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Monday, August 17, 2009

Health Care Reform Questions That Linger

Questions continue in the health care debate across the country. While every weekend I ask "Just Some Questions" for readers, here are some questions on unresolved issues that face Congress when it reconvenes in September.

The 111th Congress reconvenes in a few weeks, gathering its members from across the country as they return to Washington from visiting their Districts and their constituents. This summer has been different than any summer in recent memory as traditional summer townhall meetings and meet and greets staged by members of both the House and Senate have been the focal point of the health care reform debate. At the center is HR 3200, a proposed bill that runs 1,017 pages as currently offered by the government printing office. Typical summer vacation meet and greets and townhall meetings with members of Congress attract thirty or forty people at most, this summer's meetings have seen overflow crowds and Americans speaking directly to their elected representatives for the first time in generations. With almost 24/7 coverage of the health care reform debate, okay argument, in this country, there are many questions and issues that I feel Congress must address when its summer hiatus is over.

Former Alaskan Governor Sarah Palin created a mini-storm within the storm when she wrote on her Facebook page about "death panels" staffed by government officials who would determine which citizens would be approved to receive which treatments. Mocked, scorned and scoffed at by many, Palin stood her ground and wrote a follow up post on her Facebook page that provided more details and connecting of the dots from HR 3200 that outlined coverage by government insurance of family doctors having end of life consultations with patients, and ability to introduce no extreme measures authorizations among other issues that could be discussed. President Obama reacted by saying, "we won't be pulling the plug on Grandma." Palin and others countered that the intent and attitude of HR 3200 is to use cost-benefit analysis in determining what care can be administered; between cost-benefit analysis of keeping Grandma alive and her consultation with her doctor whom she trusts she may pull the plug on herself. When looked at rationally the argument makes sense. So much sense that members of the Senate Finance Committee have already stated they are pulling any end-of-life consultations out of any bill before them, "it's too confusing" said one member.

Against this background with the House change, modify or delete the end-of-life language in its current version?

With its new name, or new to me, Pharma, Pharmaceutical companies have long been the bad guy in any health care discussion. The number one argument made about Pharma is the huge profits they make and the incredibly expensive costs of their products--particularly products that are mostly consumed by senior citizens on fixed retirement incomes. Not presented in any of those arguments are how Research and Development costs impact those profits. As outlined in a Congressional Budget Office report Pharma's R&D costs and the number of drugs approved for market have a big impact on their profit numbers. "Adjusted for the value of its R&D assets, the drug industry's actual profitability still appears to be somewhat higher than the average for all U.S. industries, but not two to three times higher, as standard measures of profitability indicate." Pharma pays taxes on its profits and then puts money into the approximately $800 million per drug in R&D for new products. Obviously drug companies make money, otherwise they would not be in business. As obviously the profits they make that allow them to stay in business is beneficial not only for the American public but is a global benefit as Pharma has developed drugs that cure cancer, prevent pregnancies, prevent major illnesses like polio, cure our hangovers and allow better performance in certain parts of our lives. With the long and protracted process of getting a drug from laboratory to pharmacy shelf the overall cost of drug development climbs every year. For many years Pharma has been one of the go to whipping dogs of the Democrats when they jumped on the health care soap box. A few weeks ago it was leaked that the White House made a deal with Pharma without bringing in any members of Congress--yes a secret, backroom deal from the Obama Administration with the Pharma lobbyists. In exchange for $150 million in support for advertising and public relations for the Democrats health care reform, the reform would include caps on drug costs that Pharma could accept to maintain their profitability.

How will the majority in Congress deal with the deal made between the President and Pharma? Will they compromise their desire to cap drug costs at a higher level and respect the President's deal and $150 million cost for the deal to Pharma?

Currently hospitals must treat all who enter their facilities for service. The financial problems often begin after treatment has started or ended. In California if a patient comes into a hospital that is not contracted with MediCal, once the patient is stable for transport the hospital must contact hospitals in the region to see if any have beds available to accept the patient. For both MediCal/Medicaid and Medicare, once a patient leaves a hospital a bill is presented to the appropriate government bureaucracy for payment. The bureaucracy then replies back, often at a much reduced payment and multiple denials of coverage for days in the hospital, treatment, etc. After the patient has been stabilized and sent home or to another hospital, in other words once the sick patient is cured, the government entity responsible for payment denies payment to the hospital for some of the treatment provided. This post-treatment denial of coverage, decisions made by government employees without medical degrees or training, costs hospitals, doctors, laboratories, technicians, billions of dollars every year.

In HR 3200 is a lot of language about cost-benefit decisions on care. Currently those decisions are being made by government health insurance programs after care has been provided and costing our health care system billions of dollars. Expanding this process to even more patients across the country will lead to even more treatment of patients with even less payment. How will you balance the cost-benefit treatment analysis with keeping hospitals open?

HR 3200 is over 1,000 pages in length. It is incredibly detailed and complicated. This has been one of the biggest arguments against HR 3200, because of its length and complexity almost no one who reads it can understand all of it. Of all I have read and seen, the public's questions of their Representatives, the one most often repeated is, "How can you vote for something you do not understand?"

Will members of the House and Senate work to simplify HR 3200 so that most Americans, let's even say most Americans with a college degree, can read and understand the bill? Will members of Congress read the final bill before voting to pass it?

One of the biggest arguments in favor of health care reform is health insurance companies denying coverage because of pre-existing conditions. This pre-existing condition denial happens most often when an individual or family moves from one insurance company to another, which happens most often when the primary beneficiary changes employment. With the average American being much more mobile in employment between companies over his/her career than in the past, with the growing number of self-employed or independent contractors in American, more and more Americans every year are in a position where they do not qualify for a company based insurance program, or must go through the expensive COBRA option. Our health care system has evolved, through government encouragement and directive, so that employers have become responsible for the health insurance of their workers and their families. This costs employers, including public entities, billions of dollars every year in costs and at the same time limits the insurance choices now and in the future of its workers--many Americans stay in jobs they hate because of the insurance coverage for their family, especially if they have a child with a specific condition that would prevent them from getting insured from a new company should they change employers.

Will Congress create a plan that would make it more beneficial for Americans to purchase and maintain their health insurance coverage as individuals instead of their having to purchase their insurance through their employers--or the government? Will Congress changes the rules so that insurance companies can offer coverage across state lines without being subject to multiple state rules and allow a family to stay with the same carrier through many jobs, many moves and changes in their conditions?

Many have used the argument for the end of July push to get HR 3200 passed in a couple of weeks that, "we have had over 40 years to fix this, hasn't it been enough time." Or, "the Republicans had eight years to fix the health care system and didn't do it." Well yes, the Republicans had the White House for 8 years under George W. Bush and there was no health care reform, and before that the Democrats had the White House under Bill Clinton with no health care reform, and before that the Republicans had the White House for 12 years between George H.W. Bush and Ronald Reagan, and....during this time the Congress was at various times controlled by one party or the other. Just because several Administrations and Congresses have not addressed health care reform seems to be a reason for pushing through lengthy and complex legislation that has been read nor understood by almost no members of Congress, unless you just want reform of any kind without concern as to the consequences of the reform.

Will Congress take a measured approach to health care reform and divide the reform into manageable segments with the agreement of both parties? Will Congress enable thoughtful discussion and debate on a piece by piece basis addressing the current private and public insurance options, reimbursement of health care providers giving care to uninsured, ability to continue insurance with the same carrier and doctors throughout ones career/life, simplifying billing an reimbursement processes, government involvement in health care delivery and approvals?

Finally, can members of Congress, particularly those in leadership positions, quit with the divisive politics and name calling? Can members of Congress accept that most Americans consider government involvement in their health care to be somewhat scary, very unknown as to what it will mean to their future and the future of their families and very personal and as such they do not want political rhetoric, name calling and dismissive remarks and behavior? Can members of Congress do what they have been selected by the American people to do, which is to lead with the consent of their constituents?

Most Americans want our current health care system to undergo some changes and reform, our disagreements are over how those come about and what the total reform needs to be. Can members of Congress understand they can achieve national unity with a clear stated final objectives and then work together for common ground on how to achieve those objectives?

In about fifteen months every member of the House of Representatives and about one-third of the members of the Senate are facing re-election. How these members of Congress perform in the coming months on the health care reform issue will matter greatly in November 2010, for there has not been an issue in the past few decades that has gained the attention of so many Americans with disparate views. Not wars, not economies, not political scandal. Not since the Civil Rights movement of the 1960s have so many Americans who are usually silent raised their voices on an issue. Do members of Congress hear those voices? Are they all listening?



topher said...

Hi Dennis,

I always enjoy your musings and am glad that I am on your mailing list.

Your most recent blog has got me to thinking....what can we do about our conflicting desires to both have cheaper health care (which one could argue, requires free-market forces to "do their thing"), and to have gov't regulation, which is society's security planket.

Regardless of one's political views, everyone believes that there are, in fact, areas of our lives where gov't intervention is appropriate. Some believe the gov't should merely be a "night watchman", while others believe it should play a more integral role in the economy.

My question/concern is regarding the Republican proposal to essentially take down state borders with regards to health care providers. The argument, if I understand it correctly, is that if people are able to shop across state lines, they will be able to find cheaper health care through the increased competition that such border-hopping would create.

But for those of us on the Right that believe in states rights, this is a difficult issue in that the states currently are the ones who make the mandates and regulations on health insurance. Some states are active in this area where other states have deregulated and have thus seen increased premiums. Below is a link to such a situation.

Thus, the only way to take power away from the states is do it using the federal gov't, a la Reagan, who approved more pre-emptive legislation than any president before or since. As far as state's rights are concerned, the states already have health insurance under their purview. I agree that Obama's plan is problematic, but I don't think that taking power away from the states is the best idea either.

One of the ways to control health care costs is for states themselves to become more involved, rather than the federal government do so. States as a political entity are not going to want to give up their power without a fight, and it seems that if we have to choose between the least of two evils, I'll take the state over the federal gov't any day.

Dennis C Smith said...

Great comments and the states rights v Federal regulation argument on this is spot on. When it comes to commerce however I would tend to error on the side of the framers who saw that regulating interstate commerce was a primary purpose of a federal government. Having experienced California's heavy handed participation in the health system I do not venture to say removing them from the equation, especially vis-a-vis regulating health insurance companies, would lead to better competition in the marketplace. Thank you for the thoughtful comments.

Bob Schilling said...

Political minutia aside, it seems that both sides of this debate have gone over the top. One side seems to have mobilized a group of marginally functional people who rely on rumor or Fox News for their information. On the other side is an odd perception that profit is somehow immoral or corrupt, and no company that engages in the pursuit of profit can do so with integrity. Maybe those folks get all their information from MSNBC.

We all know that we desperately need to improve the way we pay for health care. We all know that we have a moral obligation to make decent health care available to all Americans. We all should know that fee-for-service and capitation don't work very well. We all ought to know that we need medical tort reform. I think we also should face the fact that using employers as the primary source of medical insurance is no longer sustainable. Conservatives should be ready to embrace an open marketplace for medical coverage in which a large number of companies can compete for customers. I would add that we need some kind of government oversight to make sure that abuses are investigated and remedied.

If those basic facts are widely acknowledged, the Congress can and should craft legislation that would address them. If they don't, we should replace our representatives, Democrat, Republican and (if you live in Vermont) Independent alike, with people who will.

And we should pay particular attention to those who think this vital national need is an opportunity for the rankest form of demagoguery.