Thursday, September 23, 2010
If the Republicans wanted to be taken seriously
In other news, the Republicans pledge with America is out and it is roughly speaking laughable, at least from a health policy standpoint (haven't looked so closely at the rest). They are trumpeting that they will repeal and replace with something that prevents pre-existing condition exclusions FOR PERSONS ALREADY COVERED. That is already banned in federal law.....that is a meaningless change, and is far less than what PPACA does. Further, it doesn't say what would be included in the way of benefits, or what premium could be charged. In short, this is a phony policy pledge.
If the Republicans wanted to be taken seriously on health policy, they could say something like this, in a face saving manner.
"We thought PPACA wasn't the right way to go [forget about the fact that it was essentially the Republican alternative to the Clinton Plan plus a Medicaid expansion, but I digress]. However, now that PPACA has been passed, we have decided that even though we were opposed to it, we now want to improve upon it. The recent Census report shows how dire the status quo is for our health care system. We applaud the President's commitment to covering uninsured persons with insurance. However, we are very worried about costs. So, we propose the following steps:
If the Republicans wanted to be taken seriously on health policy, they could say something like this, in a face saving manner.
"We thought PPACA wasn't the right way to go [forget about the fact that it was essentially the Republican alternative to the Clinton Plan plus a Medicaid expansion, but I digress]. However, now that PPACA has been passed, we have decided that even though we were opposed to it, we now want to improve upon it. The recent Census report shows how dire the status quo is for our health care system. We applaud the President's commitment to covering uninsured persons with insurance. However, we are very worried about costs. So, we propose the following steps:
- Medical Malpractice reform. There are many problems with malpractice as I have written, and there are things that could be improved upon. They have proposed med mal reform, but not the items below.
- Change in the tax treatment of employer paid insurance. They could have said it like this, "The President was on to something in proposing a tax on high cost insurance. However, he lost his nerve as the tax was delayed in the reconciliation bill until 2018. But, the original tax on high cost insurance is still in the Senate bill, and being updated by 1 point above CPI annually. That means that in 10 years when the reconciliation provisions run out, the tax on high cost insurance will likely apply to two-thirds of policies. We propose a more straightforward capping of the tax exclusion of employer paid insurance. It is time to level with the American people--they are the ones getting the tax expenditure benefit from this aspect of the tax code, and reducing it will definitely slow health care cost inflation. The President demagogued the issue by calling it a tax on insurance companies when everyone knows that the tax on insurance companies will be passed on to consumers in any event. We therefore propose capping the tax exclusion (how much premiums paid by employers that is tax free) at the national mean for insurance premiums (around $14,500 for families).
- Finally, we are certain that the baby boomers do not want to leave their children with debt to pay for their basic needs, such as health care. Given that PPACA has developed a sliding income premium support for health insurance staring in 2014, we suggest raising the Medicare age to 67 by 2025. This would mean that persons who turn 65 in Jan 1, 2014 will now be eligible for Medicare on March 1, 2014, and so on.
Negotiated rulemaking committee, Day 2
Lots of interesting, good-willed folks on the committee. The going has been slow to even agree on the issues to be discussed. [I should say it seems slow to me, one of the facilitators told me that it is just an average group in terms of getting started]. At this point, the meeting has felt a bit like running into a brick wall in preparation to visit the Dentist.
Update 4:40pm: we have agreed that the following topics will be next step priorities for us to discuss: (1) how to measure need; (2) whether there should be two designations (a la HPSA and MUA) versus one; (3) what are the definitions of two key concepts: underservice and access.
Update: 6:00pm. We ended with a plan for the next meeting in October, focus on the issues of whether there will be a single designation v. two (HPSA and MUA) with some input from HRSA about the range of programs that use the various designations. Further, we will discuss the concept of need moving into the related concepts of underservice (which I would define as the fit between the needs of a person and the health care available to that person; those obviously aggregate to population levels), and access. There is an interest in not moving directly to what can be measured as the first, even though data issues are an issue. Instead, I think we will try and decide what we would like to measure to designate areas as underserved and/or suffering from a provider shortage and then move to what we can measure. There are also several who rightly note that some things will be impossible to measure in any way other than via local efforts.
Update 4:40pm: we have agreed that the following topics will be next step priorities for us to discuss: (1) how to measure need; (2) whether there should be two designations (a la HPSA and MUA) versus one; (3) what are the definitions of two key concepts: underservice and access.
Update: 6:00pm. We ended with a plan for the next meeting in October, focus on the issues of whether there will be a single designation v. two (HPSA and MUA) with some input from HRSA about the range of programs that use the various designations. Further, we will discuss the concept of need moving into the related concepts of underservice (which I would define as the fit between the needs of a person and the health care available to that person; those obviously aggregate to population levels), and access. There is an interest in not moving directly to what can be measured as the first, even though data issues are an issue. Instead, I think we will try and decide what we would like to measure to designate areas as underserved and/or suffering from a provider shortage and then move to what we can measure. There are also several who rightly note that some things will be impossible to measure in any way other than via local efforts.
Wednesday, September 22, 2010
Negotiated Rulemaking committee Day 1
The HRSA negotiated rulemaking committee to reconsider health professional shortage area (HPSA) and medically underserved area (MUA) designations got underway today. There was a great deal of process work today, with the group discussing what consensus would mean. The statute that created the negotiated rulemaking process defines consensus as unanimous agreement....which gives me a bit of pause and makes me worry we are wasting our time. However, the facilitators have quite a bit of experience and said that many groups have been uncertain about their ability to reach consensus, but have been pleasantly surprised. They went on to further give a practical definition of what it would take for members of the committee (all 28 of us!) to agree: 70% comfortable with what was decided (no one will like it completely), with 100% willingness to publicly support the result of the committee process.
We also worked on the rules governing our committee and how we would work together. This seemed laborious to me, but is important ground work.
General Thoughts from day 1:
We also worked on the rules governing our committee and how we would work together. This seemed laborious to me, but is important ground work.
General Thoughts from day 1:
- The committee is filled with passionate advocates for underserved persons and groups.
- Most committee members have a fairly clear sense of 'who they represent' on the group. For me, I do not have such a clear sense. I was involved in research in this general area for most of the 1990s, but honestly had given it up because past efforts (in 1998) to reconsider many of these issues had failed and it seemed intractable. So, I have a history with the topic and an interest (it was my dissertation research), but have been away from it for a decade. I don't feel as though I am representing any particular group, and most want to ensure that we allocate scarce resources to aid underserved groups in the best way possible.
- There will be a great deal of technical discussion around data and the like. A big challenge will be to remember the main point: looking at a means of allocating scarce resources to best aid the disadvantaged and underserved in our nation.
- We need to get it right. History shows a great deal of inertia in such efforts to designate aeas and groups. The MUA and HPSA methods are largely unchanged since I was in elementary school and middle school. No pressure guys, but we don't need to screw it up...
- We need to land the plane. The Clinton Administration sought to reconsider these designations in 1998; the Bush administration did so in 2008. In both cases the plans went on the rocks due to lots of negative comments from those who expected to be adversely affected by any changes. We will have to navigate this.
- In several instances, people said 'what does the law say?' meaning PPACA which specified creating this negotiated rulemaking committee, or the Public Health Service Act provisions in the 1970s that did things like create the National Health Service Corps which is why HPSAs were created....often the laws are fairly vague. So, the committee will (and HHS for the past 35 years has) had to exercise a great deal of discretion in working out the nuts and bolts of these designations and programs.
Tuesday, September 21, 2010
HRSA Negotiated Rulemaking Committee Work Begins
The Negotiated Rulemaking Committee appointed by Sec. Sebelius to review the criteria and process of identifying Medically Underserved Areas (MUA) and Health Professional Shortage Areas (HPSA) begins its work tomorrow in Rockville, MD. These designation methods have been essentially unchanged for many years, and the designation makes available monies and programs such as a Medicare bonus payment for primary care physicians practicing in HPSAs, National Health Service Corps Physicians who repay medical school loans via service in underserved areas, and Community Health Centers that provide a key safety net, and in some communities the only viable primary care system. The committee is to complete its work by Spring, and if a consensus is reached, that consensus would become a recommendation for the Secretary to adopt an interim rule that would then be open to public comment. Final decisions rest with HRSA and the Secretary of Health and Human Services.
If a new set of criteria and rules are developed and adopted, they will be used to allocate resources and monies that are designed to create and support health care services for underserved areas and/or groups. The point is to develop a meaningful way in which to allocate scare resources available for this important task.
The committee was created in the PPACA, under the auspices of the Negotiated Rulemaking Act. Here is the charter of the committee. I am one of 28 members of this committee. Since the meetings are public, I am planning to be blogging and tweeting during the meetings and deliberations as the context and setting allows and is appropriate. The goal is to share a bit of insight into how this committee--one small aspect of implementing health care reform--works. I am honored to have this opportunity, and look forward to sharing it with you.
If a new set of criteria and rules are developed and adopted, they will be used to allocate resources and monies that are designed to create and support health care services for underserved areas and/or groups. The point is to develop a meaningful way in which to allocate scare resources available for this important task.
The committee was created in the PPACA, under the auspices of the Negotiated Rulemaking Act. Here is the charter of the committee. I am one of 28 members of this committee. Since the meetings are public, I am planning to be blogging and tweeting during the meetings and deliberations as the context and setting allows and is appropriate. The goal is to share a bit of insight into how this committee--one small aspect of implementing health care reform--works. I am honored to have this opportunity, and look forward to sharing it with you.
The ins and the outs
must be the same for there to be a balanced budget. WaPo with a story noting that doing nothing--which means the tax code will return to 2001 levels would come close to balancing the budget by 2015. Extending all the tax cuts (enacted via reconciliation--that is why they go away after 10 years) will add around $4 Trillion to the deficit over 10 years. That is around 4 times larger that the ARRA and the TARP combined....PPACA reduces the deficit per CBO....even the outlays alone in PPACA with no spending cuts or tax increases are around $1 Trillion over 10.
The Senate Dems have a plan to extend some of the cuts, adding about $2 Trillion to the deficit over 10 years.
Neither party at this point has shown they mean it when it comes to fiscal responsibility; the Republicans are more culpable than the Dems in my book because they talk about 'fiscal responsibility' so much (and only talk).
Perhaps extend the rates for 1 year given the recession....CBO says it will stimulate the economy a bit, but that effect will be eroded due to borrowing by mid-decade. Then, lets try the tax code the last time we had a balanced budget and see what happens.
The Senate Dems have a plan to extend some of the cuts, adding about $2 Trillion to the deficit over 10 years.
Neither party at this point has shown they mean it when it comes to fiscal responsibility; the Republicans are more culpable than the Dems in my book because they talk about 'fiscal responsibility' so much (and only talk).
Perhaps extend the rates for 1 year given the recession....CBO says it will stimulate the economy a bit, but that effect will be eroded due to borrowing by mid-decade. Then, lets try the tax code the last time we had a balanced budget and see what happens.
Why do we spend so much on health care?
I get this question a lot (I usually say we need more research, would you like to give me a grant?.....) However, Aaron Carol, over at the Incidental Economist yesterday began a 10 part series addressing this question, and providing an answer. The first post is an overview, and he frames the issue by pointing out the strong correlation between a nation's wealth and its GDP per capita (how productive the nation's economy turns out to be). The USA has the largest GDP/capita in the world, so it is not surprising we spend the most per capita on health care. The relationship between GDP/capita and health care spending/capita is shown in this graph, which is a part of a report by consulting firm McKinsey titled "Accounting for the cost of U.S. health care: a new look at why Americans spend more. (from Nov. 2008)" The report addresses in a matter of fact manner why we spend so much on health care in the U.S., as compared to other high income nations.
Given the wealth of our nation, it is basically inevitable that we will spend the most on health care, as virtually all nations invest more in health on a per capita basis as their wealth grows. What is truly remarkable is how much more the U.S. spends compared to other high income nations. The really hard question is whether we get our monies worth for the extra spending?
The U.S. in 2006 spent around $650 Billion more on health care than the GDP/capita and health spending/capita relationship would suggest; this year that number is likely around $750 Billion. This is the extra spending beyond what wealth predicts that makes the U.S. the most expensive in the world by far in terms of health care expenditures per capita.
The McKinsey report (and Aaron Carol) focuses on where the money is going, meaning literally where are we spending the extra dollars beyond what is predicted by wealth levels on a per capita basis? In post 2, Carol describes that inpatient spending is actually not the part of the system that is driving the spending gap between the U.S. and other nations; that accounts for 'only' $40 Billion of the $650 billion gap in 2006. Beneath these numbers are some interesting findings; Americans are less likely to go into a hospital than persons from other nations (we do more in outpatient settings), to stay fewer days in a hospital given that we go, but when we do go to hospitals, we spend a lot more per day.
The most important question that needs to be asked when looking at how much we spend in the U.S.: are we getting our monies worth? Meaning do we have a higher quality of life and/or live longer with the extra spending than we would without it? Carol plans a further series looking at this and related questions, but it is certainly not obvious that we do get our monies worth (in terms of quality of life gains and/or life extensions) for our extra spending, but that is easier to conclude than figuring out how to lessen spending.
If you have ever said 'we spend too much in health care' 'our system in unsustainable' 'we are spending ourselves into oblivion and saddling our kids with too much debt' then whether you realize it or not the two questions you want answered are "how much of this excess $750 Billion we will spend this year could be cut without harming patients?" and "how will we figure this out?"
Given the wealth of our nation, it is basically inevitable that we will spend the most on health care, as virtually all nations invest more in health on a per capita basis as their wealth grows. What is truly remarkable is how much more the U.S. spends compared to other high income nations. The really hard question is whether we get our monies worth for the extra spending?
The U.S. in 2006 spent around $650 Billion more on health care than the GDP/capita and health spending/capita relationship would suggest; this year that number is likely around $750 Billion. This is the extra spending beyond what wealth predicts that makes the U.S. the most expensive in the world by far in terms of health care expenditures per capita.
The McKinsey report (and Aaron Carol) focuses on where the money is going, meaning literally where are we spending the extra dollars beyond what is predicted by wealth levels on a per capita basis? In post 2, Carol describes that inpatient spending is actually not the part of the system that is driving the spending gap between the U.S. and other nations; that accounts for 'only' $40 Billion of the $650 billion gap in 2006. Beneath these numbers are some interesting findings; Americans are less likely to go into a hospital than persons from other nations (we do more in outpatient settings), to stay fewer days in a hospital given that we go, but when we do go to hospitals, we spend a lot more per day.
The most important question that needs to be asked when looking at how much we spend in the U.S.: are we getting our monies worth? Meaning do we have a higher quality of life and/or live longer with the extra spending than we would without it? Carol plans a further series looking at this and related questions, but it is certainly not obvious that we do get our monies worth (in terms of quality of life gains and/or life extensions) for our extra spending, but that is easier to conclude than figuring out how to lessen spending.
If you have ever said 'we spend too much in health care' 'our system in unsustainable' 'we are spending ourselves into oblivion and saddling our kids with too much debt' then whether you realize it or not the two questions you want answered are "how much of this excess $750 Billion we will spend this year could be cut without harming patients?" and "how will we figure this out?"
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