Health Care Reform 2009 Style

When it comes to health care reform 2009 has been an interesting year. And while comprehensive health care reform legislation will not be arriving on President Barack Obama’s desk this year, it is all but certain that will happen early in 2010. Getting to this penultimate moment has, to put it mildly, taken some doing. And the process says a lot about America and its leaders.

Health Care Reform Activity

President Obama had made clear throughout his campaign for the presidency that health care reform would be a top priority of his new administration. He lost no time making his promise real after his inauguration. Expansion of the State Children’s Health Insurance Plan, a proposal twice vetoed by then President George Bush, along with significant funding for medical technology, were a part of Administration’s economic stimulus package.

President Obama’s health care reform efforts took a serious blow in February when former Senate Majority Leader Tom Daschle was forced to withdraw his nomination as Secretary of Health and Human Services and as Director of the White House Office on Health Reform due to problems with his past tax returns. Senator Daschle is a political pragmatist who is highly regarded by lawmakers from both parties. Would the health care reform debate have been more civil had Senator Daschle led the White House reform effort? We’ll never know. What we do know is that civility quickly left the room as the House and Senate Committees with jurisdiction on the matter began their deliberations. The health care reform debate was passionate, raucous and partisan to the extreme. Neither party and no ideology is blameless for this descent into the dark side of politics. Both have benefited from it (although none as much as the 24 hour cable news channels) and both have sullied their standing with the public as a result.

Given what’s at stake when 1/6th of the nation’s economy is subjected to the legislative process, there may have been no avoiding an ugly health care reform debate. President Obama made clear in a speech in February that he wanted health care reform passed quickly. Many Republicans (and their talk show host allies) made it clear they’d rather see no health care reform rather than anything along the lines being proposed by – or that would politically benefit – President Obama. Meanwhile, the House Ways and Means, House Education and Labor and the Senate Health, Education, Labor and Pensions Committees pushed through liberal bills; anchors on the left in anticipation of the negotiations to follow. The resulting climate promoted intense partisanship.

Eventually more conservative Democrats forced the House Energy and Commerce Committee to slow done and moderate the legislation, although what they passed would still be considered “liberal” by most definitions.  All the House bills passed out of the committees without a single Republican vote. Meanwhile Senator Max Baucus was trying to fashion legislation that might gain the support of at least three GOP members of the Senate Finance Committee. (He would eventually manage to get the support of only one GOP Senator).

The difficulty of finding common ground between liberals and conservatives on health care reform was made abundantly clear during the summer of 2009. The disruption of lawmaker’s town hall meetings were reminiscent of the anti-Viet Nam War protests of the 1960’s. (I suppose it’s ironic that many of those shutting down the town hall meetings had participated in the anti-war protests more than 40 years earlier). The passion and concern of the health care reform protests were as sincere as some of the rhetoric and actions were unfortunate and despicable (death threats and swastikas are inherently contemptible and disgraceful). The protests did assure, however, that Republicans would remain united against the kind of reforms being pushed by the Administration.

Reform was being pushed by the White House even if the Administration was declining to define reform. Instead the White House broadly described the key elements they’d like to see in a reform bill. President Obama’s three core principles for health care reform called for reducing costs, guaranteeing choice and ensuring quality care for all. He would later add other conditions (e.g., reform could not add to the deficit), but the details of the bill were being hashed out in Congress by Democratic lawmakers. The result, much to the chagrin of liberals, was that over time the legislation became increasingly moderate culminating in the legislation passed out of the Senate Finance Committee with the support of only one Republican, Senator Olympia Snowe.

With all the committees of jurisdiction having staked out their positions it was time for Speaker Nancy Pelosi and Senate Majority Leader Harry Reid to pull together the pieces into bills that could pass their respective chambers. Speaker Pelosi succeeded first with the House passing a health care reform in November. The price of passage was high: liberals had to accept language dealing with abortions that sparked outrage in the pro-choice community.  It took the Senate more than a month to follow suit, but eventually they did. Now it’s up to a conference committee to pull the pieces together into one bill that can pass both the House and the Senate. Not an easy task, but with the finish line in sight it’s very doubtful lawmakers will falter now.

The Public Policy Dimension

While the activity swirling around health care reform has been … interesting, the evolution of the substance of the legislation has been even more fascinating. Not all that long ago liberal lawmakers were claiming a health care reform bill lacking a government-run health plan was no health care reform at all. They seemed to believe that a public health plan was the magic wand that would remake America’s health care system into something fair, competitive and wonderful. Or maybe they just thought the public option was a way station on the path to their promised land: a single payer system. While the House bill would create a new government health plan, the Senate legislation rejected the public option. While liberals outside of Congress continue to attack reform without a public option, liberals lawmakers seem to accept the inevitable. What emerges from the conference committee will no doubt lack a public option and liberal lawmakers will still support the reform package.

While liberals were losing a public option an unlikely coalition of conservatives and liberals were also watering down a requirement that all Americans purchase coverage. Conservatives dislike the idea as a restriction on the freedom of people to have their health care reform subsidized by higher health insurance premiums for everyone else. Liberals don’t like it because, apparently, the result is a windfall for evil health insurance companies. (OK, they offer more substantive public policy arguments against the individual mandate, but the rhetoric focuses on freedom and windfalls). Never mind that requiring health plans to sell coverage without requiring individuals to buy coverage before they incur claims is a recipe for higher insurance costs or that many states require drivers to buy auto insurance. As the legislation has moved through Congress the penalty for failing to purchase coverage has drifted toward a slap on the wrist end of the spectrum.

Other issues have taken interesting turns as well. Reimbursing doctors for counseling to seniors concerning living wills and the like was removed from the bill once the discussions were labeled “death panels.” What taxes will be imposed to pay for health care reform is still uncertain. Anti-abortion advocates have done a masterful job of inserting abortion into the debate. Both the House and Senate bills contained provisions that could “bend the cost curve” (which is apparently the new articulation of what was once called cost containment). If all the cost cutting provisions in the current bills were moved into separate legislation it would actually look like a serious effort. Mixed in with the health insurance reform dominating the current versions, however, the provisions appear weak and almost an afterthought.

Health Care Reform 2009: The Human Factor

So what to make of health care reform 2009 style?

First, that the legislative process is messy and can be downright uninspiring. Second, that tackling an issue as important and complicated as health care reform cannot overcome the need for partisans of both parties to put aside the public good for their political stratagems. Third, that the health care reform package that finally passes will be far more moderate than might have been apparent earlier this year. Fourth, criticism that Congress is moving too fast on reform are really complaints that Congress is not doing what critics leveling this charge want them to do. The health care reform bill that will find its way to President Obama’s desk in 2010 will be over a year in the making. Longer if you count the debate on health care held during the 2008 presidential election. Longer still if you include the previous health care reform efforts undertaken over the past several decades.

We elect politicians to hold office because they promise to address problems. No one has ever won a campaign on the promise to do nothing if elected. In 2008 Democrats won, and won handily, in part on a promise to solve the problems posed by America’s current health care system. They are fulfilling that promise. In the process they will create new problems.

Because the fact is we humans rarely solve problems. Instead we tend to replace existing problems with new ones. And if the 2009 health care reform process has taught us anything, it’s that the people who make up the Administration and Congress (and the general public) are only human. Anyone looking at the health care reform package emerging from Congress would find evidence of that reality.

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Walgreens Free Health Clinic Visits a Sign of the Times

You can look at this story in several ways. Walgreens is offering free health clinic visits to unemployed and uninsured individuals. According to the Associated Press, individuals and their uninsured dependents who become unemployed and uninsured after March 31 will be able to receive free treatment at Walgreen’s in-store clinic, which operates under the Take Care brand name. The typical visit costs $59 or more. Take Care’s lab partner, Quest Diagnostics, is helping out by offering tests for strep throat and urinary tract infections at no cost.

How you interpret this says something about your health care reform biases. Some will see this as further proof that the private sector can fill in the cracks of the safety net. After all, Take Care clinics are a for-profit entity. The press their receiving for this program and the positive word-of-mouth they’ll be receiving. Additionally, since the Take Care program provides free services for treatment that might otherwise wind up in an emergency room or urgent care center, they may make some sales of their other services such as immunizations or makes additional over-the-counter drug sales. So what they’re doing is an example of a market-driven win-win: consumers get care; Walgreens gets more customers.

The other perspective is that this effort highlights the cracks in the system. Newly unempl0yed who don’t qualify for government medical assistance through Medicaid or the State Children’s Health Insurance Plan (SCHIP) are poorly served by today’s system. Without employer based coverage and unable to afford individual insurance, they must rely on a drug store for their health care. There’s something wrong with that picture.

My take: Walgreens is to be commended for reaching out a helping hand to those who need it, even if they’ll profit from the gesture. And universal, portable and affordable health care coverage is needed and needed soon. The current system works well for most Americans, but as a nation it’s our culture not to leave anyone behind. The lesson here isn’t that we need a government-run system, but that we need a more comprehensive, integrated and sensible system to assure basic health care coverage to all Americans.

Coming Soon: A Down Payment on Health Care Reform

The battle over the State Children’s Health Insurance Plan (SCHIP) was one of the most emotional battles of between Congress and the White House during the Bush Administration’s waining years. Twice, bi-partisan majorities of Congress passed the reauthorization legislation. Twice President George Bush vetoed the bill. Although the votes for an override were available in the Senate, it narrowly lost in the House. That’s now about to change. Congress is working hard to have a reauthorization of the State Children’s Health Insurance Plan (SCHIP) ready for the new president’s signature as soon as possible — it will be tough, but possibly even on inauguration day.

SCHIP provides health insurance for children in households that earn too much to qualify for Medicaid, but are unable to afford private coverage. States administer the program and, within federal guidelines, may adjust eligibility. They also pay a significant portion of the program’s cost. Currently, about six million children are covered in the popular program.

Congress twice voted to expand the SCHIP program in late 2007, but could not muster enough votes in the House of Representatives to overcome President George Bush’s vetoes. That was then. Now Democrats have stronger majoirites in both the House and Senate. Even more significantly, President-elect Barack Obama is a supporter of the expansion.

According to the Associated Press, discussions on how to approach the SCHIP reauthorization have been underway in Washington.  Although there was some thought of including SCHIP expansion in the forthcoming economic stimulus package, the decision seems to have been made to move forward with the stand-alone bill. While not promising to have the legislation ready for signature on inauguration day, House Speaker Nancy Pelosi promised “we’ll be done soon,” according to AP.

The first test for the SCHIP reauthorization will be in the House Energy and Commerce Committee. The Committee’s chair, Congressman Henry Waxman, called passing the legislation a “down payment on national health insurance.”

Passage of the SCHIP reauthorization would be more than a symbolic breaking with the past. The current recession is placing greater demands on safety net programs like SCHIP. In addition, states pay a significant portion of the coverage provided by SCHIP (from  17 percent to 35 percent depending on the state). Knowing where the program stands — and how much funding they can expect — is of critical importance to state lawmakers struggling with their own hemorrhaging budgets.

How Congress will pay for expanding the program still needs to be worked out. In 2007 the legislation included a 61-cent per pack tax on cigarettes. This was expected to allow the program to insure as many as 10 million children.

SCHIP is a critical component of the patchwork quilt that is America’s health care system. A majority of both Democrats and Republicans agreed it should have happened over a year ago. That it took a new Congress and a new President to get the job done demonstrates how hard achieving comprehensive and meaningful health care reform will be. But to use Congressman Waxman’s terminology, it’s a down payment well worth making.

National Health Care Reform: Later Than Sooner?

Whether comprehensive health care reform is needed is no longer debated on Capitol Hill. The only question is when it’s coming. I’m among those who have been predicting that the Obama Administration and Congress will move quickly to enact comprehensive health care reform. I’m far from alone in this: incoming Secretary of Health and Human Services Tom Daschle thinks so, too. In fact, so does incoming President Barack Obama. Throw in several leaders in the U.S. Senate, including Senators Ted Kennedy and Max Baucus and you’ve got a growing conventional that universal coverage will be coming sooner or later.

But this consensus is not universal. Representative Pete Stark will have a big say on health care reform as chair of the Health Subcommittee of the Ways and Means Committee. And, according to The Hill, he’s saying Congress is unlikely to be ready for a vote on health care reform until “the end of 2009 or the beginning of 2010.”  The problem, according to Rep. Stark, is that there are simply too many competing priorities, including the economy, to get to comprehensive reform. This doesn’t mean less grand reforms won’t happen early in the new Administration (e.g., expansion of the State Children’s Health Insurance Program (“SCHIP”)), but even those could cause a delay in working through a major reform package, according to Rep. Stark.

Rep. Stark, a California Democrat who has served in Congress for 35 years, encourages a deliberate approach to comprehensive reform. According to The Hill he believes the House “needs to build toward health reform through the regular order. ‘I think you have to give everybody a chance to have a hearing,” including interest groups. Of note, Rep. stark pointed out the need to hear from the American Medical Association, the American Hospital Association and the Pharmaceutical Research and Manufacturers of America. He dismissed the need for the health insurance industry to buy-in to the reforms, however. Predicting they would never support a Democratic health care reform package, Rep. Stark said the industry’s opposition won’t change much. “They’re going to be easy to roll because nobody likes insurance companies.”

Rep. Stark is not the only voice suggesting health care reform will take some time. Senator Charles Schumer, who sits on the Finance Committee, in April told The Hill, “Health care I feel strongly about, but I am not sure that we’re ready for a major national health care plan.”

While there is broad consensus that reform is needed, the debate will grow contentious as details of a plan emerge. Current allies may find themselves on opposite sides when the nitty meets the gritty. Or as Michael Cannon of the Cato Institute put it in USA Today, the interest groups “all want to be at the table because they don’t want to be on the menu. Sooner or later, someone is going to be on the menu. You can’t do comprehensive reform without goring someone’s ox.”

Beneath all the flying metaphors is the realization that achieving comprehensive health care reform won’t be easy. It’s also vitally important. The Obama Administration and Congress should take the time needed to get it right. Because there are no do overs when you’re tinkering with 16 percent of the nation’s economy in the middle of a recession.

Public and Private Sectors Facing Tough Health Care Decisions

I’ve written numerous times in this blog on what’s needed to achieve meaningful health are reform: increase access to health care coverage; and constrain escalating medical costs. The latter is the most important. If we don’t get control of health care costs we won’t be able to afford to provide access. Not only that, health care costs will vacuum resources away from other important societal needs.

There’s been some success in recent years on increasing access. The State Children Health Insurance Plan has resulted in coverage for millions of children that otherwise would likely to have gone without. Carriers have created innovative products that have proved popular with young people and those seeking catastrophic coverage. (There’s also been numerous disappointments during that time, when opportunities to expand coverage failed).

In fact, a substantial component of the uninsured could obtain coverage today. As Aetna CEO Ron Williams noted at a meeting of the Business Council in Florida last week, 20 percent of the uninsured are eligible for Medicaid and the state children’s health programs, but fail to enroll in those programs. In an article on the conference by Jason Szep of Reuters, Mr. Williams also noted that 10 percent of the nation’s 47 million uninsured are college students and “could be easily and relatively cheaply enrolled for health care insurance.”

At the same conference, Angela Braly, the CEO of WellPoint, called for expansion of programs aimed at children and low-income families. WellPoint estimates this could cut the uninsured by 25 million if all 50 states acted to cover all children and increasing eligibility for Medicaid.

It’s true that too many of those eligible for public programs fail to enroll in them. It’s true that some states have had success in requiring college students to have health care coverage. And it’s true that expanding children and low-income health programs would bring many of today’s uninsured into the system. The problem, however, is that these programs are under tremendous stress. The safety net that has assured health care for all is crumbling.

In Los Angeles, for example, there are plans to shut 11 health clinics to meet the county’s $195-$331 million budget deficit. According to the Los Angeles Times,  a majority of the Board of Supervisors opposes these closures, but simultaneously, health officials are drawing up contingency plans that would shutter all of the county’s health clinics — facilities that provide “more than 160,000 urgent care visits and nearly 180,000 specialty care visits a year, mostly from the uninsured and poor.”

Meanwhile, in Sacramento, doctors providing care to Medicaid patients will see their reimbursement rates cut by 10 percent as the state makes a mid-year adjustment to its hemorrhaging budget. As a result, fewer physicians are likely to accept new Medicaid patients or some may stop seeing program participants altogether.

America’s current health care system is already a mix of private and public health care programs. The private sector is under attack for its rescission practices, among other issues. The public sector is going broke and, even in the best of economies, seems unable to reach out to all those promised care.

What’s needed is a national dialogue about priorities. If Americans are serious about expanding coverage, they’re going to have to find a way to pay for it in good economic times or bad. And that means keeping it affordable. States should not balance their budgets by breaking their promise to those whom they promised coverage.

The private sector is also going to have to clean up its act. Behaving legally is not enough, they have to act right. Carriers need to act in ways that earns the public’s respect by demonstrating an appreciation of the critical role these enterprises play in society — a role that requires them to meet a higher standard than most corporations. Business as usual could mean no business at all.

There’s a strong demand among voters to change the country’s health care system. Given all that’s happening, that’s not surprising. And, given all that’s happening, it’s not going to be easy, either.

Another Health Care Reform Disconnect (collect them all)

Dealing with health care reform does strange things to people, especially to politicians. Regardless of party. For example, it’s not uncommon to hear Democrats bemoan President George W. Bush’s veto of the State Children’s Health Insurance Plan (SCHIP) expansion and criticize California lawmakers for cutting back on health services to balance the current (now severely out-of-balance) state budget, while at the same time proclaiming that the way to improve health care is to turn it all over to the government to handle. That this is the same government that vetoes SCHIP and cuts health services doesn’t seem to faze them. Maybe I’m missing something, but isn’t this a serious disconnect between reality and theory? 

The GOP can disconnect principles from proposals, too. There are Republicans who frequently call for letting the states chart their own course on issue after issue, but who also propose doing away with a state’s ability to regulate the health insurance carriers and HMOs selling to its citizens.

I was chastised by a reader for an earlier post that discussed GOP lawmakers taking themselves out of California’s health care reform debate by refusing to consider any tax increases under any circumstances. “Since you are not a Republican, do not waste your time trying to think like one,” wrote Tom Johnston. A fair point and a kindly phrased suggestion, concerning those he could have made.

So I know I’m on thin ice here, but …. If it’s inappropriate for the federal government to tread on a state’s rights, isn’t it just as wrong for it to empower other states to intrude on those rights? If New Hampshire has one regulatory scheme, should health plans be able to sidestep it by filing in Wyoming? Won’t this jurisdiction shopping process simply lead to carriers filing in the state with the most industry friendly regulation? If regulations in a state are too severe, shouldn’t the voters of that state demand changes, not have it thrust upon them by voters somewhere else?

Yet, according to a Kaiser Family Foundation web site tracking the health plans of presidential candidates, this is exactly what health care reform proposals put forward by former-Mayor Rudy Giuliani, Congressman Duncan Hunter and Senator John McCain would do. Of course, they don’t put it this way. Instead it’s couched as “Permit individuals to purchase insurance across state lines.” Or “Promote competition and individual choice of insurance by allowing insurance to be sold across state lines.” Sounds better, but it’s the same result.

Eliminating unnecessary regulation is one way to reduce the overall cost of health insurance. But promoting states’ rights on one hand while eliminating their ability to regulate health insurance plans sold within their borders makes as much sense as condemning how poorly the government deals with health care on one hand while giving it complete control over the entire health care system on the other.

As I said, dealing with health care reform does strange things to people.

Why a Compromise Matters

It is true that no health care reform is better than bad reform. And to judge from the eulogies already being written (e.g., “Analysis: No easy Rx for health care’s hurdles,” from the Sacramento Bee and “Cost key issue for health care proposal,” from the Associated Press), it appears the likelihood of comprehensive reforms in California is increasingly unlikely.

For some, this is a relief because aspects of the reform package being negotiated in Sacramento are, well, bad. But no one should rejoice that the year of health care reform seems to be fizzling out. A series of articles on Monday in the Los Angeles Times by reporter Susan Brink shows why.

In one story, a Dana Point family of five goes without coverage because it’s “unaffordable” on their $70,000 annual income. As it turns out, focusing on this family was a questionable choice. As many of the reader comments point out, they apparently consider health care coverage less important than other, perhaps less critical, lifestyle choices. (The article also highlights the need for a good agent. The family claims coverage they’re looking for would cost them in excess of $900 per month, but a professional agent could probably find them acceptable coverage for roughly half that amount). So the story makes two points. The intended point is that there are families just beyond the cusp of qualifying for premium subsidies who are struggling to obtain care. Under either the Governor’s or the Democratic Leadership’s reform proposals, these families would qualify for state help. The inadvertent point is that there are families who make decisions that health care isn’t important to seek out even minimum coverage — until something goes wrong.

Another article in the group describes a single mother whose pay raise results in her child losing eligibility for Healthy Families. It shows the hardships families face when their priorities are in the right place, but nonetheless find themselves struggling to maintain health care coverage. Frighteningly, with re-authorization of the State Children’s Health Insurance Plan (SCHIP) stalled in a bitter dispute between Congress and the White House, even eligible children may be dropped from the program soon.

The point here is not that Governor Arnold Schwarzenegger, Speaker Speaker Fabian Nunez and Senate Pro Tem Don Perata should sign off on any plan just to get something passed. (Although it is clear the Administration and Congress need to resolve their dispute over SCHIP, and quickly). What it does underscore is the importance of getting the reforms right, even if it takes more time. After all, subsidizing premiums for families who struggle to afford coverage now won’t help much if reforms result in their premiums doubling. Yet based on the difference between what New Yorkers and Californians currently pay for health insurance that could very well happen if lawmakers aren’t careful. And it’s a reminder that while politics is closely entwined in the health care reform debate, in the end, it’s about people facing real problems and challenges. Anecdotes are a poor foundation for fashioning legislation, but they do help keep things in perspective.

State Children Health Insurance Program Problems Don’t Bode Well for Health Care Reform

Most of the health care reform packages likely to be considered by the Legislature during its current special session will include provisions to expand the State Children’s Health Insurance Program (SCHIP). SCHIP is known as Healthy Families in California. So the political drama unfolding in Washington concerning SCHIP is critical to the state. It also should serve as a warning, especially to those advocating a central role for the government in delivering health care.

Here’s where SCHIP currently stands: On September 25th the House of Representatives reauthorized SCHIP on a relatively bipartisan vote (45 Republicans voted for the bill; eight Democrats voted against it).  The legislation, H.R. 976, provides additional monies for the program and, most importantly, continues the program past it’s sunset date of September 30th — yes, as in this coming Sunday. The Senate will now consider the bill and is expected to pass it as written. This means no conference committee will be required, the measure simply goes to the President’s desk. So far, so good.

However, President George Bush has committed to vetoing the bill. One reason is the cost: the President wants to increase SCHIP spending by $5 billion over five years; Congress is seeking to increase spending by over $35 billion during this time-frame. More significantly, the White House objects to expanding eligibility for the program beyond it’s current income levels, arguing that doing so is “an incremental step toward the Democrats’ goal of a government-run health care system.” Even with Republican support, the House is unlikely to overturn the President’s veto. HR 976 passed with 265 votes in favor; it takes 290 votes to override the President.

The good news is that the SCHIP program is unlikely to end on September 30th. Congress will either tack on short term funding to an existing continuing resolution. If that doesn’t interim funding could be passed as stand-alone legislation. Then the battle for long-term continuation of the program will start-up again.

There’s more than a political soap opera going on here. What we’re also witnessing is a warning. When the government controls health care, it means health care is political. Decisions are not made to respond to market pressures or consumer demand, but to satisfy the politics of the moment. There likely will be an short-term extension of SCHIP. But then again, maybe not. Remember when President Bill Clinton and the then-Republican Congress shut down the federal government they reached a budget impasse?

2007 has provided advocates of government-run health care with lots of cautionary tales: the California budget stalemate; a California budget which slashes funding for mental illness programs and outreach for health programs like Healthy Families; and now the veto of SCHIP funding. There are problems with the current system, but I can’t help but believe that politicizing health care would only make things worse.