Thursday, January 1, 2009

Critical

2009 brings nothing new in health care.  Tom Daschle invited me to hold a group meeting t several weeks ago to discuss what is on the minds of the country ( a kind of town meeting forum) and present a group consensus of what should be done to reform health care and health care financing.

Today I received an email from him requesting my report, in a survey form. 

 

Obama-Biden Transition Team

Dear Gary,
Over the past two weeks, thousands of people representing all 50 states and every corner of the country have hosted health care discussions in their homes and communities. Just this week, I attended a discussion hosted by the Fire Department in Dublin, Indiana, and one hosted by a Senior Wellness Center in Southeast Washington, D.C.
Leading your discussion was the first step. Equally important, we want to hear back from you. I learned so much from attending discussions this week, and we want to know about your discussions, too.
The President-elect has asked me to share your feedback from these discussions -- that's why your submission is so essential.
Please tell us how your discussion went by visiting http://change.gov/reportback. We need to hear from you as soon as possible -- by Sunday, January 4th, 2009 at the latest -- so we can prepare our report for the President-elect.
Both President-elect Obama and I are committed to reforming the health care system from the grassroots up -- and leaders like you are crucial to that effort.
I'm looking forward to reading your submissions about your Health Care Community Discussions.
Thank you,
Tom
Tom Daschle
Secretary-designate
Department of Health and Human Services

Matthew Holt on The Health Blog accurately assesses this effort and mirrors my personal opinion on the liklihood of a political solution for what ails health care in America.

Matt's  takeaway points are:

Like legions of other wonks when I discovered that Tom Daschle was going to be Obama’s point guy on health care, I sent off for a copy of his book Critical. It’s a fast and easy read, but in its examination of the problem it doesn’t add much to superior books on what’s wrong with health care (much of the first section reads like an undergrad’s attempt to summarize Jonathan Cohn’s Sick) and there are some pretty weak logic flows and basic editing throughout (he refers to the book Uninsured in America on p155 as though it’s already been introduced before it actually gets introduced on p161). But ignoring all that, what does Daschle suggest we actually do?

The ill-fated & exclusive White House study groups of Feburary to May 1993 are therefore only to be repeated in set of window dressing home study groups & Internet bulletin boards—who’s participants will have as little actual positive impact on health reform as Ira Magaziner did in 1993–4. Still the process now is notably open.

Daschle likes and wants to see more of. Mental health parity is one, dental insurance is another, and long-term care a third. To be fair these are three areas crying out for a better solution, but Daschle doesn’t make it clear how we’re going to expand the current definition of insurance to include them. In addition these are areas for which Medicaid is the current de facto half-assed solution. Medicaid is a program Daschle likes, while many health policy wonks (well me anyway) think it should be abolished and rolled into a genuine universal social insurance system, or at least (as Paul Krugman suggests) be Federalized and thus removed from the vagaries of state budgets.

But the actual coverage solution Daschle proposes, which is pretty similar to the ones emanating from Clinton & Baucus are basically to expand FEHBP and give it both a Massachusetts Connector-type role and include in it a buy-in to Medicare, and to impose a pay or play option onto employers. Somehow he’d also expand Medicaid and S-CHIP, and then add to all this an individual mandate with subsidies to those who can’t afford to buy-in to FEBHP. The whole thing is tied together, sort-of, by a Federal Health Board

Daschle is damn lucky that he didn’t call his board Fannie Med, but he’s also unlucky in that he links it to the success of the Federal Reserve at a time when that “success” is looking, shall we say, shaky. However, the main role of the Federal Health Board would be as a cost-effectiveness review organization with teeth—in that Medicare, Medicaid & FEHBP would all be bound to follow its guidelines.

So the problem with this always comes back to two things.

One; most of the uninsured are working poor and their employers are the NFIB small employer crowd who are all for health reform until they figure out that it means they have to pay for it. Even despite the incredibly confused rhetoric coming out of NFIB lately, my guess is that only a puny Massachusetts type “pay” fine ($213 or so) will be little enough to get them to willingly back a public and compulsory plan for their employees. And of course at that point all but the richest of the remaining 55% or so of small employers who offer coverage will ditch it too, meaning that the public subsidy for the working poor to get insurance will have to be much greater than Daschle thinks. Not to mention the continuing administrative nightmare of figuring out whether someone should be in Medicaid, the new plan, or covered by their family member.

Second, while it may be getting harder and harder for the Sally Pipes of the world to get people worried about rationing when it’s clear that we already have it here but that they don’t really have it in Switzerland, Germany or France, the Federal Health Board will be fought tooth and nail by the industry. Sally Pipes is the author of "Miracle Cure"

As I’ve been saying for a long time, to rationally rationalize the health care system, we need to make cardiologists in Miami behave like cardiologists in Minnesota with a consequent impact on the incomes of doctors, hospitals and stent & speedboat salesman in high cost areas (Yes, Jeff, I do mean Louisiana, New York, Los Angeles and Boston too). If the Federal Health Board has teeth, that’s what it’ll do, and the AMA, AHA, AdvaMed, PhRMA et al know it.

So my guess is that the Federal Health Board, if it gets established, will get defanged by lobbyists immediately. The consequence of that is that the mish-mash of an “expand what we got now” system will cover a few more people at a lot more cost (as has been the Massachusetts experience). That’s OK because suddenly we’re rich (or at least suddenly the government is pretending it is!).

 

There is much more to be read on Matt Holt's Health Care Blog.
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