Dec 27, 2009

A good link to comparison of House & Senate Health Reform bills

Here's a good Q&A analysis of differences between the House and Senate bills as passed. Easy To read, from Kaiser Family Foundation.

Dec 6, 2009

Medco, Federal Employees Health Plan, and Vitamin D

Here's a great little piece of "evidence based medicine" courtesy of my Federal employee health plan (GEHA) and Medco, its designated pharmacy benefits manager. Just received in the mail a notice that Medco will not pay for any vitamins, even those available only by prescription. That includes my Vitamin D, which I am directed to take at doses of 50,000 IU every two weeks for the rest of my life. Without it, I don't seem to be able to keep my Vitamin D levels in the territory of normal. Why that is nobody knows, but my family has witnessed the rapid improvement in my post-hip-replacement pain (after two years of getting weaker and weaker post surgery) following the initiation of an anti-Rickets therapy of high-dose Vitamin D. So, in its wisdom, GEHA/MEDCO has said that Vitamins are out as covered drugs.
Now, Rx Vitamin D isn't very expensive. I can buy 12 capsules (3 month supply) at Costco for about $15. So, forcing me to pay for it isn't going to make any difference in my adherence to the therapy. But, it's a perfect example of how little subtletly there is in insurance coverage. Here's one medical technology (vitamin d) that's both cheap and effective (see my previous Vitamin D post for links to the strong evidence that keeps emerging. Needless to say, the blunt instrument that is coverage policy discourages its use.

Nov 22, 2009

Some early analysis of the Senate "Reid" Bill

Here is a great analysis of the Senate Bill by Keith Hennessey, a conservative, I think, but nevertheless, we should know what's in the bill, and his blog is accurate, though opinions are slanted. So I'm putting it up here, because I am just out of gas when it comes to analyzing the details of another 2000 page tome!
AND what's worse, these bills HAVE NO WORKABLE TABLE OF CONTENTS! Yes, they have a list of provisions, but they don't tell you the page. That's just a little bit of Congressional humor. "We want to tell you how to run an industry, but we can't adopt technology modern enough to create a table of contents for legislative proposals."

Nov 6, 2009

Why the House Health Care Reform bill is fatally flawed

Confession: I still haven't read beyond the first 225 pages of the House bill. I got that far because I wanted to understand the structure of the Health Insurance Exchange (HIE), especially how the public option (PO) would work. In a previous post, I concluded it was good enough, but worrisome in the long run .
But, today Martin Feldstein, a noted Harvard economist (not my favorite, but way smarter than I) has an op-ed piece in the Washington Post (Obamacare's Nasty Surprise) that lays out clearly why the House bill will not work as presently structured.
The basic flaw is that the law requires health plans to enroll all comers, regardless of health risk, but it doesn't provide carrots/sticks to individuals or businesses that are strong enough to induce the young and healthy to enroll. So, premiums will go up, kicking off a cycle of adverse selection into the HIE by the sick or high risk and opt out by the healthy.
There are ways to fix this problem, but apparently they are not in the bill, or surely Feldstein would have mentioned them.
One solution would be to charge anyone who does not sign up (or have qualified coverage) within the first year of the program a "premium penalty" for the rest of their lives. That's what happens with Medicare Part B, and why even the healthiest 65 year old is willing to pay right away. For every year of delay after you reach 65, Medicare adds 10% to the Part B premium for the rest of your life.
Another solution would be to increase income tax penalties.
A third solution would be to increase subsidies.
I like first idea, though, because instead of being seen as a "tax," the penalty would be seen as just retribution for a young person trying to game the system by delaying enrollment until he/she encounters the inevitable need for health care.
BUT... so far as I know, this solution isn't in current health reform proposals. Why not? That's where Feldstein sees the invisible hand of the single-payer lobby. As the cost of insurance goes up and up, and as fewer and fewer people are insured, a single-payer system will be the only alternative.
Design a HIE market to fail and you'll end up with a single-payer system. So many of my dear friends, family members, and readers want this outcome that I am in despair. Why do we think that a government monopoly is any better than a phone company monopoly in the way it will treat us? Supporting a move toward public monopoly of payment for health care is to say we want health care to be run the way that public education is currently run. Good teachers underpaid; average income children underserved; rich children opting out.
That's the best I can do by way of diatribe right now.
Have a great day.

Nov 3, 2009

Two Doses of H1N1 vaccine better for children

Here are the findings, in CIDRAP's News of yesterday. Still, if you can get just 1 dose for your child it's worth it, as the first dose confers some immunity and will probably make the flu less virulent in him/her. (This from a non-doc, mind you.)

Oct 31, 2009

How health reform will gradually evolve to single payer system

Leaving aside the pros and cons of a single-payer system (SPS), I'm beginning to believe that a SPS would be an inevitable consequence of any health reform proposal that contained a public option (PO), even one as benign as the current version of the House bill. (See my previous post on good points of that bill.)
I'm basing the scenario on my long-time experience as an enrollee in a prototype health insurance exchange (HIE), namely the Federal Employees' Health Benefits Program (FEHB). FEHB has about 8 million enrollees, including current federal employees, their families, and retirees.
First off, I need to explain that the FEHB program is a regulated marketplace with open season at the end of every year, during which enrollees can choose among roughly 10 plans, depending on their place residence. Government subsidizes about 75% of the arverage plan's premiums (as do many employers.) Less subsidy goes to enrollees in richer plans. None of the plans are POs. All are private, but some are not-for-profit.
Here's what has happened to me over the 30 years of enrollment. When I was young and feeling good, I enrolled in a plan with relatively low premiums (never the lowest, cause I'm risk averse). As I got older and more needy, I opted for a richer plan, paying more in premiums but using health care more. Apparently, so did lots of other aging enrollees, because the costs of that plan began to skyrocket. And, that plan began to add draconian control features to the management of its benefit. And more and more doctors opted out of that plan's network. Finally, the costs got so high and my mistrust of the plan grew so much(especially in the past year) that I chose a low cost plan and paid more for visits and drugs than before. Overall, I might have paid more for health care (counting premiums and out-of-pocket) but at open season last December I was willing to take the gamble. This year, though, I'm torn, because the lower cost plan leaves me exposed to higher drug costs and less generous coverage of some services and devices that I might need in the coming year, given my decrepit state. So, right now I'm weighing a choice between two plans whose premiums vary by a ratio of more than 2 to 1. My choice is based on what I know now about my current state of health, which none of the plans can take into account in deciding to enroll me. That's the beauty of "open season" and "guaranteed issue."
Now fast-forward to a grand health insurance exchange, as envisioned in the House bill. That plan would also have a regulated market place with private insurers offering benefits that can differ within a defined range specified in the legislation. When I say "benefits", I mean things like the deductible, coinsurance or copayments, catastrophic limits on out-of-pocket expenses, networks of physicians, hospitals and other providers, care mangement techniques like prior authorization for expensive procedures, etc. An example of a limit on benefit variation is the requirement in the current House bill that every plan cover well child care visits with no copayment or coinsurance. (i.e., free well child care--costs would be covered through the premium assessed on all enrollees.)
Without a PO, the marketplace would behave similar to the FEHB program. People would check out premiums, networks, deductibles, etc., and would choose the best plan for them. Over time, there would be sorting of enrollees, and the costs of different plans might diverge. If the House bill became law, the young&healthy would enroll in the cheapest plan possible, while the old&sick would enroll in richer plans. This process would be mitigated to some extent because in the new marketplace, plans could vary premiums by age by a ratio of 2:1. (That's not true with FEHB, where we all pay the same premium.) So, in the House bill, the young&healthy would pay less for richer coverage and at least some might be induced to buy richer coverage.
Now, enter the Public Option (PO). Under the House bill, the amount that PO pays doctors and hospitals can never be greater than the average payment rates under private plans in the marketplace. Most likely the PO administrator will "negotiate" with doctors as follows: "We're paying Medicare rates. If you want to participate, fine. If not, hasta la vista." Lots of doctors might opt out of the public option, because right now Medicare rates are about 30% below private insurance rates. Hospitals may be stuck with the Medicare rates, though, because it could be very difficult for the major or only hospital in a community to thumb its nose at a public insurer. (I just don't know what hospitals will do.)
In any case, the PO premium is likely to be lower on average than those of private plans. Who will choose the more limited PO, with its more limited, perhaps less "elite" physician network? The young&healthy, of course. That will make it easier for the PO to pay for itself with lower premiums overall. Lots of young&healthies choosing the PO would mean that their premiums would be low, and the oldster's premiums would also be held down (by the 2:1 rule). Meanwhile, the private plans will attract us old&sicksters, and their premiums will be driven up. Eventually, some of the old&sicksters will give up on the "elite" docs and will enroll in the PO. This yin and yang will continue over time until, gradually, the PO (which still has the cost advantage due to payment of hospitals on Medicare rates) has become the behemoth. With lower and lower market share, private insurers will fail, merge, exit the market, etc., and real competition will be gone.
If you've read this far, I must tell you that I'm not completely sure of my prognostication. Competition is dynamic, innovation is inherent in markets such as this. I could be all wrong. That's why I'm not wringing my hands at the public option currently in the House bill. The uncertainty is great enough for me to say, okay, let's pass a law that makes health insurance affordable and get on with it. But, I'm mindful that the great long-term danger is the decline of the health care system into a single-payer system. Perhaps in the future I'll post something on why I'm so worried about single-payer system.

Oct 30, 2009

My first take on House Health Reform Bill

Ok, okay, so I've gotten through only the first 225 pages of the bill. (Read the 1,990-pages of the House "Affordable Care for America Act" yourself, if you think I should be faster!) I like this bill better than the Senate Finance concoction, but some things are worrisome.

The Good:

  1. HIE Membership: All firms would eventually be allowed to enroll their employees through the health insurance exchange (HIE), thus encouraging over time a big pool of enrollees in this new system of competitive health care plans.
  2. HIE Administration The HIE would be national in scope (though States may opt out), so the pool of enrollees would be large (very good) and the administrative expertise to set up and regulate the exchange would be centralized. (That's efficient.)
  3. Premium Cost Structure within HIE: The range of premiums would be limited to a ratio of 2 to 1, so older people (the 50=64 crowd) wouldn't have to pay exhorbitant premiums.
  4. The Public Option - participation: The public option (PO) will not require physicians to participate as a condition for them to participate in Medicare. That is, physician participation in the PO is largely unlinked from participation in Medicare. (This is very important in keeping the whole system from slipping into a single-payer Medicare program for all.
  5. PO Payment rates to physicians: Physician payment rates under the PO would be negotiated but couldn't be more than the average rates paid by the private plans in the exchange. (Also can't be less Medicare rates.) So, if the PO administrator wanted to use the Medicare rates as the basis for participation, that would discourage doctors from participating, and the PO would become a bare bones plan in the sense that the availability of doctors to PO enrollees would be somewhat limited. (This would probably vary by area of the country.) You get what you pay for. Maybe quality for those people who choose the PO won't suffer. Who knows? What's quality in health care anyway? (If you think you know, you're wrong..Nobody knows, least of all myself.)
  6. Participation of "Other Providers" in PO: The PO administrator would "negotiate" a rate at least as high as Medicare's DRG rates, and perhaps higher. The only practical "negotiation" on the part of the PO is to specify a multiple (say, 1.05) of the Medicare DRG rate. That higher-than-Medicare rate would mollify hospitals and other non-physician providers in the short run, and they would probably choose to participate, given the high fixed costs of hospital operation (volume is the name of the game for hospitals.) Now, this is good news, bad news, in my view, because other insurers may not have the market clout to demand that hospitals pay on a DRG basis, even one that's higher than the Medicare DRG rate. But, maybe insurers SHOULD play hardball with hospitals, and it is possible that this would encourage hospitals to take the lead in developing integrated systems of care (with doctors) that provide their own insurance offerings to people in their regions. That way, hospitals and physicians could share in cost-savings from delivering care more effectively and efficiently. In any case, hospitals' and other providers' ability to refuse to participate in the public option is an important safeguard for competition.

Worrisome things (other than cost, which I think we should pay for through a dedicated gasoline tax that brings prices at the pump to $4.00,..but that's another story and is so far beyond the fringe that I won't continue with it) will come in my next post, if I can ever slog through more pages of this bill.

Oct 21, 2009

Back to the Summers Blame Game

Frontline had a great program on our gal Brooksley Born, sometime head of the CFTC who tried to regulate the credit default swap market and was blown down by chief bloviator Larry Summers et al. and Sen. Phil Gramm (he of the late night Christmas 2000 law to "modernize" the CDS market by rendering it beyond the purview of regulation). It's on-line at PBS: The Warning. (Read about Brooksley at links provided in my May 26 post about her.)
It got me back in touch with my inner raging populist once again to ask the question: What the heck are Congress/White House doing to reform the financial markets? Brooksley answered this question in her Frontline interview: NADA!
What needs to be reformed? Two things, in my view:
  1. The laws that require insurers, pension funds and mutual funds to rely on those heinous ratings agencies (Moody's, S&P, Fitch) for directing their investments. SEC anointed those three as the chosen few, even though they (ratings agencies) were paid by the issuers of the securities for the ratings that would determine how much interest the issuers would have to pay investors. (COI!) Even the FED got into the game, telling the banks it regulated that it could treat AAA securities as good as cash.
  2. The easy money policy that led to the big pot of cash for investments in these doggy instruments.

Have you heard anything lately about either of these problems being fixed by Congress? by the FED? By Larry Summers? No? How shocking!

Oct 18, 2009

New entries in the growing Vitamin D evidence base.

Friends have been alerting me to new findings on Vitamin D. Stunning evidence on its importance to human health continues to mount monthly.
If you're young and athletic, take a look at the Sept 29 New York Times blog post on Vitamin D and athletic performance. (Thanks, Lisa T.) Take the time to read the comments readers have left on the post; they crystallize the issues that believers and doubters are debating.
From Clare G. comes word of a study of high-dose Vitamin D & physical therapy in preventing falls and hospitalizations in elderly people after hip fractures. This is a clinical trial reported at the annual meeting of the American Society for Bone and Mineral Research. Good summary is in Medscape.com (You'll have to register to see the article, but it's a good site for medical literature, so why not?) The gist is this: Patients taking 2000 IU of vitamin D had a 25% reduction in falls and a 39% reduction in hospital readmissions compared with those taking 800 IU per day. That included a whopping 90% reduction in infections bad enough for hospitalization in the higher-dose Vitamin D group. What's good for the elderly is good for me! (Of course, in a few months, I will be one of the elderly, so that's a tautology.)
Finally, take a look at the following YouTube videos of a Vitamin D conference at the University of California San Diego (Feb 09):
Robert Heaney, M.D., (Creighton University) - Great talk on how much Vitamin D is enough? How much is too much? He and the data will convince you that 2000 IU is a reasonable amount to be taking and it won't hurt you.
Cedric Garland, Ph.D., (UCSD)- an epidemiologist who reviews evidence on Vitamin D and cancer prevention (and treatment). Gets pretty technical, but if you slog through it (as I did )you'll at least get the rough sense (as I did ) that the latest (stunning!) findings regarding breast, prostate, and other cancers make sense scientifically.
Other presentations - including Vitamin D and cardiovascular disease, diabetes, and autoimmune disease are also available at the Conference home page (see right hand panel for clickable presentations).

What the Obama administration is doing wrong on the banks

Here's a great 10-minute interview in the New Yorker's Blog page of Joseph Stiglitz, a liberal economist, who is critical of the Obama Administration's handling of the economic crisis, particularly bank reform. What I like most about what Stiglitz (a Nobel prize winner) has to say is his defense of market mechanisms, properly regulated. This isn't about health reform, but if you keep it in the back of your mind as you listen to Stiglitz, you'll appreciate why I'm such a proponent of a regulated competitive market place for health insurance. Public plan could be in there, provided it doesn't use the leverage of the Medicare program to exact price concessions from hospitals and doctors that private insurers cannot.

Oct 13, 2009

Medicare, Medicaid, and Mayo Clinic

Today's Washington Post has an article about Mayo Clinic's decisions to opt out of Medicare for primary care in its Scottsdale Arizona campus and to refuse to accept Medicaid patients from certain mid-western states. Here's a link to an Oct. 9 news article in the Arizona Republic covering the Medicare decision .
Doctors all over the country refuse to accept Medicaid because of states' tendencies to pay even less for physician services than does Medicare. So, Mayo's opting out of some states is no big thing, in my view. The miracle is that they do participate in the Medicaid programs of MN, WI, ND and SD.
But, the decision of Mayo Scottsdale to refuse Medicare for primary care needs more consideration. Sounds heartless on its face, but my reading is different.
Here's what Mayo-Scottsdale is probably doing to stay within the confines of the law. It must be designating certain of its doctors (those manning one of its family practice facilities) as "opt-out" physicians. That Medicare jargon means that those doctors will not accept Medicare payment for any of their patients, and Mayo will not submit a bill on behalf of the patient for any of the services rendered by those doctors to Medicare patients. The patient is on the hook for the entire charge, and Medicare won't pay a penny for the services provided by an opt-out physician. Hear me? The patient cannot get a penny from Medicare when treated by an opt-out physician. Mayo is charging the Medicare patient who wishes to have a Mayo primary care physician an annual access fee of $250, plus fees for visits that are higher than the Medicare fee schedule allows.
Once the patient needs to see a specialist of any kind (say a radiologist, an endocrinologist, yada yada), or needs lab work, or special procedures, however, Mayo will bill Medicare on behalf of the patient. And, in that case, by law, Mayo must get no more than about 115% of the fee allowed by Medicare. So, the patient is completely on the hook at Mayo only for the services of the primary care internist.
Now, the unpleasant reality is that most Medicare patients who would pay, say, $1000 each year in excess fees are unlikely to be poor. So, the criticism of Mayo as catering to the elite in its primary care is somewhat valid. (Why do you think they located a new campus in Scottsdale in the first place?) But, --and here I am an expert as a sometime member of the Mayo (Rochester) staff and an occasional patient -- what the patient gets for that extra money is the kind of attention that most of us see only in Norman Rockwell paintings. First off, the Mayo community medicine doctor lets you talk and talk. You NEVER feel rushed. This is really true! He or she takes a thorough history. The visit almost always takes over a half-hour. (Time your next routine visit to your internist to compare.) You feel as if the doctor hears you. It's wonderful. Need a referral to a specialist? You get it, and you get it fast. Need lab work? It's done there, and the results come back quick. You're not left waiting for a month as you schedule that consult across town.
Does this make Mayo infallible? I haven't found it so. Those doctors have missed things in my case. Still, I never feel angry because I chalk it up to the inevitable imperfection of doctors in the face of mind-numbing variability and complexity of human disease. I've never chalked it up to the doctor not caring. Out here in the real world, though, I often do chalk it up to that.
Now, it's no secret that Medicare underpays for primary care services relative to specialist care. See Kaiser Family Foundation's background piece on the shortage of primary care docs. So, rather than start rushing patients through the system to meet its costs, Mayo has taken a stand against Medicare's crazy fee-for-service system. Lower income Medicare patients, or those who take umbrage, will have to see other docs for their primary care; they can still be referred by those doctors for specialty care at Mayo.
This is a signal to the Medicare fee-for-service system. You just don't work!

Oct 12, 2009

How to bend the health care cost curve- some good sources of info

The New England Journal of Medicine has three good articles about health reform this week. They are all free to non-subscribers and are easy to read and understand. Obviously, they're intended for doctors, but they explore the possibilities for bringing health care costs under control. The first one is a roundtable hosted by Atul Gawande, the now famous surgeon who writes in the New Yorker on health issues. David Cutler's article, which argues that cost moderation going to happen regardless of reform, is really interesting. But, if you want to know the politics of the Baucus bill, from a polished health journalist, read John Iglehart's summary of what's happening.

Oct 6, 2009

New CDC guidelines for Docs for H1N1 treatment

I'm following the University of Minnesota's CIDRAP website for interesting news about H1N1. Yesterday's postings were very useful! They put to rest a lot of rumors about vaccine safety etc. One entry alerted me to new CDC guidelines just put out for doctors to follow in diagnosing and treating suspected H1N1 cases. CDC says these are NOT for laymen, but they're just not that hard for a layman to understand! And saying that assumes that every doctor in the world is going to be right up to speed on the latest. So, here they are for my fellow laymen for easy reference: CDC H1N1 Guidelines

Sep 30, 2009

The "Premium Bands" in health reform debate

Last Friday, the Baucus (Senate Finance) Committee debated the large variation in premiums that health plans participating in the health insurance exchanges could charge based on age. (Thanks to Michael G who alerted me to this.) The bill currently allows the health plan's premium to vary by a ratio of 4 to 1 between the youngest and the oldest. That's a reduction from the 5 to 1 in the original proposal. (So, for example, if a 25-year old is charged $2000 per year, the 64-year-old would be charged $8000 in premium.) I've already argued (in my Sept 15 post) that this high ratio is not good.
On Friday, Sen. Kerry introduced an amendment to reduce the maximum ratio to 2-1. Both Kerry and Wyden were eloquent about the issue. (If you're a health policy junky, you can hear the entire hearing on C-span, Friday 28).
Kerry ultimately withdrew his amendment, but he promised that it would come up later in the final debate on the Senate Floor. We should watch this issue. The fairness of health reform rests on three things: the premium subsidies for lower-income people; the size of the penalty for those who refuse to buy insurance; and the extent of age-rating variation allowed. So, this is an important aspect of any plan that's put forward.

Who says Canada's health system is better?

My friend George S, for one. Of course, the last time George lived in Canada he was young-- I won't say how many years ago that was, but twern't yesterday. George believes in a single-payer system, and though he is otherwise the brightest and wisest, I can't seem to get through to him on this issue. He just loves the health care he received from the province of Ontario. T.R. Reid, who just authored a book on health care systems around the world, seems to agree with George. He must be young, too! To see & hear to his lecture on how bad US health care is and how good Canada is, click here.
Now comes an article in the LA Times ("In Canada...") about the problems that Canadians have in getting access to care in Canada. At issue is whether Canadian physicians can offer care outside the province-run health care system. The article gives examples of long wait times for such things as hip replacements (ooh, that one hits too close to home) or MRIs in British Columbia.
True to my research roots, I checked this out with friend Maria, who lives in BC and knows a lot about the health care system there. "Is this for real?" I asked via email? Here's her answer:

  • "There are significant waits here for elective surgery and the situation with imaging is really quite bad. Interestingly, there is a private system for MRI's, so if you don't want to wait up to a year for one, you can legally get one privately (at about $800). Some people also opt for private cataract surgeries and this is done somehow legally. The current government in BC is "Liberal" but is curbing services in the face of budget deficits.

As a true Canadian, Maria remains optimistic and trusting:

  • "Efforts are being made to reduce these wait times and despite the system's shortcomings, it is in my humble opinion a better one than exists in the US."

So, next time George wants to argue with me about single payer, I'm prepared with facts that will matter to him now that he's no longer one of those "young invincibles."

Sep 24, 2009

Baucus Bill Changes as of Sept 22- new summary

Here's a link to the summary of the Revised Chairman's Mark for Senator Baucus' Finance Committee Bill. Over 500 amendments have been submitted. Those are beyond me to keep up with, but reading the Summary of how Baucus has changed things so far should help us keep track of where we are on the "affordability" issue. And, we should be explaining to people how very de-stabilizing will be the very big range of variation in premiums (by age and region) allowed in this bill. It simply won't work if older (55-64) people can't afford health insurance. The young NEED to subsidize the older to some extent. Furthermore, if Wyden's idea that the health exchanges should gradually replace employer sponsored health insurance, then American industry will be more competitive & the young would have more job opportunities and better wages. Without a reduction in the premium ratios, the whole scheme won't work, and the benefits to the young in the form of jobs won't come about either!

Sep 22, 2009

Cash for Clunkers cost us (taxpayers) $2000/car

Here's a great AND READABLE article in an electronic economics journal--The Economist's Voice--about the net costs to our society of the cash-for-clunkers program. By two University of Delaware economists. Net, it cost us about $1 billion extra...small change? One quote from this article is worth the whole thing: "Concentrated benefits create vocal advocates while diffused costs produce silent apathetic opponents."

Sep 21, 2009

Good news on H1N1 Vaccine Front-No adjuvant

I've been wondering what the fast-track approval of H1N1 vaccines would mean for vaccine safety. Today, Andrew Pollack's article in the NY Times, "Benefit and Doubt in Vaccine Addititve," assured me that USA isn't planning to approve any vaccines with adjuvants this go-round. That means the safety concerns associated with fast-tracking the approval aren't an issue. Only question now is whether the vaccine will arrive before the flu itself does.

Sep 17, 2009

An amendment to Baucus bill worth considering..

Sen. Ron Wyden (D-Oregon) wrote a great piece in today's NY Times arguing for a change in the Baucus bill. It would go a long way toward making health insurance work for everyone, and putting us all on an equal footing when it comes to having access to coverage.
The Baucus bill is pretty good, except for the wide variation in premiums that would be allowed on the basis of age. See my previous post for a description of the problems there. Wyden's amendment wouldn't work if such wide deviations survive in the Baucus bill, because only the young would leave employer plans for the Health Exchange, and companies would find themselves paying more for their own plans. They would soon dump their own plans, leaving older workers to buy on the exchange and pay high premiums while getting only an average subsidy from the employer. (Employer plans do NOT vary benefits by age of worker, so they would not give higher subsidies to older workers trying to buy a plan in the health exchange.

The Baucus Bill isn't that bad.

Here is the link to the Senate Finance Committee's "Chairman's Mark", released yesterday and supposedly the starting point for the compromise bill that will be acceptable to a wider range of congress.
All in all, I think it is a good framework for reform, except for a couple of things. The most important problem is that it allows private plans to charge very different amounts to different populations of people. If you're, say, 60-65 years old (too young for Medicare and too old to train for a new lucrative career), you'll have to pay a LOT for health care coverage (5 times more than for younger people). Say you're a single person 60 years of age making $50K a year. You'd be excused from the requirement of either having to buy insurance or pay a fine to IRS only if the lowest premium available to you was more than $5000. (You wouldn't be eligible for a tax credit to help defray the cost, because you'd be too rich.)
That's simply too much for most people I know, and because the 60-65 year olds will shoulder the greatest premiums, it basically says fuggedabout relief. You'll just be penalized if you don't buy coverage, and you still won't be able to afford coverage.
Let's get real. We need to provide a fair insurance system for people who can't get it through the workplace. Those same people must have incentives to be frugal about how they use their covered care. A system of COMPETING regulated health plans offering benefits with a standardized value is the best way to change the health care system to be more efficient in the delivery of care. Nothing is ever perfect, but consumers can vote with their feet by changing plans when they find one or the other not meeting their needs.
I started working on health care issues in 1971. Over the years, I would ask physicians, nurses, and other health care professionals with whom I worked on committees and panels to estimate, off the top of their heads, what percent of health care costs is wasted. It varied, but the most frequent response throughout the years was 40%. (20% also was suggested a lot.) And, it didn't get any lower as I got older.
Right now the system isn't organized to capture those savings. As patients, we all know the problems. Duplicative tests, doctors not communicating, incentives to test and prescribe too much, etc., etc. To change things in the culture of medicine, you need to change the organization of medical care. My two years working at the Mayo Clinic in Minnesota in the mid 1990's taught me that medical culture is very important, and that the organization needs to have incentives to make their practitioners change behavior.
Mayo was organized better than any system I've ever seen. They were most efficient in the conduct of individual services (xrays, lab tests, visits, etc), but they provided a very intensive set of services. Mayo is still paid largely on a fee-for-service basis. Imagine the innovation that would be forthcoming if the majority of its patients signed up as HMO members in the "Mayo Clinic HMO." Mayo would be a leader in deciding if and when services were justified on medical grounds (let alone costs). Under a competing system, Mayo might have incentives to build its HMO into an offering for most people in southern Minnesota.
So, we need the Baucus framework, with some tweaks, but we need to have the young subsidize the old (young-old, non-Medicare). The young will be old someday too. Keeping the young in the pool with the old will keep premiums more affordable to those most vulnerable. The 50+ crowd who start succumbing to chronic and debilitating disease.
If you agree or not, you can find out how to contact your congressman or senator in my recent post, How to Contact Your Congressman or Senator. They need to hear from you. Here's a good news article that shows how important your voice can be on this particular issue.

Sep 16, 2009

Does washing hands help stave off flu?

Here's an interesting Newsweek article that suggests hand washing isn't likely to be effective in preventing the spread of flu. Won't hurt, experts say, but it could make people -- especially kids -- complacent, when it's transmitted through the air. That Elmo trick of sneezing and coughing into your elbow seems to be a better tactic.

Sep 15, 2009

Who are the Uninsured?

The Institute of Medicine published America's Uninsured Crisis early this year with the most informative table I've seen on just who are the people who are uninusred in the USA. Table has demographic and income distribution data. I didn't know, for example, that immigrants (legal + illegal) make up 20% of the uninsured population. No breakdown between them. Also, the number of illegal immigrants may be too low, because the data are based on a sample, and illegal immigrants may be less inclined to respond.
Two ways to look at this: Way 1: OMG, we could end up paying a lot to insure illegal immigrants (and encourage more to come) if we're not careful. Way 2: OMG, health reform won't help a substantial portion of our hardest working and most vulnerable residents. I'm a 2nd way kind of gal, but I can see the arguments of the 1st way folks.

The Senate Finance Committee's Health Reform Plan

This is the "Baucus Committee", which is generally more conservative than the Senate HELP Committee (Kennedy, Dodd & Harkin). The SFC's bill hasn't been drafted fully, but last week Sen. Baucus released an 18-page summary of its provisions so far. I relented from my new "kill-no-trees...create-no-paper-waste" policy and actually printed a copy and then actually read the thing.
Here are some things to worry about in this bill (and why):
  • Insurance market reforms - (p2-3) - Although plans would have to refrain from discriminating against pre-existing conditions & must eliminate lifetime limits on coverage, they could vary premiums by age group, up to a ratio of 5-to-1! That's pretty substantial for the 50+ crowd who are likely to need the most care. It's basically saying that each age-group of uninsured will subsidize itself. No transfer from the young to the old. It would not provide real relief on premiums for the older laid-off crowd that can't change careers fast. Oh, and by the way, plans could offer a super-cheap policy for the "young invincibles" who wanted only catastrophic coverage, thereby siphoning off the lowest risk segment of the population from the general market. End result? VERY HIGH PREMIUMS for older uninsured people. Makes the idea of "affordability" laughable for anyone who isn't young and healthy or near-poor (see below).

  • Benefit options- (p3) - Oops! First I got this wrong. I thought that the summary was saying that Plans could keep 35% of premium collections for their own expenses & profits. What they really meant was that each plan's benefit would have to limit patients' out-of-pocket expenses to 35% of total costs (on average across enrollees). That's much better. So, I'm not worried about the plan options they're talking about.

  • Health Insurance Exchanges - these would be set up and run by the states, instead of a Federal bureaucracy. Excuse me, but I'm from New Jersey. (Enough said?) In all my years working in Washington near or in the Federal workforce I've never seen the incompetence, waste and corruption that I've followed in my home state. (Well, maybe in my first years as an intern in a dying federal agency.) It's a bad idea in this case not to have the regional markets organized by a central commission. There, instead of 50 state bureaucracies reviewing insurance offerings for their fine print, you'd have just one. Regions would be distinct, but the expertise to regulate the markets would be centralized (like Medicare).

  • Medicaid - (p. 7-9) This section is unclear, but it appears that people between 100% and 133% of poverty will be able to choose between Medicaid and the Health Insurance Exchange. That's good. And, instead of completely federalizing the funding for that newly eligible group (as in the House bills), States would have to share in the cost. At least I BELIEVE that's what the section says. Read it for yourself. Making States share in the cost of providing care for Medicaid is a good thing, since they actually administer the programs. Of course, Governors hate this because they don't have enough money right now, and how would they come up with new money? The 55/45 split between Washington and States called for in the proposal could be altered so that federal taxpayers pay more, but States should have some skin in the game if Medicaid is going to be covering these people. And giving working people the option to join the exchanges (with subsidies) is a good thing. Who wants to be in Medicaid? Nobody that I know, rich or poor, unless there is no other option.

  • Subsidies to Low income individuals (p 3-4) - Up to 400% of the poverty line, you'd get a refundable tax credit (i.e., whether or not you owe taxes). According to the Institute of Medicine, that's about 80% of the population of uninsured people. For example, at 400% of poverty, your premium payment would be capped at 13% of your income. For a family of 4, with a household income of $88K, (400% of poverty) that would mean a cap of $11K. Gov't would give tax credit for the rest. At least I think that's how it would work. Read it for yourself and let me know if I've got it wrong. jwagner@bethesda20817.net. Does that sound affordable?

  • Revenue Provisions (p. 17) - I love the new tax on employers with high-cost health plans. The tax would ultimately be 35% of the plan expenses beyond the threshold. The tax would give employers incentive to reduce their health benefit costs. And I don't like the idea of subsidizing (with my tax dollars) the high-cost plans of the richer companies. On the other hand, the bill would completely eliminate the subsidy that employers get when they give Medicare-eligible retirees drug benefits. That's currently a 26% subsidy for every dollar of benefit. It's what has kept employers from dropping health coverage for Medicare-eligible retirees. Lots of employers might drop coverage for retirees. Is that bad? Medicare drug benefit is still available for all. So, I'm not sure whether it's bad or good. More thinking to come.

Sep 10, 2009

Legistorm Gives the Skinny on Congressmen & Staff

This site, Legistorm, is fabulous for finding out what kind of travel your Congressman, Senator, and his/her staffers are taking at your (taxpayer) expense. Want to know whether your guy/gal is a big "earmarker"? You can find that out too. And, get a peek at financial disclosures, though they're much less informative than the travel expenses. And, staff salaries! That will tell you what working on the Hill will pay for, example, the Chief of Staff for the House Majority Leader. Check it out.
Of course, none of the salaries comes close to that of Michael Kaiser, CEO of the Kennedy Center... over a million a year, according to the Washington Post Magazine last week. That's the last penny KC will ever see from me! Nobody in Washington needs that much money to live the high life. I bet if KC Board told MK he'd be out if he doesn't take a 100% pay cut, he'd cave. He's the "turnaround king" for cultural institutions, and he donated a kidney to his sister. Still, half of his million could fund a lot of struggling young ballet dancers.

Aug 29, 2009

Latest on H1N1 status

College campuses are already sites of mini-epidemics, and a friend's workplace in California has had a rash of cases in the past 3 days. With schools starting, we should expect H1N1 to ramp up fast.
My favorite source of info on H1N1, and up-to-date info on whether and how it's changing, lethality, etc., is CIDRAP at the University of Minnesota. Here's a link to CIDRAP's latest info (as of yesterday-Friday Aug 29). Good news is that the virus hasn't mutated. Bad news is that some young healthy people are getting serious viral pneumonia, that MUST be treated fast. Good news is that resistance to main anti-viral drug (Tamiflu (tm)) is still isolated and rare. But, getting care right away if lower respiratory tract is involved is important!
For a list of signs and symptoms of serious swine flu infection, see my posting of Aug 1, 2009,
Check into my posting of June 26 for information on what you should expect your physician and hospital emergency room to do when you do seek care..

Aug 17, 2009

"Public Option" out! "Choice and Competiton" in!

I hoped it would happen. The Obama Administration has seen the light and is ready to give up on a Medicare-linked public option (the only kind that could give the public plan an unfair advantage in a reformed marketplace). Now, the buzz-words from HHS Secretary Sebelius and Gibbs (WH Press Officer) are "Choice and Competition". I love it!

The problem with the insurance market has NOT been the evil insurance companies. The problem has been a failure of market regulation to guard against the four sources of market failure in health care insurance:
  1. adverse selection bias into health plans -- If health insurance coverage is voluntary, and insurers can't deny coverage, only the old, or sick, or vulnerable will apply.
  2. Cream skimming by health plans -- When insurers CAN deny coverage, or charge different rates to different people, only the healthy will be able to get insurance;
  3. Incentives for over-use by the insured -- (this is called "moral hazard" by economists, a term that I consider to be incredibly stupid because it doesn't help me understand the problem. It's just an economist's way to keep normal people from thinking they know anything.) It's simple: if you don't pay the doctor anything (or very little) for a visit, or a test, or a procedure, etc., you'll have no incentive to restrict utilization or keep the doctor honest when he/she bills the insurer.
  4. The provider is your "agent" in making health care decisions. Well, we pay him/her for that, don't we? Yes, but in this fee-for-service world he/she has an incentive to do more, or at the very least not to conserve resources. So, for example, the doctor may not get any money from ordering an MRI to rule-out something very unlikely but horrible, but he has no incentive NOT to order it, and it will justify a return visit (for which he'll be paid).

If problems 1 and 2 are fixed through regulation -- health insurance must be mandatory for all & health plans cannot discriminate either in coverage or premiums -- and if plans must compete for your business, then most of these problems will dissipate over time. It's the only way to get control over health care costs without leading to a single-payer system. (And I'm against a single-payer system, because Medicare and Medicaid are NO role models for efficiency and effectiveness in health care.)

Aug 16, 2009

More on the Pros and Cons of the Public Option

Richard Thaler (a well-known economist, born in NJ, too!) has a good piece in today's NY Times on the Public Option controversy surrounding health reform: "A Public Option isn't a Curse or a Cure." He says what I said (but I'm not such a well-known economist). He even refers to Victor Fuchs as the "Dean of Health Economists"... did he read my blog post of June 1? (ha ha...don't think so, but I like to brag anyway).
Thaler points out that, given a level playing field, government run enterprises NEVER out-compete private enterprises. Only if the public plan can exact concessions from providers (through legislative means) that private plans can't, will it be successful. Thaler emphasizes the capacity of the private sector to innovate. That's JUST what I said in my final opinion against a public plan, in my July 22 post. I see the potential for hospitals and doctors to integrate into stronger networks that encourage innovation under a system of competing regulated private insurance. That's our best hope of being able to evolve a system that balances quality, costs and access to care.
One point missing from the Thaler article is that to be on a "level playing field" with competing private plans, the amount that the public plan pays to physicians must NOT be tied to the Medicare Part B fee schedule, as is currently in the bill passed by the House last month. That bill requires that physicians be paid the Medicare fee schedule +6% (in hopes that will appease the AMA). But that amount is sure to be held below the amounts that private plans can negotiate. Sounds good on its face, but it strengthens fee-for-service medicine at a time when that mode of operation has been shown to lead to overuse of visits, procedures and tests. It will slow down innovation, and it will drive out private insurers because doctors will have a choice whether they must accept the private insurance fees. If the public plan can piggy back on the Medicare rules for physican fees and participation, it will have a big cost advantage.

Aug 7, 2009

Health Reform Debate-- more agreement than you'd think.

Here is a great interview by Terry Gross of Fresh Air of Paul Krugman of Princeton and Stuart Butler of the Heritage Foundation, on health reform. They agree on most things, such as whether employer health benefits above a threshold should be taxed, whether individuals should be forced to get health insurance, and whether health plans should be regulated so that they must give decent benefits and take all comers.
The one area on which they totally disagree is whether there should be a "public option" offered along side all the competing health plans.
I've already concluded that the public option would add to the long-term drag on true reform of the delivery system that is already caused by Medicare. But, I thought that the two of them made the best case possible for each side, so you should listen. We all need to understand what's at stake with health reform.

Aug 2, 2009

Save, Save Save!....er, no...Spend, Spend, Spend!

Am I the only one tired of the mixed (confused?) signals our economic "leaders" (Larry and Tim and Ben) are sending about what we should do with our money? We Americans have spent ourselves into a debt hole in the past 20 years, courtesy of China, mainly, which has bankrolled us. Just a few months back, we were hearing about the crisis in credit card debt due to our profligate spending on cheap Asian goods over the past 20 years.
Now we consumers are being blamed for the failure of the economy to respond to the gadzillions being poured into it by the government. If we just save it, they whine, then all that spending won't do what they want it to do. Make the economy look better and therefore make THEM look better.
So, what should I do? Here's how I'm thinking about the save vs. spend dilemma. Part of me wants to save save save for the rainy day that I absolutely KNOW in my gut is on the way. That day will bring torrents of inflation, mainly through collapse of the dollar, but also because oil prices will gradually sneak upwards. But, if I save, I must put my money in something that's inflation-proof, and those investments are hard to find. Especially since the big guys like Goldman Sachs chew up idiots like me who might try to invest in commodities. I really do not know how to invest in commodities.
On the other hand, I've wanted a lot of gadgets that look like fun. HDTV, smartphones, laptops, kindles, fitness monitors, new big computer screen, new desktop, Wii, etc. etc. And, new furniture, too. And new PJ's. All of these are made in China now. So, once China makes good on its hints that it will switch its currency away from the dollar, all those goodies will get much too expensive for me. So, I'm on a China spending spree right now.
I'll save later-- my savings will be in the form of higher taxes paid to the government when the bill comes due. Since I can't keep everyone else from spending their stimulus-gotten dollars on cheap China, and since I'll have to share in the forced saving known as paying back government debt through taxes, I might as well have a few gizmos to show for it.

Aug 1, 2009

Warning Signs of Serious Swine Flu in all patients

WHO just published guidelines for patients to know whether and when H1N1 (aka swine flu) influenza has turned nasty and now requires immediate attention by medical professionals. The title is "pregnant women", but scroll down to last section, which deals with all patients. Here they are for easy access in the coming months (September and later) when the swine flu is expected to hit USA hard again.

Jul 29, 2009

Social Security and Medicare: Where to find the law itself.

For my class of '62 (hs) and '66 (college) cohort, and all those older and slightly younger : Here is a link to the Social Security and Medicare Laws. I like it because, though it's almost unreadable, you can search within the page to find what you want... for example, payment for home health services.. search "home health".. Then, references to other sections of the law are highlighted with clickable buttons. Yes, I agree that you'd have to have no life at all to want to research the law on a specific issue that you might have with Medicare, but you never know when that will be true! And think of how popular we'll be in the nursing home with our laptops to help our fellow inmates (or their children) figure out how to get reimbursed!

Jul 27, 2009

Canada to study Vitamin D and Swine Flu!

One of the things I learned from doing medical technology assessment is that Canada is a country filled with epidemiologists. Even family practitioners get masters degrees in epidemiology. At conferences, they introduce themselves as "family practitioner and clinical epidemiologist." In the USA, by contrast, epidemiologists are often considered the weirdos of the medical profession. (Why would anyone waste their precious brains on such dumb stuff when you could be stapling stomachs?) Epidemiology is the systematic study of disease in populations. Not the study of stapling technique in gastric surgery.
So, I guess I should not be surprised that the Canadians have taken the lead in using the current Swine flu epidemic to examine the link between flu severity and VITAMIN D! Just learned from CIDRAP (my favorite source on everything infectious, run by American epidemiologists, of course) that the Canadian Public Health Agency will be testing people with Swine Flu for their Vitamin D levels to determine whether those who do badly have lower levels. The Toronto Globe and Mail had a very nice article on it. Canada's press release was a little broader than just Vitamin D, since they'll also be looking for genetic factors. But, the very fact that they will actually use the current epidemic to get some info on Vitamin D and influenza is a reflection on the sophistication of Canada's approach to health research and policy. If Vitamin D actually turns out to provide some protection, as some scientists believe, it's the kind of low hanging fruit for cost-effective medicine that we need if our President's promises of lower cost health care are ever to be remotely approached. (He should stop promising that, anyway.)

Jul 22, 2009

The "Public Plan" and Health Reform - What's wrong with it?

Health reform legislation is now focusing on building a regulated marketplace (or exchange) for plans to offer insurance to individuals. The regulations would require health insurers to offer a standard set of benefits at a single (or at most age-specific) premium and to take all comers, even those of us who actually will need medical care in the near future. The idea would be that you can choose among, say, 10 plans all offering a mandated set of benefits, but perhaps varying on co-pays, deductibles, and choice of providers.
A marketplace of competitive -- but regulated -- health plans offers the best hope of reaching a reasonable balance between costs, access and quality of medical care, because consumers (that's us) would be able to exercise the strongest vote possible against a plan that skimps -- select another! Same with a plan that costs too much. Over time, plans would come to look more and more alike. But, most important to my mind is that a competitive program would hasten the integration of medical care delivery into systems of care. That's where hospitals, physicians and other providers get together to offer a health plan in which they share the savings that come from making care more rational and cost-effective. (And, in every open season, they'd have to give some of those savings back in reduced premiums in order to stay competitive.) Integrated health delivery systems can be larger than one city or county. They can involve arrangements with nationally recognized high-quality cancer centers, for example, to offer state-of-the-art care. You might be willing to pay a bit more if your plan included access to the best specialty centers for certain types of care. Most important, integrated health systems would have to compete against rivals on both quality and cost.
The current fee-for-service system is a drag on system integration, because doctors are paid piecemeal and do not benefit from talking with one another or investing in more efficient use of hospitals and technology. It's a dinosaur payment system.
How does the public option come into all of this? The public option is essentially a Medicare add-on. It will piggy back onto the Medicare fee schedule and fee-for-service piecemeal payment system. So long as it pays physicians enough to keep enough of them accepting public option patients, it will be a drag on the needed evolution to systems of care. It will perpetuate the disjointed, disconnected, dysfunctional, and dissed (by me) current system.
That's my main problem with a public plan. Even one that pays doctors generously (and therefore gets buy-in from the altruistic American Medical Association) is likely to gum up the works for real reform of the health care delivery system for a long time to come.

Become a Medicare Expert in 2 Minutes!

A little-known federal government Commission, MEDPAC, is a fount of information and advice about how to fix Medicare. (A lot of its advice I do not agree with!) It's staff is small (about 30 people) but its knowledge of Medicare is deep. The reason it's not known by most of us is that it works for the Congress, not as an educator of the general public. But, last week they put out a great Data Book: Health Care Spending and the Medicare Program, that summarizes very nicely exactly where our Medicare dollars go and why everyone in Washington with at least a smidgen of patriotism (versus self-interest) is semi-hysterical over the "Medicare problem." All you have to look at is the first 15 charts (in chapter 1 of the report) to understand why Medicare fee-for-service -- fee schedule -- medicine has NOT protected us from breaking the bank! The other 200 pages would be interesting for obsessive compulsives, but as imminent or new Medicare beneficiaries, my fellow classmates and I should at least know the basics. And, if we're still going to cocktail parties, we can spout a data point or two and be considered an expert!

Jul 21, 2009

How to Contact the White House

http://www.whitehouse.gov/contact/
My friend G., who volunteers at the White House's phone bank, says the White House actually DOES methodically monitor the content and views of its incoming calls, except for total cranks whose expletives deleted are hard to categorize. So, I'm sure they're doing the same with their E-mails.

Goldman Sachs' Perfidy????

Love that word -- perfidy? I'm not sure I'm using it correctly, but out it jumped, keeping me out of the nursing home for another week. But, that's another story.
Sister Janet alerted me to an article by Matt Taibbi in Rolling Stone Magazine (of all places) on Goldman's role in every major bubble-meltdown since the Great Depression (ours today is only the Great Recession). Today in the Washington Post, Alan Sloan tells how Goldman is arguing with the Feds, which saved its hide in the past year, over how much our (i.e., US taxpayers') stock warrants are worth. Sloan thinks Goldman is tacky and greedy. We should contact the White House with a simple E-mail -- "Make Goldman Pay!" It's easy to do that...Click Here!
My friend G., who volunteers at the White House's phone bank, says the White House actually DOES methodically monitor the content and views of its incoming calls, except for total cranks whose expletives deleted are hard to categorize. So, I'm sure they're doing the same with their E-mails.


Then, somehow, we should keep track of what Treasury does. I'll try, but if you happen to see it in the next few weeks, leave a comment at the end of this post, and I'll pick up on it.

Jul 9, 2009

Health Reform- Capping the Employer Tax Benefit

To me this is a no-brainer. Right now, the government subsidizes employer-provided health benefits by about 35% (the corporate tax rate). That creates a huge incentive for companies to provide rich health benefits for employees who might otherwise choose to opt for less generous coverage (higher co-pays, etc), and get higher wages instead. Less generous coverage would make employees use health care more sparingly (YES! We need to do that), which would lower health care costs.
Fortunately, an op-ed in the Washington Post by Len Burman (of the Urban Institute, and once a CBO analyst) makes these points much more convincgly than I can, so here's the link to "Give Up a Benefit, Get a Job."

Jul 7, 2009

Health Reform Kennedy Style

While I'm still pondering all the ramifications of having a public (Medicare-like) plan offered along side competing private plans under a Health Reform PROGRAM, I must share with you my reading of the first 200 pages (Title 1) of the latest version of the Senate HELP Committee's draft legislation. (I read so you don't have to!) (If that doc doesn't open, it means it's already been updated, so go to the Senate HELP Committee's home page to find the latest.)
One item I find particularly delightful is the provision to extend Medicaid eligibility to all individuals in households with incomes below 150% of poverty-- that's about $35K a year for a family of 4, covering about 18% of all households in the USA, according to Wikipedia.
On its face, that's not so terrible, since State Medicaid agencies are very very careful about how they spend money for Medicaid recipients. (States must pay for about 43% (on average) of total Medicaid spending. The Feds pick up the rest.) Indeed, some might say they're downright stingy! Here's the little detail: the legislation provides for the States to continue to administer the Medicaid program for those new enrollees, but this time the FEDERAL GOV'T will foot 100% of the bill. So, say you're the Governor of your state. What would you tell your Medicaid Director to do? Give 'em the BEST! Pay those doctors more! Stick it to the other 49! Of course, the other 49 will stick it too, so The COSTS, THE COSTS! They'll be out of control, and I'll probably want to qualify for Medicaid!
These are the kinds of little goodies that make me almost despair of ever getting affordable health reform. (Ironically, "Affodable Health Care" is the name of the HELP bill.) Bottom line: THANK GOD FOR CBO! I'm sure they'll cost it.

Jul 3, 2009

Three most important health reform questions

To my mind, the three most important issues in the design of a new health reform program are these:

  1. should employer plans enjoy unlimited tax deductions for health benefits; and should employers who don't offer insurance be taxed?
  2. should all uninsured people be forced to enroll, and be taxed (or jailed...just kidding) if they go uninsured? (Too poor? That's where subsidies come in.)
  3. Should there be a Medicare-like public plan offered along-side the competing private plans in the regulated marketplace that would be set up under the program?

I'm sure my former colleagues at CBO at dealing with many more questions than these, but these are the three that will determine whether we ever get a viable program that actually covers all Americans without ruining the health care system in one way or another.

I'm going to start with question number 3 in my next blog, because I'm most confused about it. I started out VERY certain about what the program should look like in this regard, but the more I think about it the less certain I get. Next post will try to lay out the pros and cons of that.

Jun 26, 2009

What your doctor should know to do about Swine Flu

Sister Janet tells me that Swine Flu (or, if I were more PC, "novel H1N1") is the scourge of the Chicago area right now. Probably everywhere, but who's counting? While number of cases reported seems low, that's because little testing is going on. So, anyway, suppose you or your kid gets sick with flu like symptoms, especially including gastro stuff (almost 40% of cases), here are two good guidelines for how you should be handled by doctors and emergency rooms. These are intended for doctors, but I can read them, so you can too. We should, having lived long enough by now, know that doctors and hospitals don't always follow best practices (witness the high rates of hospital-acquired infections in this country!)
I got these sources from the University of Minnesota's CIDRAP daily on-line newsletter. If you're a health nut, you'll really enjoy getting it too. I knew about the Nestle's chocolate chip cookies real fast.

Jun 22, 2009

Pharma's "gift" to the Medicare patient.

Perhaps you heard -- Pharma just got together with AARP to announce that they will offer a 50% discount on patent-protected brand name drugs for Medicare patients once the patient reaches the "doughnut hole" -- the point in annual spending ($2700) when Medicare takes a breather and the patient is responsible for 100% of his drug bill. (Later in the year, once the patient's total spending (out-of-pocket + Medicare-paid) reaches $6154, catastrophic coverage kicks in, and Medicare gets generous again). Though the details are sketchy, one account says that all the savings will go to the patient. That is, the full cost of the drug will count toward achieving the catastrophic limit, so the patient will get credit for the other half of the drug's price, too. The Medicare plan won't gain any savings. Sounds like a good deal for the patient, but not if it takes the pressure off drug companies to keep total prices down, and if it induces patients and their docs to order more brand name drugs. Then the cost of the drug plans will rise, and both the gov't (us) and Medicare enrollees will pay more in premiums. Also, how can the administration be considering using the savings to pay for health reform when there don't appear to be any savings to the program itself?

If, however, Pharma means that the patient's actual spending will be what counts toward the catastrophic limit, then the patient won't gain as much, and he won't gain anything if the total costs of his drug coverage take him to the catastrophic limit. He'll just get to the limit more slowly during the year.

So, it seems for now that everyone is being duped but the drug companies. Or is everyone (AARP, Prez Obama, drug industry) trying to take credit for something that's too byzantine for us to follow?

White House Whitewash of Ratings Agencies

Way back in one of my earliest blogs, Nov 5 to be exact, I issued a guide to good radio programs on the web that explained the sources of the meltdown in a way that I could understand. A long list of programs, but here's what I said about those rating agencies:

  • Are the real culprits the Ratings Agencies (S&P, Moody's, Fitch)? -- I think so, and here's the best explanation! C-Span -House Hearing on Credit Rating Agencies - Henry Waxman (D), Chr. This is a 4-hour hearing, boooring... but if you can navigate to the statement of Sean Egan, Managing Director, Egan-Jones Credit Rating Agency– minute 31:13-39:10 - and again in answer period 44:00-46:05, you will want to start knitting quietly in true Madame DuFarge style! See Hearing.

So, I've been anxiously awaiting the Administration's proposal for regulatory reform to see what they're going to do about these rogue agencies that gave AAA ratings to junky credit default swaps. Last week's Treasury Report outlining the proposals made me think there is no hope, because those ratings guys & their regulators were almost completely let off the hook, except for an Obama-style sermon about how they should go forth and sin no more.

Before I could write a scathing blog piece, however, the Wall Street Journal did it in an editorial that lays out the perfidy of our financial leaders in both the private and public sectors. (WSJ-The Triple-A Punt) Here's a couple of choicest comments from that editorial, which you can read on the web free.

  • "Without the ratings agency seal of approval -- required by SEC, Federal Reserve and state regulation for many instituitonal investors -- it would have been nearly impossible to market the structured financial products at the heart of the crisis."
  • The Fed's standards for banks "...allowed Wall Street firms to claim that highly-rated mortgage-backed securities on their books were almost as good as cash as a capital standard."
  • The treasury's report "..blame[s] the victim. 'Market discipline broke down as investors relied excessively on credit rating agencies'."
  • "..the Fed, which until recently would accept as collateral [from banks] only securities that had been rated by S&P, Moody's or Fitch, has lately acknowledged the flaws in this approach."

WSJ wants the government to embrace full reform of the entire ratings system. So do I. It's ironic that the Federal regulators that played the biggest role in causing the ratings debacle -- the Federal Reserve and the SEC -- come out as winners in the reshuffling of regulatory powers under the plan. Only hope now is Congress -- Do you live in Connecticut? Threaten Senator Dodd with further exposure as a patsy (or collaborator) in his role as Banking Chair as he fights for re-election. Live in Mass? Write Barney Frank telling him to find his inner populist! Live in California? Tell Henry Waxman you expect him to walk and chew gum at the same time -- he can reform the agencies while he reforms health care. Here's how to email any member of Congress.

Jun 15, 2009

Babies born to Unmarried women - 40% in 2007

This was a hard-to-believe statistic I learned from the latest Data Brief issued by the National Center for Health Statistics. Of all babies born in 2007, 40% were to unmarried women. The percentage is rising among all age groups, not just teens; it's rising even in women 25 years of age and older. For example, the birthrate for unmarried women between 30 and 34 years old was 21 per 1000 births in 1980. By 2006 it was 55 per 1000 births.
That doesn't mean that Daddies aren't around, of course. But is it the Brangelina effect; or is it the greater economic independence of women and reluctance of men to have children; or is it the continued existence of a marriage tax that is undermining the institution of marriage?
I'm not sure how bad this is for society, if at all. Just don't know the evidence to comment. But it sure did surprise me.

Jun 10, 2009

Just took the new Alzheimers 5 min test & passed!

Hooray -- no nursing home for me this week. British Medical Journal just reported on a new 5-minute test for Alzheimers, just 2 pages long. It's supposedly much more sensitive than other tests. Here's a link to the test on-line. It's biased in favor of Brits and against Americans because of one cultural question. So, don't freak over that one. Haven't found the scoring system yet but will post when I do. Best for you to answer every question successfully. That way you'll have a perfect score and know that you, too, will stay in the community for a while, at least.

Jun 8, 2009

The "brilliant" Larry Summers

Yes, it's Larry Summers time again. This time it's a piece in the New York Times on the workings of Obama's West Wing economics team. Here are the main descriptions of our Bad Boy in that article :
  • the brilliant but sometimes supercilious Mr. Summers
  • Mr. Summers, given his prickly personality,
  • His argumentative style
  • under Mr. Summers, meetings became “endless debating sessions,”
  • “Larry Summers is one of the world’s most brilliant economists,” said Mr. Orszag,
  • He enriches any discussion he participates in,
  • "....pretty good at making the case against anything.’
  • The arguments became so heated that Mr. Summers stormed from one meeting,
  • “incredibly inclusive” and “listens to the economic arguments"

So, there, amidst the questionable traits, and some good traits, is the ubiquitous "brilliant" description. Why do economists and the press that covers them continue to describe this man as "brilliant?" I'm sick of it. The man was instrumental in fostering public policies that led directly to the immensity of our current "Great Recession" (as we're now calling it). And, he has never owned up in public to his role in it.

So, can we now start referring to him as " the inclusive and argumentative, but mentally challenged, Mr. Summers?"

I'd feel so much better if the press would stop lipsticking the pig.

Jun 4, 2009

Robert Reich on GM, bailouts, productivity and US.

My prolific reader friend Lupi sent me link to three pieces by Robert Reich(Labor Sec'y under Clinton) on the future of our economy, as seen through the prism of the GM bailouts. (ReichPartI; ReichPartII; ReichPartIII). She knew I would like them. Reich always makes sense to me, but his sensible ideas never seem to make it into policy.
We really DO need a new political party in this country -- the Common Sense Party? -- the Centrist Party? My advisors tell me I'm a dreamer to imagine that the grass-roots power of the internet could bring about such a thing. I'd follow Reich if he announced such a move.
Turns out Reich has a blog where he posts wonderful stuff on all manner of public policy issues. Check it out here: Reich Blog. I'll put a link to it in the list of blogs here (scroll down to bottom in left column), so you can always find it. Or, just add it to your own Favorites list.

Jun 3, 2009

What it's like to be a Public school HS teacher at end of year

Early this week I learned in the Washington Post that students in a local suburban high school are waging a campaign to allow cell phone use in school.
At lunch, at the very least, they say. And today a Post editorial actually endorsed the change. (If that happens, all the more reason to send your kids to private or parochial schools.)
Now our "Teaching Stories" author (Ynonymous) has sent along another description of her life as a high school science teacher in a local suburban public school district. Issue 3- End-of-School-Year Thrills helps to put the state of the adolescent mind into perspective. Why would we want to enable students to self-distract any more than at present? Read it. You'll feel like you're there in the classroom, but you'll be glad it's she and not you!

Jun 1, 2009

Do workers need a week of guaranteed sick leave?

Now that we're through taking ownership of the company that makes the cars that we refuse to own, time to turn to improving working conditions for those of us who still have jobs. The Dems (101 of them) in the House have introduced legislation (HR 2460) to require every employer with more than 15 employees to offer 1 hour of paid sick leavefor every 30 hours worked, up to a total of 7 days per year. Read all about it in an informative About.com article. Sen Kennedy says that 89% of low-wage workers (low-wage undefined in article) are without any paid sick leave.
On the face of it, this sounds like a good idea. (Who wants coughing/hacking co-workers at the MacDonalds?) But Lupi R, who has close-up experience with small businesses that compete with low-cost producers in other countries, points out that it will put further strain on those firms struggling to make it in this economy. She believes that workers will be inclined to "use up" their sick leave every year, whether sick or not. Businesses that need to keep running will have to pay other workers time and a half to make up the difference. (As a retired Fed who hoarded sick leave, but only up to the point that I couldn't carry it over into the new year, I'm afraid she may be right. When it's use-or-lose, let's face it, we're gonna use!)
If you accept the labor economists' argument that total compensation is what employers pay (TC= wages + benefits), then greater benefits means higher TC. That makes us even less competitive than we already are. Or, more likely, employers will adjust wages downward to keep TC about the same as before. Of course, not every employer will do this right away, but the more competitive the sector, the more necessary such downward adjustment will be. Some employers will hire fewer workers and squeeze more work out of 'em. (How can that be? Aren't we a bunch of cellphone slaves as it is?) Some might demand higher cost-sharing for health coverage (oh, joy). Things have a way of working through the system. And, if they don't squeeze wages down, that's just more unemployment due to our even more evolved inability to compete globally.
Bottom line for me is that it's better to keep things as they are. If we want to subsidize workers without such benefits, we can do it through the myriad programs we already have to augment their incomes (earned income tax credits; subsidy programs; unemployment benefits, etc.) Mandates on employers, especially small businesses, are not the way to go right now, and perhaps right ever.
Do I sound like a Republican? Jeez! Either way you come out on this, you can weigh in with your congressman in minutes. Here's how.

Health Reform and the "Public Plan" option

The political energy in Washington has centered on two issues of late:
  1. Whether there should be a "public plan" option (think Medicare fee for service) along side private insurance companies
  2. Whether employers that offer health insurance should be able to deduct those costs as business expenses (a 35% tax subsidy if the company is making money). If so, should the deduction be capped in some way?

Number 2 -- that's important, and maybe I'll figure it out. (I'm not betting on it.)

Number 1- I don't have to figure it out. Victor Fuchs, the dean of health economists, figured it out for me in this week's New England Journal of Medicine. Here's the free link to his article in NEJM. Bottom line: public-schmublic...it's not going to matter that much. It's no panacea for the problems we've got, and it won't kill private insurance. The latter I'm not so sure about. The former -- based on all we know about how ineffective Medicare has been these past 50+ years in controlling costs or assuring quality -- is a slam dunk.

May 30, 2009

Why am I a Vitamin D advocate? Here's why..

As a health economist whose career was spent evaluating medical technologies, starting with the hypothesis that they do not work (i.e., show me!), it's been difficult for me to accept my own evolution to an advocate for Vitamin D testing and supplementation.
It took a failed hip replacement to get religion (as outlined in my Jan 1 post). Now, I may have tendency to go too far with my enthusiasm (see May 17 post), but I just found a great keynote presentation by Michael Holick, M.D., at a European medical symposium on calcium which explains why I'm a believer. Holick is a professor of medicine and physiology at the Boston University Medical School, and director of BU's clinical research center. We're not physicians, but this is still a fun presentation and will teach you a lot about why the medical profession is gradually coming around to the importance of Vitamin D. Ostoporosis, osteomalacia, fibromyalgia, rickets, TB, psoriasis, rheumatoid arthritis, prostate cancer, colon cancer, breast cancer, MS, ..etc. He'll make you understand the evidence and you'll enjoy the talk. So click on his presentation and take the 20 minutes to listen. Also - it will allay your fears (and maybe your doctor's fears) of overdoses.
Dr. Holick's own web page VitaminDHealth.org is geared toward physicians but is a great resource on clinical questions regarding D.
Update: June 22- A really interesting comment pointed to this blog post by an anthropologist whose contrary view seems very well reasoned.

May 28, 2009

Social Security-Medicare for the @65 crowd

Since my time for Medicare eligibility is creeping up at its petty pace, I paid attention to this report out of the Kaiser Family Foundation, detailing how the cost-of-living-adjustments (COLAs) for Social Security (SS) and the Medicare Part B premium updates are going to interact for 2010 and 2011. And, since many of my friend-readers are in my age group, you should know about this too.
First off -- for 2010 and 2011, it looks like the SS COLA is going to be 0%. (If you're old, you did well in 2009 with your 5.6% COLA increase, so don't complain.) But Medicare premiums are going to increase, which means that your net SS check would decline.
But WAIT, there's a "hold-harmless" clause in the law that says -- with certain important exceptions outlined below -- if the extra Medicare premium exceeds your SS COLA update, the Medicare Part B premium will be adjusted down, so your net SS check doesn't decline. So, that means with a 0% SS increase, you won't have to pay more for the Medicare premium in 2010 and 2011. Great huh?
But WAIT... it might NOT help you, especially if you're around my age and are not going to be enrolled in BOTH SS and Medicare in 2009. (About 25% of all 2010 Medicare beneficiaries don't get the benefit.)
The three groups who will NOT benefit from this hold-harmless clause, and WORSE, who will actually pay for the entire cost increase for all 100% of beneficiares are as follows:
  1. People who are NOT in both programs in 2009. That's US, baby, especially if we have our critical 65 birthday Jan 1 or after. Or, if we delayed taking our SS until the full benefit kicks in when we turn 66. So, if you're entering one or both programs (SS & Medicare) in 2010 or 2011, you'll be paying higher Medicare Part B premiums, not only for self, but for your older sisters (!!!!) and brothers who will be sitting pretty. (About 3% of 2010 Medicare enrollees fall into this category according to KFF.)
  2. People who are "filthy rich." According to government, that's anyone who's in both programs in 2009 but whose "modified adjusted gross income" was $85,000 or greater for individuals and $170,000 or greater for couples. (For vast majority of us, MAGI=AGI. For full definition, click here.)- about 5% of Part B enrollees.
  3. People who are in such dire straits that they're eligible for both Medicare AND Medicaid. They don't pay any Medicare premiums anyway..The Medicaid program pays Medicare on their behalf. (Medicaid is a shared Federal-State government program, so our tax dollars or Treasury debt will pay for this part of the Medicare population's increase.) (About 17% of 2010 Medicare enrollees.)

Bottom line? If you're in Group 1 and/or 2: get ready for a 2010 Medicare Part B premium of $104.20; if not, you have to pay only $96.40 a month. In 2011 it becomes even more Kafka-esque: You'll pay $120.20 if you come of age in 2011 (group 1) or if you're still rich. Your not-so-disadvantaged older sisters will still be paying $96.40.

If you want to complain to your congressman, see my post of April 29 on How to Contact your Congressman or Senator. As for me, I'm just going to accept this surcharge as payment for the many times sister Janet took me to the Castle Theater in Irvington NJ to see Sylvester and Tweety bird. She could have let go of my hand at Springfield and Clinton, and the world would have been spared my blog!

Message to Janet: You're going to owe me a steak dinner in 2011!

May 26, 2009

A Heroine for Our Time -- Brooksley Born

When I started blogging back in October 08 with screeds against Rubin, Summers, Greenspan, and Phil Gramm (The 4 horsemen -- Hear No Evil, See No Evil, Speak No Evil, and Evil) I did mention "our gal Brooksley Born" as the voice in the wilderness back in the late 90's.
Today, the Washington Post has a wonderful profile of Born, and it's a MUST READ for 2 reasons.
First, it should make us email the White House, demanding that Larry Summers actually apologise for his role in the meltdown as a condition for keeping his job. Alan Greenspan did it, and I've forgiven him. Phil Gramm is a jerk, and he's now out of Congress, so we won't worry about him. Rubin...well, he's only in the background today, and he made a half-apology, which is good for neanderthal man. But Summers has apologised only for not having predicted an 8-year Republican administration that would 'ruin' all his great work. (Heard that one on Boston's WBUR On Point, April 3, 2008.) Is an apology enough? For that man, it's a necessary first step to humility, the economist's equivalent of sobriety.
Just as important, though, is the profile of Brooksley Born's life in the Post article, which should be read by every post-feminist woman (i.e., 20-somethings) who hasn't lived in a time when a truly extraordinary woman would face barriers at every turn. I was shaking after reading the story. She was a pioneer at a time when professions weren't open to women, and she was active in the women's movement to help open up opportunities. Sandra Day O'Connor's and Ruth Bader Ginsburg's stories we know. Brooksley Born's I didn't. I love her!

May 19, 2009

Face Masks and Swine Flu

My earlier questions (May 7 post) about whether face masks will be available if the "novel H1N1" (aka Swine!) flu becomes more Spanishy over time has been answered by an excellent article in today's Time Magazine. (We'll miss the mainstream news media, won't we?) "New Pandemic Fear: A Shortage of Surgical Masks".
Short answer -- yes, they'll be in shortage, but maybe they don't work anyway. All I know is that I rub my nose a lot, and having something between my hands and it would be a good thing in an airplane, or anywhere in public, for that matter. Hand sanitizer is still a must, of course.
Friend Linda (a true health policy wonk--some of you know her) shared 2 N95 masks with me on my last plane trip -- which I still have (thankyoulinda) -- and also shared the following email (from May 7) from a major distributor of N95 masks :
The N95 mask that you are looking for is on a manufacturer backorder currently. We do have a similar N95 mask. It is from Kimberly Clark. Our item # is 153-4801. The difference is it is slightly smaller and a little different shape, but still is N95 equivalent. It is on page 261 of our catalog. It comes 35/box and the price is $40.79/box. Please take a look at that mask in our catalog. If you do not have a catalog, please visit our virtual catalog on our website at www.henryschein.com.
So, there you have it. Info on whether the gov't is ready (no), and a ready source (at least as of May 7) of N95 masks.
Hope I don't have to retract this post. It's so embarrassing.