Tuesday, September 08, 2009

healthcare reform 2.0

well, it's the eve of obama's big speech to a joint session of congress trying to sell his healthcare reform. or is it health insurance reform? regardless, here are a few random thoughts on this whole mess.

1. upon further inspection, the additional 2.5% tax on adjusted gross income isn't completely unprecedented (see prior post). heck, we already pay a whole bunch in medicare and social security so the idea isn't new. it's not necessarily a tax on being alive but a tax on making money. so technically you can opt out by not making any money but that makes life a little difficult. plus, we already pay enough taxes.

2. i'm not necesarily against a public option per se. it's true a type of public option already exists with medicare and medicaid. so if there was a public option to cover those who can't afford any insurance and to cover catastrophic events, that's not necessarily a bad thing. but the problem is, how will we afford this??? i am in awe (in a bad way) when i hear people talk about how medicare is not that bad and why not expand it to everyone? hello?! it's about to freakin' go bankrupt, that's why. recently they moved up the estimated year when this thing would go belly up unless something changes, see here. if we can't even keep up with medicare costs, how in the world are we going to afford this for everybody?

3. i still don't understand how you can focus on cutting costs in healthcare without addressing tort reform. well, okay, it's easy to understand from this perspective: trial lawyers are a big part of the democratic party. that's why obama doesn't want to add tort reform to this bill. howard dean himself acknowledged this point (do a search for "trial lawyers" on the link). it is simply not an honest discussion about cutting costs if this issue is not addressed.

dean's comment is so telling. this bloated 1000 page bill covers almost everything under the sun including how to change time accounting for training resident physicians yet they didn't want to add more by addressing one of the most important issues?! that is nonsense.

why the need to tackle so many issues in such a large bill that many haven't even read? this whole reform started on a platform of "the 47 million uninsured" but has now encompassed more than they can handle. why not just start with the few important issues and settle those without trying to disrupt the whole system? some will say that it's because the whole system needs fixing, which i don't necessarily disagree with but it's not in ways that these guys are talking about. i will discuss those below and in later posts.

4. i'm tired of hearing all the complaints about the republican party. now, for full disclosure, i do tend to align myself with conservative ideas usually but am certainly not a card carrying republican. nevertheless, the democrats have a filibuster-proof majority. if they want to pass a plan, they can, so quit complaining about the republicans and formulate a plan that your own party can at least approve. the opposition party is not the problem when you have a majority congress and the white house!

5. it's a myth that anyone can guarantee that you can keep seeing your same doctor under the current proposal. see section 102 and 142 on the prior post with the link to the full summary of the bill. first of all, obama wasn't even familiar with the details of the bill as is evidenced here. section 142 basically sets up a health care "czar" who can force all plans to meet certain requirements. section 102 says that if you are in a plan after the bill takes place, that plan has 5 years to meet these requirements. now, i don't want to sound skeptical of our government, but if they decided to formulate the requirements in such a stringent way that no limited resources private plan could meet it, that would essentially eliminate all other plans. since this is more than a remote possibility, the fact is, if you have a new doctor and new plan after the bill (theoretically) passes, you ARE NOT guaranteed continuity of care. this is made even worse by employer-based health insurance which needs to be eliminated. more on that later.

6. what i find most amazing is some of the comments obama has made regarding physician practices. not surprisingly, most of these comments are made ot (off teleprompter). for example, remember the july 22 press conference when he said the following (full text here):

"And part of what we want to do is to make sure that those decisions are being made by doctors and medical experts based on evidence, based on what works -- because that's not how it's working right now. That's not how it's working right now. Right now doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there.

So if they're looking -- and you come in and you've got a bad sore throat, or your child has a bad sore throat or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, you know what, I make a lot more money if I take this kid's tonsils out. Now that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies, maybe they have something else that would make a difference."

are you freakin' kidding me? is this how he thinks doctors think and act? now i know he never took any type of hippocratic oath in law school but most doctors i know act in the best interest of their patients. you'd be surprised to find out how frequently surgeons are actually unwilling to cut! and while we're on this topic, can we please dispell another myth? most doctors do not get paid by ordering more labs and tests and scans. this is patently false and ridiculous. this is only true if they own their own lab or testing machines which is not the majority of doctors.

now, if you thought the above statement was crazy, the one below is more unbelievable (from august 11):

"All I'm saying is let's take the example of something like diabetes, one of --- a disease that's skyrocketing, partly because of obesity, partly because it's not treated as effectively as it could be. Right now if we paid a family -- if a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's $30,000, $40,000, $50,000 -- immediately the surgeon is reimbursed. Well, why not make sure that we're also reimbursing the care that prevents the amputation, right? That will save us money. (Applause.)"

now, in all fairness his main point is to pay primary care providers more money for preventive care. not gonna argue against that. but again, he shows his incredible ignorance (most likely ot again) about how doctors get paid in this country. there is a wide gap between what a hospital might charge for a procedure and how much a doctor actually gets paid. in fact, medicare pays aorund $1000 to a surgeon for an amputation, not tens of thousands of dollars! and to assert that this reimbusement is immediate??? are you kidding me? yeah, what you do is bill medicare and hope to get money within 90 days for services you already provided.

in all honesty, this is the kind of stuff you would expect spewing out of the mouth of w, not this supposed post-partisan president who is such a fluent orator.

7. the big question comes up, how are we going to pay for such sweeping reform? not receiving as much press is the question as to who is going to take care of all these patients? already many do not want to go into primary care for a variety of reasons so you can expand health insurance to every plant and animal in this world but if there aren't the doctors around to take care of them, have we solved anything?

who is for this bill?

8. why is the ama for this reform bill? who knows but one thought is because they got a deal from obama to eliminate the sgr, the sustainable growth rate which is an archaic formula that medicare uses to pay physicians. that itself is actually a good thing but the ama is a joke and the organization does not represent the majority of doctors. is there some other reason they are supporting this bill? i have no idea.

9. why are the hospital organizations for the bill? section 1156 which essentially eliminates physician-owned hospitals as of this year by choking off the current supply. here's a commentary.

10. why is pharma (pharmaceuticals research and manufacturers of america, the umbrella organization for the nation's drug companies) for reform? because they get the guarantee that the governmentwon't negotiate for lower prescription drug prices. here's one article on this. another slate article.

so then, what's the answer? read this article for a closer glimpse into the problem. here's another one but i'm not sure how long it will be accessible. first off, you have to identify the real problems. the first article is written by david goldhill, a democrat but a businessman and he identifies many problems very well from a business perspective (although i don't agree completely with all his solutions). the second article is written by whole foods ceo john mackey. the essence of both articles is actually to use less insurance and to increase transparency in pricing. this will promote more competition but to facilitate this, you also need to remove barriers to insurance access, in particular allowing portability of insurance across state lines. it's too late to get into this in detail right now so i will in a post to come real soon i hope.


Kristi said...

These are all great points, and I really enjoyed reading your post (and agree with your points). I'm going to be writing about this tomorrow, and it already makes my head hurt. See TennCare/CoverTN for a great example of how NOT to do a public option ... seriously, some things about TennCare did or could work well, but it was abused and mismanaged and now has been cut down to nothing, so it's hard to measure how much good it could have done. Not that I personally have any answers for how we should be doing a public health-care plan. You are right that tort reform (and, in my opinion, reform of the insurance industry also) should play a big part.

Karen said...

I am still not over the election.