.’s and other pre-existing savings vehicles.
He also could have focused on low-income workers, as Social Security’s
central role is to be a safety net for seniors. He could have done this
by supporting a higher benefit for low-income workers than their record
of contributions might offer, or by matching their contributions to
private savings incentives with refundable tax credits. To pay for
these changes and restore Social Security’s long-run financial
stability, Congress could have slowed the growth rate of benefits for
middle- and upper-income workers. Such a compromise would have achieved
the goals of increasing private saving for retirement and shoring up
Social Security’s ability to meet the retirement needs of millions of
Americans. Yet Mr. Bush’s emphasis on both personal accounts and the
future viability of Social Security allowed opponents to exploit
inconsistencies in his reform agenda.
President Obama is now making the same kind of mistake with his
relentless emphasis on the public option and universal coverage — two
pet causes during his campaign. The big issue for health care reform is
high costs relative to the value of health care received. The currently
insured face high premiums, which act as a powerful disincentive for
the uninsured to buy coverage. Large, looming fiscal burdens from
Medicare and Medicaid are another burden on both taxpayers and the
economy as a whole.
The Obama administration seems to understand the importance of reducing
health care costs. But the president’s universal coverage and public
option proposals are directly at odds with his emphasis on cost
containment. A public option that reduces costs through public
subsidies simply shifts the expense to taxpayers (still us!), while
increasing the share of health care the government (again back to us)
would pay for with taxes. Mr. Obama’s rhetoric is also extremely
divisive: many Republicans see the public option as the thin end of a
wedge to crowd out private health arrangements and are thus fiercely
opposed to his reform efforts.
Universal coverage also undercuts the president’s mantra of cost
containment. Universal insurance coverage would enshrine the present
inefficient system by increasing aggregate demand for, and thus the
prices of, health care services. The increases in insurance costs for
those already covered are estimated at 10 percent from this effort
alone.
There is, however, a clear route to compromise. Limiting the tax
exclusion for employer-provided insurance would promote cost sharing
and reduce the cost of health insurance. Regulatory reforms to make
lower-cost insurance options available to individual purchasers would
also help. These cost reductions would make coverage available to a
greater number of people. Revenue from limiting the tax exclusion could
be used to offer modest tax credits to the currently uninsured, to
subsidize coverage and to support the expansion of community health
centers.
In the case of Social Security, we should have had two debates. The
first would have been about how to shore up Social Security’s long-term
standing. Again, reductions in benefit growth for middle- and
upper-income individuals offered a budget-neutral progressive solution.
The second should have been about how to accomplish the president’s
goals of more private saving for retirement. There, enhanced savings
incentives — including for lower-income households — offered a solution.
In the case of health care reform, we also need two debates. The first
is over how to reform insurance arrangements to reduce cost growth and
provide better value for the money spent. The second should be about
access to health care. To achieve these goals, the president could
embrace a compromise of tax and regulatory reform for cost containment,
and progressive intervention to offer assistance to low-income
individuals. But President Obama, like his predecessor, has been
unwilling to let go of his campaign goals even as his words fuel
intense partisan debate and obstruct his ultimate objective of
improving health care value.
President Obama’s message on reform is even more inconsistent than Mr.
Bush’s on Social Security, and his opponents know it. The president
should stop talking about a “public option” and “universal coverage”
and focus on real reform.
R. Glenn Hubbard, the dean of
Columbia Business School, was the chairman of the Council of Economic
Advisers under President George W. Bush.
Good or Useless, Medical
Scans Cost the Same
NYTIMES
By GINA KOLATA
March 2, 2009
When Gail Kislevitz had an M.R.I. scan of her knee, it came back
blurry, “uninterpretable,” her orthopedist told her.
Her insurer refused to pay for another scan, but the doctor said he was
sure she had torn cartilage that stabilizes the knee and suggested an
operation to fix it. After the surgery, Ms. Kislevitz, 57, of
Ridgewood, N.J., received a surprise: the cartilage had not been torn
after all.
She had a long rehabilitation. And her insurer paid for the operation.
But her knee is no better.
More than 95 million high-tech scans are done each year, and medical
imaging, including CT, M.R.I. and PET scans, has ballooned into a
$100-billion-a-year industry in the United States, with Medicare paying
for $14 billion of that. But recent studies show that as many as 20
percent to 50 percent of the procedures should never have been done
because their results did not help diagnose ailments or treat patients.
“The system is just totally, totally broken,” said Dr. Vijay Rao, the
chairwoman of the radiology department at Thomas Jefferson University
Hospital, in Philadelphia.
Radiologists say a decent M.R.I. scan should have clearly shown whether
the cartilage in Ms. Kislevitz, a meniscus, was torn. But bad scans,
medical experts say, are part of a growing problem with medical imaging.
Many factors contribute. Insurers pay the same for a scan done on a
10-year-old machine as one on the latest model, though the differences
in the images can be significant.
Insurers do not distinguish between scans that are done poorly or done
well or read by less- or more-qualified doctors. Aside from
mammography, whose standards were established by a law that went into
effect more than a decade ago, the field is largely unregulated. And
increasingly, doctors refer patients to scanning centers they own and
profit from.
Ten years ago, the age of a scanner might not have mattered so much.
Now, said Dr. Gary Glazer, the chairman of radiology at Stanford,
technology has advanced so much that the older scanner “is not the same
machine.”
“I can tell you from my experience that between those extremes the gap
is huge,” Dr. Glazer said.
Yet, he added, many scanning machines used today are a decade old.
Imaging centers can, if they choose, become accredited by the American
College of Radiology. That requires, among other things, scanning a
phantom, a device that simulates a body part. Technologists must also
be certified, and there are standards for supervising physicians. And
the scanners must be regularly assessed to ensure they are properly
functioning.
But many centers are not accredited, although the percentage is not
known because there is no national registry of imaging centers.
Accrediting will be partly addressed by a little noticed aspect of a
wide-ranging Medicare law passed last year. After it goes into effect
in 2012, Medicare will pay only for scans done at accredited centers.
But imaging experts say the law fixes only part of the problem.
High-tech scanning is complicated, and there is no consensus on
objective measures to ensure quality. Even with the new law, there is
still little assurance that scans will be appropriately ordered and
interpreted or that a scanner will be up to date.
Radiologists are struck by the wide variation in the quality of scans,
and they say there is little patients can do other than to ask why the
scan is necessary and, if it is, to ask about accreditation, the
credentials of the person reading the scan and the age of the scanner.
“The studies I see coming from the outside vary from marginal quality
to very good quality,” said Dr. Chris Beaulieu, a Stanford radiology
professor. “Some of it is related to equipment, and some is related to
people with very good equipment who don’t know how to use it right. And
on the interpretation side, there is also a very wide range of quality
or accuracy, in my opinion.”
Interpretation can be crucial, Dr. Beaulieu added. “A good radiologist
can sometimes accurately read scans off of a lower-quality scanner,” he
said. “I see that all the time. A good radiologist and a lower-quality
scan could be better than a bad radiologist and a good scan.”
But logical as it might seem to pay more for a better scan, there are
problems. Health insurers have no way of knowing whether scans are
good, said Susan Pisano, a spokeswoman for America’s Health Insurance
Plans, a trade group. Doctors, not insurers, receive the images and
reports, and all insurers can do is notice if there are frequent
requests to redo scans from a particular center.
“We see a lot of poor-quality scans,” said Dr. Freddie Fu, the chairman
of the orthopedic surgery department at the University of Pittsburgh
Medical Center. “I joke with the patients: The insurance pays the same
amount of money for the scan. You get a hamburger somewhere else and a
prime rib here for the same price.”
Another concern is the growing number of doctors who refer patients for
imaging done by scanners they own and profit from. Studies have found
that up to 3.2 times as many scans are ordered in such cases
In a recent report, the Government Accountability Office said nearly
two-thirds of the money Medicare paid for imaging was for scans in
doctors’ offices. And, the report added, doctors were receiving an ever
larger part of their income from providing scanning services. Not only
were patients more likely to have scans if a doctor did this, but the
quality of some of the scans was questioned.
“No comprehensive national standards exist for services delivered in
physician offices other than a requirement that imaging services are to
be provided under at least general physician supervision,” the G.A.O.
wrote.
Private health insurers were concerned, too. “These are alarming
patterns that have also been observed in the private sector,” America’s
Health Insurance Plans wrote in a response to the G.A.O.
It is clear why self-referral can be tempting, said Dr. Bruce Hillman,
a radiology professor at the University of Virginia.
“It’s all profits,” Dr. Hillman said, adding that a group of doctors
can make an extra $500,000 to $1 million a year simply by acquiring a
scanner.
For now, radiologists said, patients and insurers are often in a bind.
“If you are going to buy a car,” said Dr. Beaulieu, the Stanford
professor, “and you have a certain amount of money to spend, you know
what you are getting. You know what you will get if you buy a Yugo or
if you buy a BMW.”
But with imaging, Dr. Beaulieu said, “you don’t know: you might get a
Yugo and you might get a BMW.”
The hard fact of healthcare costs
The president's jubilation
at passing a health care bill in the House of Representatives is
understandable. It suggests the endgame is on.
But it is not going to become law as it stands. It doesn't
stand a
prayer of passing in the Senate. Joe Lieberman who is an independent
with a habit of flirting with both parties, says he will join a
filibuster to prevent anything with a public option getting through.
To
British eyes this focus on the public option seems a little odd. It
would just mean one government-run, but not funded, insurance scheme
among many others. Some Republicans fear it is the thin end of the
wedge and would lead, horror of horrors, to something like our National
Health Service.
Of course to many of us Brits, the cry "keep government out
of
health care" just sounds a little kooky, on a par with "keep government
out of defending the nation" or "keep government out of building
roads". In Britain one of the main things the government does, one of
the main reason people pay taxes, is for health care, so naturally the
revulsion at it in the States seems a little strange.
In the USA people fear this would lead to rationing of health
care, which is how the stuff about "death panels"
came about over the summer. Someone who wrote in to my last post on
healthcare pointed that taxpayer funded healthcare gives governments
the excuse they wanted to pontificate about smoking or drinking. This
is true, although Government here does pretty well on the pontification
and restriction front without what is called "socialised medicine".
But
I think in the debate between all the different systems of health care
one vital point is missed. Whether they are left, right or centre, they
are becoming unsustainably expensive. It is after all the cost of the
American system that leads many to conclude it needs radical overhaul.
At the debate's heart are two points. The number of people
who don't
have insurance, because they can't or don't want afford it. And the
industry's reluctance to pay out for those with serious conditions.
Private or public it is a scare resource, and that is what leads to
rationing.
Some years ago a UK Government-sponsored report into the NHS
said
that it was a potential 'black hole" for spending. This is the
depressing truth, born of amazing advances in medicine. People in the
West live to have very expensive treatment for cancer and heart disease
because they no longer routinely die of measles or TB. The longer we
live, the more we need spend on medical treatment. I don't see how any
commercial or political fix can deal with this hard fact.
NYTIMES Editorial Opinion page, May 31, 2010:
From a collection of opinions on the subject of "How
High Can the Retirement Age Go?" - below, a French
view...and the sacred cow story.
The social security sacred cow
NYPOST
By JACOB SULLUM
Last Updated: 1:32 AM, September 1, 2010
Posted: 1:14 AM, September 1, 2010
Alan Simpson violated a taboo last week when he likened Social Security
to “a milk cow with 310 million tits.” But contrary to the
dictionary-deprived critics who accused him of sexist vulgarity, the
former Wyoming senator’s transgression had nothing to do with his use
of a perfectly acceptable synonym for teat. Simpson’s real sin was
“belittling a bedrock program,” as the AARP put it — i.e., showing
insufficient reverence for a sacred cow.
To Simpson’s detractors, it is self-evident that a man who supports
entitlement reform has no business serving on, let alone co-chairing, a
presidential commission devoted to fiscal responsibility. But anyone
who takes an honest look at the federal budget can see how crazy that
position is.
Just three entitlement programs — Medicare, Medicaid and Social
Security — account for two-fifths of federal spending, representing 10
percent of gross domestic product. Without reform, they are expected to
consume half of the budget and about 20 percent of GDP by 2050.
It’s true that the fiscal outlook for Social Security, which has about
$18 trillion in unfunded liabilities, is not nearly as bad as the
fiscal outlook for Medicare, which has a long-term shortfall five times
as big. Simpson’s controversial comments nevertheless reflect some
important truths.
First, Social Security is neither a pension fund nor a means-tested
assistance program for the needy. It is a pay-as-yougo system of
transfer payments that takes money from relatively poor workers and
gives it to relatively affluent retirees.
Second, despite all the talk of a “$2.5 trillion surplus,” Social
Security is indeed “in trouble,” thanks to a shrinking ratio of workers
to retirees and repeated raids on its revenue by legislators looking
for easy spending money. The year of reckoning is not 2037, when the
program’s imaginary “trust fund” is expected to run out — it is now,
since the cost of benefits already has begun to exceed annual revenue.
There is nothing in the trust fund but IOUs from the federal
government, which can be redeemed only through cuts in other programs,
more taxes or more debt.
Third, entitlement reform — including Medicare cuts as well as changes
to Social Security — will be fought tooth-and-nail by the AARP, the
National Organization for Women and other denialist defenders of the
status quo. That much was confirmed by the reaction to Simpson’s
complaints about charges of “ageism” and “sexism,” which were cited as
further evidence of his ageism and sexism.
Yet this self-hating senior citizen, who turns 79 this week, is right
to question a retirement age that was set at 65 in 1935 and has been
raised by only two years (for people born after 1959) since then.
Meanwhile, life expectancy at 65 has gone from about 13 more years for
men and 15 for women to 17 for men and 20 for women, and those numbers
are projected to continue rising.
Simpson is also right to point out that Americans receive Social
Security (and Medicare) benefits regardless of how wealthy they are.
You might think progressives would welcome means testing. But as Trudy
Lieberman explained in the Columbia Journalism Review, they worry that
targeting benefits to people who actually need them would undermine
“the program’s social solidarity.”
Translation: Voters love middle-class entitlements, but they hate
welfare. That’s why progressives were so upset about Simpson’s cow
comparison, with its implication of unseemly dependence. Sen. Bernie
Sanders (I-Vt.) and Rep. Peter DeFazio (DOre.) claimed to find the
simile “beyond comprehension” but nevertheless concluded that it was
both “false” and “demeaning.”
Transforming Social Security into a true pension program by letting
workers invest part of what they now see disappear in payroll taxes is
likewise anathema to the “social solidarity” crowd, since it would let
people go their own way instead of forcing them to participate in the
government’s Ponzi scheme. Simpson is not suggesting anything nearly so
radical, which makes the silly, sanctimonious storm over his comments
all the more depressing.
Jacob Sullum is a senior editor at
Reason magazine.
Work Into Your 70s: Raise the
age of retirement to at least 70
and then increase it to track with life expectancy.
Veronique de Rugy (Veronique de Rugy is a senior research fellow
at the Mercatus Center at George Mason University).
According to combined recent data from 15 federal agencies on
population trends, economics and health issues, Americans over the age
of 65 are in remarkably good shape compared to those of previous
generations.
Their average net worth has increased almost 80 percent over the past
20 years; they form a larger share of the high-income group and a
smaller share in lower-income group than their predecessors; they are
far better educated, and they live longer and healthier lives.
Compared with previous generations the United States’ Social Security
system is in remarkably bad shape. Social Security’s long-term unfunded
liabilities have increased drastically and now total over $15 trillion.
Social Security’s problems are inherent in its design. Created in 1935
as an innovative form of “social insurance” rather than a welfare
program, its founders based it on the premise that there would always
be substantially more workers paying into the system than retirees
receiving benefits. And it did that by setting the retirement age at
the same age as average life expectancy: 65.
Life expectancy today is 78.8, but, even with recent changes, the
retirement age is far below that: 66 for those born after 1943 and 67
for those born in 1960 and later. Also instead of the 16.5 workers to 1
retiree ratio of 1950, we now have 3.3 workers for each recipient, and
this ratio will only get worse. The system is near collapse.
Jagadeesh Gokhale, an economist and senior fellow at the Cato
Institute, shows in his new book “Social Security,” that the system’s
future is even bleaker than public estimates make it out to be. Reform
is not an option, but a necessity.
The best option is to cut benefits. One way to do that is to raise the
age of eligibility to at least 70 and then progressively increase it to
track with life expectancy. This won’t be popular, but Americans’
dependency on government programs is less entrenched than that of
Europeans.
According to the economist Gary Shilling, today more than half of all
Americans now depend on government for their income and the share of
government transfer as a share of personal income is growing. But this
number pales in comparison that found to most European countries. In my
own country of France, for instance, everyone receives government money
in one form or another.
State hospitals facing Medicare cut
Deirdre Shesgreen, CT MIRROR
June 14, 2010
The federal government plans to slice about $66 million from the annual
Medicare payments it sends to Connecticut hospitals in the coming
fiscal year, which would deal a significant budget blow to many of the
state's health care facilities.
Connecticut hospital officials are fighting the proposed cuts announced
by the federal Centers for Medicare and Medicaid Services (CMS). Other
hospitals across the country will also be affected by a change in the
way CMS calculates its Medicare payments, but Connecticut could be
particularly hard hit.
"It's hugely detrimental," said Stephen Frayne, a senior vice president
with the Connecticut Hospital Association, which will be submitting a
formal protest with federal officials in the coming weeks in an attempt
to reverse the cuts.
Medicare officials say the changes simply reflect an effort to recover
overpayments to hospitals--in Connecticut and around the country--in
previous years.
"A good deal of this reduction is because hospitals were overpaid" to
treat patients with illnesses like pneumonia and other conditions
starting in 2008, said Ellen Griffith, a CMS spokeswoman.
At issue are payments that Medicare, a federally funded program
providing health insurance for the nation's elderly, makes to hospitals
for inpatient care. Each year, these payment rates are adjusted for
inflation and other factors.
Before 2008, hospitals were paid the same amount for treating an
otherwise healthy patient with pneumonia, for example, as they were for
a pneumonia patient who had other complications. Then Medicare
officials changed that system to reflect more severe diagnoses,
creating a more varied payment scale that reflected the higher costs of
treating severely ill patients.
That result was more money flowing out of Medicare's coffers to state
hospitals. Griffith says some hospitals "bumped up" their patients to a
more severe diagnosis category than was necessary, resulting in
overpayments. "There's always a tendency to find a way to increase the
amount of money that should be reimbursed," she said.
Hospital officials adamantly deny that accusation.
"It's not that we gamed the system, or that we're getting paid more,"
said Thomas Marchozzi, executive vice president and chief financial
officer at Hartford Healthcare Corp., the Connecticut hospital network
that includes Hartford Hospital and three others, as well as other
non-acute facilities.
"What CMS did was properly pay, and now their upset about that,"
Marchozzi said. "They're trying to recoup payments that hospitals
legitimately earned because of the severity of illnesses. They just
never expected hospitals to be good at coding" patients' illnesses.
Either way, for this coming year, Medicare's proposed increase for
inflation is wiped out by the agency's reductions to recoup that money.
In addition, the new health care reform law called for a .25 percent
decrease in Medicare hospital payments.
In Connecticut, hospitals face additional reductions in payments
because CMS came up with a reduced reimbursement calculation for the
state's hospital wage costs.
Frayne said the result is a combined 4 percent cut in federal Medicare
payments to Connecticut hospitals. Each of the state's hospitals would
see different variations in that figure, but the proposed changes will
have wide repercussions across the state. For many hospitals, Medicare
makes up 40 to 60 percent of their revenue, so even a small decrease
translated into a major loss of cash.
"What it means on the ground is significant downward pressure" on
costs, which could force hospitals to delay raises for nurses and other
staff, to postpone the purchase of new equipment, and to take other
belt-tightening steps, Frayne said.
For the last 15 years, Frayne said, Connecticut hospitals have seen, on
average, about a 1.5 percent increase in Medicare payments, even as
inflation has been at about 3 percent or more. This year, he said,
hospital executives may be content if Medicare just agrees to maintain
last year's payment levels, with no increase or decrease.
"It will be a significant relief if we don't get cut," he said.
CMS's Griffith says the agency will issue a final rule on the payments
in August.
In the meantime, hospital officials are in limbo as they craft their
budgets for next year.
"They are trying to figure out ... are we going to give raises, can we
buy new stuff?" And right now, Frayne said, there aren't any clear
answers.
Marchozzi says Hartford Hospital is currently working through the
details of next year's budget and has not yet figured out what it will
do if there's a net reduction in funding from Medicare, which accounts
for 40 percent of the hospital's revenue. Marchozzi said just a one
percent decrease would cost Hartford Hospital $4 million.
Right now, Marchozzi said, "I lose money on every Medicare patient," so
if the reimbursements are cut, the hospital will lose even more for
each of those elderly Medicare patients.
"I will have to look at programs that are not core to our institution,
and I may have look at the services we provide," he said. "It's
going to be a fact of life going forward," he added.
Germany cuts health care spending,
raises premiums
YAHOO
6 July 2010
BERLIN – Germany will raise premiums and cut spending on health care in
an effort to plug an euro11 billion ($13.9 billion) hole in the
country's health care system.
Chancellor Angela Merkel's center-right coalition had pledged to give
the German health system a significant overhaul.
It decided Tuesday to increase premiums from 14.9 to 15.5 percent of
workers' gross pay. Contributions will be split between employers and
employees.
The hikes — which are expected to rake in about euro6 billion ($7.6
billion) — will be coupled with around euro3.5 billion in cuts spread
out among hospitals, insurers and pharmaceutical companies.
Health care reforms start today:
A guide
Arielle Levin Becker, CT MIRROR
September 23, 2010
Some of the first major changes under the health reform law take effect
on its six-month anniversary today.
Well, sort of.
The changes affect new plans now, but won't apply to existing plans
until they're renewed. For many people with health insurance, that will
be Jan. 1.
Some of the changes apply to everyone with health insurance, while some
apply only to group plans and new plans sold on the individual market.
Many existing plans will be "grandfathered" and exempt from certain
regulations. But those plans could lose their exempt status if the
benefits they offer or costs consumers face change significantly.
Confused?
You're not alone. Doctors, industry experts and consumers have
professed varying levels of bafflement at the changes and what will
apply to whose plans when. Meanwhile, the effect the changes will have
on insurance rates has become a subject of fierce debate.
Here's a guide to help decode it.
What are the changes that apply to all
plans?
Young adults up to age 26 will be allowed to remain on their parents'
health insurance plans, although they might be ineligible if they are
offered insurance through their own jobs. The change, which some
insurers adopted earlier this year, is projected to affect about 9,050
people in Connecticut. State law already allows people to stay on their
parents plans through age 26, but the federal law includes groups not
covered by the state law, including young adults who are married or
live out of state but don't attend school. The federal requirement also
applies to self-insured insurance plans, which are not subject to state
regulation.
Health insurance plans will no longer be allowed to have lifetime
dollar limits on "essential benefits," such as doctor visits,
hospitalizations and prescription drugs. Nearly 102 million people have
policies with lifetime limits, and between 18,650 and 20,400 people are
believed to exceed their limits each year.
In addition, insurers will be prohibited from denying payments because
of an error or technical mistake made on a customer's insurance
application - an uncommon but widely criticized practice known as
rescission.
The changes apply to new plans beginning today and to existing plans in
their next "plan year" - that is, when the plan is renewed.
What changes only apply to some plans?
Some changes apply only to new plans and to existing plans that are not
grandfathered. (Most group health plans are likely to be grandfathered
at least through 2011. More on the term "grandfathered" later.)
Plans affected by these changes will be required to cover preventive
services with no co-payment, deductible or coinsurance for the consumer.
The plans will also be required to allow customers to select their own
doctors from within the insurers' networks and will be prohibited from
charging more for visits to emergency rooms that are outside the plans'
networks.
People covered by those plans will also get a new way to appeal
insurers' decisions to an independent party.
Many people with employer-sponsored coverage will not see these changes
yet if their existing plans do not change substantially when they are
renewed.
In addition, two changes will apply to all group plans and new
individual-market plans, but not to existing plans sold on the
individual market if they are grandfathered.
Annual dollar limits on "essential" health benefits, which some health
plans impose, can be no lower than $750,000 for plans issued or renewed
through Sept. 23, 2011. The minimum limits will rise each year after
that until 2014, when the limits will be prohibited.
And children under 19 cannot be excluded from insurance coverage
because they have a pre-existing condition.
What does it mean for a plan to be
grandfathered?
Health insurance plans that were in effect on or before March 23 - the
day the health reform bill became law - can be exempt from certain
provisions of the law, a status referred to as being "grandfathered."
The plans will lose grandfathered status if they make significant
changes to reduce benefits or increase costs to customers.
Grandfathered plans are exempt from the requirements to cover
preventive care at no cost to the customer, allow patients to select
their doctors, charge equally for emergency rooms visits that are in
and out of network, and be subject to an independent-party appeals
process.
Grandfathered individual-market plans are also exempt from the
restrictions on annual benefit limits and from the requirement to cover
people under 19 with pre-existing conditions.
Plans that are grandfathered are to send statements to participants
saying so.
How does a plan lose grandfathered
status?
Plans will lose their grandfathered status if they significantly reduce
benefits; significantly raise co-payments or deductibles; raise
coinsurance; significantly lower employer contributions or tighten
limits on what employers pay; or change insurers.
The definitions of "significant" are different for each category, but
are related to either the rate of medical inflation or set at a fixed
percent change.
How many plans will remain
grandfathered?
It's impossible to tell, but the federal government expects it to vary
based on the type of plan.
For plans sponsored by employers with 100 or more employees, which
cover some 133 million Americans, the federal government has predicted
that more than 75 percent will be grandfathered in 2011. A smaller
portion will likely remain grandfathered by 2014.
The federal government has estimated that 70 percent of small business
health insurance plans will be grandfathered in 2011, but that could
fall faster after that because small plans are more likely to make
substantial changes than large plans.
Fewer individual plans are likely to be grandfathered because
individuals who purchase insurance change plans more frequently,
sometimes within one year.
Fully-insured plans that are subject to collective bargaining will be
grandfathered until the agreements terminate.
What effect will these changes have on health insurance rates?
This is one of the big points of contention in the health care debate,
and there's no easy answer.
The effects on individual plans will largely depend on what the plan
already offers. Those that have annual and lifetime benefit limits, for
example, are likely to see larger cost increases than plans that do not
have them. For plans subject to the provision prohibiting charging
customers for preventive care, the impact on premiums - and the extent
the plan will need to change - will depend on what co-payments and
other cost-sharing a particular plan had.
The insurer Anthem offered a glimpse at the potential effects of
various provisions in its request to the Connecticut Insurance
Department for rate changes on new individual policies and those sold
since March 24. The largest change was an increase of up to 22.9
percent - depending on the plan - for removing annual benefit maximums,
with a particularly large effect from removing limits on pharmacy
coverage.
Covering children with pre-existing conditions could add 4.8 percent to
premiums and fully covering preventive services could range from no
effect to an 8.5 percent increase, according to the insurer. Covering
dependents up to age 26 could increase premiums by 0.2 percent.
Removing lifetime benefit maximums and banning rescissions were
projected to create no change in premiums.
The plans that see an increase in cost because of the health reform law
will include more benefits than they did before, Anthem spokeswoman
Sarah Yeager said.
"There's a range, and it's important to note that everybody's not going
to get that big rate increase. It depends on the product that they
had," she said. "If you purchase a product that had limited benefits,
you're now getting expanded benefits."
The effect of the new requirements on insurance rates has become the
subject of dispute in recent weeks.
Connecticut Attorney General Richard Blumenthal has called for more
public scrutiny of the rate increases and has asked the Connecticut
Insurance Department, which approved Anthem's rate requests, to reopen
the filing so policyholders can review and comment on it. The state's
five U.S. Representatives have also asked the department to "remain
vigilant of excessive rate increase requests by insurance providers
that surpass expected costs of these changes."
HHS Secretary Kathleen Sebelius blasted insurers sending what she
called "misinformation" to enrollees, linking the health reform law to
higher premiums.
"The Administration, in partnership with states, will not tolerate
unjustified rate hikes in the name of consumer protections," she wrote
in a letter to Karen Ignagni, president and CEO of America's Health
Insurance Plans.
In the letter, Sebelius cited studies that suggest the health reform
changes would produce "minimal" effects on premiums, ranging from 1
percent to 2 percent. She also wrote that consumers would see
out-of-pocket savings from the effects of the law.
Keith Stover, a lobbyist for the Connecticut Association of Health
Plans, said premiums reflect medical costs. Of the projections that
suggested only minor impacts on costs, Stover said it is important to
know whose projections they were and to understand the debate in its
political context.
"I think that it was important rhetorically as this bill was making its
way through the process in Washington DC to say, 'oh no, no, this is
such a revolutionary change that it's not going to cost anybody
anything to have all these new benefits,'" Stover said. "But at the end
of the day, an actuary takes out her calculator and computes the cost
trend and applies whatever the medical costs are to the particular
range of benefits and comes up with a number."
"Frankly, it's not that complicated, and a lot of the political
invective is, in all honesty, fundamentally irresponsible because
you're continuing to, for political purposes, try to send out this
message that everything's free and then there's the stunning moment of
clarity when it's clear that it ain't," Stover said.
Marianne Udow-Phillips, director of the Center for Healthcare Research
and Transformation, which is affiliated with the University of Michigan
Health System and Blue Cross Blue Shield of Michigan, said projections
of health care spending by the federal Centers for Medicare and
Medicaid Services could offer an indication of the likely effects of
the health reform provisions.
A forecast released by CMS this month projected that national health
expenditures will increase by an average of 6.3 percent a year between
2009 and 2019, or 0.2 percentage points faster than estimates made
before health reform predicted.
Health care spending is expected to rise by 5.1 percent in 2010 and 4.2
percent in 2011, according to the forecast. In 2014, when many of the
major health reform provisions take effect, health care spending
is projected to rise 9.2 percent, which is 2.6
percentage points higher
than what was projected before health reform.
Wealthy Suburbs Not Immune To Hunger Struggle
Hartford Courant
7:07 p.m. EDT, July 16, 2011
For 28 years, Cathy Hartley of Glastonbury brought home a good paycheck
from her job at Aetna.
But last Tuesday, she was in line with her two young granddaughters for
free produce from Mobile Foodshare at the First Church of Christ
Congregational on Main Street.For Hartley, who said she was laid off
from her job as a project manager about six years ago and then laid off
from a subsequent job two years ago, every little bit helps. Her
eligibility for unemployment ran out two months ago.
"It supplements our food," Hartley said of the Foodshare truck.
"They've been very helpful, and it's fresh, healthy food."
Avon
Mobile FoodShare
Hartley is among a growing number of people who live in Connecticut's
upper-middle class suburbs and who need help putting food on the table.
"Not a week goes by that we don't hear at a mobile site or … from a
pantry somewhere saying this family came in that said 'I used to give
to this program. I never thought I'd need help, but I got laid off or
my wife got laid off or we both got laid off, and here we are because
we need to feed our kids,'" said Gloria McAdam, president and CEO of
Foodshare.
Since the Great Recession started, Foodshare, a Bloomfield-based
nonprofit that serves as the food bank for Hartford and Tolland
counties, has expanded its mobile program to towns like Glastonbury,
Avon and Hebron.
The Mobile Foodshare program fills trucks with donated produce and
sends them to different sites every day. It started with deliveries in
places like Hartford and New Britain, and now makes nearly 50 stops in
20 towns.
Food pantries in these and other seemingly idyllic communities are
serving a population that is growing at a rapid rate.
Foodshare served 128,000 people in Connecticut last year, or one in
eight. Of those, 50,000 were children, according to McAdam. That's up
from 100,000 people just two years ago, an increase that can be
attributed to need and not just Foodshare's growth, she said.
"The need has grown by 30 percent, but we're only growing 3 or 4
percent each year," she said.
In Glastonbury, usage of the social services department's food bank has
tripled since the 2007-2008 fiscal year, said Janine Fiedler, social
services coordinator. That year saw 153 people visit the food bank,
compared with 450 in 2010-2011.
"I can say that we've been having people come in and say, 'Well, we
always gave to the food bank, and now we have to receive,'" Fiedler
said. "It's true — people are in their houses and have their mortgages
and then they get laid off. Where does the money come from?"
Hartley, whose husband teaches at Guitar Star Studio, is one of those
people.
"I made a lot of money at Aetna. Every year, I got stars on my
performance reviews," she said. And then one day, she said, she was
asked to pack up her desk and leave by the time the Christmas luncheon
ended.
"I try to accept the fact that here is where I am right now," said
Hartley, who cares for her three grandchildren while her daughter
works. "God must have wanted me to be a full-time grandma at some point
in my life."
In Avon, the number of households using the food bank at the Church of
St. Ann has tripled in the past two or three years, according to Alan
Rosenberg, the town's director of social services. In June, 94
households, or 263 people, were served, he said.
"In the old days, it would be 25 or 30 households," Rosenberg said.
"There are around 300 families that are actually eligible. That's gone
up at least double in the past couple years."
Avon had 140 eligible households in 2008.
"In addition to [single-parent households or a household headed by an
elderly or disabled individual], we are seeing many more traditionally
structured families, typically consisting of two parents with two to
three children," he said.
In Simsbury, the town's "Cheese Day" program, where qualified families
receive bags full of fresh food and canned goods, has increased almost
200 percent to 206 people from 70 in 2006-2007. Usage of the weekly
"Bread Day" program has gone up 400 percent, from 10 people each week
to 50 people.
"It's not huge numbers, but for a suburb to go up that much in a few
years is unusual," said Mickey Lecours-Beck, director of social
services in Simsbury.
The sheer numbers of hungry people may not compare to those in the
inner cities, but the rates at which the numbers are increasing are
high for suburban towns.
"It surprises people that it's not just the Staffords and the
Rockvilles of the suburbs, but we also have mobile sites in
Glastonbury, Farmington and Avon," McAdam said, "suburbs that you think
of as being wealthy."
Many local food services are aimed at getting people back on their feet
until they can find another job. McAdam said that about one-third of
Foodshare's clients use the program for six months or less, one-third
use it for six to 18 months, and the rest use it for the long term,
usually because of a disability or another hurdle.
"There will always be people who need assistance, whether for the short
term or the long term, but it doesn't have to be one out of eight of
our neighbors," she said.
Until places like Foodshare can reach their ultimate goal — eliminating
hunger — they try to arm people with the tools necessary to rectify
their situations. They make sure eligible clients are enrolled in the
federal food stamp program, and provide as much fresh food as possible.
"We're one of the few people that would like to be out of work because
there wasn't a need for us to be doing what we're doing anymore,"
McAdam said. "I think there'll always be a need for what we do, but I
believe that need could be smaller."
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