Doctors Wage War Against Obama's Health Care Overhaul

[Midwest Alice]

As President Obama pushes for passage of his first major domestic policy change, some physicians are waging an all-out war against a health care reform bill they say amounts to nothing more than socialized medicine.




http://www.foxnews.com/politics/2009...care-overhaul/

[gdpawel]

There are some Canadians that have a certain clinic they like or doctor they like that is a tradition in going back and forth across the border with the United States. But according to the Canadian government, 85% of Canadians like the health care they are receiving in Canada. You don't see long lines of Canadians in health care clinics in Detroit.

A former Ontario health and economic minister notes that Canada spends more than a third less per capita on health than the United States and still covers "everyone," wheras the United States system leaves 47 million people without insurance. In Canada, doctors do not have to waste time seeking insurance approvals. Medical need is the only requirement, and pre-existing conditions don't matter.

When it comes to making coverage decisions based on medical evidence, for-profit insurers have a pretty spotty record. In the 1990s, when insurers said they were trying to "manage care," many were simply "managing costs." For example, some decided which drugs to include in their formularies based simply on whether the manufacturer would give them a deep discount. In return for the discount, the insurance company would assure the drug-maker that it would not cover a competing product. This had nothing to do with which drug was more effective.

The public will always be suspicious of decisions made by for-profit insurers even when their decisions are based on sound medical evidence. For-profit insurers just don't have the political or moral standing to make these judgments. By contrast, most patients are much more comfortable with Medicare's coverage decisions which is why we need a federal agency (MedPAC - an independent group that advises Congress, but give it some meat behind it) testing and comparing the effectiveness of new treatments.

Comparative research has the potential to tell us which drugs and treatments are safe, and which ones work. This is not information that the private sector will generate on its own, or that the "industry" wants to share. Companies want to control the data, how it is reviewed, evaluated, and whether the public and government find out about it and use it.

Comparative-effectiveness research can help doctors and patients, through research, studies and comparisons, undertand which drugs, therapies and treatments work and which don't. Doctors will still have the ultimate decision, along with the patient.

If people begin talking about health care, they may begin to really think about it. It may even occur to them that perhaps it wouldn't be so terrible to borrow a few ideas from other countries. If another country builds a better car, we buy it (Toyota, Honda, Nissan). If they make a better wine, we drink it. If they have better healthcare ... what's our problem?

For those who still have health insurance and think you'll lose it with an "option" program, your premiums nearly doubled over the last eight years, and the health care system controlled costs by dropping coverage for many workers: a safety valve of uninsured to dump out of the system. If you can increase prices and have relatively inelastic demand (people forced to drop out), you'll find enough people stay paying into the system so that the total amount paid in goes up. Are you next?

In another five years, the $10,000 cost of family insurance will be $15,000, and more and more employers will have dumped people either into higher-deductible health plans or into the uninsured pool. This is really going to hurt before it'll create a constituency that will support universal health care. The increases in health care costs will have impacted virtually everyone.

In the meantime, your family doctor has to become an employee of your local hospital, instead of being independent. And you'll continue to have a corporate bureaucrat between you and your doctor.

Conservatives in and out of power, are doing everything they can to stand in the way of major reform. The right is taking its lead from GOP pollster Frank Luntz, who authored a memo laying out a rhetorical strategy for conservatives to demonize Obama's proposal.

In the memo, Luntz outlined the "script" for opponents of health care reform. He argued that a politician had to first pretend to support it, but should then use phrases like "government takeover," "delayed care is denied care," "consequences of rationing," and "bureaucrats, not doctors prescribing medicine." That jargon is routinely heard by conservatives arguing against reform.

Luntz recently admitted that he is urging conservatives to attack reform as a "government takeover" regardless of what the actural legislation coming from Congress says. Opponents of health care reform in Congress are proposing amendments that would maintain the status quo.

Wendell Potter worked in the health insurance industry for more than 20 years. He rose to be a senior executive at Cigna. He was on their calls, at their board meetings, in their books. He testified at a Senate Commerce Committe hearing.

The industry, Potter said, is driven by "two key figures: earnings per share and the medical-loss ratio, or medical-benefit ratio, as the industry now terms it. That is the ratio between what the company actually pays out in claims and what it has left over to cover sales, marketing, underwriting and other administrative expenses and, of course, profits."

The best way to drive down "medical-loss," explained Potter, is to stop insuring unhealthy people. You won't, after all, have to spend very much of a healthy person's dollar on medical care because he or she won't need much medical care. And the insurance industry accomplishes this through two main policies. One is policy rescission. They look carefully to see if a sick policyholder may have omitted a minor illness, a pre-existing condition, when applying for coverage, and then they use that as justification to cancel the policy, even if the enrollee has never missed a premium payment.

Rescission is important to the business model. At a hearing before the House Subcommittee on Oversight and Investigation, Rep. Bart Stupak, the committee chairman, asked three insurance industry executives if they would commit to ending rescission except in cases of intentional fraud. "No," they each said.

Potter also emphasized the practice known as "purging." This is where insurers rid themselves of unprofitable accounts by slapping them with "intentionally unrealistic rate increases." One famous example came when Cigna decided to drive the Entertainment Industry Group Insurance Trust in California and New Jersey off of its books. It hit them with a rate increase that would have left some family plans costing more than $44,000 a year, and it gave them three months to come up with the cash.

The issue isn't that insurance companies are evil. It's that they need to be profitable. They have a fiduciary responsibility to maximize profit for shareholders. Potter reasoned that we generally like markets because the profit incentive spurs useful innovations. But in some markets, that's not the case. We don't allow a bustling market in heroin, for instance, because we don't want a lot of innovation in heroin creation, packaging and advertising. Are we really sure we want a bustling market in how to cleverly revoke the insurance of people who prove to be sickly?

As a rule, the "profit" motive and "free" enterprise are hard to beat when it comes to systems for allocating resources in a free society, but some institutions like churches, education and healthcare are and should be exceptions to that rule.

So many people have a stake in the healthcare economy. With the wealth comes political clout and powerful influence over public awareness. If you so much as talk about reigning in doctors or drug companies or health insurance, you're branded as a advocate of socialized medicine.

[Midwest Alice]

As President Obama pushes for passage of his first major domestic policy change, some physicians are waging an all-out war against a health care reform bill they say amounts to nothing more than socialized medicine.
America's Affordable Health Choices Act of 2009 would create a public health insurance alternative and require coverage for most Americans and from most employers.
The American Medical Association -- the nation's largest physician organization with nearly 250,000 members -- initially opposed the president's plan, but backed the House Democrats' version of the bill last week. That has led to an internal dispute that has resulted in some physicians leaving the nation's largest doctors' association.
Some doctors charge the bill will lead to inferior patient care as physician offices around the country triple their patient lists and become forced to ration care.
"This is war," Dr. George Watson, a Kansas physician and president-elect of the American Association of Physicians and Surgeons, told FOXNews.com Thursday. "This is a bureaucratic boondoggle to grab control of health care. Everything that has been proposed in the 1,018 page bill will contribute to the ruination of medicine."
But congressional leaders like Rep. Jim McDermott, D-Wash. -- who is a psychiatrist -- say the physicians' argument is baseless and phrases like "socialized medicine" are used as a scare tactic to undermine the president's plan.
"The doctors who have responded this way exhibit a serious case of doctor greed," McDermott told FOXNews.com. "They have lost sight of the common good and the pledge they took in the Hippocratic Oath."
"These people are practicing fear without a license and they should be subject to a malpractice suit. If things are so good, why are doctors buried under an ever-increasing mountain of paperwork from insurance companies?" McDermott asked.
Watson said the president's reform bill is loaded with rules and regulations that will ultimately result in shoddy patient care and long waiting lines. He blasted the bill as "insidious" by forcing doctors contracted with Medicare into the nationalized plan -- a "trap" he described as "involuntary servitude."
The AMA -- which has long opposed government health care intervention, including the Clinton's administration's attempt to revamp the system in 1994 -- issued a statement calling the House version of the bill "a solid start to achieving health reform this year that makes a positive difference for patients and physicians."
"The status quo is unacceptable," president Dr. J. James Rohack said in July 18 video statement posted on the AMA Web site. Rohack praised the legislation for providing health coverage for 97 percent of Americans, and said the president's plain will "eliminate coverage denials based on preexisting condition" and "repeal the fatally flawed Medicare physician payment formula."
Still, Rohack said, "the debate is far from over," adding that the AMA will have a hand in drafting the final legislation, including a push for medical liability reform.
Some physicians charge the AMA is putting its business interests above the most critical issue at stake: patient care.
"The AMA is not representing patients or doctors anymore," Arizona physician Dr. Elizabeth Lee Vliet told FOX News. "Eighty-five percent of their revenue comes from non-membership sources. They are in the business of medicine."
While most doctors support some form of health care reform, a growing number are blasting the president's proposal and calling for a dramatically different approach -- one that calls for a system that pays for quality rather than quantity of medical procedures available to patients.
"There's no need to rush a bill through Congress," said Dr. Donald J. Palmisano, a leading surgeon and former president of the AMA who heads the physicians group Coalition to Protect Patients' Rights. "We don't get praise for getting out of the operation room quickly. We get praise for doing the right thing for the patients," he said.
Palmisano said he opposes the president's plan because patients will no longer be able to properly contract with their doctors. He is proposing a patient-centered system that will allow the patient to own the policy, which he said could be achieved by using tax credits to buy insurance.
"The government takeover of the practice of medicine will destroy the private health insurance companies, and will result in rationing, long lines, and loss of access to physicians in the patient hour of need," he said.
The Mayo Clinic, a non-profit organization and internationally renowned medical practice group, took issue with patient care quality that will result if the president's bill becomes law:
"Although there are some positive provisions in the current House Tri-Committee bill -- including insurance for all and payment reform demonstration projects -- the proposed legislation misses the opportunity to help create higher-quality, more affordable health care for patients."
"In fact, it will do the opposite," the clinic said in a July 16 statement on its Web site.
But Rep. Vic Snyder, D-Ark., a family physician, called the claim that expanding health coverage to the uninsured will lead to poor quality "one of the most ridiculous criticisms I have ever heard."
Opponents of the bill also charge that it will deter prospective doctors from pursuing a medical degree -- adding to preexisting concerns over the current number of doctors.
While the number of doctors available to see patients has been steadily declining, the House committees on on Ways and Means, Energy and Commerce and Education and Labor have included a provision that immediately expands primary care and nurse training programs to increase the size of the workforce.
The measures include strengthening grant programs for primary care training institutions and bolstering existing preventive medicine programs. The bill also calls for improving existing student loan, scholarship and loan repayment programs in an effort to increase the number of health care professionals.

[gdpawel]

According to the Columbia Jouranlism Review, there was a virtual press conference where health care experts were to discuss the ramifications of a public plan. The real purpose, by CMPI Advance, a newly-formed advocacy offshoot of the Center for Medicine in the Public Interest (CMPI Advance), was to introduce the new Hands Off MY Health campaign aimed at spotlighting the risks of government-run health care. The moderator Robert Goldberg, explained that the campaign consisted of a “labyrinth of sites” which examine single-payer systems around the world and give some thoughts on what a public plan can and cannot do.

APCO Worldwide is a super influential PR consulting firm that specializes in grassroots organizing, coalition building, and using political campaign tactics to create an environment that supports their clients’ legislative and regulatory goals. A 1995 APCO Associates pamphlet entitled “Political Support Services” says that “APCO applies tactics usually reserved for political campaigns to target audiences and recruit third-party advocates.”

The Center advocates a free-market approach to health care, especially when it comes to drugs and medical devices. In 2006, according to Politico, its biggest contributors were Pfizer and Pharma. Sourcewatch says its advisory board includes such right-wing think tank luminaries as Sam Kazman of the Competitive Enterprise Institute, Dr. Merrill Mathews from the Council for Affordable Health Insurance, and Grace Marie Turner, president of the Galen Institute.

Could insurance company and Big Pharma fingerprints be found on the Hands Off My Health campaign, whose goal seems to be stopping a public plan? According to Sourcewatch, APCO’s clients have included Novartis Pharmaceuticals, Pfizer, Roche, and Pharma. And after all, insurers and drug companies are not exactly friends of a public plan option.

And is CMPI Advance the kind of third-party outfit APCO says it specializes in recruiting—a surrogate for insurers and drug companies to spread their messages far and wide throughout the conservative and mainstream media?

Dr. Gary Puckrein, president of the National Minority Quality Health Forum, said “we have tremendous reservations about government plans,” and Dr. Val Jones, founder and CEO of Better Health Network, said that a public plan would force physicians to treat people as codes, not patients. (Presumably she meant the medical billing codes that doctors use.) Their comments mirrored the tone of the content found on the campaign’s labyrinthine Web sites, which—sleekly designed, supplying tons of information in short, digestible bites—have clearly been done by a pro.

The sites are awash with stuff that raises doubts about a public plan and the possiblity of stifling medical innovation, such as op-eds by Goldberg from outlets like the American Spectator and the Detroit News. There are quotes disparaging or questioning such a plan from academics like Princeton economics professor Uwe Reinhardt, elected officials like Sen. Joe Lieberman and Michael Enzi, and editorial boards of newspapers like The Washington Post and the Chicago Tribune. There are links to articles by people like Family Research Council senior fellow Ken Blackwell, who casts doubts about the actual number of uninsured folks in the country.

Page after page urges site visitors to join the fight against government-run health care by signing a petition telling politicians to do no harm to our health care system, and noting that the public plan is a poison pill for patients, doctors and the entire American health care system.

Doesn't smell good, does it?

[Midwest Alice]

Your source is said to smell too.
I think we should read the actual Health care bill @ http://patientsunitednow.com/?q=node/233, and see what we feel we can live with and not live with. Then contact our sentors and congressmen.

Peace, Alice

In another case of a blogger breaking a story and establishment media following up on it, a blogger known only as "David M" reported on May 31 that "Victor Navasky, publisher, editorial director and apparently co-owner of iconic left wing journal The Nation, is running the Columbia Journalism Review; however, he is not on the masthead."
To understand the politics of The Nation, consider that its writer Eric Alterman, in his book, What Liberal Media?, criticized the magazine for running columns by "longtime Stalinist communist Alexander Cockburn�" Alterman, a liberal himself, said that Cockburn's writings were characterized by "unabashed hatred for both America and Israel, coupled with his ravings against such stalwart progressives as democratic socialist representative Bernie Sanders of Vermont and the late Senator Paul Wellstone of Minnesota�"
CJR Executive Editor Michael Hoyt told David M that he reports to Navasky, but that the latter's role was mostly related to the business of CJR: "he hasn't done much editorially. Most of his work has been on the business side." By the time Editor & Publisher followed up on the story on June 1, Hoyt's comments suggested Navasky had absolutely no editorial involvment. Hoyt said that, "It could give somebody an opportunity to make a connection, but the connection is not there. He doesn't push anything editorially."
Compare that to what Navasky told David M. "Asked if he has been providing any editorial direction to CJR, Navasky said that he feels free to provide editorial direction to anyone he wants, including the New York Times or anyone else." Adding to the vagueness, Navasky told David M "I'm trying to help them out. I'm hoping to provide more editorial direction down the road, but I'm focused now on improving the finances."
Not surprisingly, Navasky downplayed his role to the blogger and merely said he had been given the dean's green light to do whatever needed to be done to help the magazine.
The responses from CJR and Navasky portray a casual and undefined relationship that has spanned some months. That contrasts with E&P's reporting that CJR Executive Editor Michael Hoyt and CJR Publisher Evan Cornog report to Navasky, who in turn reports to Nicholas Lemann, dean of Columbia University's Graduate School of Journalism.
CJR executive editor Michael Hoyt said in a phone conversation with David M: "I think he should be on the masthead as soon as possible." I should think so. Apparently, it's been decided (perhaps rather quickly) that Navasky will be termed "chairman" of the Columbia Journalism Review.
The Mediacrity blog, written by an anonymous "media insider," howled over the lack of coverage of the news in the mainstream media. It also noted that it must be "just pure happenstance that CJR has completely ignored the controversy around The Nation's payola pundit, Ian Williams, reported everywhere from this humble blog to Accuracy in Media and Front Page Magazine and Fox News? Williams worked for the UN as a 'media trainer' and writer while working for the UN-a conflict of interest that has been abysmally handled by The Nation and Salon, which also runs Williams' stuff."
Apart from E&P and The New York Sun, there has been no coverage of the CJR-Navasky connection. One can imagine the broad coverage that would ensue would it be learned that some outspoken conservative was pulling the strings behind a major journalism's school's prime publication. Adding to the intrigue would be why was the relationship hidden from the public?
In a February article for the D.C. Examiner Laura Vanderkam, a contributing editor to Reader's Digest, and member of USA Today's Board of Contributors, took CJR to task over their hypocrisy. In "Hammered: How blogs are shattering the arrogance of the Columbia Journalism Review and why that's good for journalism" Vanderkam rapped CJR for its double standard.
Among her points:

• CJR labeled right-of-center Daily Oklahoman as the "Worst Newspaper in America" in 1999, partly because the paper had no liberal columnists. Yet Vanderkam's search through the past few years' CJRs yielded no discernibly conservative writers in its pages, either.
• Vanderkam contrasts CJR's question posed to Fox News in 1998: "Can a news network dominated by conservative hosts be genuinely 'fair and balanced,' particularly toward those on the left?" with their move in 1996 to send a regular contributor to The Nation to profile the conservative editorial page of The Wall St. Journal. Not surprisingly, the assessment was not favorable.
• In 1996 CJR published a piece called "The Alar 'Scare' Was For Real" written by former American Journalism Review managing editor ELLIOTT Negin. Negin criticized the notion that the Natural Resources Defense Council hyped the Alar chemical story. Vanderkam notes Negin was referred to as a "Washington D.C.-based writer." CJR didn't tell the public that at the time Negin himself was a writer for the Natural Resources Defense Council. It was a classic case of a news organization running PR disguised as news.*

Ironically in 2004 CJR would follow the lead of the New York Times reports on video news releases and eviscerate the Bush administration for blurring the lines between public relations and news. On March 22, 2004 Zachary Roth wrote erroneously. "Nor, more importantly, does there seem to be a precedent for an administration making a VNR that includes a p.r. professional impersonating a reporter, and signing off "reporting from Washington." As AIM has previously reported, the very same GAO report which the New York Times (and CJR) used as a springboard to criticize the Bush administration's production of unlabeled VNRs included information on the Clinton administration's production of a VNR on the very same subject (Medicare prescription drug benefit), using a former PR professional and political appointee Lovell Brigham as a "reporter." It was hardly the sole incidence of Clinton-produced VNRs. The rest of the Roth piece, as most of the mainstream media's reporting on the subject, is marred by a lack of historical context.
CJR, which bills itself as the nation's premiere media monitor, should help media leaders understand why they are losing their audiences, Vanderkam contends. Instead, publisher Cornog penned a piece entitled "Let's Blame the Readers" which advanced the notion that thanks to conservatives, Americans are no longer civic-minded, and this is why they dislike mainstream media. Says Vanderkam: "Prominent villains blamed for this decline include both Presidents Bush and, oddly, speechwriter Peggy Noonan." That piece appeared in the January/February edition which also featured Corey Pein's "Blog-Gate" article. Pein argued, to the disdain of bloggers, that blogs had not been instrumental in exposing CBS's Memogate and that "liberals and their fellow travelers were outed like witches in Salem, while Bush's defenders forged ahead, their affinities and possible motives largely unexamined."
A current piece in CJR on the "Rise of Faith-Based News" by Assistant Editor Mariah Blake shows partly how Navasky may be helping CJR. The endnote states "Mariah Blake is an assistant editor at CJR. The magazine gratefully acknowledges support for her research from the Nation Institute's Investigative Fund." Also in the current issue is an article on Sinclair Broadcasting, "Fox News's cruder but equally zealous acolyte."
If Navasky gets his wish to provide more editorial direction one may well ask what the results will be. In 1993 Navasky wrote a piece for CJR entitled "Degrees of Sleaze: The Trouble with Balanced Reporting." In it he lamented the "neutrality" of the press as having contributed to New York Senator Al D'Amato's 51-49 percent victory over Attorney General Robert Abrams. Referring the reporter's required "narrative neutrality" Navasky asked "But what if this universally accepted convention has a hidden impact?" He contended "Mainstream journalists, who pride themselves on their noninvolvement and would be the first to declare their commitment to balance, fairness, and the ideal of objectivity, may have literally determined the outcome of the race they were reporting." Their "narrative neutrality" withheld information that one candidate was worse than the other, Navasky complained, and journalists thereby "helped elect the 'wrong' man"-"Senator Sleaze," as Navasky referred to him. The "he-said, she-said" coverage reinforced and created an image of moral equivalence, he said. While it's true that journalism is short on accurate and incisive analysis that puts together the "big picture" for citizens, one wonders, with Navasky's commitment to The Nation, if any conservative would ever be the "right" candidate.
The critical differences between the candidates were blurred, he wrote, "not because the reporters fell down on the job, but because they did their job according to the rules of the game. Perhaps it's time to have another look at the rules of the game." At the Columbia Journalism Review, it's likely Navasky will get the chance to do just that.
Correction:
The Natural Resources Defense Council hired Elliott Negin as its Washington communications director in May 1999. He was not, as stated in this column, working for NRDC in 1996 when he wrote the article for Columbia Journalism Review. Our column cited an article published by the D.C. Examiner in February 2005. The Examiner corrected that error in the online version of the article several days after the column originally appeared, but we were not aware of that correction. We regret the error.

[gdpawel]

The venue at one of the lastest Institute of Medicine forums on assessing and improving value in cancer care, was the pharmaceutical and biotechnology industry's efforts to beat back efforts at cost control in cancer care, which is increasingly seen as the next big income generator for Big Pharma. No wonder the "industry" is worried.

They put together a coalition, the so-called Partnership to Improve Patient Care, which includes the lobbying arms of the drug, device and biotechnology industries as well as patient-advocacy groups, most of which accept pharmaceutical industry donations, and medical-professional societies, to lobbying Congress to give the "industry" a major say over how it will be run.

The drug and medical device industries mobilized to gut a provision in the stimulus bill that would spend money on research comparing medical treatments. The research funding would be doled out to the National Institutes of Health and other government bodies to focus on producing the best unbiased science possible.

Comparative effectiveness research has the potential to tell us which drugs and treatments are safe, and which ones work. This is not information that the private sector will generate on its own, or that the "industry" wants to share. Companies want to control the data, how it is reviewed, evaluated, and whether the public and government find out about it and use it. Just about the way they are controlling data now.

Do publicly traded companies have a seat on the governing board of the Securities and Exchange Commission? Should Boeing and Airbus be given the right to determine the scope of the National Transportation Safety Board's inquiry into airplane crashes? It is simply bad governance to give "industry" a seat at the table when officials decide what comparative effectiveness studies will get done.

Sometimes clinical practice guidelines are questioned on the basis of profit conflicts. Specialty medical societies work to insure their specialist members get reimbursement for common procedures/treatments, the drug industry works to produce evidence statements that promote use of their drugs, so some questions arise that do not seem comfortable that many trials are unobjective and balanced.

The entire premise upon which these societies base their evidence-based guidelines may be biased towards maintaining flow of their life blood-industry funded clinical trial dollars. Could it be that they focus on guidelines to both justify and feed the proposition that because cancer patients are probably going to die, then the FDA, CMS and taxpayers are supposed to pay for any combination of these wanna-be cancer drugs for any type of terminal cancer?

Evidence-based medicine has morphed into pharma-based medicine and HMO-based medicine. Evidence is based on data from medical journal articles, epidemiology and economics, which relies on randomized clinical trials, which doesn't even require a medical education. Nonphysicians trained in social science, science or even public policy analysis, have judgement over medicine. Where doctors defined the "standard of care," now payers and purchasers of medical services redefine the standards for appropriate medical care, encouraging doctors to act in ways to promote their financial interest when they make medical decisions.

The use of clinical trials to establish prescribing guidelines for evidence-based medicine is highly criticized because such trials have little relevance for the "individual" patient in the real world, the individuality and uniqueness of each patient. In cancer medicine, the best reform to the system is to totally remove the profit incentive from chemotherapy administration. Take physicians out of the retail pharmacy business and force them to be doctors again.

Conservatives have been misinforming the public about the health IT provisions of the stimulus package by falsely claiming that it would lead to the government telling the doctors what they can and cannot treat, and on whom they can and cannot treat. The Hudson Institute fellow, Betsy McCaughey, claims that legislation will have the government monitor treatments in order to guide your doctor's decisions.

The language in the bill tasks the (already existing) National Coordinator of Health Information Technology (NCHIT) with providing appropriate information so that doctors can make better informed decisions. The NCHIT provides counsel to the Secretary of HHS and Departmental leadership for the development and nationwide implementation of health information technology.

Contrary to Ms. McCaughey's statements, the language does not establish authority to monitor treatments or restrict what your doctor is doing with regard to patient care. It addresses establishing an electronic records system so that doctors can have complete, accurate information about their patients. Converting an antiquated paper system to a computer system by making the health care system more efficient.

[Jackie07]

Just wanted to note that Dr. J. James Rohack, the current President of AMA, happens to be here in our town. He has been in charge of the Scott & White Health Plan and knows much about the insurance situation.

The S&W Hospital and Clinic (the teaching hospital of the School of Medicine - Texas A&M University) is non-profit and covers a large area of small and mid-sized towns in Central Texas.

The premium (for my husband and me) has gone up so much - 17 years ago, the monthly premium was close to 1/4 of my unemployment check. Now it bites off almost 1/2 of the unemployment check. (I'd warned my church friends before - eveytime I had major health issues and the subsequent job loss, there would always be war and bad economy...)

The last time I read about his opinion on the Health care reform in the local newspaper he seems to be pretty optimistic about the future. I think if the reformed plan covers over 97% of the population, there will be less emergency room visits and ER bills (which usually triples the costs) And the way S&W has been treating its patients - focusing on preventive medicine - is a good model to cut down the overall cost.

Having had 4 major surgeries handled by S&W and haven't gone broke, I think whatever Dr. Rohack recommends is going to be good medicine for health care reform.

[Jackie07]

AMA Supports H.R. 3200, "America's Affordable Health Choices Act of 2009"


House bill expands access to high quality, affordable health care for Americans
WASHINGTON, DC — Today, the American Medical Association sent a letter to House leaders supporting H.R. 3200, "America's Affordable Health Choices Act of 2009."
"This legislation includes a broad range of provisions that are key to effective, comprehensive health system reform," said J. James Rohack, MD, AMA president. "We urge the House committees of jurisdiction to pass the bill for consideration by the full House." H.R. 3200 includes provisions key to effective, comprehensive health reform, including:

• Coverage to all Americans through health insurance market reforms
• A choice of plans through a health insurance exchange
• An end to coverage denials based on pre-existing conditions
• Fundamental Medicare reform, including repeal of the flawed sustainable growth rate (SGR) formula
• Additional funding for primary care services, without reductions on specialty care
• Individual responsibility for health insurance, including premium assistance to those who need it
• Prevention and wellness initiatives to help keep Americans healthy
• Initiatives to address physician workforce concerns

"The status quo is unacceptable," Dr. Rohack said. "We support passage of H.R. 3200, and we look forward to additional constructive dialogue as the long process of passing a health reform bill continues. This is an important step, but one of many steps in the process. The AMA is actively engaged with Congress and the administration to achieve health reform that best meets the needs of patients and physicians. We are committed to passing health reform this year consistent withprinciples of pluralism, freedom of choice, freedom of practice, and universal access for patients."

[gdpawel]

"I think if the reformed plan covers over 97% of the population, there will be less emergency room visits and ER bills (which usually triples the costs)."

Aye! Very good point and fits very much into the health care reform equation. People WITH insurance may not realize that their added premium cost includes a lot of those uncompensated emergency room visits by people WITHOUT insurance. The health care reform bill will help to prevent the passing on of uncompensated costs to the insured population.

[Jackie07]

Scott & White also operates a weekend clinic. We can call the 24-hour oncall nurse line to figure out if we need to see a doctor. If we do want to see a doctor (our choice - based on the oncall nurse's recommendation), we can go to the weekend clinic (taking calls from 7:30 am) which opens both Saturday (whole day) and Sunday (afternoon.)

[Midwest Alice]

Hey Jackie, and Gdpawel, Agreed the people without insurance going to ER because they don't have insurance is a problem for their health and everyone because of the cost.

We need to make sure when bills are passed they are bills that will improve all of these problems not make everything worse.

The following is long, but worth reading. Its written so I can understand it, talks about each bills under consideration, resources are doctumented.

I read it, but I printed it off so I can take it with me today and read it better.

This is a very important issue and I want to understand it fully.I appreciate you commits.

Make it a great day ALIce


July 30, 2009
A Federal Health Insurance Exchange Combined with a Public Plan: The House and Senate Bills
by Robert E. Moffit, Ph.D.
Backgrounder #2304

Members of Congress, pursuing President Barack Obama's health policy agenda, want to create a national health insurance exchange as a platform for a public health care plan to compete against private health insurance.
Variants of the exchange proposal are embodied in the America's Affordable Health Choices Act of 2009 (H.R. 3200), promoted by the leadership of the U.S. House of Representatives,[1] and the Affordable Health Choices Act, sponsored by Senators Edward Kennedy (D-MA) and Chris Dodd (D-CT).[2] Both of these huge bills are backed by the President and the Democratic congressional leadership.
While a national health insurance exchange is sometimes described as a nationwide pool of health insurance providers that would facilitate access to coverage for individuals and employers, its major function would be to provide a platform for a government-run public health plan that, using Medicare-style administrative pricing, would "compete" against private health insurance. Congressional champions of the idea say that this would increase the range of choice and competition available to Americans. In fact, it would do exactly the opposite.
In reality, the result would be a massive erosion of private health insurance. According to a recent analysis by the Lewin Group, the nation's most prominent health policy econometrics firm, assuming full implementation of the House bill, 103.9 million Americans would be covered under the public plan, and 83.4 million of them would no longer be covered by private health insurance.[3] Moreover, a federally designed health insurance exchange would consolidate federal control over the financing and delivery of Americans' medical services.
Initially, Americans may respond positively to the idea of a national health insurance exchange, but they are almost certainly unclear about its functions, how it would affect them, or which health policy problems it would solve. The maddeningly elastic language used in the health care debate can conceal as much as convey the true meaning of proposals embodied in the complex provisions of the mammoth House and Senate health care bills.
A Better Alternative: A State Option. A state-based health insurance exchange can indeed be a sound way to achieve a level playing field and a statewide market for a variety of different private health plans to compete directly for the business of employers and employees, individuals, and self-employed persons. That is why conservatives in Congress and elsewhere have promoted the exchange as a voluntary option for those states that could use such a mechanism as part of their reform of their often-dysfunctional health insurance markets.[4]
Though a health insurance exchange has been promoted as a policy initiative in many states, so far it has been translated into working models in two: Massachusetts and Utah.[5] Given the radical differences in these two states' insurance markets, regulatory climates, political cultures, and policy objectives, it is hardly surprising that the implementation and operation of a health insurance exchange is very different in these two states as well. It is further unsurprising that the concept has also been a source of seemingly limitless confusion as different proposals are advanced to achieve very different policy objectives.
The underlying policy objectives determine the functions of the health insurance exchange. In a truly competitive market based on real consumer choice and genuine competition, the suppliers of goods and services would operate on a level playing field and government would be confined to making and enforcing rules to protect consumers from fraud and misleading advertising, establishing minimum standards for health and safety, and enforcing contracts.
An exchange could facilitate that process. The government would not undermine competition by fielding its own enterprise with the special advantages of taxpayer subsidies, picking winners and losers, or imposing discriminatory tax or regulatory policies on different consumers or firms. The key to a level playing field is that the government would in no way favor one competitor over another or give any legal advantages to any player in the competition.
Federal Control. Based on the provisions of the House and Senate bills, as well as the proposals offered by President Obama, the structure and dynamics of the national exchange would be very different from those proposed by reformers who design state health insurance exchanges as optional mechanisms for consumer choice and competition.

• Instead of a single market open to any willing private health plans, the leading House and Senate bills would allow participation only by plans that met highly prescriptive federal standards, foreclosing any other options for consumer choice and competition.
• Instead of establishing a level playing field among different insurers, the House and Senate proposals would foreclose the possibility of anything even barely resembling a genuinely level playing field for fair competition.
• Private health plans would assume all risks and remain subject to a variety of state and federal laws beyond the proposed House and Senate provisions for a level playing field.
• With the new public health plan, taxpayers would retain the risk, and the public plan would function apparently free of the legal requirements that burden private health plans.[6]

With Congress fielding its own plan in competition against private health plans, taxpayers would be forced in effect to underwrite the marketing costs of an entity designed to displace their own private coverage. Based on recent experiences with Fannie Mae and Freddie Mac, it is certain that Congress would force taxpayers to underwrite the cost overruns of such a health insurance enterprise no matter how unsuccessful its performance. Medicare alone, a prime example of congressional micromanagement, has an accumulated unfunded liability of $38 trillion.[7] In a national health insurance exchange, taxpayers could be certain that the deck would be stacked against private-sector players in a game that is rigged from the start.
How Congress Would Create a Health Insurance Exchange
Among Administration and congressional champions of a national health insurance exchange, the structure or functions vary. Likewise, the intellectual rationale for the health insurance exchange is, based on the plain record, maddeningly elusive. If there is a specific health policy problem that a national health insurance exchange is designed to solve, it is not at all clear what exactly that problem is or why it simply cannot be solved by other, more direct and less intrusive means.
The Obama Proposal. President Obama proposed a national health insurance exchange as elemental to his health care reform agenda. There are precious few details in Obama's campaign documents on the national health insurance exchange itself or how it would function. He briefly described it as a "watchdog" agency.[8]
Thus, the national health insurance exchange would serve as a regulatory rather than purely administrative body. It would be a national rule-maker and enforce a common set of rating and insurance rules that would apply to private health plans within the national exchange, as well as to the public health plan itself. It would also serve as the regulatory vehicle to enforce the decisions of his proposed "institute" to judge the comparative effectiveness of medical treatments and procedures.
A version of this idea of an "institute," the 15-member Federal Coordinating Council for Comparative Effectiveness Research, has already been enacted in the stimulus bill earlier this year. The new agency is charged with making determinations on the "comparative effectiveness" of different medical services, devices, drugs, and procedures. In short, in Obama's version, the national exchange would be not only an independent regulatory agency in itself, but also the central channel for the regulatory decisions of other federal agencies, governing both public and private insurance options.
Outside of this centralized system of muscular control, the rationale for the national exchange, at least as championed by independent health policy analysts, is somewhat elusive.
First, in sharp contrast to the champions of a statewide health insurance exchange--for whom the remedy of federal tax inequities is the primary rationale for its establishment--the President does not even mention the unfairness of existing federal tax policy, even though it undercuts millions of Americans' access to affordable health insurance.[9] If President Obama wanted to rectify this problem and advance progressive tax relief, as recommended by Jason Furman, one of his top economic advisers,[10] he could simply have proposed a consequential change in the federal treatment of health insurance and eliminated the unfairness and inefficiency of the current tax system. In other words, there would be no reason to create a national health insurance exchange to secure the objectives of a rational tax policy.
Second, the President is not pursuing a national exchange as a way to create a robust and competitive national market for health insurance. Health insurance is an odd exception to the general rule. There is a robust and competitive market for virtually every other set of goods and services in the economy, including complex items, and none of these requires the congressional creation of anything like a national exchange, administered by a commissioner, to facilitate their availability to consumers. If the President wanted to create a national market for health insurance, he could simply propose the repeal of outdated provisions of federal law that erect barriers to the purchase of health coverage across state lines. The President is obviously not interested in creating anything like a normal national, competitive market for health insurance.
Third, and most important, the national health insurance exchange would become the mechanism for the new government health plan to compete against private health insurance plans. This would seem to be its main function. The national health insurance exchange would be the "level playing field," or the arena for such a competition, and would thus serve as the key mechanism to secure the crowd-out of private health insurance coverage and pave the way for a single-payer system. As Martin Feldstein, professor of economics at Harvard University, has recently observed:

The Obama plan to have a government insurance provider that can undercut the premiums charged by private insurers would undoubtedly speed the arrival of such a single payer plan. It is hard to think of any other reason for the administration to want a government insurer when there is already a very competitive private insurance market that could be made more so by removing government restrictions on interstate competition.[11]

Again, based on the best independent evaluations of such an arrangement, millions of Americans throughout the United States would end up losing their private coverage, particularly if employers dumped workers and their families into the new public plan.
The House Tri-Committee Bill. Under Section 201 of Title II of the America's Affordable Health Choices Act of 2009, Congress would create a national health insurance exchange.[12] This exchange would be administered by a powerful Health Choices Commissioner who would head a new federal agency called the Health Choices Administration. The commissioner would be appointed by the President and confirmed by the Senate. Among the commissioner's chief duties would be to establish a process for the enrollment of eligible individuals and employers, to negotiate contracts with congressionally defined "qualified health plans," and to enforce statutory requirements relating to federally defined health benefits.
Under Section 208, the commissioner could approve health insurance exchanges created by a state or group of states that perform "all of the duties" of the national health insurance exchange and could terminate state exchanges that do not meet these federal standards.
Under Section 203, the commissioner would specify each year the health benefits and benefit levels (four levels are statutorily required based on cost-sharing) for health plans that participate in the national exchange,[13] consistent, of course, with congressionally determined benefit requirements. The commissioner would also establish a process for a phased-in enrollment of eligible individuals[14] and small businesses, and would have the authority to expand eligibility for enrollment in the exchange as the commissioner "deems appropriate." Assuming full implementation, the Lewin Group estimates that the number of Americans with private coverage would fall from 172.5 million to 83.4 million, or a 48.4 percent reduction in private coverage.[15]
Under Section 204, the commissioner has contracting authority to solicit bids and enter into negotiation with federally "qualified" health plans on an annual basis, with an option for automatic renewal. Congress further specifies that these plans must be licensed in the states in which they operate and must comply with the commissioner's requirements to provide requested data or other information, as well as the commissioner's standards and procedures for "grievances and complaints" and "network adequacy." The commissioner would also see to it that approved health plans implement the subsidies and credits for persons needing assistance, participate in "risk pooling" arrangements, provide for "culturally and linguistically appropriate services and communications," and make contracts with "essential community providers."[16]
Under Section 205, the commissioner is to establish outreach and enrollment processes for "exchange-eligible" individuals and for "vulnerable" populations, including adults and children with disabilities and cognitive impairments. Under Section 207, Congress would create a Health Insurance Exchange Trust Fund for the deposit of funds to finance the operations of the Health Choices Administration.
The House Public Plan. Under Section 221 of Title I, the Congress would require the Secretary of Health and Human Services to create a "public health insurance option" to be offered within the national exchange in 2013. The public plan would be required to offer the same benefits required by law for private health plans and obey the same insurance rules and other statutorily defined network and consumer protection requirements.
Under Section 222, the Secretary would set the premium to cover all benefit costs and projected administrative costs of the plan, as well as a "contingency margin." The bill would authorize an initial $2 billion for start-up costs and initial reserve requirements. Congressional sponsors insist that the public plan must be self-sustaining, based on its premium income.
Under Section 223 of Title I, the Secretary would set payment rates for doctors and hospitals and other medical professionals based on the Medicare payment rates, plus 5 percent for those health care professionals who also participate in the Medicare program. The bill would also abolish the Medicare update for physicians' services based on the Sustainable Growth Rate formula, a special formula for updating physicians' payment based on growth in the general economy.
By 2016, the Secretary would have greater flexibility in setting rates and would "modernize" payment for the public plan consistent with reforms in the delivery system to achieve higher quality care. For doctors and other medical professionals, Congress outlines the conditions for participation and would apply Medicare's existing anti-fraud and abuse rules to the public plan.
Because the payments in the House version of the public plan are based on Medicare payment rates, the Lewin Group estimates that the premiums for the public plan would be approximately 25 percent less than those obtainable in the private sector.[17] Payment below private market rates would ensure cost-shifting from the public plan to individuals enrolled in private health plans, which the Lewin Group estimates at $460 per person under the terms of the House bill.[18] Not surprisingly, moderate and conservative Democrats complain that the House bill tilts the playing field against private providers.[19]
Under Section 225, doctors who accept the payment in the public plan as payment in full would be "preferred physicians"; "non-preferred physicians" are those who agree to the balance-billing limitations that prevail in Medicare. For all physicians, the HHS Secretary would be authorized to make more detailed requirements, presumably through regulation, for "conditions of participation" in the public plan.
The Kennedy-Dodd Bill. Under Section 143 of Title I of the Senate bill, the Congress would create "affordable benefit gateways" that would function as a health insurance exchange for each state based on the proposed federal standards. The bill provides some flexibility for the states in setting up or administering these federally sponsored "gateways," and one gateway could operate in more than one state.
To assist the states in doing this, the HHS Secretary would provide grants and would have discretion over the amount of the grants given to the states. If a state was not making progress toward establishing a gateway in conformity with federal standards--for example, by including a public plan to compete against private health plans--the Secretary would have the power to intervene and establish such arrangements.
The gateway would fulfill the conventional administrative functions of a health insurance exchange, making health insurance available, providing information on the federally qualified health plans, and facilitating outreach to eligible individuals and their enrollment in plans provided through the gateway or other government programs such as Medicaid, SCHIP, or the new public plan. Gateways would also be able to contract with private entities, called "navigators," that would help to raise public awareness of the existence of the gateway and available health care plans. Health insurance plans that are not "qualified plans" could still operate outside of the gateway.
Under the Senate bill, the gateways would be required to establish a risk-adjustment system, thus providing an appropriate payment to health plans that have enrollees with health risks higher than the prevailing average in the state. Each year, the state-based gateways would also be required to report to the Secretary of Health and Human Services on their financial condition.
Under Title I of the Senate bill, the health benefits and medical procedures for health plans would be established by a new federal agency, a Medical Advisory Council. The council would be composed of medical experts who would make recommendations to the Secretary on what health benefits are "essential" and what would constitute "affordable coverage." The Senate bill would also provide a process for congressional review of the benefit decisions, and Congress could reject the Secretary's benefit decisions through a joint resolution of disapproval.
The Senate Public Plan. Under Title I of the Senate bill, Congress would create a new public plan, called the "community health insurance option," to compete against private health plans. This public plan would have to be offered in each state through the gateway and compete with private health plans in the gateway. Congress would establish a State Advisory Council to make recommendations to the Health and Human Services Secretary on the public plans' operations in each state.
The public plan would offer the "essential benefits" determined by the Medical Advisory Council, but the states could also require the public plan to offer additional benefits. The HHS Secretary would be authorized to set payment rates for doctors and hospitals, but they could not be higher than the "average rate" paid by health plans participating in the gateway. The HHS Secretary would also have the authority to contract with private entities to execute the duties associated with the public plan.
As with the House bill, the Senate bill would create a special trust fund for the financial operations of the public plan. The Senate sponsors intend that there would be no additional costs to the taxpayer beyond start-up costs and that premiums would cover the costs of the Senate version of the public plan.
The Baucus Proposal. Senator Max Baucus (D-MT), chairman of the Senate Finance Committee, is trying to produce yet another major Senate health care bill. Outside of a legislative product, however, Senator Baucus has also proposed a national health insurance exchange that would "organize affordable health insurance options, create understandable, comparable information about those options and develop a standard application for enrollment in a chosen plan."[20]
In the Baucus proposal, health plans participating in the national exchange would be able to compete on the national, regional, state, or local level, and benefit packages could differ "within reason," but they would have to meet federal actuarial standards.[21] Congress, however, would not actually do the work of fixing the actuarial standard or defining the meaning of coverage or affordability. Like former Senator Tom Daschle (D-SD),[22] Baucus would delegate such tasks to a special body of political appointees.
This is also congruent with the Senate Health, Education, Labor and Pensions Committee bill, which would create a Medical Advisory Council, and the House Tri-Committee Bill, which, within statutory guidelines, would delegate authority to set health care benefits to the HHS Secretary with recommendations from an Advisory Benefit Committee whose members would be appointed by the Secretary.[23] In the Baucus proposal, a new agency, the Independent Health Coverage Council, would define the meaning of "affordability" and "coverage" for participating health plans, as well as standards for chronic care and quality reporting.[24] This would mean, of course, that Americans would be subjected to decisions over which they would practically have little or no control.
Under the Baucus proposal, health plan premiums would reflect differences in benefits, not risk, and premiums offered by plans in the national health insurance exchange would have to be the same as those offered outside of the exchange.[25]
In contrast to President Obama, Baucus appears to be more flexible: He would require a division of labor between federal and state authorities in the regulation of health insurance. While determinations of affordability, actuarial equivalence, and benefit standards would be federal responsibilities, all plans participating within the national health insurance exchange would be subject to state laws and regulations governing consumer protection, solvency, reserve requirements, and premium taxes.[26]
In short, the rules governing health plans in the national health insurance exchange would be both federal and state laws. The federal government would make rules governing the insurance coverage, and state governments would make and enforce rules governing consumer protection.
The National Health Exchange and a New Public Plan
Irrespective of their differences, leading congressional health care proposals are strikingly clear in their main features: centralized decision-making in Washington and a dominant role for the federal government at the expense of the states in regulating health insurance.
Control by Washington means that special-interest politics concentrated in the nation's capital would dominate Americans' health care decisions even more than they do today. As with Medicare, it would be inevitable. According to The Washington Post, health care industry lobbyists have made $298.9 million in contributions to Members of Congress since 1989, and nearly 60 percent of that amount has gone to Members who sit on the five key congressional committees that handle health care legislation.[27]
Decisions would focus on a myriad of issues: what is or is not to be covered in the health benefits package; which and how many plans can participate in the national health insurance exchange; which states--if any--will or will not be able to chart a more or less independent course. This would guarantee the frenzied lobbying of powerful special interests desperate to secure their competitive advantage.
It is fanciful to believe that government officials at HHS, a board, or a council would be able to devise a set of fair and equitable rules that would efficiently and effectively account for the very diverse and distinctive circumstances that prevail in different states across the country. Proposals to insulate such a process from special-interest politics by creating a body of politically appointed "experts," ensconced somewhere in the administrative offices of HHS, or a commissioner administering a National Health Exchange[28] reflect the triumph of fantasy over experience. No such body or official will be immune from either K Street lobbyists and their lucrative campaign coffers or powerful congressional committee chairmen.
Politics of the Public Plan. The introduction of a public, government-run health plan would further complicate the operation of a national health insurance exchange. If the exchange became a powerful regulatory agency--Obama's vision-- Congress would have equally powerful incentives to set the rules to the advantage of its own health plan. This could be done in a variety of ways: by setting the government's health plan premiums artificially low (using Medicare rates as in the House bill); by reducing or eliminating cost-sharing requirements; or by manipulating benefits to make the government health plan more attractive than the private health plans. Congress would have every incentive to make sure that its own creation did not incur the legal or financial risks that private firms ordinarily bear.
Because the public plan is a political creation, political decisions would overrule all other considerations concerning key items: benefit levels, premium levels, co-payments, the kinds of medical treatments that could or could not be included. The annual lobbying circus that accompanies annual Medicare legislation is instructive as congressional leaders fight to preserve or maintain existing federal reimbursements for favored groups against competition, most recently for payment for durable medical equipment and supplies.[29]
A massive crowd-out of private coverage would be accelerated under the employer mandate, embodied in both the House and Senate bills, as employers dropped private coverage and paid the requisite tax. Likewise, lobbyists for businesses or private insurance industry executives might see the government health program as a convenient dumping ground for high-risk individuals or families, which would reduce business and insurance industry costs but would also amount to significant adverse selection against the taxpayers. Faced with the rapidly rising costs of the public plan, let alone Medicare and Medicaid, taxpayers have demonstrably fewer lobbyists working on their behalf in Washington than those who are reimbursed with public or corporate money.
Double-Edged Sword? Lobbying for or against the policies and decisions of an administrator, council, or commissioner of a national health insurance exchange would be, of course, a two-way street. Once established, the legal and regulatory powers of such an agent or agency could turn out to be a double-edged sword, wielded by proponents of the public plan or advocates of private insurance. A public plan, after all, would be a wholly owned subsidiary of Congress.
Though admittedly far less likely, the political dynamics could run in a direction exactly the opposite of the "single-payer" conclusion for which the Left yearns so passionately. Congressional conservatives could decide--for budgetary or ideological reasons--to enact measures, amendments, and riders to expand private health plans and shrink the public option, create payment limitations or more restrictive reimbursement rules, and discourage public program enrollment. Currently, liberals in Congress, upset about existing levels of payments to private health plans in Medicare, which they deem excessive, are committed to rolling them back, hoping to halt the rapid growth of these increasingly popular Medicare Advantage health plan options.[30]
The more likely outcome of this political process is that the national health exchange would serve as an efficient mechanism to erode what is left of private health insurance. On the part of many in Congress, particularly those who favor a direct federal takeover of the entire system or the enactment of a single-payer health care system, the national health insurance exchange provides an arena for the destruction of the hated private health plans that, in their view, consume so many dollars in unwanted and unnecessary administrative costs and "immoral" profits.
There is good reason to believe that a public plan operating within a national health insurance exchange would accomplish the single-payer objective. In a December 2008 independent assessment of the likely impact of a public plan, the Lewin Group concluded that there would be major shifts from private to public coverage: Anywhere between 10.4 million and 118.5 million Americans, depending on how many are eligible for enrollment and the plan's payment rates, could be transitioned out of private health insurance.[31]
In its first analysis of the House Tri-Committee bill, Lewin estimated that, based on the statutory requirement for the use of Medicare rates as payment rates in the public plan, plus the progressive eligibility of all employees over time, the House bill would result in a dramatic expansion of government enrollment and that an estimated 113.5 million Americans would lose private coverage.[32] A recent Urban Institute study[33] and Lewin's most recent estimate of the latest version of the House bill show a smaller displacement of private coverage, but nonetheless a massive crowd-out.
During the markup of the Kennedy-Dodd bill, Douglas Elmendorf, director of the Congressional Budget Office (CBO), reported to the Committee on Health, Education, Labor and Pensions that, as a result of the provisions of the $1 trillion Senate bill, several million Americans would lose their employer-sponsored health insurance coverage.[34]
At the very least, the creation of a national health insurance exchange as a platform for a public plan to compete against private health insurance would cut short state innovation in health insurance market reform and accelerate the already rapidly growing federal domination of the financing and delivery of health care. Even more likely, it would ensure the eventual triumph of a single-payer system of national health insurance run by Washington. The national health insurance exchange combined with a public plan, falsely advertised as a mechanism to advance consumer choice and market competition, would be the institutional vehicle to guarantee the exact opposite.
Conclusion
President Obama and the congressional leadership are intent on creating a national health insurance exchange. In its various legislative forms, their version of the health insurance exchange is a powerful regulatory agency; it is not merely an administrative agency to facilitate enrollment and to promote choice and anything remotely approaching free-market competition.
In many respects, the national health insurance exchange resembles a solution in search of a problem. If the President or Congress wanted to create a national health insurance market, they would not need to create a national health insurance exchange--they would merely have to repeal existing federal barriers to insurers competing across state lines. If the President and Congress wanted to fix the inequities of the federal tax law, a key rationale for creating a health insurance exchange at the state level, all they would have to do is to reform the federal tax laws governing health insurance and end the practice of discriminating against those who cannot or do not get health insurance through their place of work.
If the objective of the President and Congress is to expand the role of the federal government in providing health insurance and determining the kind of health insurance that Americans will get, the national health insurance exchange is a convenient tool for that federal expansion and control. It would be tantamount to a national arena for the public plan to undercut private health plans and erode existing private health coverage.
There is little doubt that a national health insurance exchange, combined with a public plan, can achieve that policy objective. But there is also little doubt that such an objective is not what most Americans had in mind when they embraced the cause of comprehensive health reform.
Robert E. Moffit, Ph.D., is Director of the Center for Health Policy Studies at The Heritage Foundation.

[1]For an overview of the House Bill, see Robert E. Moffit, "The House Health Care Bill: A Blueprint for Federal Control," Heritage Foundation WebMemo No. 2515, July 1, 2009, at http://www.heritage.org/Research/HealthCare/
wm2515.cfm.

[2]The act was reported out of the Senate Committee on Health, Education, Labor and Pensions on July 15, 2009. For a preliminary overview of the Senate bill, see Robert E. Moffit and Stuart M. Butler, "Why the Kennedy Health Bill Would Wreck Bipartisan Reform," Heritage Foundation WebMemo No. 2481, June 12, 2009, at http://www.heritage.org/Research/HealthCare
/wm2481.cfm.

[3]The Lewin Group, "Analysis of the July 15 draft of The American Affordable Health Choices Act of 2009," Memorandum from John Sheils and Randy Haught, The Lewin Group, to Stuart M. Butler, Vice President for Domestic and Economic Policy, The Heritage Foundation, revised July 23,2009, p. 5. Hereafter cited as Lewin Group House Draft Analysis.

[4]For example, Senators Tom Coburn (R-OK) and Richard Burr (R-NC) and Representatives Paul Ryan (R-WI) and Devin Nunes (R-CA) are sponsoring the Patients' Choice Act of 2009 (S. 1099 and H.R. 2520). It creates an option for the states to pursue state-based health insurance exchanges, described by the sponsors as "a one-stop marketplace to compare different health insurance policies and select the one that meets their unique needs."

[5]In Utah, the state health insurance exchange is an "Internet-based information portal" that connects individuals and families to comparative health plan information, enabling them to make the choice of a health plan and enroll electronically. It is designed to move the Utah market decisively in the direction of a consumer-driven system in which the financing would be based on an employer's voluntary defined contribution to the premium costs.

[6]For example, a truly level playing field would not only subject the public plan to state health-benefit mandates, which the House bill does, but also apply to the public plan state and federal contract laws, state and federal taxes, tort laws that apply to insurance firms, state-level financial solvency requirements in states where the public plan would compete, accounting rules that measure current and future liabilities, state and federal taxes that are levied on private plans, anti-trust laws, and state and federal privacy-protection laws. A level playing field would also require the public plan to abide by the laws and regulations that govern the marketing and sale of health insurance in the states where the public plan would compete.

[7]On the gravity of Medicare's existing liabilities, see 2009 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, May 12, 2009, at http://www.cms.hhs.gov/reports
/trustfunds/downloads/tr2009.pdf (July 24, 2009).

[8] See "Barack Obama's Plan for a Healthy America: Lowering Costs and Ensuring Affordable, High Quality Coverage for All," at http://www.barack
obama.com/issues/healthcare. See also Robert E. Moffit and Nina Owcharenko, "The Obama Health Plan: More Power to Washington," Heritage Foundation Backgrounder No. 2197, October 15, 2008, pp. 5-6, at www.heritage.org
/research/healthcare/bg2197.cfm,

[9]Given the President's insistence on fairness and efficiency in the provision of health care, his omission of a serious reform of the federal tax policy that governs health insurance, the single most important ingredient in comprehensive health care reform, is conspicuous and inexplicable. Giving every taxpayer tax relief for the purchase of health insurance would spur real competition among private plans, different types of health care options, and greater personal ownership and portability of health insurance.

[10]See, for example, Jason Furman, "Health Reform Through Tax Reform: A Primer," Health Affairs, Vol. 27, No 3 (May/June 2008), pp. 622-632.

[11]Martin Feldstein, "Obama's Plan Isn't the Answer," The Washington Post, July 28, 2009, p. A17.

[12]The congressional leadership has released two versions of the Tri-Committee bill. The version referred to here is the America's Affordable Health Choices Act of 2009 (H.R. 3200), as prepared by the Committees on Energy and Commerce, Ways and Means, and Education and Labor of the U.S. House of Representatives on July 14, 2009.

[13]The four levels are basic, enhanced, premium, and premium plus. Under Section 203 of Title II, Congress prescribes the cost-sharing variations among these levels of coverage.

[14]The House bill specifies the individuals who are not eligible for enrollment in the exchange: enrollees in Medicare, military health programs, the Veterans Administration, and, generally, Medicaid. Under Section 202, there is a major exception for certain Medicaid enrollees: childless adults with incomes under 133 percent of the Federal Poverty Level ($14,400) who had other coverage in the previous six months. These persons would be able to enroll in either the Medicaid program or the national health insurance exchange.

[15]Lewin Group House Draft Analysis, p. 5.

[16]This is a significant requirement because it relates directly to the mandatory provision of abortion. It is worth noting that during the Senate Health, Education, Labor and Pensions consideration of the Senate version of the health reform bill, Barbara Mikulski (D-MD) secured passage of an amendment requiring health plans to include "essential community providers" within their networks for women's' medical services. This would include clinics run by Planned Parenthood, a major abortion provider.

[17]Lewin Group House Draft Analysis, p. 14. Moreover, the public plan, as Lewin notes, would not provide either profit margins or broker commissions.

[18] Ibid., p. 18.

[19]"Using Medicare's below-market rates would weaken the financial stability of our local doctors and hospitals and doctors." Letter to Hon. Nancy Pelosi, Speaker of the House of Representatives, and Hon. Steny Hoyer, Majority leader, from Representative Barron Hill (D-IN) et al., July 9, 2009.

[20] Senator Max Baucus (D-MT), "Call to Action: Health Reform 2009," p. 17, at http://finance.senate.gov/healthrefo...whitepaper.pdf (July 22, 2009).

[21]Ibid.

[22]In Senator Tom Daschle's version, the national health insurance exchange would be a national "pool" like the Federal Employees Health Benefits Program (FEHBP). The FEHBP has no public plan, and its regulatory regime is modest. Daschle's national exchange would be an administrative agency that would carry out the decisions of his proposed Federal Health Board. In Daschle's scheme, the board, modeled after the Federal Reserve Board, would serve as the ultimate arbiter of what is or is not to be offered to patients in public and eventually private health insurance plans, as well as what is or is not to be reimbursed. The board would work with Medicare officials to create a special government health plan that would also compete with private health plans in a national pool, Daschle's version of a national health insurance exchange. For further details, see Sen. Tom Daschle, with Scott S. Greenberger and Jeanne M. Lambrew, Critical: What We Can Do About the Health Care Crisis (New York: Thomas Dunne Books, 2008), especially pp.116-137.

[23] Unlike the provisions of the Senate Health, Education, Labor and Pensions Committee bill, there are no provisions in the House bill for a congressional override of the Secretary's benefit decisions. Congress could, of course, intervene at any time and impose restrictions or guidance on the Secretary with respect to benefit matters.

[24]Baucus, "Call to Action," p. 19.

[25]Ibid., p. 18.

[26]Ibid.

[27]Dan Eggen, "Industry Cash Flowed to Drafters of Reform," The Washington Post, July 21, 2009, p. 1.

[28]For Senator Daschle, the solution to the messy problem of special-interest lobbying would be simple: Remove the key decisions to a Federal Health Board that would function like the Federal Reserve Board and be insulated from the normal processes of democratic persuasion. Ideally, the more isolated the board (presumably) and the more authoritarian its decision-making, the better the policy outcomes would be. Even so, it is hard to imagine any such board affecting the health care of the entire nation and achieving any such political isolation from Washington politics.

[29]See Christopher Lee, "Suppliers Fight Plan to Cut Medicare's Equipment Costs," The Washington Post, June 10, 2008, p. A8.

[30]On this aspect of the Medicare debate, see Kerry Weems, Acting Administrator, Centers for Medicare and Medicaid Services, "Medicare Advantage: Increased Spending Relative to Medicare Fee for Service," statement before the Subcommittee on Health, Committee on Ways and means, U.S. House of Representatives, February 27, 2008.

[31]Cited in Robert E. Moffit, "How a Public Health Plan Will Erode Private Care," Heritage Foundation Backgrounder No. 2224, December 22, 2008, at http://www.heritage.org/research/healthcare/bg2224.cfm.

[32]John Shiels, Vice President, The Lewin Group, "The Impact of the House Health Reform Legislation on Coverage and Provider Incomes," testimony before the Committee on Energy and Commerce, U.S. House of Representatives, June 25, 2009.

[33]In the recent Urban Institute analysis, based on different assumptions, researchers project that roughly 47 million Americans would enroll in the new public plan. See John Holohan and Linda J. Blumberg, "Is the Public Plan Option a Necessary Part of Health Reform?" Urban Institute, Health Policy Center, June 2009, p. 8.

[34]Senator Mike Enzi (R-WY), "Houston, We have a Problem! CBO Analysis of Kennedy Health Bill Highlights One Trillion Problems," press release, July 10, 2009; see also letter from Senator Mike Enzi to Douglas Elmendorf, Director, Congressional Budget Office, July 9, 2009.









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[gdpawel]

And in case you’d forgotten what the health care reform battle is really about.

http://www.thehealthcareblog.com/the...m-matters.html

[Jackie07]

Received this from the 'White House' and thought I would share it with everybody. (I wrote an e-mail one time about how our health insurance premium had increased to the equivalent of 1/2 of my unemployment check compared to less than 1/4 of my unemployment check in 1991 after my first brain surgery - even though the amount of unemployment compensation has almost doubled.)

*******************************

Dear Friend,

This is probably one of the longest emails I’ve ever sent, but it could be the most important.

Across the country we are seeing vigorous debate about health insurance reform. Unfortunately, some of the old tactics we know so well are back — even the viral emails that fly unchecked and under the radar, spreading all sorts of lies and distortions.

As President Obama said at the town hall in New Hampshire, “where we do disagree, let's disagree over things that are real, not these wild misrepresentations that bear no resemblance to anything that's actually been proposed.”

So let’s start a chain email of our own. At the end of my email, you’ll find a lot of information about health insurance reform, distilled into 8 ways reform provides security and stability to those with or without coverage, 8 common myths about reform and 8 reasons we need health insurance reform now.

Right now, someone you know probably has a question about reform that could be answered by what’s below. So what are you waiting for? Forward this email.

Thanks,
David

David Axelrod
Senior Adviser to the President

P.S. We launched www.WhiteHouse.gov/realitycheck this week to knock down the rumors and lies that are floating around the internet. You can find the information below, and much more, there. For example, we've just added a video of Nancy-Ann DeParle from our Health Reform Office tackling a viral email head on. Check it out:



8 ways reform provides security and stability to those with or without coverage

1. Ends Discrimination for Pre-Existing Conditions: Insurance companies will be prohibited from refusing you coverage because of your medical history.
2. Ends Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.
3. Ends Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.
4. Ends Dropping of Coverage for Seriously Ill: Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.
5. Ends Gender Discrimination: Insurance companies will be prohibited from charging you more because of your gender.
6. Ends Annual or Lifetime Caps on Coverage: Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.
7. Extends Coverage for Young Adults: Children would continue to be eligible for family coverage through the age of 26.
8. Guarantees Insurance Renewal: Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won't be allowed to refuse renewal because someone became sick.

Learn more and get details: http://www.WhiteHouse.gov/health-insurance-consumer-protections/


8 common myths about health insurance reform

1. Reform will stop "rationing" - not increase it: It’s a myth that reform will mean a "government takeover" of health care or lead to "rationing." To the contrary, reform will forbid many forms of rationing that are currently being used by insurance companies.
2. We can’t afford reform: It's the status quo we can't afford. It’s a myth that reform will bust the budget. To the contrary, the President has identified ways to pay for the vast majority of the up-front costs by cutting waste, fraud, and abuse within existing government health programs; ending big subsidies to insurance companies; and increasing efficiency with such steps as coordinating care and streamlining paperwork. In the long term, reform can help bring down costs that will otherwise lead to a fiscal crisis.
3. Reform would encourage "euthanasia": It does not. It’s a malicious myth that reform would encourage or even require euthanasia for seniors. For seniors who want to consult with their family and physicians about end-of life decisions, reform will help to cover these voluntary, private consultations for those who want help with these personal and difficult family decisions.
4. Vets' health care is safe and sound: It’s a myth that health insurance reform will affect veterans' access to the care they get now. To the contrary, the President's budget significantly expands coverage under the VA, extending care to 500,000 more veterans who were previously excluded. The VA Healthcare system will continue to be available for all eligible veterans.
5. Reform will benefit small business - not burden it: It’s a myth that health insurance reform will hurt small businesses. To the contrary, reform will ease the burdens on small businesses, provide tax credits to help them pay for employee coverage and help level the playing field with big firms who pay much less to cover their employees on average.
6. Your Medicare is safe, and stronger with reform: It’s myth that Health Insurance Reform would be financed by cutting Medicare benefits. To the contrary, reform will improve the long-term financial health of Medicare, ensure better coordination, eliminate waste and unnecessary subsidies to insurance companies, and help to close the Medicare "doughnut" hole to make prescription drugs more affordable for seniors.
7. You can keep your own insurance: It’s myth that reform will force you out of your current insurance plan or force you to change doctors. To the contrary, reform will expand your choices, not eliminate them.
8. No, government will not do anything with your bank account: It is an absurd myth that government will be in charge of your bank accounts. Health insurance reform will simplify administration, making it easier and more convenient for you to pay bills in a method that you choose. Just like paying a phone bill or a utility bill, you can pay by traditional check, or by a direct electronic payment. And forms will be standardized so they will be easier to understand. The choice is up to you – and the same rules of privacy will apply as they do for all other electronic payments that people make.

Learn more and get details:
http://www.WhiteHouse.gov/realitycheck
http://www.WhiteHouse.gov/realitycheck/faq

8 Reasons We Need Health Insurance Reform Now

1. Coverage Denied to Millions: A recent national survey estimated that 12.6 million non-elderly adults – 36 percent of those who tried to purchase health insurance directly from an insurance company in the individual insurance market – were in fact discriminated against because of a pre-existing condition in the previous three years or dropped from coverage when they became seriously ill. Learn more: http://www.healthreform.gov/reports/...age/index.html
2. Less Care for More Costs: With each passing year, Americans are paying more for health care coverage. Employer-sponsored health insurance premiums have nearly doubled since 2000, a rate three times faster than wages. In 2008, the average premium for a family plan purchased through an employer was $12,680, nearly the annual earnings of a full-time minimum wage job. Americans pay more than ever for health insurance, but get less coverage. Learn more: http://www.healthreform.gov/reports/...sts/index.html
3. Roadblocks to Care for Women: Women’s reproductive health requires more regular contact with health care providers, including yearly pap smears, mammograms, and obstetric care. Women are also more likely to report fair or poor health than men (9.5% versus 9.0%). While rates of chronic conditions such as diabetes and high blood pressure are similar to men, women are twice as likely to suffer from headaches and are more likely to experience joint, back or neck pain. These chronic conditions often require regular and frequent treatment and follow-up care. Learn more: http://www.healthreform.gov/reports/women/index.html
4. Hard Times in the Heartland: Throughout rural America, there are nearly 50 million people who face challenges in accessing health care. The past several decades have consistently shown higher rates of poverty, mortality, uninsurance, and limited access to a primary health care provider in rural areas. With the recent economic downturn, there is potential for an increase in many of the health disparities and access concerns that are already elevated in rural communities. Learn more: http://www.healthreform.gov/reports/hardtimes
5. Small Businesses Struggle to Provide Health Coverage: Nearly one-third of the uninsured – 13 million people – are employees of firms with less than 100 workers. From 2000 to 2007, the proportion of non-elderly Americans covered by employer-based health insurance fell from 66% to 61%. Much of this decline stems from small business. The percentage of small businesses offering coverage dropped from 68% to 59%, while large firms held stable at 99%. About a third of such workers in firms with fewer than 50 employees obtain insurance through a spouse. Learn more: http://www.healthreform.gov/reports/helpbottomline
6. The Tragedies are Personal: Half of all personal bankruptcies are at least partly the result of medical expenses. The typical elderly couple may have to save nearly $300,000 to pay for health costs not covered by Medicare alone. Learn more: http://www.healthreform.gov/reports/inaction
7. Diminishing Access to Care: From 2000 to 2007, the proportion of non-elderly Americans covered by employer-based health insurance fell from 66% to 61%. An estimated 87 million people - one in every three Americans under the age of 65 - were uninsured at some point in 2007 and 2008. More than 80% of the uninsured are in working families. Learn more: http://www.healthreform.gov/reports/...ing/index.html
8. The Trends are Troubling: Without reform, health care costs will continue to skyrocket unabated, putting unbearable strain on families, businesses, and state and federal government budgets. Perhaps the most visible sign of the need for health care reform is the 46 million Americans currently without health insurance - projections suggest that this number will rise to about 72 million in 2040 in the absence of reform. Learn more: http://www.WhiteHouse.gov/assets/documents/CEA_Health_Care_Report.pdf

[gdpawel]

A new study published in the Journal of the American Medical Association finds offering end-of-life counseling aids last days. Offering such care to dying cancer patients improves their mood and quality of life. It was funded by the National Cancer Institute.

A House proposal allows Medicare to pay doctors to chat with patients, if they desire it, about living wills, hospice and appointing a trusted person to make decisions when the patient is incapacitated.

In the new study, trained nurses did the end-of-life counseling, mostly by phone, with patients and family caregivers using a model based on national guidelines. All the patients in the study had been diagnosed with terminal cancer.

Half were assigned to receive usual care. The other half received usual care plus counseling about managing symptoms, communicating with health care providers and finding hospice care.

Patients and their caregivers also could attend monthly 90-minute group meetings with a doctor and a nurse to ask questions and discuss problems in what's called a "shared medical appointment." Patients who got the counseling scored higher on quality of life and mood measures than patients who did not.

Accoring to one of the researchers, patients getting such counseling often thank the nurses helping them. They seem to feel a whole lot better knowing there's someone who's looking at the rest of them and not just the tumor.

In both groups, hospital stays were rare: six to seven days on average during the patients' last year of life. It is patients and families in their own living rooms who are dealing with end-of-life care. They're not in the hospital,they're at home.

This is about helping people live with the diagnosis the doctor has given. This study reflects on what kind of support people deserve when they're dying.

[Rich66]

I would like the country to have a look at the current federal employee arrangement. If we are already paying into that, and it works(they want to keep it)..would it work to expand it out to the rest of us? This is a system we should have data on. Costs should go down with the pool broadened. We could have some regulation to reduce nasties like unreasonable pre-existing penalties and use of trivial application errors for policy cancellation.
I guess I have read, heard and experienced too much that suggests a public option would (due to subsidy) crowd out private plans leaving in place a Medicare for all system which sounds great until realizing it is unlikely sustainable without the current cost shifting to private plans, huge debt or rationing. Note how the CBO analysis has been totally ignored by proponents. http://www.washingtonpost.com/wp-dyn...071602242.html

Medicare reimbursement to oncologists (and cardiologists) is already targeted for lowering. The hope pinned on increased use of primary care is hindered by a shortage of PC physicians.
I do think the "death panel" hysteria is a distraction from the larger picture and that there are plenty of reformable aspects of our current system.

[gdpawel]

The CBO and the staff of the Joint Committee on Taxation (JCT) worked together to produce a preliminary analysis of the major provisions related to health insurance coverage that are contained in draft legislation called the America’s Affordable Health Choices Act. Among other things, those provisions would establish a mandate for most legal residents to obtain insurance, significantly expand eligibility for Medicaid, and set up insurance “exchanges” through which certain individuals and families could receive federal subsidies to substantially reduce the cost of purchasing that coverage. The analysis does not take into account other parts of the proposal that would raise taxes or reduce other spending in an effort to offset the federal costs of the coverage provisions.

The tables included in the report summarize their preliminary assessment of the coverage provisions’ budgetary effects and their likely impact on rates and sources of insurance coverage for the nonelderly population. According to that assessment, enacting those provisions by themselves would result in a net increase in federal budget deficits of $1,042 billion over the 2010–2019 period. By 2019, CBO and the JCT staff estimate, the number of nonelderly people who are uninsured would be reduced by about 37 million, leaving about 17 million nonelderly residents uninsured.

The figures do not represent a formal or complete cost estimate for the draft legislation. First, these figures do not address the entire bill. Second, the analysis was based on specifications that were provided by staff of the three committees and that differ in important ways from the “discussion draft” version of legislative language that was released in June. The specifications that were analyzed are supposed to be reflected in the draft language released by the committees, but have not yet been able to analyze that language to determine whether it conforms to those specifications. Third, their analysis does not incorporate the administrative costs to the federal government of implementing the specified policies nor all of the proposal’s likely effects on spending for other federal programs and do not expect that they will have a sizable impact on their estimates. Finally, the budgetary information reflects many of the major cash flows that would affect the federal budget as a result of implementing the specified policies, and it provides preliminary assessment of the proposal’s net effects on the federal budget deficit.

Some additional cash flows would appear in the budget—either as outlays and offsetting receipts or outlays and revenues—but would net to zero and thus would not affect the deficit. The CBO will continue to work on an ongoing basis with the House and Senate committees involved in health care reform to provide estimates and analyses as legislation is considered.