So why I am so hopping mad about the “single payer” bill–SB 562–currently making its way through the California legislature?

My frustration is with how the bill exploits widespread confusion about what good health policy outcomes are, and how other countries achieve them. The bill’s proponents lead people to believe that only the United States has a profit-based system and everywhere else has a fully government-run system that produces better care at a lower cost.

In truth, every industrialized country has a hybrid system and all are wrestling with the same challenges we are, especially in terms of controlling health care costs. Health care, it turns out, is complicated, and snake oil solutions from the right or left undermine incredibly important efforts to learn from both our own experience and the models of other countries.

But the advocates for this bill press on. SB 562 is a compassionate bill, they say. It will bring health care access to people who can’t afford it, we are told. It is backed by all right-thinking Democrats.

Poppycock. 

If you care about people, you have to care about policy. And this proposal is very poorly designed and impossible to implement. It was a mistake for the Democrats to pass this out of the state Senate. Those legislators ignored the spectacular work of the staff of the Senate Appropriations committee, who pointed out all the bill’s basic and fatal flaws. In any sane world, that would have sent the proponents of the bill back to the drawing board. Instead it sent them to the barricades, declaring that the bill is the only way to save health care and denouncing anyone who might oppose it.

What are these flaws? Start with the total illegality of the bill. It plans to take all of the health care money being spent in the state through Medicare, Medicaid, the Veterans Administration and other programs and put it into a big pot. California could ask for waivers from federal laws so we could spend this money as we please, we are told.

In fact, we could not. There are procedures that allow states to temporarily waive certain requirements of the Medicare and Medicaid programs to experiment with improving those programs. These waivers do not allow states to do away with these programs entirely. The only funds for which there is a process that could clearly apply is federal private insurance subsidies, and that’s a $5 billion drop in the bucket of our $300 billion plus health care spending. It would take a change in federal law to make the basic financing scheme for this bill possible, and there are many other provisions that would violate other federal laws, such as the federal prohibition on state regulation of the health benefits of large employers.

Second, the bill takes an enormous problem—rising health care costs—and makes it a runaway train. The Senate Appropriations Committee gave the bill a price tag of $400 billion, more than twice the size of the current state budget. This would obviously crowd out spending on any other state priority such as transportation, housing, or education (the investments most closely connected with better health, as it turns out). But as big as the initial spending would be, the long-term cost also would be much, much greater, as this bill would rapidly accelerate health care cost growth.

The bill’s provisions encourage people to consume more health care of any type, adding to costs. The bill makes private payments for health care, such as co-payments that people pay for doctor’s visits and prescription drugs, illegal. And the initial draft of the bill proposed that only providers of medical care would determine what is medically necessary, and that patients would be able to access any provider without a referral. The legislation is also based on a fee-for-service system—doctors would get paid for every procedure. Such a system is what California has been trying to get away from for decades, because these kinds of payments encourage a higher volume of procedures and health care interventions, rather than effective and valuable health care.

There is literally nothing that we have learned about health care in the past century that this bill’s drafters appear to understand.

Universal affordable health care cannot be achieved without a willingness to learn. Countries around the world do health care in many different ways, and we Americans have much to glean from these countries. But this bill does not look at other models or apply lessons. This single-payer system is not based on systems in Europe or Asia or anywhere else.

Some of the bill’s proponents say their system would be “Medicare for All,” but this proposed system wouldn’t work the way Medicare does either. Medicare has cost-sharing for patients and involves private insurers through the “Medicare Advantage” programs. This bill would entirely eliminate cost sharing as well as private insurers.

One argument is that the bill, whatever its flaws, is better than any other proposals out there. But only in the sense that a Pegasus is better than a pony. 

Flying horses, of course, don’t exist and there are many reasons why a system like this doesn’t exist anywhere in the world. A good health care financing system incorporates competition and private companies to drive down costs and drive up value. Cost sharing, if appropriately designed, can help encourage people to be better at utilizing the system, seeking health care preventively and at lower cost, and discouraging the use of low-value care.

Health care systems, especially government-run systems, require management. And the system being proposed here is essentially unmanaged. No country or state could afford such a system, in which patients are encouraged to consume as much health care as they want and doctors are paid more for every additional service they offer.

The final frustration of this phony single payer bill is that the efforts of those who are truly committed to universal affordable health care are needed elsewhere. The American Health Care Act, making its way in fits and starts through Congress, would take a buzzsaw to our progress on universalizing health care, not only wiping away the gains of the Affordable Care Act but also handicapping (if not destroying) the half-century-old Medicaid program for lower-income individuals.

The California legislature desperately needs to be devoting all its attention to opposing the federal legislation, and saving Medicaid, which is known as Medi-Cal here and covers nearly one-third of California adults and half of our children. Instead, the legislature is wasting its time on this nonsense proposal. Californians should be united around real progress on health care reform, not scattered by divisive fantasies.

The post California’s Single Payer Health Care Bill Is Dead on Arrival appeared first on Zócalo Public Square.

Beginning in 1966, Henderson led a global effort based at the World Health Organization (WHO) to accelerate smallpox vaccinations. In an extraordinary campaign that required vaccinating people in the poorest and most remote areas of the world (and detailed in his book Smallpox: The Death of a Disease), the disease vanished, with the last known naturally transmitted case of smallpox occurring in 1977.

Ever since, we have made great strides in the global control of infectious diseases, and even progress towards disease eradication, but frequently the endgame has been disrupted by an unexpected turn of events. In a recent book, I estimated that most of the world’s poverty-related neglected diseases are paradoxically found in the G20 nations. There are at least a half dozen diseases for which disease elimination or eradication would be feasible were it not for war or national turmoil, political malaise, or a growing anti-vaccine movement.

Some of the most dramatic examples of game-changing disruptions in disease control have been noted for human parasitic and tropical infections. During much of the 20th century, tremendous strides were made in the elimination of the highly lethal Gambian form of African sleeping sickness (human African trypanosomiasis or “HAT”) through a combination of case detection and treatment and tsetse fly control. Many of the methods used to wipe out sleeping sickness were developed by Dr. Eugene Jamot, a French physician working in Cameroon who pioneered the use of portable and movable treatment teams during the early 20th century.

By the 1960s, Gambian HAT was near elimination in many African nations. But when hostilities and civil and international conflicts broke out in Angola, Democratic Republic of Congo, Sudan, and elsewhere, public health control was interrupted, so that by the 1990s the incidence of HAT had returned to pre-Jamot era levels. More recently, as tensions have eased and mass treatment and tsetse control efforts have been reinstated, we have seen a 73 percent reduction in deaths from HAT between 1990 and 2010. With only about 10,000 cases of HAT remaining, we may still yet see the global elimination of this deadly disease.

War, conflict, and political instability also have halted or interrupted other global efforts to eliminate or eradicate parasitic diseases. Breakdowns in health systems in Venezuela are resulting in resurgences of malaria and Chagas disease. Public health disruptions from the ISIS occupation of Syria and Iraq have allowed the number of cases of cutaneous leishmaniasis, a disease transmitted by sandflies and often associated with a disfiguring ulcer on the face, to skyrocket and spread into neighboring countries. The only good news is that although wars in the Sudan almost derailed global guinea worm eradication efforts led by the Carter Center, the Centers for Disease Control, and WHO, through the perseverance of these organizations, this disease may soon become only the second disease ever eradicated .

Next to war and political instability, probably the next most corrosive factor thwarting public health gains against infectious disease is simple absence of political will. During the 1950s and ‘60s, under the auspices of the Pan American Health Organization, an ambitious effort to control yellow fever and dengue resulted in the eradication of the Aedes aegypti mosquito in more than a dozen Latin American and Caribbean countries. But lapses in mosquito control efforts and other factors allowed Aedes aegypti to reestablish, resulting in the reintroduction of dengue into the region during the 1980s. Now yellow fever has returned to Brazil, where it could gain access to Aedes mosquito populations and threaten urban centers.

Perhaps the most disheartening examples of infectious disease control going off the rails are instances in which there are deliberate attempts to block vaccination efforts. Today, the transmission of polio has been halted everywhere except in Afghanistan and Pakistan (and before that northern Nigeria) due in part to concerted efforts by religious extremist groups to kidnap or assassinate vaccine workers.

And now in the United States and Europe we have anti-vaccine groups who allege links between vaccines and autism, despite massive scientific data showing conclusively there are no links or even any plausibility for vaccines causing autism.

A particular concern is the resurgence of measles, because it is one of the most contagious of all the vaccine-preventable diseases and often is the first to re-emerge following a decline in vaccine rates. But really any one of the major childhood illnesses targeted for vaccination could re-appear. Measles was eradicated in the United States in 2000. However, it returned to California in 2015, and now the state of Texas is especially vulnerable because tens of thousands of children are not being vaccinated for non-medical exemptions. Globally, between 1990 and 2010 there has been an 80 percent decline in measles deaths and for the first time the number of young children who die of measles globally has dropped below 100,000. However, there are concerns that an American-led anti-vaccine movement could now derail this achievement and possibly even lead to a reversal of sustainable and global goals for health and poverty reduction.

We need a concerted effort by global leaders to close current gaps and explore final steps to eliminate our great plagues. To do so will require international cooperation by the WHO member states, especially the 20 wealthiest economies comprising the G20 nations. Taking on the considerable political and social hurdles will become one of the great international challenges in freeing populations from the tyranny of epidemics or pandemics.

The post To End Infectious Disease, We Must Cure Our Societal Ills appeared first on Zócalo Public Square.

And maybe, in the last few months, you’ve started getting calls from your doctor’s office, following up on your last appointment, making sure you’re taking your medication, checking on your mood.

Welcome to the world of ACOs (short for accountable care organizations), the latest attempt to save our healthcare system and our economy. How you respond to these calls–whether you end up spending less money on care, whether you avoid extra trips to the hospital, whether your chronic health conditions stabilize and improve–may determine whether ACOs become part of a bona fide solution–or whether they’re just another also-ran in the scrap heap of healthcare reform ideas.

“Our healthcare system is sort of like a big rig going downhill with failing brakes,” says Gerald Kominski, director of the UCLA Center for Health Policy Research. In the ’80s and ’90s, everyone from the Center for Medicare and Medicaid Services (CMS) to healthcare economists to academics thought managed care was going to be the brake on the system. “We wore out the last pair of brakes” with HMOs. “And we don’t know if this new braking system is going to be more effective or not.”

The new braking system, the ACO, was created in 2011 by CMS. An ACO is a formal network of independent doctors, specialists, and hospitals who agree to care for a group of patients for a lump sum.

This is a major departure from how traditional Medicare works. Today, non-ACO doctors are paid on a fee-for-service model that rewards more tests, more screenings, more surgeries, and more treatment, all without proof that they are improving the lives or prognoses of their patients.

“Doctors who do interventions make more money, and doctors who talk to patients get far less money,” Dr. Otis Brawley, chief scientific officer of the American Cancer Society, told a group of healthcare journalists in April. His book, How We Do Harm, delineates the blame, which he spreads out among everyone in the healthcare system, including patients who insist on getting every treatment or test regardless of whether it’s appropriate. “The incentive is for doctors to get patients in and out and not talk to them.” The result: healthcare spending accounts for nearly 18 percent of the U.S. gross domestic product–nearly $8,000 per patient, the most per capita in the world.

The question is whether ACOs can change all that.

Under the ACO model, healthcare providers will be expected to meet both quality and cost targets. They have incentive to do so. If they meet the quality targets, they are eligible for a share of any savings they achieve. The theory is that, in order to provide better care for less, these doctors will shift how they practice, working together with hospitals and patients. Doctors will emphasize preventative care. They will follow up more frequently with patients with more than one chronic condition to make sure patients adhere to their treatments, thereby reducing complications and the need for additional services. They will use electronic medical records to better coordinate between offices and save money. The list goes on.

It’s not yet clear how much healthcare consumers–which is to say, just about everybody–will see and feel this. A lot of things are being shuffled behind the scenes to try to provide higher quality care while curbing the stratospheric growth of healthcare spending in the U.S.

So far, at least 1.1 million of the 45 million Americans covered by Medicare are getting care through ACOs, mostly in areas selected for pilots of the new approach. For most of these patients, the shift to ACOs is invisible. If their current doctor joins one, they’re part of one. Since ACOs don’t penalize patients for going outside the ACO network for care, they may never be aware. If the concept works there–that is, if patients and their providers meet various measures of cost and quality–it’s likely to spread to the rest of us in coming years.

This sort of approach isn’t entirely new. It resembles how Kaiser Permanente is organized, says Mark Pauly, Ph.D., a healthcare management professor at the University of Pennsylvania. Kaiser is a closed system of doctors and insurers who work together to manage your care, prevent some screenings and tests, and do procedures when medical literature indicate they will help.

But Pauly is quick to add that doctors often don’t know what tests are necessary in particular cases. In ACOs, “[CMS] will try to get doctors to provide care based on evidence that it is effective,” he says. “But nothing will be perfect and in many cases the evidence doesn’t exist yet.”

Will ACOs work? The approach makes intuitive sense, and some early results are promising. The Michigan Pioneer ACO was able to reduce hospitalizations and their associated costs and medical complications. An ACO-like demonstration called the Physician Group Practice Demonstration showed that all systems improved quality and many achieved savings; the doctors got bonuses as a result.

But there are already doomsayers. Regina E. Herzlinger, a professor of business administration at Harvard Business School, recently declared in the trade journal Managed Care that “ACOs will implode just as … HMOs did in the 1990s,” when HMOs denied care not because it was medically unnecessary but because they didn’t want to cut into their profit margins.

The problem, she and others argue, is implementation. Herzlinger suspects that inefficient electronic medical records, the lack of team culture in healthcare, and the vagaries of setting up state insurance exchanges will frustrate attempts to control costs and boost quality. As Dr. Elliott Fisher of Dartmouth College, who coined the term ACO and helped create the model, only halfway joked recently, “They’re the perfect solution. If only we can get them right.”

Getting them right means there’s a lot of pressure both on patients and on the healthcare industry to stop doing unnecessary tests. Getting it right will mean that healthcare providers will have to get on board with the concept. There are as many as 160 ACOs in the U.S. already, but every month a new article comes out with doctors and medical associations claiming that the model has already failed, that’s it’s unrealistic and too confining to attract enough specialists to reach a critical mass. Getting it right will require that ACOs don’t consolidate to the point of becoming monopolies–and that they won’t use their ability to coordinate care with all their providers to fix prices and actually drive up the cost of healthcare.

Providers will have to resist the urge to give less care for less money. Since providers will get a lump sum per patient, they could try to push off their rolls patients whose complicated cases don’t get better with the innovations offered under ACOs.

And of course, the success of ACOs will depend on us–people who may not know they’re even in an ACO. For this to have a chance of working, we will have to stay in the ACO network, follow doctor advice, stop asking for antibiotics for viral infections, and resist the urge to demand the newest, unproven treatment just reported in the newspaper.

“What we’re talking about is collaborative care–doctors collaborating with one another and patients collaborating with doctors,” says Pauly. “I’m not sure Americans are ready for collaborative care.”

Heather Boerner is a healthcare writer based in San Francisco. Find her at www.heatherboerner.com.

*Photo courtesy of Brewcaster.

The post Why Does the Doc Keep Calling? appeared first on Zócalo Public Square.

Most of us know that the U.S. healthcare system is the most expensive in the world, even though it underperforms many of its less expensive counterparts. What fewer of us know is how much of the cost is due to unnecessary medical testing. PricewaterhouseCoopers’ Health Research Institute has found that “excess tests” are costing the U.S. healthcare system $200 billion a year, roughly 10 percent of what the system spends annually.

According to Miriam Laugesen, a health policy expert and assistant professor at Columbia University’s Mailman School of Public Health, superfluous testing occurs in several incarnations. There is repetitive testing, when a test has already been done elsewhere but the patent’s record is incomplete or missing. There is misplaced testing, when a test intended for one specific population (one susceptible to a rare hereditary condition, for example) gets applied to all patients indiscriminately. There is testing because of patient pressure or fear of being sued.

And then there is testing because of the professional mindset of healthcare providers. John Schumann, a general internist who blogs at GlassHospital.com, notes that modern medicine embraces the idea of using every tool at your disposal. “There’s a culture in American medicine of no stone left unturned,” he says. “Residents are quick to learn they have to have their bases covered. They don’t want to look foolish on rounds.”

This means that most residents–doctors-in-training–at hospitals around the country are ordering a full round of blood tests on every patient in the hospital every morning, even when it’s not clinically necessary. These can cost from $50 to $200 each. Multiplied across every teaching hospital around the country, that figure runs into the billions. Perhaps more importantly, it’s ingraining a culture of over-testing.

It’s not just new doctors ordering tests. “We all do it,” Schumann admits. “And we all look for justifying ordering a test.” To curb over-testing, Schumann thinks doctors need to be incentivized or penalized in their test-ordering. He points to Medicare as a case study of restraint. If a physician can’t offer a good justification for a test, Medicare doesn’t cover it. The system then allows a doctor to reflect on his reasons for ordering a test and either pinpoint a justifying diagnosis or acknowledge that the test is superfluous.

Curbing over-testing is a message that has been resounding lately. Nine medical societies–including the American Board of Internal Medicine–put out a list this month of 45 common tests and procedures that doctors should perform less often. The initiative, Choosing Wisely, asks physicians and patients to limit, among other things, antibiotic prescriptions for sinus distress, cardiac imaging in asymptomatic patients, and imaging for most back pain.

Whether the 374,000 physicians represented by these professional societies will adhere to the guidelines is of course far from certain, and the societies can’t enforce the recommendations, but the message at least is loud and clear. Reinforcing it in the academic world is Steven Weinberger, CEO of the American College of Physicians. In a recent letter published in Annals of Internal Medicine, he called for the emphasis of “stewardship of resources” and “practicing in a cost-conscious fashion.” He says such cost consciousness should even be added as a seventh clinical competency-core medical training guidelines set by the Accreditation Council for Graduate Medical Education. Weinberger’s idea would have doctors trained early on to decrease unnecessary care, saving everyone time, money, and resources.

The money saved isn’t just that of the insurer. Columbia’s Laugesen thinks patients might hesitate to order so many tests if they think more about how large a share of the costs they themselves would have to pay. So the next time you go to the doctor, talk out your options and ask for the doctor’s medical opinion. You could be saving yourself–and everyone else–a lot of money.

Aleszu Bajak is a writer in Buenos Aires.

*Photo courtesy of Lorenzo Sernicola.

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“I was expecting to see mostly homeless and indigent people, grungy-looking,” she says. “But they were people like me and you–people dressed nice and embarrassed to be there.”

According to the National Association of Dental Plans, 10 million people lost their dental coverage between 2008 and 2009. People without dental insurance risk associated illnesses, infections, and even death. And poor access to low-cost dental services is driving up healthcare costs, contributing to the Medicare and Medicaid funding crisis, reducing workforce productivity, and hitting the pocketbooks of taxpayers.

“The costs skyrocket when you no longer have access to a dentist,” Leonard Cohen told me. Cohen, DDS, MPH–not to be confused with the musician–has spent more than 15 years researching the effects of lack of dental care on poorer populations through the University of Maryland’s Dental School Department of Health Promotion and Policy. He found that when dental coverage is no longer available, visits to the emergency room jump.

According to a study published in a 2010 issue of the Journal of Evidence Based Dental Practice, the cost of dental visits to the ER ran about $110 million for the year 2006. And that was just for cavities. ER visits for toothaches that turned out to be dental abscesses and visits to community health clinics and other locations cost the system even more.

Unless those numbers have declined–and there’s no reason to think they have–ER visits for dental health are costing more than $110 million a year. Let’s break that down. The mean cost of an ER visit for cavities is about $1,500–the same amount generous dental plans pay for annual coverage. The cost of the same care in a non-hospital setting? $104. So instead of getting people dental care outside of emergency rooms, we spend 10 times what it would cost us to provide people with preventive dentistry.

These ER visits cost a lot, but half of them go unpaid, according to a study in Annals of Emergency Medicine. Which is to say that the rest of us pay–in higher hospital fees and health-insurance premiums. Or it comes out of our taxes in the form of Medicaid payouts.

Speaking of Medicaid–the federal health program for very low-income families, the elderly, disabled, and pregnant–dental care isn’t included in the coverage, except for kids. (Medicare, the program for the elderly, doesn’t cover dental either.) And the Medicaid reimbursement rate, set by each state, is so low that many dentists refuse to treat Medicaid-covered children.

Those who do make their way to emergency rooms don’t necessarily get good results, either. Emergency rooms aren’t set up for dental care. They don’t have dentists on staff, and people don’t come to the ER for cleanings. So most patients go home with prescriptions for antibiotics and pain medicines, some of which go unfilled because they cost too much. Kyle Willis, a 24-year-old Cincinnati man who died in September 2011 from an untreated dental abscess, couldn’t. Most people don’t die, of course, but one in four of those who visit the ER for dental care will be back within a year with the same complaints, according to a 2010 study in the Journal of Public Health Dentistry. Sometimes, ER staff will admit a patient for dental problems, maybe to drain an abscess. That runs about $16,000.

It doesn’t help that a painful tooth is a terribly tardy warning sign. “By the time your tooth starts to ache, you’ve probably already experience enamel or bone loss,” says Jim Crall, DDS, director of the National Oral Health Policy Center at UCLA’s Center for Healthier Children, Families, and Communities. In other words, by the time you notice a problem, there’s probably extensive, expensive damage–damage that could have been avoided with regular checkups.

Painful teeth lead people to miss work and school. According to a study in the Journal of Public Health, industry loses about 164 million hours in worker productivity to tooth problems every year. Children with poor dental health miss more than 52 million school hours every year–and these absences were associated with poorer school performance.

The good news is that we have the means to fix this quickly and fairly cheaply. Crall, who testified before Congress when 12-year-old Deamonte Driver died from a dental abscess in 2007, knows that consistent dental care can change someone’s life. He pointed me to a 2004 study in the journal Pediatrics that found that the earlier that children get care, the less their long-term dental costs run. For children who had their first dental visit before age one, their dental costs for the first five years of life were just $262. The numbers escalated for every year a family waited to take their child to a dentist: $339 when the first dental visit occurred at age 2 and $546 when a first visit was at age 5.

“If you can get those kids in on a regular basis, clean up the backlog, and put on fluoride and put on sealants, you can change the disease trend in those kids,” said Crall. “And when you teach healthy dental habits like brushing with fluoride toothpaste, you change their disease trend for life.”

Our healthcare system is groaning under the weight of the highest costs in the world, even without delivering the world’s best care. Sometimes, the problems are complex. But not always. Get people dental care and we’ll spare ourselves a lot of expenses. And a lot of pain.

Heather Boerner is a healthcare writer based in San Francisco. Find her at www.heatherboerner.com.

*Photo courtesy of Polifemus.

The post The Tooth Hurts appeared first on Zócalo Public Square.

For Starr, the only way to make sense of America’s peculiar relationship to healthcare is to explore its history: this was not a foregone conclusion. Although Americans like to use “American self-reliance” to explain their resistance to public healthcare, Americans are also egalitarian. “How is it that we never hear the phrase ‘socialized education?’” he asked, drawing laughs from a full house at the Skirball Center, at an event sponsored by the California HealthCare Foundation.

The healthcare industry has gotten rich off privatized care, and those Americans who are protected by current policies (what Starr called “the best-organized groups in society”) feel that they deserve their healthcare for moral reasons. They don’t want to be taxed for other groups who haven’t “earned” their healthcare. This attitude is “partly responsible for the bitter, vituperative aspect” of our healthcare politics, said Starr.

To illustrate the history of America’s healthcare wars, Starr likened the conflict to a play in three acts, which continues today.

Act One begins in the post-World War I era, when the first proposals for a government healthcare program in the U.S.–to be instituted at the state level–were modeled on well-established European systems, and Germany’s in particular. Opponents called this “a plot by the Kaiser” and succeeded in defeating it across the country, including in New York, where Franklin Roosevelt was governor. He’d put healthcare reform on the back burner as a result. And once the Cold War began, government-run healthcare was equated with Soviet socialist policy thanks to a script that the American Medical Association and other groups had developed over time.

In Act Two, Lyndon B. Johnson passed the 1965 Social Security Act to establish Medicare in the hope that it would be the first step to a universal health insurance system. But the high cost of both programs (thanks to steep concessions) made them an obstacle rather than a boost. And though Richard Nixon and John F. Kennedy both had healthcare plans–Nixon’s in 1974 was in fact to the left of both Bill Clinton and Barack Obama’s plans–Watergate (and a scandal involving a stripper and Congressman Wilbur Mills, one of the architects of Johnson’s plan) ultimately meant failure.

Act Three, said Starr, is “the escape from the health policy trap”–perhaps. In the 1980s and early 1990s, healthcare costs were increasing more quickly than earnings. Americans could agree that the current healthcare system wasn’t working, but there was no consensus about a solution. Bill Clinton’s plan (on which Starr advised) “began with a lot of optimism, energy, and belief that something was going to happen” before devolving into divisions between Democrats and Republicans and within the Democratic party itself. When the Republicans who had offered cooperation withdrew their support to unite against Clinton, the plan was dead–and then 1994 saw Newt Gingrich take power in Congress. (“When I wrote the book, I thought was writing about a historical figure,” Starr quipped.)

Why did Obama succeed where Clinton failed? The answer lies in what Starr called “minimally invasive reform.” Healthcare reformists concluded that any legislation that could possibly pass would need to solve the most urgent problems of the uninsured and eventually control costs–but it couldn’t disturb people who were employed and had good insurance or conflict with the major interest groups.

Ironically, it was the right who led the way. In Massachusetts, Mitt Romney passed a plan (designed by the Heritage Foundation) that relied on a health insurance exchange with subsidies for private insurance and an individual mandate. In the Democratic primaries in 2007 and 2008, Hilary Clinton, John Edwards, and Barack Obama all put forth proposals following Romney’s framework.

By 2009 and 2010, the people leading the effort to get Obama’s legislation passed had the battles of 1993 and 1994 under their belts. “They had become both more cautious and more determined,” said Starr–as well as willing to make many more concessions. And the top leadership in Congress was determined, too, to pass the bill.

“It’s a miracle that they were able to get all 60 [Democrats] when they had 60, in order to pass it in December of 2009,” said Starr. Although he has criticisms of the bill, he was clear that its passage was above all “an achievement … given the long history that preceded it and all of the obstacles that stood in its way.” This is the most important legislation in decades for improving the lives of low-wage Americans, he said.

Starr didn’t hesitate to point out the bill’s problems: the four-year lag between passage and implementation in 2014; the individual mandate, which is the focus of legal challenges and political opposition; and the fact that “the bill is unloved by Democrats because it doesn’t live up to their expectations, and hated by Republicans.” If the bill fails, said Starr, our healthcare war will continue–and the search for remedy will resume under a cloud of uncertainty.

Watch full video here.
See more photos here.
Buy the book: Amazon, Skylight, Powell’s.
Read expert opinions on why America’s healthcare reform wars are so bitter here.

*Photos by Aaron Salcido.

The post The Not-So-Great War appeared first on Zócalo Public Square.

You remember that goal of comprehensive reform? Cover everybody, improve the quality of healthcare services, lower costs? Before its passage, at least we knew what we were waiting for: a law that accomplished all these things. Now, in its anti-climactic aftermath, we are still waiting … not unlike the characters in Samuel Beckett’s Waiting for Godot, who know they have to remain waiting, but can’t recall why, or for whom, or what.

What’s our problem? Why is this so hard? Everyone knows a story about someone who needs healthcare but can’t afford it, or someone else who is suffering under the burden of healthcare costs. Why can’t America the Great just get its act together on this basic need?

There are several answers. The healthcare system is so complicated that most of us can barely understand it. The issue is so personally and politically charged that we can’t stop fighting about it. And healthcare is so expensive that we can’t afford it. The last answer encompasses a big “we”–everyone is poor these days–the federal government, state governments, the private sector, and patients.

The United States, in its embrace of a free market and no-entitlement-to-healthcare ideals, can boast of a system that is utterly complicated and totally broken. It is embarrassing to explain our regular failure to deliver appropriate care, our inability to control costs, and the converse incentives to providers that lead to inefficiencies that would never be acceptable in another industry. Not to mention the labyrinth that is the public and private investment in healthcare delivery, with so many overlapping federal, state, and corporate efforts intertwined in knots.

We Americans do not do well with complicated. Explaining the problems with the healthcare system takes a long time, let along taking a stab at some solutions. We like big-picture fixes like Herman Cain’s “9-9-9” tax code (the candidate may have left the scene, but the dream goes on) or snappy, reductive slogans like “it’s the economy, stupid.”

Washington’s response to the complexity underlying the healthcare system is to compensate with simplistic, ideological, and polarizing quarrels around the issue. The same emotional factors–does Grandma live or die and so on–contribute to the coarsening of political discourse around healthcare. Take a position on any significant question on the future direction of the nation’s healthcare sector, and you’re likely to be labeled a raving socialist or a heartless capitalist.

Supporters of President Obama recently declared that he intends to launch a defense of the law on the campaign trail. Odd, no? The president’s posture is to defend a legislative victory? This lack of leadership in communicating and educating about the health law makes it impossible to tame its complexity. How can there be a shared political and cultural narrative around healthcare when one of the most professorial and clear-spoken of presidents is strangely unable, or unwilling, to recast healthcare as a comprehensible dinner conversation for American families? We need politicians to frame a solution in a way that we can digest so we know what makes us upset and what we want to do about it.

Polls indicate that many Americans disapprove of the health reform law overall but appreciate specific elements of it. If asked, people will say they like the elimination of coverage denials for pre-existing conditions or the provision allowing young adults to stay on their parents’ insurance plans until age 26.

Without the clear leadership of the president, the political landscape will only become more caustic and confusing, rife with uncertainty and this sense of being in limbo, waiting for something. This drift makes the future all the more frightening to unstable private markets, to state governments that are struggling to balance their budgets, and to Americans who avoid seeing the doctor or filling a prescription for fear of the costs.

On the ground in the states, leaders are not as focused on the bickering inside the Beltway in Washington. They are worried about making their health systems work at the local and community level, despite all the uncertainty emanating from Washington. Notwithstanding the anti-“Obamacare” rhetoric from governors’ offices, state governments have created task forces and are passing laws to create new insurance marketplaces–so that health insurance can be accessible to individuals and small businesses that cannot afford these benefits now.

With states facing the worst budget shortfall in 60 years, hundreds of millions of dollars have been distributed by the Department of Health and Human Services to help state governments build health information technology systems, help consumers find the best healthcare insurance, and keep insurance company premiums in check. And considerable efforts are being made to create a more streamlined determination of who is eligible for Medicaid or premium tax credits for private insurance.

The health reform law is not perfect, and it is not enough to solve the problems facing America’s healthcare system. But it does represent forward momentum at a time of transformation for the healthcare system.

The real world can’t wait for Washington to indulge in too many more political tantrums or in a protracted stalemate on healthcare matters. Whatever you think of the legislation that passed, the fact is that states need to prepare for a massive expansion of the Medicaid-eligible population and the development and launch of health insurance exchanges in the years leading up to 2014, along with a myriad of reforms to the individual and small group insurance markets already underway. Like so many people have opined before me, regardless of what the Supreme Court decides in the spring, the real world still needs to resolve the challenges of sustainable healthcare delivery and financing.

Unfortunately, as state and national political leaders and the American people wait for the outcome of the Supreme Court’s decision and the 2012 election, we’re likely to see very little movement over the next six to nine months. We’re waiting on healthcare, and we’re likely to keep waiting. With the American healthcare system in crisis, we have no time to waste. So are all the reasons we’re waiting really worth waiting for?

Julie Barnes is the director of the Health Policy Program at the Bipartisan Policy Center in Washington, D.C.

Photo courtesy of D. Sharon Pruitt.

The post The Wait Goes On appeared first on Zócalo Public Square.

“With an aging population and rising healthcare costs, we are spending too fast to sustain the program,” the President told a joint session of Congress in September. He already has set in motion or proposed cuts to reimbursement rates for doctors and hospitals that are so steep that future seniors will be lucky to find providers who still take Medicare patients.

Meanwhile, all but six Republicans in the House of Representatives have voted to turn Medicare into a voucher program–a vision endorsed by all but one of the GOP’s presidential candidates as well. This proposal would, according to the Congressional Budget Office, leave the next generation of seniors paying nearly 70 percent of their healthcare expenses out of their own pockets while having to wait until age 67 to receive any federal benefit from Medicare at all.

Why have both parties declared war on Medicare? While all politicians fear the wrath of the AARP and the growing number of hard-pressed seniors, Medicare’s relentless squeeze on the budget seems to give party leaders no choice but to attack the program’s spending regardless of the political cost. Medicare’s ever-expanding claims on the Treasury threaten to crowd out Democratic priorities (bullet trains and decent public schools) and Republican ones (avoiding future tax increases and fighting draconian cuts to the military).

Yet both parties are ignoring a relatively painless and proven fix that offers the upside of vastly improving the quality of U.S. healthcare. If every Medicare provider were required to follow best practices in healthcare, Medicare costs would be easily manageable, most of the federal government’s long-term deficit would melt away, and patients would receive better care.

For evidence of this claim, consider Intermountain Healthcare, a healthcare system in Utah that requires the use of best practices. Dartmouth researchers John Wennberg and Elliot Fischer have estimated that, if all providers could achieve the same level of efficiency for inpatient care as Intermountain, Medicare hospital spending would fall by 43 percent–mostly by eliminating unnecessary surgery, redundant testing, and other forms of wasteful and often harmful treatment. Other examples of healthcare delivery systems combining high quality and cost effectiveness include the Mayo Clinic and the government’s own veterans healthcare system (VA), which, after a remarkable turnaround, is vastly outperforming most for-profit healthcare systems.

What these examples have in common is organization. Their doctors are all on salary, which means they have no incentive to engage in overtreatment. This is no small matter, since it is now widely accepted that about a third of all healthcare spending in the U.S. goes for treatments that benefit no one except the doctors and specialists billing for unnecessary services.

These are also large, integrated systems in which various specialists work together with primary care doctors as a team using electronic medical records, so patients don’t wind up being prescribed harmful combinations of drugs. This is also no small matter, since medical errors in U.S. hospitals kill upwards of 100,000 Americans a year.

Finally, these systems operate under fixed budgets. They don’t get paid for performing services without regard to outcome. Instead, they are paid a fixed amount per patient and make ends meet by keeping their patients well, thereby giving them a business case for investing in prevention, primary care, and effective management of chronic conditions such as diabetes and heart disease.

What are healthcare providers who combine these features called? Well, don’t scream, but technically they are Health Maintenance Organizations. But not just any HMOs. They are all non-profit institutions. And as such, they are not under pressure from Wall Street to produce short-term profits, and don’t face the perverse incentives that led many profit-driven HMOs in the past to deny beneficial treatment to patients.

They are also large institutions that hold onto a significant portion of their customers year after year. The money they spend up front to help patients quit smoking, lose weight, or manage their diabetes comes back to these institutions in the form of lower healthcare costs for these same patients down the line.

These examples pose a choice: either we “save” Medicare by cutting back eligibility and/or compensation to doctors, as both parties propose, or we go for a true solution: get Medicare out of the business of paying for wasteful medicine and into the business of paying for best practices in medicine.

Practically, that means setting a date certain when all Medicare providers will have to be organized like Intermountain Health–as integrated, non-profit HMOs.

Will that mean less choice of doctors? Yes, it will. But except for current Medicare beneficiaries, few Americans today have unconstrained choices of doctors. And for most younger Americans, receiving Medicare in a quality HMO would be a far better outcome than any other proposal would produce.

Phillip Longman is a senior fellow at the New America Foundation and the author of Best Care Anywhere: Why VA healthcare would be better for everyone (Third edition, Berrett-Koehler, 2012).

*Photo courtesy of jodimarr.

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Most Americans agree that everyone needs doctors, hospitals, and access to the best medical care possible. Countries compete for the highest life expectancies and the lowest infant mortality rates. But in the U.S., when we start talking about how to get there, we stop agreeing–at all. Healthcare has become a political rallying point and a subject it might be unwise to bring up at the dinner table, but it’s not like this in other countries. How did a policy become a symbol for so much more in America today? In advance of Paul Starr’s visit to Zócalo to discuss our healthcare wars, we asked health policy experts what makes us a most peculiar nation when it comes to this issue.

Healthcare Realities Clash with Our Beliefs

Policy disputes about healthcare in the U.S. are about much more than healthcare. They’re really about our perceptions of ourselves as individuals and as a society. They are disputes about who we are, what we inherited from our history, and what kind of society we want to be.

The U.S. is divided between two groups. One group thinks the U.S. should become more like European countries, which have strong values of social solidarity and universal health systems. The other group is convinced the European model is the wrong way to go. Meanwhile, healthcare policy disputes force us to confront three deeply held beliefs:

1. The belief that the U.S. has the best healthcare system in the world. The Speaker of the House of Representatives, John Boehner, has insisted that the U.S. healthcare system is the best in the world. Experts in the U.S. and elsewhere know that is simply not true.

2. The belief that everyone in the U.S. who really needs medical care will receive that care, regardless of ability to pay. Many patients in the U.S. receive free or discounted care, but many other patients fall through the cracks.

3. The belief that Americans are “rugged individualists” who cannot be forced to do anything. Americans may indeed be more individualistic than other people, but they accept federal mandates like the payment of federal income taxes and Social Security taxes.

Debates about health policy and health reform force us to confront these deeply held beliefs. That’s never easy.

Dean M. Harris is a clinical associate professor in the Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill.

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It’s a Three-Ring Circus: Politics, Symbolism, and Defining Ourselves

When Harry Truman first proposed national health insurance, Senate minority leader Robert Taft (R-Ohio) promptly tagged it “the most socialistic measure that this Congress has ever had before it.” Shouting “Socialism!” in the middle of the Red Scare was a serious charge, and Democratic Committee Chair James Murray responded furiously. “You have so much gall and so much nerve,” Murray screamed at his colleague. “If you don’t shut up, I’ll have … you thrown out.”

Every time the issue comes up (and it has come up often: 1946, 1949, 1962, 1964-5, 1974, 1979, 1991-4, and 2009), the rhetoric runs long, loud, and hysterical. Why? Because big health reforms always plays out on three different levels–every one of them a killer.

First, the debates rest on honest philosophical differences. Liberals believe healthcare is a basic human right while conservatives insist it is a market commodity. There are not many policy areas where the disagreement is so stark. Healthcare has become a badge of shame for liberals (“We’re the only nation without national health insurance”) and a point of pride for conservatives (“We’re the only nation without national health insurance”).

Second, national health insurance proposals provoke intense images. Never mind the actual proposal on the table; opponents always see the triumph of socialism, the death of free enterprise, the iron rule of the bureaucrats, or the cruel murder of innocents. “If this program passes,” warned Ronald Reagan about Medicare in 1963, “one of these days we will tell our children and our children’s children what it was like in America when men were free.” Sarah Palin offered the most memorable image during the latest round of health reform. “The America I know and love is not one in which my parents or my baby with Down syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide … whether they are worthy of healthcare. Such a system is downright evil.” Palin’s “death panels” went viral. Talking heads, bloggers, radio jocks, editorial writers, Congressmen, and citizens all repeated and dissected the phrase.

Those supporting healthcare reform are invariably stunned by the assault. They try to dismiss the exaggerated charges. No, Medicare was not the end of the land of the free. No, health reform did not include death panels or anything like them. But their efforts don’t matter much, because even if the attacks are exaggerated, they connect with real anxieties. What reformers must articulate in response are hopes and dreams that go as deep as people’s fears.

Third, healthcare systems are about life, death, comfort, dignity, and pain. Every healthcare system in the world tells us something important about the society that created it. Healthcare reform gets to the most fundamental question Americans can ask: Who are we as a nation? That’s why the debate touches all the hot-button issues, like abortion and immigration. The debate gets especially angry when images of our community degenerate into nasty pictures of “us” and “them.”

So keep those seatbelts fastened. There’s lots more health reform turbulence ahead. It’s a political circus with three rings: a great debate about the nature of healthcare policy, lots of anxieties about the state of the nation, and a conflict over the deepest question of all: who we are as a nation and a people. If all that were not enough, there’s one final thing to consider: healthcare is often decisive in the battle for control of Washington, D.C.

It may not be pretty. But it’s the way we’ve been doing health reform since Harry Truman first tried it in 1946.

James Morone is professor and chair of political science at Brown University and author of The Heart of Power: Health and Politics in the Oval Office (written with David Blumenthal) and Hellfire Nation: The Politics of Sin in American History.

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The Financial Stakes Are Higher Here

Because medical care involves the most basic issues of life and death, and because healthcare is a major segment of the economy in every wealthy nation, healthcare systems spawn endless debate and consternation all over the world. But health policy disputes in the U.S. tend to be the nastiest of all, for two reasons. First, the U.S. spends much more of its wealth on medical bills than any other country. We’re putting 17 percent of our GDP into health care; the other industrialized democracies spend about half as much. So there’s a lot of money at stake in our debate.

Beyond that, all the other industrialized democracies have already recognized the first principle of a healthcare system: they cover everybody. They consider it a moral imperative to do so. The United States has never committed to universal coverage. In 2011, we had 49.9 million people without health insurance.

Americans tend to do the right thing over time–the civil rights revolution is proof of that. Eventually, we will recognize that the world’s richest nation has a moral obligation to provide medical care for anyone who needs it. Until we do, our debates over health policy will continue to be angry and polarizing.

T. R. Reid is an author, lecturer, and documentary filmmaker. He is the author The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (Penguin Press).

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It’s An Existential Debate

While people in Japan, Canada, and other nations enjoy gains in life expectancy every year, in the majority of U.S. counties, life expectancy is actually decreasing. Worse still, this reversal of fortunes is occurring in the context of the most significant health spending in the world.

According to Austin Frakt, a health economist at Boston University, there is no good explanation for the poorer outcomes and higher costs observed in the U.S. He writes: “Our population is younger than the average OECD country (source). Growth of U.S. health spending is much higher than that of other OECD countries even after controlling for population aging (source).”

In the presence of these evident shortcomings, you’d think that policy debates would be more technical, focused on any payment, pricing, or quality solution that promised to improve health and save costs. Instead, U.S. healthcare politics is anything but technical. Instead, the politics are party-driven, theatrical, and just plain nasty. Health reform was termed Obama’s “Waterloo” by Republican lawmakers in spite of its similarity to earlier Republican proposals. Don Berwick, a highly qualified technocrat, has been accused of an unpatriotic “affection” for the British model. The estimates of the non-partisan Congressional Budget Office are said to be “gamed.”

But while OECD countries aren’t different in terms of health behaviors and demographics, there are at least two reasons why their politics are less ugly.

First, there’s just less at stake. Financial and economic interests are just more limited. Most countries spend less than 9 percent of GDP on health. In the U.S., we spend almost double that amount. When the health sector is less important to the economy, there are fewer, less significant economic interests to lobby politicians and legislatures. Unlike the U.S., government is the main funder of care in most countries of the OECD. When government is the main purchaser, insurers and providers have less political leverage. Contrast this to the U.S., where multiple small-scale purchasing agents (employers, individuals) are dispersed, not easily organized, and lacking purchasing know-how and market information.

In most countries around the world, there is consensus on the role of government in healthcare. People expect their governments to help mitigate health and financial risks on their behalf. Political debates in these countries focus on why the government isn’t doing more or why the government is not obtaining sufficient value for money. They’re not focused on existential debates on whether risk sharing for the poor or sick should exist at all or whether people should be obliged to be insured.

Amanda Glassman is director of Global Health Policy, Center for Global Development.

*Photo courtesy of mediateletipos.

The post A Sickening Dispute appeared first on Zócalo Public Square.

The 2010 legislation calls for the establishment of insurance exchanges, subsidies to the poor and near poor to make insurance affordable, and a mandate requiring individuals to maintain a minimum level of health coverage. That approach was championed originally by the leading conservative think tank, the Heritage Foundation. It was the basis of legislation co-sponsored by 20 Senate Republicans in the early 1990s, and it was the framework of the reforms that Mitt Romney enacted when he was governor of Massachusetts. Romney isn’t the only Republican presidential candidate haunted by his record on the issue; his main rival, Newt Gingrich, also used to support an individual mandate, though he has now apologized for it.

Moreover, the framework of the 2010 Democratic reforms bears a striking resemblance to current Republican proposals to convert Medicare into a “premium support” system. Under those proposals, Medicare would remain compulsory; Americans would have no choice about paying taxes for the program during their working years. Then, when they became eligible for Medicare–whether at age 65, as under current law, or at age 67, as under the budget introduced by Rep. Paul Ryan and approved by House Republicans–they would receive a “premium support” (more generally called a voucher) to cover part of the cost of enrolling in a private insurance plan.

Democrats object to Ryan’s proposed elimination of the traditional, public Medicare program and his plan to tie the value of the voucher to the consumer price index, which has long grown more slowly than medical costs. These provisions would dramatically shift healthcare costs to the elderly. But the Republican plan for Medicare does resemble the 2010 Democratic legislation in its basic “architecture”: health insurance exchanges, affordability subsidies, and an individual mandate.

Medicare is not the only area where Republicans would like to introduce changes that resemble the 2010 healthcare law. GOP proposals for privatizing Social Security follow a similar pattern. Under those proposals, Social Security would remain a compulsory program; workers would have no choice about whether to pay into it. But they would be able to choose among a set of private-investment alternatives (and the value of the annuities they received would vary with the success of their investment choices). In other words, there would be an individual mandate for retirement savings, but the vehicles for these savings would become private.

So while conservatives now object to the individual health insurance mandate and other provisions of the 2010 law, it’s not clear that this is an objection on principle. The rule seems to be that a mandate for private insurance is acceptable when they propose it, but when Democrats do, it is an intolerable violation of individual liberty.

As so often happens in the United States, a debate about whether a policy is legitimate has become a debate about whether it is constitutional. This coming spring, the Supreme Court will hear arguments about the constitutionality of the individual mandate. If the law had been drafted differently, it could have provided a clear constitutional rationale under the taxing power of Congress–the same rationale that Social Security and Medicare have. For example, the law could have imposed a healthcare tax and then provided an off-setting credit to all those with private insurance; the net result would have been the same as the mandate. But Democrats shied away even from the use of the word “tax” and instead justified the mandate under their authority to regulate interstate commerce. That choice has left the law vulnerable to challenge.

But should thoughtful conservatives want to see the mandate overturned? After all, a decision against the mandate could have wider implications, undermining the legitimacy of other proposals conservatives favor.

That concern was raised in a fascinating opinion on the individual mandate by Judge Brett Kavanaugh, a conservative, Republican appointee to the District of Columbia Circuit Court of Appeals. The D.C. Circuit is one of the appellate courts that ruled in favor of the constitutionality of the mandate. Judge Laurence Silberman, appointed to the bench by Ronald Reagan, wrote the majority opinion, a striking affirmation of the mandate’s constitutionality.

But just as striking was the dissent by Judge Kavanaugh, a figure who bears watching.
Some observers have suggested that although we don’t yet know who will win the Republican presidential nomination, we do know the identity of the next Republican nominee for the Supreme Court–Brett Kavanaugh.

To the disappointment of some conservatives, however, Judge Kavanaugh did not vote to strike down the mandate. Nor did he vote to uphold it. He ruled instead that under the 1867 Anti-Injunction Act, no one has standing to contest the mandate until penalties are imposed under the law–that is, not until 2015. But by then, he noted, the law might be revised (or possibly repealed), so the courts would never have to resolve the issue at all.

Toward the end of his opinion, Kavanaugh introduced another reason–a “results-oriented” consideration–for judicial restraint on the mandate:

This case also counsels restraint because we may be on the leading edge of a shift in how the Federal Government goes about furnishing a social safety net for those who are old, poor, sick, or disabled and need help. The theory of the individual mandate in this law is that private entities will do better than government in providing certain social insurance and that mandates will work better than traditional regulatory taxes in prompting people to set aside money now to help pay for the assistance they might need later. Privatized social services combined with mandatory-purchase requirements of the kind employed in the individual mandate provision of the Affordable Care Act might become a blueprint used by the Federal Government over the next generation to partially privatize the social safety net and government assistance programs and move, at least to some degree, away from the tax-and-government-benefit model that is common now. Courts naturally should be very careful before interfering with the elected Branches’ determination to update how the National Government provides such assistance.

The only surprise about this point is that it took so long for a conservative to make it. The individual mandate is the child of conservative thought. Killing that child might be satisfying for immediate political reasons, but it would make no sense from the standpoint of conservatives’ long-term goals. In thinking about what the Supreme Court will do, conservatives might heed an old caution: watch what you wish for.

Paul Starr, a professor of sociology and public affairs at the Woodrow Wilson School at Princeton, is co-editor of The American Prospect magazine and author of Remedy and Reaction: The Peculiar American Struggle over Health Care Reform.

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*Photo courtesy of IowaPolitics.com.

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