Saturday, February 7, 2009

A Bit of a Digression: The Health Care Reform Debate from the Left

As you might have noticed, there is a lot of talk around the country about reforming health care in America.  Most of the conversation is about reforming the mechanism of payment for health care, but there are also those of us who are interesting in developing systems of care that go with the new payment system. I haven't much about payment on this blog, although it is more or less the elephant in the room.  Our new systems of care, in mental health or in health care in general, will need a payment system.  So, on this Saturday, I took advantage of a discussion sponsored by Physicians for a National Health Care to hear the arguments for a "single payor" system over the "mandate" system currently being instituted in Massachusetts, and advocated in Senator Daschle's book Critical.  This argument assumed that the government has a role in establishing a decent health care system, and moves in the realm of what should that role be.We opened with a talk by Steffie Woolhandler, who began by defining the problem, an argument that she has made in many articles and journal.  Uninsured and underinsured patients are rampant,  we are rationing health care in the face of a surplus of resources that are distributed in a way that doesn't match the needs of the people.  And her estimation, many of the problems can be traced to the addition of profit maximization to the business of medicine.  The key to her thinking is the "20-80" rule-  20% of the patients are responsible for 80% of the cost, a fact which drives insurance companies to do many things that fall under the category of cherry-picking.  Listening to her talk, and reading her literature (here, and here for example),  it is hard to see a place for profit in the business of medicine, a thought echoed by the Health Care conversation we hosted last month.So what, you may ask, about the argument that we can't afford national health insurance? It turns out that, between the cost of health insurance and lost tax revenue, we are already paying much more for our non-system than most countries pay for their systems.  (She showed some bargraphs with this information)  She also also pointed out that a National Health Plan is the only way that one can get a handle on cost control (market forces haven't managed that)  It seems to be the right answer, and yet, to talk to many folks in government, it is politically dead in the water.  So, how do you make it happen?  This group of people feel that this can happen and that the problem is how to address the powerful interested that are currently managing the profit in the system.
I went to the workshop on tough questions, because I wanted to hear that was perceived as the tough questions in this debate.  The attendance at this meeting is interesting;  a mix of doctors and non-doctors, supporters and learners, all focused on the question of single payor.  
#1:  What about the waiting lines in Canada?  We know about the waiting lines in Canada, because in Canada they measure it, and they try to fix it.  Here, there are lines, but they are a private tragedy instead of a public discussion.  Others suggested looking at "phantoms in the snow", an article that looked at this problem.
#2:  Why is no one talking about the way in which "fee for service" payment warps the way in which we practice medicine?  One of the side effects of a fee for service system is the perverse incentives to specialize, increase the flow of patients and only do that for which they get paid.  Good argument for a salary based system.
#3:  Why can't we just regulate the insurance industry?  A movement strong enough to regulate the insurance industry is a movement that is strong enough to create a single payor.  Why not go all of the way.
#4:   A more efficient system would but hundreds of thousands of people will be swept out of work.  What about them?  Part of the reform would have to be retraining the folks that make up the currently bloated administration system within the insurance industry.  There likely will be things for them to do.
How does this happen on the ground?  They think that the debate is go on for a long time, and that we need to keep single payor in the conversation while the discussion is going on, and that the single payer will move up on the list.
We reconvened to talk about health care to business, and that led to an interesting discussion of framing.   I will try ot reconstruct the argument.  First, one must get the business point of view:  we are paying too much for healthcare, costs are high because people are using too much care, they are concerned about the insured, not the uninsured and and they, in general, don't trust the government.  Business folks think in terms of systems, budgets, fixed cost or efficiency;  we need to frame the discussion in those ways.  So, with that in mind:
  1. Few people are using health care at any one time (we all use it eventually)  Remember the 80/20 rule.  80% of health care uses less than $1400 per person.  Cost is in the top 20%.  Either share the burden, or fight to avoid it.  So health care administration is largely devoted to avoiding payment of the top 20% of costs.
  2. Most costs are fixed.  Fixed costs are 70%- salary and infrastructure.  We want the services to be there when we need it, and we don't know what how much that is, because there is no system. 
  3. We are already paying the whole bill.  Who should be responsible?  Not clear-  we finance the services on a "wing and a prayer".  The financing is based on cost shifting, with the public as a back up.   In the end, we have a system that is funded by taxpayers (60%), business (20%) and out of pocket costs (20%). 
  4. We don't have a system so we can't fix anything.  This is the ultimate problem.
Why do other counties do it better?  Administrative simplicity, negotiated prices, more primary care and prevention, health planning and global budgets.  They have a system, and they use it to improve the health of the population.  A National Health Plan will allow us to do the same thing.
It was interesting that they chose to focus on a model business talk during this session;  it underlines the need to align the interests of these "liberal" doctors with the business community if we are to make progress.  She thought that there are a lot of "closeted" businesses that want to move the government into the leadership business community.
MassCare:  Critique of Health Reform.  So, to start with, we have health reform:
>300% FPL  :  You must buy health insurance
How is it going?  Depends who you talk to.
While people support the law,  it is (mostly) costing more. We have insured a lot of new people, but some of the new rules include more restrictions on folks who used to be cared for by the free care pool.  The biggest problem is the 10 day rule-  many patients do not apply for Commonwealth Care in time, and then are denied care.
Individual mandates:  Effectively, this is a "poll tax"- a regressive tax that punishes those with less money.  It blames those without insurance for their problem.  Not a great way to run a system.  (But is that worse than funding SCHIP from a cigarette tax)  
Affordability:  The folks who are buying insurance are buying high-deductible plans, which actually is costing the CHCs more money, as folks often don't pay their deductible.  
Safety net providers:  All of this is causing a budget crisis in the safety net institutions.

He is pretty pessimistic about this approach:  this said that Minnesota was unable to reduce the percentage of folks who are uninsured in 1993.  Neither were Tennesee or Oregon.  All ran into the problem of rising costs.

His conclusion:  "You can't cross a chasm in small steps."

Interesting graphic.

Dr. Woolhandler referred to this as "robbing from the poor to give to the poor."  They strongly feel that it is likely to fail.
I then went to the session on "how to talk about single payer".  She used the "iron triangle" of cost, quality and access, as the framework for the argument;  she made the point that the argument needs to be framed differently for different audiences.  Business, as noted above, will be interested the business argument.  Labor, it seems, can be approached by the ability to take health care OUT of their collective bargaining sessions.  Another point was the "framing" of the question of choice:  patients want choice, not of a health plan, but of doctor and hospital.  The Harry and Louise ads conflated those two ideas.
So, what did I get out of today's discussion?  My belief remains that our current systems are too complex, and do not create the kind of health care that we want- wholistic, based on science and founded in the relationship between a family and a doctor or nurse practitioner.  We would benefit from a drastic simplification of the payment system, and such change would make it easier to begin the process of reforming the delivery system.  I don't see America accepting a single payor system, whether for health care or the phone company, even though it would make lots of sense.  Massachusetts is trying mightily to make the politics work toward creating a system that is closer to the ideal;  it is not there yet, and the process of change is messy.  It will be messier still on a national level.  The clearer we can make the message, the more likely we are to succeed.

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