The Alan Katz Health Care Reform Blog

Health Care Reform From One Person's Perspective

Health Care Reform 2009: Required Reading

Posted by Alan on January 18, 2009

Health care reform will be painful enough without requiring home work, but such is life. Here then is the required reading list for understanding the 2009 health care reform debate, where it’s going, and why.
(Note: a second list of health care reform required reading was added June 2, 2009 and a third list was added on August 11, 2009)

1. Critical: What We Can Do About the Health-Care Crisis by Tom Daschle withScott S. Greenberger and Jeanne M. Lambrew.

Former-Senator Daschle will be leading President Barack Obama’s health care reform effort, both in his position as Secretary of Health and Human Services and as Director of the Office of Health Reform inside the White House. Ms. Lambrew will be serving as Deputy Director of the Office of Health Reform. That there even is an Office of Health Reform highlights the importance of this issue to the incoming administration. That the Director of this office is also a Cabinet Secretary enhances the prestige — and clout — of both the office and its leader.

This makes understanding soon-to-be Secretary Daschle’s outlook on health care reform, well, critical. His book, Critical serves as a blueprint to his thinking.  Although the book was written before the identity of the Democratic nominee would be, Senator Daschle was an early supporter of Senator Barack Obama. It’s not surprising that his proposal ties-in well with the then presidential candidate’s health care reform proposal. Senator Daschle’s book, however, goes further.

Core to his solution for what ails America’s health care system is the creation of a Federal Health Board. Modeled after the Federal Reserve Board, it’s aimed at removing effort to control health care costs one step away from the day-to-day politics of Capitol Hill. “I believe a Federal Health Board should be charged with establish the [health] system’s framework and filling in most of the details. This independent board would be insulated from political pressure and, at the same time, accountable to elected officials and the American people. This would make it capable of making the complex decisions inherent in promoting health system performance. It also would give it the flexibility to make tough changes that have eluded Congress in the past.”

Specifically, Senator Daschle would have the Board set the rules for the national health exchange he would create. Through its own research and helping to prioritize research by other federal agencies, the Board would help promote “high value” medical care by “ranking services and therapies by their health cand cost impacts.” Senator Daschle would also have the board “align incentives with high-quality care.”  This would be done through evaluating new technologies as well as by aligning provider payments made by the federal government with health outcomes, rather than with services delivered. Finally, Senator Daschle would ask the Board to assist in “rationalizing our health-care infrastructure” by issuing an annual report identifying where investments are needed across the country — and where they’re not.

In addition to providing a blue print for the Obama Administration’s future health care reform proposals, Senator Daschle does an exceptional job of describing the history of America’s health care reform efforts from 1914 through the present day. As a participant in much of that history, his review can’t help but reflect his own biases, but Senator Daschle ably places today’s debate in an appropriate context.

What’s most encouraging about Critical is that it signifies a clear understanding of the central role controlling medical costs holds in reforming the system. This doesn’t mean Senator Daschle won’t seek to change the health insurance industry. He calls for expansion of federal programs, including a government program that would insure most individuals and small groups. For insurance agents, what is most disconcerting is that Critical never once mentions the role agents play in the current system nor what role Senator Daschle foresees agents playing in his vision for a future system.

 Nonetheless, Critical is important reading as Washington prepares to address America’s health care challenges.

2. Key Issues in Analyzing Major Health Insurance Proposals, by the Congressional Budget Office, published December 2008.

The Congressional Budget Office provides critical input to lawmakers on the expected impact of their legislative proposals. A negative analysis ruling can — and probably should — kill a bill; a positive one can help build momentum and support. Key Issues is not aimed at instructing members of Congress what to do about health care reform. Instead, it lays out how the CBO intends to evaluate whatever proposals Congress generates. As the report notes, “This document does not provide a comprehensive analysis of any specific proposal; rather, it identifies and discusses many of the critical factors that would affect estimates of various proposals.”

The budgetary impact of any health care reform proposal will be critical to its eventual success. The CBO document lays out in significant detail how it will go about measuring that impact. In doing so, the CBO provides a host of statistics, graphs and data that will be bandied about during the debate.

As if all this wasn’t enough to make Key Issues  a must read, Peter Orszag was Director of the CBO when the report was prepared. Mr. Orszag will be Director of the Office of Management and Budget in the Obama White House. In that role, he will have a great deal to say about the financial impact of various reform plans. Given his involvement, it’s not unfair to expect the Administration’s analysis to closely mirror the Congressional analysis described in Key Issues.

3.  Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program,” by the Centers for Medicare & Medicaid Services.

The upcoming reform debate will be peppered with calls for “transparency,” paying for “value, not services” and for making commercial coverage as cost effective as Medicare. So it makes sense to see what the folks who run Medicare are thinking about concerning these issues. This report is CMS’ effort to help lawmakers “create rationale approaches to lessen healthcare cost growth and to identify and encourage care delivery patterns that are not only high quality, but also cost-efficient.”  The report describes the programs and demonstration projects already put in place by CMS to “foster joint clinical and financial accountability in the healthcare system.”

The CMS report is a tougher read than the other’s on this list. But given that any reform proposal will need to tackle skyrocketing medical costs, the report is worth the time.

I’ll add to this list in later posts, but these three items are a good place to start. And remember, if you think the reading list for health care reform is bad, just wait until you see the final exam.


9 Responses to “Health Care Reform 2009: Required Reading”

  1. Helmut said

    The current health care debate will not lead to any acceptable solutions because it addresses peripheral questions which are subject to demagoguery and influence peddling. The debate has to be reframed about allocation of limited resources. Yes, even other people’s money (taxes, insurance premiums and chinese investments in government paper) is a limited resource. In any insurance plan, government or private, we spend a limited resource. Rationing, therefore, is inevitable. The question is how do we want to ration and what do we want to ration? We are currently rationing healthcare without contentiousness in the case of organ transplantation because the resource limit is obvious to everyone. This is done by an evidence based allocation system which generally works well in spite of many competing interests, Mickey Mantle’s case not withstanding.

    To this end the government can provide the legal framework and infrastructure for healthcare reform without getting directly involved in healthcare decisions.
    Individuals have to be become aware of and take some personal responsibility for the costs, it will get everyone focused on meaningful reform. The market and choices by informed individuals with an apparent and understandable financial risk will do the rationing.

    A few simple suggestions: Remove the unfair tax break for employees receiving health insurance through their employment. If we subscribe to the concept that everyone should have access to healthcare the insurance risk pool should be the entire nation and not carved up by regions, age groups and other means that facilitate cherry picking by insurance companies. Healthcare insurance is different from car insurance. This of course implies that every one has to participate. Individuals who opt out do so at their own risk. They can join later with a premium on their rates (similar to what is currently done by Medicare). The government would have to support those who cannot afford the costs of a basic plan through gradated tax rebates or similar tansfer systems financed by an healthcare specific income tax surcharge. Everyone buys his or her individual policy which is portable and cannot be cancelled. Have the same rate for any insurance plan offered nationwide, without regard for age or preexisting condition. Discounts or increased premiums should be allowed to encourage behavior modification (smoking, weight reduction etc). Under this concept one could even consider gradually rolling over Medicaid and Medicare into the system. The insurance companies would then truly compete on price and would have an interest in fostering preventive care since their risk does not stop at age 65. Insurance companies can negotiate with care providers and pharmaceutical companies for best prices and reimbursement methods e.g. global payments for episodes of care and similar concepts to align incentives and get away from fee for service payments. Negotiated fees and reimbursements should be transparent and in the public domain. To further reduce over-utilization co-pays are essential, possibly supported by healthcare savings accounts.

    The government should heavily invest in outcomes research so that evidence based guidelines for best practices can be developed and updated as new technologies are being developed.

    Electronic medical record systems have been advertised as a huge potential saver of healthcare expenditures. These systems are in their infancy, expensive and so far have not lived up to their expectations. Development of a national standard for compatibility between systems is essential for transfer of information if reduction in the duplication of tests is to be realized.

    Since defensive medicine is another driver of costs, tort reform should be part of healthcare reform.

    Since we spend 30% of Medicare expenditures during the last month of life the issue of futility, predictors of outcome, and end of life choices have to be discussed without cheap rhetoric of “pulling the plug on grandma”. To this end the government should support and fund outcomes research so that individuals and their surrogates can make informed choices based on credible recommendations by their physicians. We have oversold technology and raised false expectations for too long a time. The american public has to learn again that death is an inevitable part of life and not an option. This will take a major shift in attitudes and expectations which unfortunately cannot be solved by any legislative reform.

  2. Andy said

    What are your thoughts on Obama’s new Robin Hood Health care reform. As I discussed recently, , this bill may have a shot at working despite many an administration having fallen into the deep abyss of health care reform, because none have had the political capital and forces that support the Obama administration.

    Still if you are rich, this plan is going to hurt you.

  3. I have to say, that I can not agree with you in 100%, but that’s just my IMHO, which indeed could be wrong.
    p.s. You have an awesome template for your blog. Where have you got it from?

  4. It is heard every time at the time of election, Health care Crisis , Health Care reform over and over the candidates discuss it but never resolve it. Ameriplan USA offers an alternative to the crisis with its’ consumer driven health care benefits. The benefits are affordable and cover every preexisting condition and 1 low price covers the entire household. Ameriplan is not Insurance so a Consumer does not have to worry about a bean counter sitting behind a desk and denying them a much needed treatment. Physicians like the program because it increases cash flow and no billing or collections costs are accrued. The Physician or specialist receives payment from the Consumer at the time service is performed and the Consumer receives a discount. This is a win win situation for all parties concerned and controls health care costs. The new Administration should take a look at this Company that has been doing tis for over 17 years now.

  5. mike said

    This is my first time to this site and I must say, very interesting reading and forwarding thinking individuals. While I am sure that with more time for perusing I would find what I’m looking for, but what about the providers. Is there anyone out there with a finger on our pulse? Does anyone understand the dilemma that faces the practitioners’ in this equation. If the system is to be based on the efficiency of the MediCare system, I think we may all be in for a rude awaking. If I were to have to sustain my practice on the fee schedules from payers’ like Medicare and BCBS, I would without a doubt be out of business. Is there anyone out there with a few reassuring words for someone like myself who’s surgical practice hangs in the balance.

  6. Liz said

    Have you read the new ‘Call Letter’ by CMS, it just came out on January 20, 2009. it is about 90 pages this letter explains the new guidelines for MEDICARE.
    although they talk about using a NPI for contractors and Online enrollments only, they have not yet made a “commission statement” like the one they issue on December 24 08. We all should pay attention to CMS/MEDICARE since it seems that’s how “universal health care will go “

  7. Govindan said

    It was quite a good read, will come back for more.

  8. On January 16, 2009, the Centers for Medicare & Medicaid Services (CMS) released 3 publications outlining the activities that CMS has undertaken to improve the quality and value of health care and move the Medicare fee-for-service system toward paying for the quality and value of care. See the Medicare Update weblog’s post at

  9. All essential reading, to say the least, as they already occupy a sizeable corner of my “reading table”! Might I suggest two additional resources that I have found very helpful as well:

    1. “Healthcare Ethics in a Diverse Society”, by Micael C. Brannigan and Judity A. Boss

    2. The newly launched website by the RAND Corporation “Comprehensive Assessment of Reform Efforts” at which is a first-of-its-kind online resource that synthesizes what is known about the current health care system, provides information on proposals to modify the system and delivers insight about how potential policy changes are likely to affect health care delivery and costs in the United States. Beware, it is a bit addictive and could be called a policy wonks version of a cerebral video game!

    The challeng of reform will require best efforts on all our parts and a good deal of homework as you have said!

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