It was bound to happen

The health care debate has come around to abortion politics. As this article in the NY Times explains, anti-choice groups are pressuring Congress to prevent consumers who receive federal subsidies from purchasing coverage from health plans that currently cover abortion.

Their claim is that consumers who purchase these insurers' health plans could potentially use those federal dollars to access abortion care. Public funding for abortion was banned, with limited exceptions, under the Hyde Amendment of 1977, which is part of Medicaid law.

This has the potential to pressure private insurers to remove abortion care from their list of covered medical procedures in order to allow consumers who receive federal dollars as part of the health care reform proposal access to coverage. As the frantic action alert I received from Planned Parenthood today succinctly states:
if [this effort is] successful, access to abortion will be practically eliminated in health care reform. And without access, there is no choice.

Whatever your personal politics, it is a remarkable thing when a small but vocal minority can hijack a national issue so effectively and with such sweeping implications. In this case, those who could be hurt include not only insured women who need access to safe and legal abortion care but uninsured women who are just trying to get comprehensive health coverage.

Goodbye Public Option

Yes it was expected, but it is still sad to see that although 2/3 of Americans approve of the public option (CBS poll 9/24), it was voted down by 2/3 of the Senate Finance Committee. Although there were various reasons each senator gave for their nay vote, I found Senator Max Baucus’ reasoning most intriguing, “My first job is to get this bill across the finish line…No one shows me how to get to 60 votes with a public option". I think we all agree that something is better than nothing, but how much compromise must take place before a much-needed big shift is watered down to something that resembles yet another increment? In this case though, I am confident that whatever happens will be more than just an increment in policy change, but one has to wonder how much is enough when it comes to gutting up good policy in the name of passable policy. Furthermore, I have to say that this whole business about a real Democratic filibuster-proof majority is just an illusion, overblown by party members as well as the media. There was so much hype when Al Franken was made the 60th Senator, but what has really come of that? One thing that the federal government truly needs to learn from successful is the notion of under-promising but over-delivering. Government seems to do just the opposite (remember FEMA, No Child Left Behind, “mission accomplished") but I suppose that’s what happens when you want to make your electorate happy and get elected to office. Not to sound facetious, but I hope that those who are against or voted against the public option, or any of the reform efforts live long and prosperous lives…long enough to witness a true reformation of healthcare in the future. Imagine that!

faith as the solution to health care costs?

I watched this really interesting 3 minute clip on ABC's World News today about an alternative to traditional health care insurance...faith. While I was quick to scoff when I heard the title of the segment, "Faith-based Health Care for Evangelicals," by the end I was surprised how simple and apparently effective this is.

How it works:
There are three Christian health plans in the US, where members cover each others' major medical bills. To be a part of these health plans, one must be a church-going Christian and agree not to smoke, drink heavily, or have extramarital sex. Families pay $285/month to these faith-based health plans like Samaritan Ministries, which in turn distributes the money out to members who have medical bills that month.

The video made sure to point out what the critics are saying, things like...since it is not technically insurance, it is not regulated by the government and there is therefore no guarantee that medical bills will be paid. Even though there is no guarantee that everyone's bills will be paid, Samaritan Ministries says that they have never failed to cover a member's medical bills in their 15 years of existence. That's more than can be said about a lot of other insurance companies...

After watching this I still have a lot of questions, like about how this health plan deals with preventative care or ensuring that their members adhere to the requirements (namely, going to church and staying faithful in marriage). But nevertheless, it appears to be a cheaper alternative that is working for tens of thousands of Americans.

Here's the link to the video and article:
http://abcnews.go.com/Health/faith-based-health-care-evangelical-christians/story?id=8696127

Here's an article in the New York Times trying to dispel some public fear about the H1N1 flu vaccine (and, really, vaccines in general). Their main point is essentially that negative health events happen all the time, and just because one of those occurs after getting the vaccine does not mean it's linked. (They also talk a bit about the swine flu vaccine disaster of 1976 - for those of us reading The Swine Flu Affair it's an interesting perspective) The Associated Press published a similar story, also explaining that not all adverse health events are linked to the vaccine just because they occur shortly after, and also spending more time detailing government tracking. Finally, ABC and other news agencies are playing up the fact that "swine flu causes heart attacks but vaccine protects." Normally the press tends to be the fear-mongers and nay-sayers (negative news gets more of an audience than positive), but now they are taking a larger role in dispelling rumors and convincing people to get the vaccine. It will be interesting to see how the swine flu vaccine plays out this time around, and how the press continues to react.

Health Insurers' Income Statements!

Yayy, numbers! Well, not exactly (if you don't want to see them but want some qualitative idea of what they are). But I found it really helpful to get an idea of what kind of profits insurance companies are looking at. Surprisingly, it's not that much percentage-wise. I honestly thought that they were making a much larger profit margin.

http://blogs.wsj.com/health/2009/09/25/unpacking-a-big-health-insurers-income-statement/
(or see below)

--

By Jacob Goldstein

In a year when everybody’s talking in sweeping, vague terms about health costs and the insurance industry, it’s useful to pause and dig into some really specific numbers to better understand how the money flows.

That’s what Princeton health economist Uwe Reinhardt does today, dissecting an income statement from the health insurer WellPoint in a guest post over at the New York Times blog Economix. Here are a few of the figures.

In 2008, the company’s total revenue was over $60 billion, more than 93% of which came from insurance premiums. About 6% came from fees for administering insurance for self-insured companies, and 1% came from the float.

WellPoint paid out about 84% of the premium revenues it collected to pay for health care and drugs for the people the company insures. That percentage is known as the medical loss ratio or the health benefit ratio.

The company spent roughly $9 billion, or 14% of total revenue, on marketing and administrative expenses.

The company’s net income was $2.5 billion, which means its profit margin was 4%. Profits were just over 5% of total assets deployed by the company, and 11.6% of the equity shareholders had in Wellpoint. “Relative to other industries, these are not particularly high numbers, nor are they particularly low,” Reinhart writes.

He notes that marketing and administrative expenses “typically are a far bigger enchilada” than profits for insurers. “It is here that the health insurance industry is being challenged to search for economies.”

--

Blogs and more blogs

Hi Everyone-

Sorry if you have already gotten an email blast about this, but I wanted to let you know about some other health policy blogging going on...PolicyMatters, the journal of the policy school, has a blog as well, and if you scroll about halfway down, you can see some entries about health care, for your reading pleasure.

http://policymatters.net/

Also, on the lighter side of the things, check out how celebrities are doing their part to make sure we remember who the real victims of health reform are:

http://www.funnyordie.com/videos/041b5acaf5/protect-insurance-companies-psa

PBS special - TONIGHT, 9/24!!!!!

PBS is airing a special 90-minute program on health care reform. NOW, Tavis Smiley, and Nightly Business Report are all contributors to the program. Not to be missed!

http://www.pbs.org/now/shows/health-care-reform/index.html

Obama on Letterman and Healthcare Reform

Check out Obama on Letterman talking healthcare reform. The health care reform talk is near the end and includes Obama's take on racism as a main cause of all the dissent, anger and town hall madness or even the most Rep. Joe Wilson behavior during his address.

I find it interesting and frankly, quite striking, that Obama is using popular media like the media to advocate for health care reform. That's meant to be a good comment by the way. Talk about getting out there and promoting the cause. I guess in terms of convincing people, you gotta give the guy credit for taking the road less travelled. I think this goes back to some of the comments that were brought up at the health care reform workshop and in some ways points back to the idea in policy that the President has a national constituency and in that sense has a unique leverage.

I don't necessarily know if Letterman's audience are in some ways biased or if Letterman himself is biased, it is New York afterall and maybe the optimist in me would still like to believe that using this new form of advocacy by the President would reach a wider audience. In 200c, Oprah was noted to be one of the most effective health educators around.

In that case, Mr. President, has your staff been talking with Oprah's people? After all, she does have a new season and most likely a new couch.

"My question, then, is what you all think about whether people can really be convinced either that things aren't as great as they seem, or that what they think they like really won't change. Or is it even necessary to convince people of either?"

Hmmm - Andrea, convincing people is always so difficult. If it were to happen, I feel like this is an instance where we need to somehow get the little penguins to join together to tell their parents that they should buy into this. Maybe Obama should start a nationwide college tour to build momentum/support and show people that there are supporters out there. It's great trying to bring everyone together, but I think that when you hold multiple town halls/joint sessions of congress (okay, so maybe that couldn't be helped :P ) where there are loud, angry dissenters, supporters might begin to feel as if they're on the fringe.

for your health...and your entertainment?

While flipping through the channels earlier tonight, I was taken by surprise when the face of none other than Professor Art Reingold appeared on the TV screen. It was the CBS5 news, and he was addressing...you probably guessed it...swine flu. In an example of true public health epidemiology, he was making an announcement to the public that, contrary to common belief, hand washing is not enough to protect you from the swine flu, or any flu for that matter.

Since stopping breathing isn't really an option...time to get vaccinated? Tang Center's flu shot schedule: (http://www.uhs.berkeley.edu/home/news/pdf/FluShotFlier09.pdf)

You can read the article and watch his interview here:
http://cbs5.com/health/hand.washing.h1n1.2.1194097.html

Most insured Americans at least say they're happy

I just came across this study by the Kaiser family foundation that found that, of all insured Americans, the majority say they are happy with their plan. Deeper digging revealed that different groups of people, including those in lower socioeconomic groups, were not so pleased. Furthermore, more questions showed that even those people who said they were pleased with their plans really did have quite a few gripes. I think this data gets at part of the challenge of convincing US citizens that health reform is necessary. Most of the time, people will be relatively happy with the status quo. In many cases, if people are the ones who have chosen the status quo (i.e. people feel as though they're choosing their health insurance), they're even more likely to say they're happy with it, if only to justify their choice. When you start asking more questions, you may find, as this study did, that people are unhappy with most aspects of something, but they're still, overall, going to be convinced they mostly like it, if only because it's familiar and they know they don't hate it. If the majority of Americans are insured (which they are), and if the majority of the uninsured claim to like their insurance provider (which this study claims), and if many people believe that the public option (or, more broadly, health care reform of any sort) will change their insurance (which people do), then it will be very hard to convince people to change. By that logic, there are 2 options: convince people that all those things they said they didn't like about their insurance are actually large enough problems for them to admit they're dissatisfied overall with their insurance, or convince them that the public option won't affect their own choices. Obama has clearly been trying to do the latter in his speeches, and the former seems time-consuming and complicated (pointing out the faults of these enormous insurance companies will not be a politically-popular move). My question, then, is what you all think about whether people can really be convinced either that things aren't as great as they seem, or that what they think they like really won't change. Or is it even necessary to convince people of either?

Special Interest Groups: What's their role in the reform?

Hey guys.

I'm going to respond to Patrick's post, and then pose a couple (somewhat-rhetorical) questions. I found it very interesting that while the AMA's position is one against the public option, the majority of physicians belonging to AMA are in favor of the public option, in some shape or form. Off the bat, I just have to throw the fact out there that the majority of physicians sign up for the AMA because it's "what you do", you get your little purple ID card, keep it in your wallet (or the back of your desk drawer), and conspicuously arrange your free subscription to JAMA on your desk as to assure your patients will see it. Somewhat of a cynical exagerration, but you catch my drift. That being said, I guess it's not too hard to conceptualize how the majority of the group's members feel one way, yet the official position of the group fails to reflect the majority vote. The average doc out there, "working 75+ hours per week, trying to please a million masters, attempting to keep his head above water in the sharktank" is about as invested in the AMA as schoolchildren are in classwork on the day before Christmas vacation. In fact, this lack of leadership and interest has been a topic of concern for the AMA for decades. And it's sad, because as much as the reform (in whatever form it eventually takes) is going to effect patients, insurers, etc...it's going to rock the worlds of physicians.

As Patrick mentioned, the medical community is widely split on the reform issues. So much so, in fact, medical schools host debates (tactfully-advertised around campus as "expert panel discussions on health reform") between physicians from the two camps: mainly the AMA and PNHP (Physicians for a National Health Plan.) Med students pile into auditoriums to listen to middle-aged docs battle it out over reimbursement, treatment of the uninsured, and how there are more billers in their office than physicians due to the headaches involved with billing several different insurance companies. In general, primary care physicians side with PNHP, and specialists side with AMA--but this is a gross overgeneralization (as the statistics in Pat's article illustrate.) I guess I'm having a hard time reconciling how the AMA, whose vision is to "help doctors help patients by uniting physicians nationwide to work on the most important professional and public health issues", can publicly take a stance on such a massive issue as national reform, with an opinion that does such a mediocre job of capturing the best interests and feelings of so many (the majority!) of its constituents. Sure, there will always be a few dissidents in every interest group...but this is more than that. In this case, with so much on the line, and such a massive discrepancy of opinion amongst its constituents, is the AMA justified in publishing any official stance on health reform? That's what an "interest group" is supposed to do, right? Attempt to influence policy, in some way, by at least taking some official stance on the issue. Or is this a classic example of the squeaky wheel speaking inappropriately on behalf of the silent majority?

New survey in NEJM finds that, overall, doctors support a public option

Hi all,

I found this interesting article published by NPR in my daily read. In it, the authors describe that physicians as group have traditionally had difficulties giving an official stand on health care reform. As a medical student, I can definitely see this as being true. From my personal experience, doctors in primary care tend to prefer a public option and those in high-paying specialties tend to be content with the status quo. However, in this article, a recently published survey in the New England Journal of Medicine has found that 63% of doctors favor a mixed system that includes both private and public insurance; an additional 10% favor a single-payer only system. When the public was polled, about 50-70% said that they are in favor of a public option.

What else is interesting is that the majority of the doctors who are members of the American Medical Association (AMA) are in favor of a public option, though the organization itself is opposed to it. The AMA has historically been opposed to health care reform as one of its main objectives is to protect the interests of physicians, not improving patient access or care. Also, I've heard that the AMA only represents about 20% of physicians; in the NPR article, the authors state that less than one-third of physicians belong to the AMA. Most physicians join their own specialty groups. If this is true, then here we have a very powerful lobbying group against a public option who does not actually represent the opinions of its constituents.

Instead of looking to the AMA as the voice of physicians, one can find differing opinions from other medical groups. The American Medical Student Association (AMSA) represents the future physicians of America and has a very firm commitment to universal health care and enstating a single-payer system. However, not every medical student is involved with AMSA.

Just the other day, massive protests against federal spending took place in Washington DC. Given this NPR article stating that the majority of both doctors and the general population actually favor a public option, one has to wonder who exactly these protesters are. Are they simply the loud minority? How do these statistics fit in with what we discussed in class -- that most Americans are happy with their own health coverage?

I have included both the NPR and NEJM articles below:

http://www.npr.org/templates/story/story.php?storyId=112818960

http://healthcarereform.nejm.org/?p=1790&query=home

Let's discuss!

"Socialized Medicine"

Hey everyone, I thought this would be a great article to share:

http://www.nytimes.com/2009/09/03/opinion/03kristof.html?_r=1&em

Here's a small excerpt:

"Until the mid-19th century, firefighting was left mostly to a mishmash of volunteer crews and private fire insurance companies. In New York City, according to accounts in The New York Times in the 1850s and 1860s, firefighting often descended into chaos, with drunkenness and looting. So almost every country moved to what today’s health insurance lobbyists might label “socialized firefighting.” In effect, we have a single-payer system of public fire departments.

Throughout the industrialized world, there are a handful of these areas where governments fill needs better than free markets: fire protection, police work, education, postal service, libraries, health care. The United States goes along with this international trend in every area but one: health care."

The article also discussed how the government run health care systems (VA, Medicare) are what people actually like, has better performance and is cost-efficient. I just find it intriguing that other systems in America--like fire-fighting--are okay to be set up with a single-payer system but health care is constantly faced with extreme opposition and fear of reform. Granted, health care is a different area, even creating/proposing small incremental changes exerts a lot of effort and time. Maybe, like this article points out, when put into the context of looking at the spectrum of activities/positions in the US that are so-called "socialized" people can begin to understand the positive implications the single payer system or public option could potentially have. What do you think?

End of life care needs more attention

I mentioned these videos in class and I highly recommend you watch the eye-opening 15 minute talk by Dr. Diane Meier on long term care (just scroll to the bottom): http://www.healthaffairs.org/issue_briefings/2009_08_20_fact_vs_fiction/2009_08_20_fact_vs_fiction.php

I worked with Dr. Meier at Mount Sinai Medical Center and she is such a ground breaker in Palliative Care advancement. She is the director of the Center to Advance Palliative Care at Sinai and is a Geriatrician/Palliative Care physician, but she is planning to take a 1 year leave to move to DC and work on healthcare reform.

If you follow the topic, her name will continue to appear like in her recent Newsweek article on the Death Panel controversy. In her powerful healthaffairs.org speech, she talks about 2 patients at the end of their lives, each of whom have VERY different experiences. If we want to control costs, this issue urgently needs to be pushed to the forefront of the political discussion. The way we treat very sick and very elderly patients sometimes defies all reason and I have always wondered why. Is it the way we educate medical students? Is it our pervasive fear of death? Demands from patients and families? Is it all about money and physician incentives?

"Did you hear the one about..."

... The woman whose kidney surgery had to be redone after Medicare stopped paying for her anti-rejection drugs? Just ran in the Times:

http://www.nytimes.com/2009/09/14/health/policy/14kidney.html?ref=health

Yes, it's another potentially incendiary story that will inevitably be mentioned in one of Obama's upcoming speeches, but it's also an example of potential good will that doesn't go far enough, often out of necessity.

"The rationale for leaving out younger transplant recipients was simply that the money was not there, Congressional aides said." Not to be nihilistic, but it's useful to remember that policies put forth with the best of intentions can fall short, independent of our tireless efforts; but it's no reason to stop trying.

Medical Ethics during Hurricane Katrina

Hey Everyone,

I read this article in the New York Times Magazine a few weeks ago, and found it really interesting. The article tells the story of a for-profit hospital in New Orleans during Hurricane Katrina and the difficult decisions its physicians faced in deciding how to evacuate its patients during the storm. Some of the physicians have been accused of hastening the deaths of some terminally ill patients by delivering lethal injections of medications to those they deemed not able to survive the storm. I am looking forward to hearing everyone's perspectives on the article:

http://www.nytimes.com/2009/08/30/magazine/30doctors.html

Doug

Redefining the level of Health Care Competition

If there was one defining article I read that convinced me that I needed to go back to graduate school to learn more about how to change a non-system, this was it.

Porter, M. & Tiesberg, E.O. "Redefining Competition in Health Care". Harvard Business Review. June 2007

http://ucelinks.cdlib.org:8888/sfx_local?genre=article&issn=00178012&title=Harvard+Business+Review&volume=82&issue=6&date=20040601&atitle=Redefining+Competition+in+Health+Care.&spage=64&sid=EBSCO:bth&pid=

HBS Professor Michael Porter and Darden School Professor Elizabeth Olmstead Tiesberg discuss the various stakeholders in the health care system and how each can potentially undergo a transformational change to improve the quality and outcomes of the US health care system.

If you find this article enlightening, I HIGHLY recommend reading their book, "Redefining Health Care" (2007). It is by far one of the best books I have read on innovation in health care.

If you have read the article or the book, do you agree with their suggestions? Are some of their suggestions too radical (not as in right-wing but as in idealistic)? Which ones are the most feasible?

Let's discuss!

Healthcare Reform, Illustrated

For those who - like me - feel embarrassingly uninformed about the details of healthcare reform, I thought I'd pass along this set of "napkins" illustrating the main points of the debate. I can't vouch for the presence/lack of bias, but it helped clarify some things for me. Also, there are pictures!

Click here for the full slideshow.

"Meaningful" Reform?

I enjoyed the discussion at the HPM workshop this afternoon, but I think one point that was glossed over was the idea of "meaningful" reform. For the sake of argument, let's suppose that Professor Robinson's predictions come true: Obama signs a bill in the next few months that includes an individual mandate, no public option, some malpractice reform, etc. But none of these components - and really none of the discussion that I've seen of health reform so far - have given any real evidence of containing costs.

I certainly think it would be an accomplishment to pass a plan that makes a dent in the huge number of uninsured, but covering more people isn't necessarily going to contain costs. I understand the argument that with more people, particularly young healthy people, in the insurance pool paying premiums the costs per patient may go down slightly, but I don't see how this could cap any skyrocketing costs due to technological advances and expensive pharmaceuticals, for one. So my question is: can we call a plan without any real cost-containing measures "meaningful" health reform?

Welcome to Fall 09 HPM Class

Hi everyone - welcome to the Foundations class blog. I hope you find it a vibrant place to post, comment, share, discuss over the semester. Lots to talk about! Hope you are all planning to watch the President's speech tonight and I expect a firestorm of blogging as a result!

Kim