Wednesday, December 15, 2010

The Democrats Had Better Hope the Supreme Court Overturns the Individual Mandate Before the Middle Class Understands How Bad It Is For Them

This post first appeared as a column at Kaiser Health News

Is The Individual Mandate Really A Lynchpin In The New Health Law?

If the Supreme Court does rule the individual mandate unconstitutional will it really bring down the whole law?

I don't see it.

First, the individual mandate isn't even close to what it has been made to be -- a provision that would protect the integrity of the health insurance market by forcing people to buy health insurance before they became sick. At best, it's a tepid attempt at that.

The individual mandate's fine for not buying coverage is 1 percent of family income or $95 for each family member not covered, whichever is greater in 2014; 2 percent of income or $325 per family member, whichever is greater in 2015; and $695 or 2.5 percent of income or whichever is greater in subsequent years (kids are half price!).

These are meaningful fines for not buying insurance, but only a fraction of what a consumer would pay for health insurance.

Here's how the individual mandate's fine for non-compliance actually works for a number of representative family income levels based upon 2010 incomes and poverty levels:

Alternatively, here is what families would be required to pay under the health law toward their health insurance premiums based upon their total family income -- net of the federal subsidy -- in 2010 dollars:

A family of four making $55,000 per year is at 250 percent of the federal poverty level this year. Based upon today's incomes, the maximum they would pay in the exchange for health insurance is 8.05 percent of their income, net of the federal subsidy -- $4,428 annually.

So, under the health law's individual mandate, this $55,000 family would likely pay no more than $1,100 ($550 for each adult) in fines the first year, $2,200 the second year and $2,750 in fines the third and subsequent years; or, alternatively, have to pay $4,428 for insurance net of the federal subsidy in the exchange.

A family making $85,000 a year (400 percent of poverty) would have to pay $8,075 for their share of the cost of health insurance in the exchange or likely pay a fine in the first year of $1,700 that would likely cap out at 2.5 percent of $88,000, or $4,250, in later years.

Families would also have to pay their share of deductibles and co-pays within the insurance policies they purchased.

The fine families would pay for ignoring the individual mandate to purchase health insurance is significant but only a fraction of what the insurance would cost.

If the individual mandate is eventually held unconstitutional by the Supreme Court there will be attempts to substitute an alternative means to protect the insurance market from the "anti-selection" that would occur as people held back on purchasing health insurance until they needed it.

One possible alternative to the individual mandate would be to allow consumers to purchase coverage only at limited open enrollment periods -- buy it now or you won't be able to get it when you get sick.

Given how tepid the current individual mandate penalties are--the penalties don't even apply if health insurance costs more than 8% of a families income--such an alternative scheme could be much more effective in protecting the insurance markets, as well as far more politically palatable for consumers faced with paying either an unaffordable insurance fine or an even more unaffordable insurance premium, than the current weak individual mandate before the courts.

All of the focus on the recent Richmond federal court ruling misses the big picture on health insurance affordability under the new law: Many middle class families will not be happy with or be able to afford the fines nor will they be able to afford the much higher cost of health insurance -- even after the federal subsidy.

Thursday, December 9, 2010

Back to the Future—Biggest Health Plans Reported to be Building Their Own Political Coalition

I had a real sense of déjà vu this morning reading Bara Vaida’s story in Kaiser Health News:
Five of the nation's largest health insurance companies are taking a key step toward building their own inside-the-Beltway coalition to influence implementation of the new health law and congressional efforts to change it. The companies – Aetna, Cigna, Humana, UnitedHealthcare and Wellpoint – are shopping around Washington for a public relations firm to represent them…

Several industry observers said the companies want their own "subcommittee" within AHIP to influence the group's political and policy choices in 2011. "I think some of the companies felt the small and non-profit company interests were getting more attention within AHIP and they wanted to make sure their interests were considered too," said one health insurance executive whose company is a member of AHIP. "I think this is just about normal tensions within trade associations…"

Others speculated that the health insurers were seeking a way to reestablish ties with congressional Republicans, who were angered that the companies, via AHIP, worked with the Obama administration for much of 2009 on health care legislation.
This reminds me of the early 1990s. In the wake of the insurance industry being made to be the bad guys during the Clinton Health Plan debate, many of the largest members exited the historically dominant Health Insurance Association of America (HIAA) for the competing HMO dominated trade association.

At the time, many observers saw a cynical irony in the move; it was those dominant members that drove much of the policy that got the industry in trouble. Once the brand [HIAA] had been spoiled, many felt at the time, the big guys declared themselves the innocent ones and used the move to begin anew their Washington lobbying from a new platform.

Ironically, some years later HIAA and the HMO trade association merged to form AHIP.

Guess the largest health insurance companies once again were outflanked by a bunch of little guys and not-for-profits, this time on the AHIP board, and forced, once again, into a failed political strategy that was not of their doing.

Monday, December 6, 2010

What Would Happen If You Were To Pass a Big Health Care Bill Without Bipartisan Support?

During the recent health care debate I heard many people on both sides of the debate worry out loud about passing a heath care bill that did not enjoy broad support.

I guess this question is no longer a theoretical one.

December will be a big month when it comes to seeing some of the fallout accruing from the very partisan passage of the Patient Protection and Affordable Care Act.

First, the White House is worried big time about a Richmond federal judge who has said he will rule by year-end on a suit brought by the Virginia Attorney General, and a number of others, on the constitutionality of the individual mandate. This Republican appointee has already telegraphed a cynical view of the administration’s constitutional defense of the bill. More problematic, the Senate staff forgot to put a “severability clause” in the new health care law. That means the whole thing (2,800 pages) can get thrown out if a core element of the law is found unconstitutional. And, there are lots of people in this town worried this judge just might do that.

We all know this is going to be finally decided by the Supreme Court—make that by Justice Anthony Kennedy in what could well be a 5-4 decision—but getting the whole thing thrown out in even one of the many pending suits could send shockwaves of uncertainty into the health care industry trying to figure out just what it will finally have to implement, taxes it will have to pay, and which people it will have to cover. A bad decision for the new health law will also present lots of fodder for its conservative critics.

Second, we’ve got the infamous 1099 requirement in the new law that will have every business going crazy sending out tax forms to everyone it does business with beginning in 2011. I keep hearing this will be repealed but no one can tell me where the money is going to come from—$17 billion will be needed over ten years to do it.

Then there is the doc fix. Now the docs are scheduled to get their Medicare fees slashed on January 1, 2011. Again, everyone says the Congress is going to fix this one for the docs but no one knows where the money will come from—about $1 billion for each month they patch the problem and a total of $300 billion over ten years.

The Congress, both Republicans and Democrats, are intent, make that desperate, to find the money for both the small business and physician lobby. It also looks like Republicans are bent on blackmailing the Dems over where to get it by demanding billions come out of the new health care law—from places like preventive health care spending to insurance subsidies—in order to come up with the cash needed to get the small business and doc lobby off everyone’s backs.

I will suggest that while many of those eager to ram this new law through didn't see the need for bipartisan support a year ago they may understand its value now.

Friday, December 3, 2010

"Care and Cost"

Good friends David Kibbe and Brian Klepper have finally started their own blog--aimed at becoming a forum for many contributors to the health care debate.

I suggest you add, "Care and Cost"––"Health Care Conversations About Hard Choices and Emerging Solutions" to your bookmarks.

Sunday, November 28, 2010

"Don't Litigate, Innovate." How To Implement A Fully Funded Alternative To The New Health Care Overhaul -- And It's Already In The Law

This post of mine first appeared at Kaiser Health News last week.

What if a Republican governor and a Republican legislature had the ability to implement their version of health insurance reform and the federal government would have to pay for it? It's a great idea. And I'm thrilled to say that a bi-partisan bill has already been introduced in the Senate by Ron Wyden, D-Ore., and Scott Brown, R-Mass., that would help facilitate exactly this end.

First, let's review section 1332 of The Patient Protection and Affordable Care Act to realize how states are already -- at least eventually -- given the ability to innovate in this manner. Here is a simplified summary:
  • A state may apply to the Health and Human Services secretary for a waiver of all or any requirements with respect to the insurance exchanges, mandates, and subsidies with respect to health insurance coverage within that state for plan years beginning on or after January 1, 2017.
  • The secretary has to provide for an alternative means by which the aggregate amount of the tax credits and subsidies, which would have been paid on behalf of participants in the exchanges, would instead be paid to the state for purposes of implementing their own version of the law.
  • The secretary may grant a request for a waiver only if the secretary determines that the state plan will provide coverage that is at least as comprehensive as the coverage defined under the new law and offered through similar exchanges established by the states.
The bottom line is that the new law invites states to present HHS with an alternative to the insurance provisions of the new health law and gives the secretary the ability provide the state with the same funding it would have received under the overhaul so long as the state can get the same number of people covered under similar coverage.

Arguably, that waiver request could be absent the individual mandate, the employer mandate or any other key provision in the new law so long as the state made a credible argument that they could reach the same expansion target.

Is it a pipe dream that any state would take the same amount of federal money that would have been spent there anyway as a result of the health overhaul and instead build its own version of health reform? Maybe not. And the Republicans may be perfectly positioned to put such plans into action.

The 2010 mid-term elections were not only a big congressional victory for the Republicans but a big victory in the governors mansions and state legislatures as well. Republicans picked up 680 seats in state legislatures (by comparison Republicans won 472 seats in the last Republican landslide in 1994). They now control both houses of the state legislature in 26 states. And they control the entire state legislature and the governor's mansion in 16 states! In other words, Republicans have the electoral "trifecta" in 16 states -- they can pretty much pass whatever they want.

If Republicans really know how to implement the right kind of health care reform system they have a heck of an opportunity because the Democratic health care law says that, with a waiver, they can get their hands on all the health law’s federal money.

And it's not just Republicans that might want to innovate. I am hearing there are a number of Democratic governors taking a look at this provision in the law. The one catch is that neither Republicans nor Democrats can implement their state version of a health insurance system prior to January 1, 2017.

But then the Congressional Republicans say they want to fix the new health care law the Democrats just passed.

It would seem to me that House could pass a bill enabling the states to move much sooner than 2017 and, if it did, Democrats in the Senate, as well as the President, would be hard pressed to block them.

After all, a state wouldn't be entitled to the federal health insurance reform money unless a Democratic HHS Secretary (a certainty until at least January 2013) certified that the state's plan was going to cover at least as many people as well as the federal law was going to do it.

In fact, the bill introduced by Sen. Wyden and Sen. Brown would roll the date back to January 1, 2014.

Maybe some of these Republican state attorneys general ought to drop their lawsuits that call into question the constitutionality of the new health law and just suggest their governors get behind the Wyden-Brown bill and show us how to do it the right way!

Tuesday, November 23, 2010

Will it Be the Bond Market That Finally Forces Serious Health Care Financing Change?

When will the Congress and the White House finally make the hard decisions in order come to grips with the federal deficit problem?

When will we finally deal with real health care reform and get the entitlements, and with them the private health care cost issue, under control?

My focus on trying to answer those questions has always centered on what's going on in the health insurance market: When will costs simply become untenable and therefore force real change?

Watching "Meet the Press" on November 14th, it occurred to me I may have been missing the catalyst for real health care change.

Here is an exchange between moderator David Gregory and former Fed Chair Alan Greenspan:

MR. GREGORY: But don't we have to have an adult conversation with people about what the real [deficit] problem is?

DR. GREENSPAN: Look, I think something equivalent to what Erskine Bowles and Alan Simpson put out [Deficit Commission Chairs' report] is going to be passed by the Congress. The only question is, is it before or after a bond market crisis?


DR. GREENSPAN: Because there's no alternative. Look, I...

MR. GREGORY: But you got to explain a little bit more what that means. You're talking about debt.

DR. GREENSPAN: Well, here, here's the issue. Right now we have very low bond prices, the markets are functioning in a reasonably good way. The big, serious problem is whether or not the outlook for the longer term deficit spooks the bond market to a point where long-term interest rates and mortgage rates move up very sharply. If that happens, that will cause the double dip. And I'm just basically hoping that we have enough sense to realize that we've got to resolve this issue before it gets forced upon us

"The only question is, is it [our finally dealing with the debt and entitlement problems] before or after a bond market crisis?"

The single biggest driver in our national debt problem is the cost of our health care entitlements.

It may in fact not be the health care system itself and its unaffordable costs that finally force real action for health care cost containment––it may be the global bond market and its lack of confidence in America's ability to finally deal with our debt, and its health care driver, that will cause a crisis that forces health care action.

But would such a crisis force meaningful and rational health care reform or just draconian fee schedule cuts across the board that puts the health care sector––particularly the providers––in a crisis of their own?

Monday, November 22, 2010

The 300 Page MLR Rules—About as Valuable as Taking Your Shoes Off at the Airport

This whole medical loss ratio (MLR) provision in the new health care law is a fool’s errand. When it comes to controlling health care costs it is about as productive as taking your shoes off at the airport is valuable at improving air travel security.

Without a doubt, the new health care law does far too little toward making health care costs affordable. And, marginal health insurance carriers have little hope of doing a lot to bring costs under control.

But for consumers what matters is cost--and that is measured by a health plan's monthly premium. The cost of an insurance policy is market driven. In any market on any day, that insurance company has to quote a competitive price no matter what their expense ratio in that market.

Which insurance policy is low cost health insurance is determined by its price—not some convoluted MLR formula developed by bureaucrats that runs about 300 pages.

Too often people inside the Beltway underestimate how price competitive the health insurance market is. Go to the Internet and you can almost instantly get a number of quotes comparing benefits and price. Go to your local insurance agent and you get the same thing.

Show me a health plan with a 78% MLR and one with an 81% MLR and I cannot tell you which one has the lowest price. The higher MLR plan may be doing more to manage costs and thereby producing a lower premium rate. Heck, Medicare has the lowest MLR in America and is under constant criticism that it does not manage costs.

And don't underestimate the value these little health insurers bring to the market. They are the ones who must quote low rates to survive and they do more than many can imagine to keep the big guys honest.

But the authors of the new health care law think consumers are dumb and need the federal government to draft thick incredibly complex MLR regulations so they can be saved from themselves.

The insurance exchanges make a whole lot more sense than these MLR regulations—side-by-side comparisons of plans by cost and benefits making the health insurance shopping experience clear will be enough without this huge addition to the federal bureaucracy.

By HHS’s own calculations over 20% of those in the individual market are in plans that spend more than 30% on administration—another 25% are in plans that spend 25% to 30% on administration.

HHS expects 9 million consumers to get premium rebates.

But that assumes that the insurance companies that would pay those rebates are going to stay in the market and lose money paying them. Of course many insurers with little hope of ever being able to comply are not going to do that.

The new guarantee issue and pre-existing condition reforms don’t go into effect until January 1, 2014.

How many of those 9 million consumers are going to see their insurance company exit the market instead of lose money paying rebates?

If these consumers lose their insurance because their carrier exits they have to buy it from a different insurance company—but they are going to be subject to underwriting and pre-existing condition rules that are still in effect. You can see the headlines: “Cancer patient loses coverage under the Obama health plan and can’t get new coverage.” And, yes they can go to the new high risk pools--in six months and maybe for less coverage and higher costs.

Afraid that many people will lose their coverage, HHS has said it will grant waivers to these rules when there is the potential for the market to be “destabilized” by the implementation of the MLR rules.

I presume that means Democrats are scared of headlines reporting about consumers who have lost the insurance they wanted to keep because of the new law.

So, when the day is done, HHS is getting ready to implement a huge and complex regulation complete with massive reporting requirements but won’t do it if it disrupts any of the high expense carriers with big state market share the law is intended to go after.

And to the extent HHS does implement these new MLR rules who do you think the winners are going to be? It won't be consumers, it will be the giants of the health insurance market who dominate the market today and have an expense ratio advantage driven by their size. This is the jumbo health insurance company full employment act!

HHS and the TSA—just take your shoes off and keep your mouth shut!

Sunday, November 21, 2010

Health Care—Tell Us the Truth Before You Tell Us Why You Are Right

This is post of mine that appeared last week at Kaiser Health News.

Just after the election, I saw an exchange between CNN’s Anderson Cooper and the head of the Tea Party House Republican caucus, Michele Bachmann. Cooper tried to pin Bachmann down on just exactly what “specific spending cuts” she would make to get federal spending under control. When he suggested that Medicare was going to need big changes if the deficit was going to be reduced, Bachman wouldn’t be specific but responded that we “need to reform the system” but this “can’t be about scaring senior citizens.”

If the Republicans are serious about getting America’s fiscal house in order they are going to have to do a lot better than that.

During the election, I heard one Tea Party Republican candidate for the House say that we needed to get on top of all of the deficit spending and to do that we needed to reform the entitlement programs. But then he said hospitals and doctors are underpaid and we need to be sure they get better reimbursements.

Democrats aren’t much better at confronting the entitlement problems. President Obama has been telling the American people that the health care bill they passed in March -- the Patient Protection and Affordable Care Act -- will make health insurance affordable. Heck, it’s in the title of the bill. He’s also been saying that the new law actually reduces the deficit.

It is true the Congressional Budget Office (CBO) does estimate the new health care law will cover about 30 million more people and reduce the deficit by $138 billion over ten years. Of course to reach these numbers the bill uses plenty of budget gimmicks like front-end loading revenue and back-end loading benefits, ignoring the $300 billion physician fee crisis and raising taxes by $500 billion.

But, accepting the claim that the bill does reduce the deficit by $138 billion, we also need to remember that the same CBO report predicts we will add $12.7 trillion to the deficit over the next ten years -- a big chunk of it because of the health care entitlement costs that are out-of-control. To put this into perspective, without the $138 billion reduction in the deficit because of the health care bill, the CBO would have projected a $12.838 trillion increase in the deficit!

So both sides aren’t exactly facing our nation’s biggest fiscal problems in an honest way.

The Democrats refuse to admit their new health care law is not the kind of health care reform that would have at least begun to fix the entitlement problem.

Republicans haven’t done more than go negative on the new health care law and haven’t put up any real proposals for how they would deal with this conundrum. Their favorite campaign sound bite was to call for selling insurance across state lines. Just which state’s health insurance policies are affordable and would make health insurance affordable if they were sold in the rest of the states?

The health care entitlements, the old ones and the new one, simply swamp the federal budget. Take a look at the chart below. It comes from the same CBO report that affirms President Obama’s claim that the new health care law actually reduces the deficit by $138 billion.

There are a couple of thing to note about the CBO’s long-range federal budget projections:
  • While Social Security is a challenge, it’s a pretty modest a challenge when compared to the health care entitlements.
  • If the Democrats had really done health care reform this year, the trend line for the cost of the health care entitlements would not be continuing its startling upward trend.
  • All of the rest of federal spending, including for defense, is a fairly small part of America’s deficit and debt challenges. Big cuts there hardly matter if you aren’t going to tackle the health care entitlements.

The full CBO Report

Don’t “scare” seniors? I’ve read the reports and I’m scared. What we just saw occur was “health care reform?” Hardly.

We need more proposals like those being made by the President’s deficit reduction commission, and the Medicare reform proposal authored by Republican House members Paul Ryan of Wisconsin, Eric Cantor of Virginia and Kevin McCarthy of California. Irrespective of whether they are the best proposals, their authors started from a place where they told the truth.

More than scaring seniors, or anyone else, both Democrats and Republicans need to treat the American people like adults and be honest about just how critical a problem we have with health care spending. If both sides could do that first, then it would make it a lot easier to have a real conversation about the trade-offs we will, someday, inevitably have no choice but to make.

Thursday, November 11, 2010

Shame on AARP For Their Response to the Deficit Commission Co-Chairs' Report

The Co-Chairs of the President’s Deficit Reduction Commission are out with their preliminary recommendations.

They’ve done a great job—they’ve offended about everyone!

But we have a nearly impossible but unsustainable challenge in front of us if we are ever going to crawl out of this deep hole.

It is not so much what is on their list as what this list tells us about just how fundamental the changes are going to have to be for anyone who depends in any way on the federal government—which would be everyone in this country born or going to be born for decades to come.

In fact, the preliminary report calls for the Congress to revisit the Public Option if health care costs don’t meet a set of initial five-year targets. Nothing has been left off the table whether it is an unfettered discussion of how bad things are or the wide range of controversial options that now must be considered.

So how does AARP respond to the truth about the problem and an honest attempt to deal with it?

Some separate quotes from their press release yesterday in response to the report:
“With the release of the Co-Chairs’ proposal from the President’s Fiscal Commission today, AARP has responded with concern about how these recommendations would hurt the health and financial security of middle class Americans in particular, and believes that the proposal is contrary to the best interests of American families.”

“During these tough economic times, the last thing we should be considering is targeting the guaranteed, inflation-protected Social Security benefits that millions of Americans count on every day,’ said Nancy LeaMond, AARP Executive Vice President.”

“We're also deeply concerned that the Co-Chairs' Proposals would aim to reduce the deficit by shifting health care costs onto seniors in Medicare. Raising costs on the sick and the most economically vulnerable is both wrong and counter-productive policy. Instead, we should be focused on efforts to lower costs throughout the health care system.”
I liked Senate Budget Chair Kent Conrad’s response a whole lot more, "People can say we want to keep what is. What is is not affordable.”

Of course any report like this is going to be "dead on arrival" on Capitol Hill. But it's real value is that it can be the beginning of an honest discussion on what we will have to do.

AARP has lots of people at its Washington headquarters that understand these problems better than most and very much care about maintaining the integrity of our entitlement programs.

I expected a lot more from them.

AARP should be doing its part getting our people ready for change not pretending that it can somehow be painlessly avoided.

AARP should be taking the lead in explaining to seniors, and those on their way to becoming seniors, just what the problems are and just how fundamental the change is going to have to be if we are in fact going to hand our children and grandchildren a sustainable American Dream.

Shame on AARP! If anyone could be providing critically important leadership here it is them.

Download the Co-Chair's Report

Monday, November 8, 2010

Health Care and the 2010 Mid-Term Elections--the Only Thing Now Certain is the Uncertainty

The election has given us a Republican House and a still Democratic controlled Senate. But, instead of Democrats having the 60 Senators they had when health care was passed in December, they will have a slim majority in the new Congress of 53 seats when the two Independents who caucus with them are counted.

Exit polls clearly show an anti-health care law sentiment. Exit polls done for the AP found 48% of Tuesday's voters want the new health care law repealed, 31% want it expanded, and 16% want it left as is.

Remember those swing Democratic House votes that were on the fence over the health care bill last March? Most who voted for it are now out of work—and all but 11 of the 34 of them who voted against it also went down to defeat. Why did even those who voted against the new health care law lose their jobs? Because of one vote they all had in common--they voted for Pelosi as Speaker.

The two most prominent Democrats who touted their yes votes in their campaigns for reelection—Wisconsin Senator Russ Feingold and North Dakota House Democrat Earl Pomeroy—lost.

So, does this mean there is an overwhelming tide running toward repeal of the law?

The election results are likely a prescription for gridlock. With an Obama veto and the Democrats still controlling the Senate by a slim margin, it will be difficult, if not impossible, to get a health care repeal bill passed in the next Congress.

I do expect the Republican House to pass a bill repealing the health care bill very early next year. Then it goes to a Senate run by Democratic Majority Leader Harry Reid—good luck with that!

More likely, what we saw in the mid-terms was the opening act toward the 2012 elections. Republicans will be blocked from any major repeal action by the Obama veto and the lack of a majority in the Senate and will use that to call for voters to finish the job by giving Republicans control of everything in 2012.

The biggest problem the Republicans have is a lack of an alternative health plan. Repeal and replace the existing law with what?

Without a doubt there is a strong anti-health care law sentiment running. And, it might be possible to scare up a bare majority in the Senate for partial repeal legislation that comes under budget rules requiring only 51 votes. With the Republicans ending up with 47 Senate seats, they might also be able to get the new West Virginia Senator, Joe Manchin, to vote with them. Democrat Ben Nelson of Nebraska can’t seem to figure out if he is a Republican or a Democrat, and maybe Independent Joe Lieberman of Connecticut could be another pick-up. They would still need at least one more Democratic vote to get to 51.

And, Obama would have to go along with the changes for them to become law.

But it would take 60 votes to repeal all of the law. And, 67 to sustain an Obama veto of any outright repeal law.

Changing the health care law with 51 votes will require Republicans to put something up that dealt only with budget items and made a compelling argument that it was a prudent change. Just trying to repeal the individual mandate (a budget item) but leaving in place the underwriting reforms (which would require 60 votes to repeal) would create lots of unintended consequences that could well scare away not only these swing votes but even more Republicans as well.

It is possible that Republicans could try to amend the new law’s insurance subsidies to look more like their tax credit proposals, for example. But even there they risk looking like they want to repeal employer-based health insurance and that would be a very tough sale.

Republicans might also try to restore the Medicare Advantage cuts. But to do that they would have to come up with about $150 billion to offset that cost in order to avoid just adding to the budget deficit.

So, the viability of any repeal effort, or any effort to pass major amendments, will require Republicans to put a plan on the table that is compelling. I have no idea what that is based upon what I have heard the candidates and the Republican leadership say during the campaign.

The new House majority will enable Republican House committee chairmen to harass the Obama administration’s regulators at HHS. We should expect lots of testy hearings, which would have more political value as Republicans try to build momentum toward 2012 than accomplish a lot the Senate, would pass.

I would have to believe that the Obama regulators are at least a bit chastened in the wake of the election. The final MLR rules are due out in the next few weeks and a number of state insurance commissioners have called for more flexibility in implementing them. Based upon what happened last Tuesday, will Sebelius grant that flexibility? One would think so.

Just as interesting will be the need to fix the Medicare physician payments by the end of November. It will cost about $15 billion to patch that problem for just 13 months. With the voters saying, “no more debt” just what is the “lame duck” Congress going to do about that? Add to that the small business “1099” problem that would also cost about $17 billion to fix before it becomes effective on January 1, 2011.

The election results were also good news for Republicans in the states where they picked up at least 10 new governors’ seats. In separate races for insurance commissioner, two went to opponents of the law while California elected a supporter.

These state races will affect just how aggressive the states are in establishing the insurance exchanges due to become available in 2014.

We could see Democrats and Republicans simply to agree to disagree over the new health care law--maybe even seeing appropriations, like the money needed to build the 2014 insurance exchanges, held up until the 2012 elections finally decide who will be in control in the lead-up to 2014.

For now, the election results add more uncertainty as we immediately begin the 2012 election campaign and everyone gets ready for the 2014 implementation of the bulk of the new health care law.

You know, one of the things we talked about on this blog, on the way to seeing this bill passed, was the sense that you can't pass something as big as health care reform without a consensus of support for it. If you did, there would be a huge risk that it would not likely have the necessary support to be properly implemented or even sustained.

If a Republican "defunding" fight over appropriations leads to the two sides gridlocked and finally just agreeing to table implementation until after the 2012 elections, we might just see health care as the preeminent 2012 issue--a vote for Republicans meaning repeal it and a vote for Democrats meaning implement it.

So, what was it exactly that was accomplished last March?

Monday, March 8, 2010

Passing the Democratic Health Care Bill is Not the “Right Thing To Do”

Any big health care bill will be full of compromises—political or otherwise. But this bill doesn’t even come close to deserving to be called “health care reform.”

As the Democrats make their final push to pass their health care bill many of them, and most notably the President, are arguing that it should be passed because it is the “right thing to do whatever the polls say.”

Their argument is powerful: We will never get the perfect bill. If this fails who knows how long it will be before we have another big proposal up for a vote. There are millions of uninsured unable to get coverage because of preexisting conditions or the inability to pay the big premiums and this bill would help them.

But as an unavoidable moral imperative, enacting this bill would fall way short:
  • It is unsustainable. Promises are being made that cannot be kept. As the President has said many times, we need fundamental health care system reform or the promises we have already made—the Medicare and Medicaid entitlements, for example—will bankrupt us. What few cost containment elements the Democrats seriously considered are now either gone from their final bill or hopelessly watered down—most notably the “Cadillac” tax on high cost benefits and the Medicare cost containment commission.
  • It is paying off the people already profiting the most from the status quo. Many of the big special interests, that will have to change their ways if we are really going to improve the system, are simply being paid off for their support. The drug deal, the hospital deal, promises not to cut or change the way physicians are paid, all add up to more guaranteeing the status quo rather than doing anything that will bring about the systemic change everyone knows is needed.
  • Nothing in these bills will fundamentally change our current fiscal course. As the CBO, and every other expert has said, if this bill becomes law we will continue on the same cost trajectory we are already on. Yes, the CBO says the Democratic plan will reduce costs during the next ten years by about $100 billion—but that only means they would be $100 billion less than the $35 trillion they would have been anyway! That is merely a rounding error on the track we are already on.
  • There is nothing here that will stop unaffordable health insurance rate increases. Lately supporters have said this bill is the solution to the recent big individual health insurance rate increases we have been reading about in the press. But there is little in this bill that will mitigate or control any such increases because so little would be done to impact underlying health care costs.
We often hear the argument, “Let’s get this entitlement expansion bill passed and it will force us to deal with costs later.” If we don’t now have the political courage to face daunting health care costs in the face of exploding deficits how will we have that courage later?

I will suggest that adding 30 million more people to an unsustainable system expecting it will create an even bigger crisis and thereby force real reform is tantamount to reboarding the Titanic in the hopes it will sink faster. It is also hard to see how doing such a thing is the politically courageous thing to do.

Just where is the moral imperative in ramming a trillion dollar entitlement expansion through knowing full well it will make our long-term deficit nightmare even worse—for those now uninsured and for everyone else?

The Democratic health care bill makes little if any systemic changes to the health care system—certainly not at the level we need.

The Democratic health care bill makes promises we cannot keep.

Proponents of the Democratic health care bill make the claim that it will make health insurance affordable, improve our deficit outlook, and make our health insurance system sustainable. None of those claims are even close to being true and everyone who knows anything about this debate knows that.

Heck of a foundation for doing the “right thing.”

Sunday, March 7, 2010

The Issue Has Become Arrogance Not Health Care

Away from Washington people I talk to are just amazed at what the Democrats are in the process of doing on health care.

What I think the Democratic leadership is missing is that this is no longer about passing a health care bill in the minds of lots of these voters—a majority of voters from what the polls say.

To these people, this is about Democratic arrogance. What the polls don't measure is the anger I hear from people who can't believe what is going on. After the last few recent state elections and all of the polls that overwhelmingly say, “stop” or “start over” they just keep plowing along anyway. To defend themselves, the Dems point to the many times the Republicans have used the legislative tactic of reconciliation before—the Bush tax cuts, Part D, welfare reform.

They are right. But those were popular bills.

The Dems may be scoring debating points but instead what the voters I talk to see is a demonstration of political arrogance—not a health care legislative process.

The Democratic logic is that they have already voted for it so they might as well put a finished product on the table for people to appreciate on Election Day.

But the problem with that logic is that the the bill’s real benefits—eliminating pre-existing conditions and medical underwriting as well as the subsidies to buy insurance—don’t start until 2014.

What voters, particularly the swing independent voters, now see is not a health care bill but political arrogance—and that is really the issue Democrats are going to have to deal with.

What I think this is finally going to come down to is a few House Democrats putting their finger in the air to see which direction the political wind is blowing from. It's pretty clear to me there will be a gale force wind blowing from the direction of "no."

Saturday, March 6, 2010

Why Rush Vendor Certification of EHR Technologies?

Why Rush Vendor Certification of EHR Technologies?


A surprise move by ONC/HHS indicates the wheels may be falling off health IT reform at about the same rate they've fallen off Democrats' broader health reforms.

David Blumenthal and his staff have unveiled two separate plans to test and certify EHR technology products and services. We don't think this is a good idea. We've supported the purpose and spirit of the ARRA/HITECH incentive programs, and believe ONC's/HHS' re-definition of EHR technology puts it on a trajectory to improve the quality and efficiency of health care in the U.S. But this recently-announced two-stage EHR technology certification plan bears all the marks of a hastily drawn up blueprint that, if rushed into production, could easily collapse of its own bureaucratic weight.

The new Proposed Rule puts vendors through the wringer, twice. As defined by ONC, vendors with "complete EHRs" and those with "EHR modules" will have to find an "ONC-approved testing and certification body" (ONC-ATCB) that will take them through a "temporary certification program" from now until end of 2011. Then in 2012, under a "permanent certification program," they'll have to switch over to a National Voluntary Laboratory Accreditation Program (NVLAP)-accredited testing body for testing, after which they must seek an "ONC-approved certification body" (ONC-ACB, not to be confused with ONC-ATCB) that can provide certification. The ONC-ATCB will be accredited by ONC, but the ONC-ACBs will be accredited by an "ONC-approved accreditor" (ONC-AA).

Confused? This is just the start. We can't imagine many federal agency Notices of Proposed Rule Making (NPRM) that have created, in a single document, more new acronyms. And the prose in the document can challenge even the most focused minds. For example, the drafters of the NPRM recognize that things could get a little complicated, saying:

"Should CMS finalize its proposed staggered approach for meaningful use stages, we recognize that some confusion within the HIT industry may arise during 2013 and 2014 because of this apparent inconsistency and the divergent use of the term “meaningful use.”

But, then they go on to clarify:

"We would anticipate, therefore, that ONC-ACBs would clearly indicate the certification criteria used when certifying Complete EHRs and/or EHR Modules, and identify certifications according to the calendar year and month rather than the meaningful use stage to reflect the currency of the certification criteria against which the Complete EHRs and/or EHR Modules have been certified. Consequently, if an eligible professional or eligible hospital were seeking to obtain a certified Complete EHR or certified EHR Module in 2014, for instance, that eligible professional or eligible hospital would look for Complete EHRs and EHR Modules certified in accordance with certification criteria current in 2014, rather than Complete EHRs and EHR Modules certified as meeting certification criteria intended to support meaningful use Stage 1, Stage 2, or Stage 3. We request comments on ways to ensure greater clarity in the certification of Complete EHRs and EHR Modules."

Got that? Glad they're requesting comments, though we're not sure where to start. The use of the word "staggered" to describe ONC's programs is apt: this new NPRM is going to leave a lot of people staggering, as in punch drunk.

We would like to see ONC and HHS abandon temporary certification in favor of a single, permanent certification process, even if it means delaying testing and certification until mid- or late 2011. The hurry appears to be related to the need to have at least some EHR technology tested and certified by the end of 2010, so at least some physicians and hospitals can meet the meaningful use criteria. That would require them to use "certified EHR technology" by the official start year for the incentive programs, 2011.

But we don't think this timetable makes sense any longer, and the rush may jeopardize the whole program. Between meaningful use, accreditation, testing, and certification, there are simply too many moving parts to implement and coordinate in too short a time.

Delays seem inevitable. For example, we know that the release of the meaningful use final rule will be postponed until early summer and perhaps longer due to the large number of comments received and their implications. A consortium of physician membership groups will soon recommend that the meaningful use criteria be simplified. It also predicts that many small and medium sized medical practices will sit on the sidelines during 2011 and 2012, rather than rush into risky attempts to meet the meaningful use requirements. In addition, CMS has said it won't be ready to accept EHR technology product and service data until 2012, at the earliest. That timeline could be ambitious by about a year.

The ONC/HHS interim final rule (IFR) may have inadvertently caused another kind of delay. It set initial standards and implementation specifications for EHR technology - we applauded this - endorsing a modular EHR technology approach that opens the door to industry innovation. But it will take time for market entrants to bring modules and components to their customers, and perhaps longer to integrate different EHR vendors' modules in plug-and-play fashion. In other words, by opening up the market, ONC/HHS created circumstances that will almost certainly delay the goals it seeks.

So what if, to get the certification process right, ONC were to postpone payments by one year? It would be worth it.

The "permanent certification" plan in this new NPRM is very reasonable. Under it, NIST would be involved in setting up the testing of EHR technology software under the auspices of the National Voluntary Laboratory Accreditation Program. A single accrediting body would be chosen by ONC/HHS to oversee, supervise, and accredit the certification entities, following established international standards, including the International Organization for Standardization's (ISO) standards 17011 and Guide 65, that have guided conformity assessment in numerous industries, and ISO 17025 that is used for assuring quality of testing and calibration laboratories.

So each vendor would follow an orderly progression: first, ensuring that the product meets the technical testing criteria and then, having passed those technical tests, moving on to certification. The stability of this process has much to commend it.

We're not alone in thinking that delaying the EHR incentives start date is a good idea. At a HIMSS session on Monday, March 1, Congressman Tom Price (R-Ga.), an orthopedic surgeon, said that ONC's delay in issuing guidance on the certification process has prompted him to organize Congressional members. They'll send a letter to federal officials asking to postpone the start date for for demonstrating meaningful use to qualify for incentive payments. Price said members of Congress are currently collecting signatures for the letter and could send it to HHS within a week.

David Blumenthal is smart, dedicated, and is hiring many talented, experienced people into ONC. But rushing ARRA/HITECH's policy and statute beyond what is humanly possible could ultimately be at cross-purposes with the very goals they're trying to achieve.

David C. Kibbe, MD, MBA and Brian Klepper, PhD write together about health care technology, innovation, market dynamics, and reform. Their collected writings can be found here.

Thursday, March 4, 2010

"What a Disaster Looks Like"

In case you missed Peggy Noonan's column in the WSJ yesterday, let me suggest it is worth your time.

I think she hit the nail on the head:
It is now exactly a year since President Obama unveiled his health care push and his decision to devote his inaugural year to it—his branding year, his first, vivid year.

What a disaster it has been.

At best it was a waste of history's time, a struggle that will not in the end yield something big and helpful but will in fact make future progress more difficult. At worst it may prove to have fatally undermined a new presidency at a time when America desperately needs a successful one.

In terms of policy, his essential mistake was to choose health-care expansion over health-care reform. This at the exact moment voters were growing more anxious about the cost and reach of government. The practical mistake was that he did not include or envelop congressional Republicans from the outset, but handed the bill's creation over to a Democratic Congress that was becoming a runaway train. This at the exact moment Americans were coming to be concerned that Washington was broken, incapable of progress, frozen in partisanship.
You can read her full column here: "What a Disaster Looks Like--ObamaCare Will Have Been a Colossal Waste of Time If We Are Lucky."

Monday, March 1, 2010

After the Failure of Reform

After the Failure of Reform
Brian Klepper and David C. Kibbe

The stalemate in the bi-partisan health care summit was cast the moment it was announced. Republicans demanded that the reform process start anew, and Mr. Obama insisted on the Senate bill as the framework going forward. The President may now offer a more modest reform bill that can demonstrate some progress on the health care crisis, but that remains to be seen.

We hoped the White House would seize the opportunity presented by Massachusetts’ election of Scott Brown to begin again, huddling away from the lobbyists to develop a new set of provisions that would include reasonable Republican elements, like medical liability reform, as well as other meaningful cost reduction provisions excluded from the first round of bills: pricing/quality transparency, a move away from fee-for-service reimbursement, and the re-empowerment of primary care.

They took a different path. As Ezra Klein speculated in the Washington Post, Mr. Obama and his advisers may believe that, with the 2010 elections bearing down on Congress, there is too little time to begin again.

But this is a questionable political calculation. The reform process soured the American people and American business on the health care bills. A January 27 Towers Watson/National Business Group on Health (NBGH) survey found that 71% of employers believe the bills "will increase the overall cost of health care services in the United States." A February 11 Rasmussen survey found that 61% of voters think the bills should have been scrapped and the process started over.

And no wonder. Over the past year, the legalized bribery that is special interest lobbying was fully on display, with members of both parties (but led by the Democrats) taking contributors' money with a gusto unprecedented since the Republican feeding frenzy set off by Newt Gingrich's K-Street Project. A new report from the Center for Public Integrity shows that "more than 1,750 companies and organizations hired about 4,525 lobbyists — eight for each member of Congress — to influence health reform bills in 2009." Together, they spent $1.2 billion on health care, more than one-third of the $3.47 billion spent by special interests in 2009 to buy influence over policy.

And then there was the brazen political deal making. Mary Landrieu brought $300 million in federal aid home to Louisiana for voting with the Democratic Leadership, which the GOP promptly dubbed "the Louisiana Purchase." Ben Nelson got the Feds to pay for most of Nebraska's Medicaid perpetuity. And, on the eve of the Massachusetts Senatorial election, the White House cut a deal that exempted unions from the tax on "Cadillac health plans" until 2018.

The resulting reform provisions - a cynical combination of expert advice, uncompromising ideology and donor quid pro quos - would have extended entitlements while rescuing the industry at the top of a financial bubble, exacerbating the cost growth problem during a recession by replacing dwindling private funding with public dollars. At the same time, the bills specifically avoided committing to approaches that could wring excessive cost from the system.

In truth, either passing or blocking such poor bills would have had little impact on the increasingly threatening crisis. Short of starting over, American health care will continue to face some very harsh realities. More individual and corporate purchasers, particularly small employers, will be priced out of coverage as health care costs explode. This erosion in mainstream coverage is translating to a reduction in total health plan premium - the engine of the health care economy - and to escalating uncompensated care cost loads throughout the system. A plummeting number of insured patients will find it harder and harder to pay for a rapidly growing number of uninsureds and under-insureds.

These are recipes for instability and disaster. And as health care - the nation's largest economic sector, representing one dollar in six and one job in eleven - becomes increasingly unstable, so does the larger US economy.

Americans are increasingly aware that a government in which both parties are compromised by political ideologies and special interests will likely leave them to their own devices in dealing with health care. American business had, to a great extent, put health care benefits decisions on hold until reform was complete. Now it is resigned to continuing to cope with that burden, but with a renewed commitment to innovation. A February 22nd Towers Watson/NBGH survey found that "83% of companies have already revamped or expect to revamp their health care strategy within the next two years, up from 59% in 2009," a clear sign that businesses now think they need to act on their own behalves. (Of course, most individual Americans don't have that latitude.)

One thing is clear. Without reform as it was constituted and the subsidies it promised, the industry faces an onslaught of actions from the marketplace that will focus on its excesses, drive down reimbursement, and hold it more accountable. A long list of innovations - re-empowered primary care; data collaboratives that identify and then create incentives for making the best choices; new technologies like minimally invasive surgeries, point-of-care testing, and clinical decision support tools; medical tourism; clinical groupware; check lists; Health 2.0 business-to-business ventures that streamline health care processes - are now proving they can improve the quality of care while reducing cost.

The result is inescapable. No system this far out of balance can remain unchanged indefinitely. So long as it was influencing the policy process, the health care industry would never course correct in ways that are in our national interest. But as the environment continues to intensify, the market will be driven to embrace and integrate these solutions. One way or another, the health industry is in for real change over the next few years.

Meanwhile, until America meaningfully addresses cost and access through policy, proper health care will continue to be out of reach to many and will threaten many more with personal financial ruin. It will continue to sap the nation's economic strength, and compromise our efforts to lead and compete internationally.

Which is why the President should begin again, and make achieving serious health care policy reform a dedicated goal. In the process, he could challenge special interest influence over policy, and work to refocus the political process on the common interest. We believe the American people can see how the current paradigm is corroding our nation, and would rally behind this approach. More to the point, this was the premise of Mr. Obama's election. The American mainstream is waiting for him to assert his leadership in this way.

Health care reform has stalled and possibly failed for the moment. But the stakes are so great for America that failure cannot be an option.

Brian Klepper and David C. Kibbe write together on health care reform, market dynamics, innovation and technologies.

Saturday, February 27, 2010

Post-Summit Health Reform: What a Mess

Everyone agrees our health care system is unsustainable and too often unfair. At the White House health care summit, that was the only common ground between Democrats and Republicans.

Many Americans are either left-brain liberals or right-brain conservatives, with the remainder somewhere in the middle. These left- and right-brain types look at the same facts but come to different conclusions—no matter what.

This past election, something unique occurred. The independents were so frustrated with the Republicans about the Iraq war, the financial meltdown and the spendthrift ways of Congress that they swept liberals into power and apparently gave them a mandate to pass health care reform.

The liberals set about doing just that. No false advertising was involved—they crafted health care bills consistent with their campaign promises. But when conservatives erupted over the legislation last summer, they reminded many of those independent voters about their more-moderate political instincts.

You can read the rest at Kaiser Health News.

Thursday, February 25, 2010

The White House Health Care Summit--Democrats: 0 Republicans: 0 -- The Republicans Win

There is politics and there is policy.

On the policy front what we saw today was the same exchange of the old talking points we have watched for a longtime. No progress was made toward any kind of health care bill. That is no surprise--this was never going to be the place to fashion any kind of compromise.

At the end the President asked the Republicans if it was worth it to spend another month or six weeks trying to come to some agreement. I am glad he did that. I am not optimistic but a "yes" from the Republicans would be the right answer for the country.

On the political front this was a win for Republicans because it was a draw. Granted, they have a very thin health care agenda but all they had to do was hold their own over the course of the day. Politically, if not on policy, they did that. No minds were changed in the room and likely none out in the country. The left will still say get on with passing this, those on right will say kill it, and the majority of critical swing voters will still be concerned that the Democratic bills are going too far too fast in the face of the Great Recession. This is the biggest reason I don't hold out a lot of hope there will be a lot of Republican willingness to come to the table--at least before the November elections.

Ironically, this "bipartisan summit" may have just increased the political cynicism in the country because it went off so predictably.

Most importantly, I don't see the President and the Democratic leadership having accomplished their real goal: To "stiffen the spines" of the moderate Democratic votes they need to ram their health care agenda through using reconciliation rules.

A week from now, I expect the polls will still show only about the same 40% approval rating for the Democratic health care agenda and the moderate Democrats won't have the political cover they need to vote for a reconciliation strategy.

Unless the President gets a positive response from the Republicans on his offer to spend a few weeks trying for a bipartisan bill, it will be on to "Plan B" for the Democrats.

Recent post regarding "Plan B":
Obama to Uneasy Democrats: Please Walk the Plank for Me But If It Doesn't Work Out Here's Plan B

Live Blogging During the Health Care Summit

I am blogging live with a number of others at the NewsHour site.

Obama to Uneasy Democrats: Please Walk the Plank for Me But If It Doesn't Work Out Here's Plan B

The President and the Democratic leadership have been pushing hard on the idea that the Democrats should ram their unpopular health care bill through by using reconciliation--no matter how many Democrats in swing districts lose their jobs over it this November.

But Laura Meckler had an important story in the Wall Street Journal yesterday that is bound to give many of the nervous moderate Democrats some real insecurity about walking that plank for their leader:
President Barack Obama will use a bipartisan summit Thursday to push for sweeping health-care legislation, but if that fails to generate enough support the White House has prepared the outlines of a more modest plan.

His leading alternate approach would provide health insurance to perhaps 15 million Americans, about half what the comprehensive bill would cover, according to two people familiar with the planning.

It would do that by requiring insurance companies to allow people up to 26 years old to stay on their parents' health plans, and by modestly expanding two federal-state health programs, Medicaid and the Children's Health Insurance Program, one person said. The cost to the federal government would be about one-fourth the price tag for the broader effort, which the White House has said would cost about $950 billion over 10 years.

Officials cautioned that no final decisions had been made but said the smaller plan's outlines are in place in case the larger plan fails.
So much for all of this confidence they have the votes to pass their big health care bill.

Monday, February 22, 2010

The President’s Health Care Plan—Not a Game Changer

It is hard to see how the health care plan the President released this morning changes anything.

There is nothing new in it save a health insurance rate regulatory board that is an awkward political proposal at best. What powers would it really have and how would it operate in conjunction with the states already charged with insurance company oversight are just two of the first questions it does not answer.

Fundamentally, what good would insurance rate regulation do if the President’s plan has only tepid cost containment built into it in the first place?

There are not the votes in the House right now to pass this new proposal—or the Senate bill. There are not likely even the votes in the Senate under a 51-vote rule for the President's new plan.

That could change if the President scores a game changer on Thursday at Blair House that finally moves the polls from the 40% approval rating Democrats have had on health care to something over 50%.

But there is nothing in the White House health care proposal that was released this morning that will do that.

If the President thinks he can do it alone on the back of his “communication skills” then all the adulation on the part of his supporters, like his Nobel Peace Prize, has gone to his head.

If Obama wants to score a real game changer on Thursday, when the Republicans call for starting over on health care, I will suggest, the President ought to say, “Deal.” Then call on the Republicans to join he and the Democratic leadership in 60 days of intensive negotiations to get a bipartisan deal. That would really put the Republicans on the spot—and Democrats as well.

If what both sides want is bipartisan health care reform then what they should be agreeing to do is achieve that in a time certain with no preconditions on the table.

Then let’s see who comes to the table in good faith.

The outcome of that exercise, successful or not, would give us a real health care issue to take to the polls in November.

Tuesday, February 9, 2010

Wellpoint and Their “39%” Rate Increase

Wellpoint is getting killed in the press over a “39%” rate increase for their individual health insurance block in California.

HHS Secretary Sebelius has pointed to the Wellpoint individual rate increases demanding an explanation. The President even brought it up in his interview on Sunday. At a time Democrats are fond of calling insurance executives “villains” this story just adds more fuel to the fire.

No less than five reporters have called me in the last day asking me to explain it all.

Falling back on my industry experience it is probable:
  • The “39%” headline is anecdotally the biggest increase the press has found—the average is probably less albeit in the high 20% range.
  • This is likely driven by a combination of increasing medical cost trend, a bad economy, and anti-selection as healthier people disproportionately drop their coverage leaving a sicker group in the pool.
  • The rate increase is probably “defensible,” at least actuarially, based upon the actual experience in that block.
When the day is done this probably says more about why systemic health care reform is so critical than about any one company’s behavior. Last week we heard national health care spending skyrocketed to 17.3% of the economy. This is a real life example of what that macroeconomic statistic really means.

But I am not about to defend Wellpoint having been burned once. A few years ago Lisa Girion of the Los Angeles Times called me to say Wellpoint was retroactively rescinding health insurance policies for inadvertent and immaterial mistakes people had made on their health insurance applications. Falling back on my years of industry experience, I said that couldn’t be true—only the sleazy insurers pulled that sort of thing, Blue Cross of California would never do that.

Of course, Lisa was right and it was the beginning of the California rescission controversy. Not what I would call the best example of public relations at a time the country was debating the industry’s future.

So, what Wellpoint needs to do, and do yesterday, about these increases is to be transparent. Put all of the facts on the table.

Is this another symptom of a health care system run amuck or the actions of a “villainous” insurance company?

Just what is it that Wellpoint is waiting for?



Perhaps this is what they were waiting for. Here's what happens when you stand there like a deer in the headlights and let events take over.

From the LA Times today:
Congress opened an investigation Tuesday into Anthem Blue Cross' rate increases in California as President Obama cited the company's premium hikes -- some as high as 39% -- in his bid to pass national healthcare legislation.

The House Committee on Energy and Commerce and its Subcommittee on Oversight and Investigations announced they are examining the increases, which are set to take effect March 1. Anthem is the state's largest for-profit insurer and a unit of Indianapolis health insurance giant Wellpoint Inc.

Committee Chairman Rep. Henry Waxman (D-Beverly Hills) and subcommittee Chairman Rep. Bart Stupak (D-Mich) asked WellPoint's chief executive, Angela F. Braly, to appear at a Feb. 24 hearing of the subcommittee in Washington. They requested that she provide a detailed explanation of the reasons for the rate increases, which have enraged policyholders.

Monday, February 8, 2010

The Health Care Summit—Who’s Gonna Win the Photo-Op?

Getting Democrats and Republicans to constructively engage on health care is the best way to make progress.

To date, the Democrats have blown health care reform once again by being too arrogant in thinking they could just ram their version through.

The Republicans have no health care proposal. Their “black book” list of ideas they handed the President in Baltimore is a collection of second and third tier proposals at best.

So, what is the Blair House meeting about?

Well, I am not optimistic that it will be about real bipartisanship and a good will attempt to change the game.

It will more likely end up being an opportunity for each side to simply continue the petty bickering and once again try to convince a majority of voters their ideas really aren’t so bad.

Obama hopes his health care details will finally appeal to viewers as they realize he holds the only real plan. The problem with that logic is that the Democratic health care reform “well” has already been irretrievably “poisoned”.

The Republicans would like voters to believe their list of ideas will appeal to voters but the reality is that all of the attention they will now get will likely lead to a consensus, particularly among independent observers, that the Republicans, save for their tort reform proposals, aren’t holding any real cards.

I doubt either side will end up winners here.

The Democrats will only reinforce the sense they just don’t get it and Republicans will continue to come across looking like they think voters have forgotten that they were the bums who lost the last two elections.

When the day is done, I will suggest the Republicans are right about this: They all need to start over.

When Baucus and Grassley were in the midst of their Senate Finance negotiations last summer, I said I didn’t see them being able to accomplish anything—not because they couldn’t have. To me, the real problem was that the talks were taking place at the far out edges—left and right. Republicans were being told that bipartisanship was the same thing as capitulation—“Our bill is the only way.”

Republicans, including the Republican members of the “gang of six” in Finance last summer, had and have no plan. But, in Finance, they were quite willing to agree to a far-reaching bill that would have covered tens of millions of those presently uninsured. Things got a lot closer than most people realize. I do think the Democrats can eventually—although not likely in this election year—bring lots of Republicans onboard a new initiative that first takes the current bills off the table.

Real bipartisanship will occur when both sides find common ground in the middle and begin to work their way as far out toward both the left and right as they can and still hold the needed votes. It is about starting in the middle where they agree.

It's my sense that Blair House will be about the same old here’s my plan and if you want to be bipartisan you will come on board with my ideas. It will not be middle-out and it will fail to jumpstart anything for that reason.

Presuming that is the Obama strategy, the best thing the Republicans could do is call for new negotiations with no preconditions and let the Democrats just continue defending the plan that has already been roundly rejected.

They really do have to scrap it all and start over.

Sunday, February 7, 2010

A Way Out of the Health Care Wilderness?

I just came across an interview that I will suggest we all may have missed and perhaps charts the way out of this health care reform wilderness we now seem to be in.

It was on February 2nd and was between the Washington Post’s Ezra Klein and rising Republican House star Paul Ryan (WI).

Ezra asked Ryan about the bipartisan Wyden-Bennett bill as a place for both sides to find common ground. It’s a bill that blends the Democratic notion that everyone needs to be covered sooner rather than later with the Republican idea that we use tax credits to make people better consumers. And, the bill pays for itself on the front-end.

Ryan responded, “I have a lot of respect for that plan. If I were a Democrat, it’s the bill I’d be on. He’s got more mandates than I’d like. But if Ron Wyden and I were in a room, we could hammer out a deal by tomorrow.”

“If Ron Wyden and I were in a room, we could hammer out a deal by tomorrow”?

Well if all you guys need is a room there are plenty of those on Capitol Hill.

I suggest Ron Wyden give Paul Ryan a call and get to it!

Thursday, February 4, 2010

“Plan B” Has Begun

With word that the House is likely to take up the repeal of the health insurance industry anti-trust exemption it is now clear the Democratic leadership has begun Plan B.

It is also clear that this is much more a part of a political Kabuki dance then any substantive effort at even piecemeal health care reform.

The House probably has the votes to pass the repeal. The Senate does not. I doubt that even all of the 59 Senate Democrats will vote for it if and when it does come up on the floor of the Senate.

The base of the Democratic Party, as well as many “progressive” Dems in the House and Senate, are rabidly mad about not being able to ram their health care bill through. That is why you continue to hear all of the talk about reconciliation options even though there is no chance such a scheme would pass either the House or Senate.

But what to do?

The apparent answer is to bring up a few smaller health care bills the Democratic leadership views as popular back home and expect the Republicans will vote against them. Right now health care is a big negative issue for the Dems given the unpopularity of their effort to date. But if they can be seen trying to pass a few smaller measures “we can all agree on” only to be thwarted by Republican opposition their hope is they can turn the table on this issue to their advantage—well before they get to November.

Interesting politics but no hope for any real progress while these games play out.


When the Democrats say they believe they can still pass a health care bill are they bluffing? That's my opinion.

Here is a first rate story from Politico on their options and the dismal political reality each faces.

Saturday, January 30, 2010

Friday in Baltimore--The Way to Actually Accomplish Something

Intentionally or unintentionally, my sense is that the White House came out of Baltimore thinking they are now on to something, and I hope the Republicans took the same lesson away.

Constructive good faith political engagement in Washington actually works.

It is just incredible that House Minority Leader John Boehner has had not direct contact with the White House for about a year. A pox on both their houses for that. The party leadership never talks to each other--save being across the table from one another on talk shows. The two sides just level charges and counter charges at each other apparently never caring whether they actually accomplish some good policy for the rest of us.

But a funny thing happened in the midst of Friday's photo-op meeting between the President and the Republican House caucus. Good faith, an airing of ideas, and a mutual respect of each other's views actually resulted in both a political coup for both sides and some very first level progress on important issues--not the least was health care.

Can you believe it? Good manners and good intentions actually have a political value!

I will suggest that the next best step is for the President to take the lead in inviting the Republican and Democratic leadership to the White House on a regular basis in an attempt to broker some real progress on the important issues. If the President wants to turn his job approval ratings around that kind of good faith leadership would take them to the stratosphere.

I am not suggesting that the very thin Republican "play book" has any big ideas for health care reform. But I do believe that many of the Democratic ideas to cover 30 million people could be embraced by lots of Republicans if the two sides could show each other some respect and not just try to jam the majorities' ideological ideas (Republican or Democratic) down the other's throat. It wouldn't also hurt the Democrats to concede some points to the Republicans.

As bad as the left has been recently in thinking they were just going to ram a health care bill their way because of the results of the last election, I saw the right do exactly the same thing when they had control in recent years. (Remember the Republican chairman of the House Ways and Means Committee who tried to get the minority Democrats arrested for boycotting a meeting?) That kind of "take no prisoners" approach to government is what is really at the heart of gridlock while the country just continues to drift downward.

Worst case, if we did see a real effort and it eventually broke down, the side that would lose would be the side that didn't behave themselves. Now that would be a political outcome we could all live with.

Wednesday, January 27, 2010

The State of the Union--The President Came to a Fork in the Road and He Took It

As Yogi Berra said, "When you come to a fork in the road, take it."

The President came to a fork in the road tonight on health care reform. Would he do what many liberals have demanded--push harder to pass the Democratic health care bills? Or, do as many moderate Dems and some Republicans have called for--work to get a smaller but bipartisan health care bill?

Listening to his speech he seems to be taking both forks.

Continue pushing the Democratic plans: "As temperatures cool, I want everyone to take another look at the plan we’ve proposed. There’s a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo."

Looking for a bipartisan approach: "But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. Here’s what I ask of Congress, though: Do not walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people."

The President came to that fork in the road tonight and instead of giving the Congress a clear sense of where he was willing to put his remaining political capital he just took it.

Is he willing to put his Congressional majorities on the line in an election year to keep pushing for the now unpopular health care bills? Or, is he willing to put his political capital on the line in an effort to pull the far left in his own party to the center and call the Republicans out on their offer of bipartisanship in order to produce a modest bill?

In the wake of the President's State of the Union Address, we have no better idea just where he wants to lead his party, the entire Congress, or the country on health care reform.

Tuesday, January 26, 2010

Plan B—There Isn’t One—But There Could Be

As the State of the Union approaches Democrats are considering their health care policy options. There are lots of reports about “Plan B”—pushing through the Senate bill with a parallel corrections bill that could be passed in the Senate using reconciliation rules.

That’s as dead as the original House and Senate health care bills. Moderate Democrats have no stomach for such a legislative stunt in the face of Massachusetts and bad health care polls. Many liberals even question that strategy.

Everyone is awaiting this week’s State of the Union speech. Will the President:
  1. Embrace the call by many on the left to Democrat-up and just ram it through?
  2. Call for a scaled back bill built around modest and popular first steps that could attract bipartisan support?
  3. Just jabber in a way no one can figure out which course he really supports?
My bet is on number three.

As I have said before, I think getting even a modest bill is a long shot in this election year but it is not impossible.

I like the idea of focusing on tax credits for small business as a first priority more than trying to help the individual market. The small group market is guarantee issue and government tax credits have the impact of encouraging matching funds—government money would encourage employer contributions making coverage even more affordable for the uninsured.

Add to that a modest Medicaid expansion, the albeit tepid cost containment parts of the current bills such as the pilot programs and giving CMS more authority to implement them, modest insurance reforms like ending rescission and funding for high risk pools, proving good faith with Republicans by including tort reform, and we have a bipartisan down payment on health reform.

Democrats need to erase the bad taste voters so far have for their dead health care efforts. They could do that with this kind of modest first step health care bill. Republicans also have something to prove on health care—the Democratic problems shouldn’t be confused with any sense on the part of voters that Republicans have yet to make any constructive contribution to this debate.

In my mind, the smart political move for Democrats is to call the Republicans out on their offers to be bipartisan by putting a deal on the table Republicans couldn’t refuse.

If the Republicans take the offer, the Democrats can get beyond the health care political mess they are in. If the Republicans don’t, the Dems have the leverage they need to turn the tables on the Republicans before the November elections.

They could also, coincidentally, actually help out a few million people.

Lots of folks think there is no chance anything positive can now come out of this poisoned political environment.

I am not so cynical.

Thursday, January 21, 2010

A Smaller Bipartisan Health Bill? What It Could Look Like

In the wake of the Massachusetts vote, Democrats are scrambling to find a way out of the health care political mess they are in.

Right now they are in a daze standing by waiting to see if any of the "trial balloons" they have launched gain any traction. So far, ideas to ram though the now toxic Senate bill in the House in one parliamentary form or another are falling flat.

Last night, the President formally launched one of his own trial balloons--doing some kind of a scaled back bipartisan bill.

The problem with bipartisanship now is that the Republican base is not about to let any of their own Senators do anything to take the Dems off the political meat hook they are now dangling from.

Democrats could well try to create a very popular stripped down health bill with a win-win objective--if it passes they are off the hook and have something to take to the November elections and if Republicans block it they have themselves an issue on which they can try to neutralize the Republicans.

But that sounds great in principle--health care details are always problematic.

What follows is a post that I did the day after Barack Obama was elected President. In it I suggested a modest bipartisan bill was the only thing I could see passing in 2009--or 2010 for that matter.

You will note that suggestion #1 has already been accomplished--as well as some positive health IT steps.

From Wednesday, November 5, 2008:

There is Now a Real Bipartisan Opportunity in Health Care

President-Elect Obama, and about every candidate for Congress, has said he wants to change the partisan tone in Washington. Obama, the Democratic Congressional leadership, and the Republicans have a terrific opportunity to do just that on health care when they all come to Washington early next year.

As I posted earlier, I do not believe there is any chance we can see the enactment of the comprehensive Obama health plan in the near term.

But there are a number of important steps that can be taken next year and each of them have enjoyed strong bipartisan support during the past year:
  1. Reauthorizing the State Children's Health Insurance Plan (SCHIP) and increasing the number of kids covered from six million to ten million. The Congress passed exactly that kind of reauthorization twice by strong bipartisan margins only to come a few votes short of being able to override two Bush vetoes of the bill. Those attempts met pay-as-you-go requirements by boosting the cigarette tax to pay for it.
  2. Rearranging Medicare spending by equalizing the payments private Medicare plans get with the payments the traditional Medicare plan receives for the same seniors. The Medicare physicians face a 21% fee cut on January 1, 2010 and there are other serious cost issues for Medicare. In July, the Congress took the first step toward payment equalization with a veto proof margin of 70-26 in the Senate and 383-41 in the House. The really hard part here is crafting a new Medicare physician payment system that is desperately needed but the first step, where to get the money, has strong bipartisan support.
  3. John McCain and Barack Obama had a number of similar and relatively non-controversial cost containment ideas in their health plans which would cost the federal government little or nothing. These similar proposals included the expansion of health information technology and a patient medical record; improving transparency about health care quality and costs including prices, errors, staffing ratios, infection rates, and disparities in care and costs; wellness initiatives including an emphasis on healthy lifestyles; development of best practice standards, requirements for disease management programs; requiring effectiveness reviews for procedures, devices, and drugs; and requiring providers to collect and report data to ensure standards for health quality are followed.
  4. There is bipartisan support for assisting small business in providing and paying for health insurance. In 1999, 56% of employers with 3-9 workers provided health insurance to their workers. By 2007, that had dropped to 45%. By contrast, employers with more than 200 workers provide health insurance 99% of the time. The one place employer-provided health insurance is melting away is in the small employer area. A modest bill to assist the small employer enjoys support among both Republicans and Democrats.
A big $100 billion [per year] comprehensive health care reform plan like the Obama health plan is not realistic in these times of financial crisis.

But, there is already bipartisan support for a children's health insurance (SCHIP) extension and the means to pay for it, reform of Medicare provider payments and the means to pay for that, a list of commonly agreed to cost containment initiatives that would cost the government little or nothing, and bipartisan support for help to the small employer to offer health insurance.

To be sure these steps would only make a dent in the number of those uninsured and these bipartisan cost containment items will only help our cost problem around the edges.

But all of these bipartisan steps would be progress, are doable, and are affordable.

President-Elect Obama and the Democratic leadership can do what the last two Presidents did--promise bipartisanship and then quickly employ the same old partisanship out of the mistaken belief they had the majorities in Congress that would enable them to steamroll the opposition. That mistake led to the 1994 Republican takeover of the Congress in the first case and two straight election defeats, in 2006 and 2008, in the second.

President-Elect Obama, the Democratic leadership, and the Republicans have the road map at hand to truly show a bipartisan commitment to health care change and progress. They could actually break the gridlock on health care and make some modest progress.

Will they take the road less traveled or just give us more of the same?


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