Access to the best care

is what is at stake in allowing end of life preferences and planning discussions to be covered in annual wellness exams for Medicare beneficiaries. When I teach my class in health policy, and give lectures about health reform and health policy, I typically start with the first of two basic laws that govern any health system:

• Everyone dies, it is only a matter of when and from what.

When I say this in lectures, there is always a nervous laughter. Of course everyone knows this to be true, but I think the laughs are saying why start there? I start there because it is the only thing I know to be absolutely certain about health policy and our health care system.

Allowing physicians to be paid to discuss the options that Medicare beneficiaries have as they move inexorably toward death (we are all one day closer than yesterday, right?) is a matter of ensuring access to high quality care. I have written about the benefits of palliative care (care designed to improve quality of life regardless of age or prognosis) including ways in which I think the hospice benefit in Medicare should be opened up and expanded to allow persons to access many of the services offered even if they wish to continue aggressive medical treatments.

As a culture, we really need to grow up and learn to talk about the inevitability of death, both with family members, our health care providers, and more broadly. In the same talks with community groups that I mention above, after the nervous shifting is done, later people insist that we have to control out of control health care spending. Then as I walk through ways we might do this, the audience doesn't like any of them. I conclude that we are a profoundly delusional people when it comes to facing death and the amount of money we spend to forestall it. The root of this delusion is that we don't know how to talk about hard things in health care.

We have come a long way in talking about choices that people have as they approach death in the past 30 years or so since the Medicare program started covering hospice care (in 1983) and when there began to be books and dialogue around the concept of a good death, and amplifying patient choices. We still have a ways to go, and expanding access to discussions of this sort between doctors and patients if they want them is a good step.

Mark A. Smith, RIP

Mark Smith, one of the top researchers in the field of Alzheimer's Disease died unexpectedly on Sunday at the age of 45. Mark was the Editor-in-Chief of the Journal of Alzheimer's Disease, and I have been honored to have been an Associate Editor for the journal during 2010. JAD has posted the following in memory of Mark. Remembrances of Mark can be submitted via the JAD as follows George Perry (george.perry@utsa.edu) and Beth Kumar (editorial@j-alz.com).

I pray blessings on his wife and children and all his friends and colleagues at this difficult time.

Taking a break

I will be taking a break from blogging for the next week or so. Merry Christmas and blessings for the New Year!

What would a compromise look like?

While the rhetoric around health reform has been incendiary from day one, in policy terms, a compromise between Democrats and Republicans using the outline of the Affordable Care Act (ACA) has always been available. The two primary problems with the health care system are costs and lack of coverage. The ACA does pretty well on the second, and is a start on the first, but much more is needed. It will be very hard to get a handle on health care costs, and we will likely only succeed in doing this if both parties are on board.

This is what a deal to move ahead could look like.

• Replace the individual mandate to purchase insurance with guaranteed catastrophic coverage that is universal. I suggest individual caps of $10,000/family $15,000. I would do this via Medicare because it is simple, and could be implemented quickly. Others have suggested new federal initiatives that would provide catastrophic coverage; it is surprising to me that conservatives would want a new federal apparatus to implement this, but I follow the logic of their wanting to focus on catastrophic coverage. I would gladly trade true universal, catastrophic coverage for slowly creeping up on universal coverage with more comprehensive benefits. This allows progressives and conservatives to get what they most want: universal coverage and catastrophic, instead of first dollar coverage, respectively.
  

• End the tax exclusion of employer paid insurance. This is easily the most consequential policy that we could undertake to slow cost inflation in the private market. The Deficit Commission suggested this. It has long been a mainstay of Republican health care plans, like Sen. McCain's, and the Patients' Choice Act, the most comprehensive Republican bill submitted in the last Congress (but never scored by CBO). The tax on high cost insurance that is in the ACA (delayed by the reconciliation bill until 2018) is a back door way of achieving the same policy goal of slowing cost inflation. It would be better to cap this tax subsidy in a more straightforward manner and to do so sooner rather than later. It will take both sides to take this politically difficult step.

• Set up insurance markets for coverage underneath the catastrophic cap. Some would stick with the catastrophic level of insurance, others would want more coverage. People should buy this insurance with after tax dollars; employers could arrange such cover but the premiums they paid for workers would be taxable as income. I think you would expect employer involvement in insurance to decrease over time, which I think would be good. We could have income-based premium support. States could be given broad discretion in setting up these markets. There are many details to work out, but the parties should be able to do so if they can agree on the goal of helping people shop for insurance.

• Medical Malpractice reform. Our current malpractice system does almost nothing well. I always thought the route to the deal went through malpractice reform. The Republicans could have gotten quite a lot on this after Scott Brown's victory last January, and they missed an opportunity to advance a long term interest of theirs given that the ACA passed. However, they thought they could kill it, and preferred that to moving ahead on this issue. Politics aside, there are good policy reasons to have malpractice reform, especially if we can use that opportunity to develop a comprehensive quality improvement approach that is hard to develop in the midst of an adversarial malpractice system. I think the cost savings of malpractice reform are real but overstated, but there are many reasons to move ahead in this area.
  

• Transition Medicaid. Medicaid is now essentially two programs: Acute Care Medicaid, which covers mostly pregnant women and children, and with the ACA adults up to 133% of poverty. Long Term Care Medicaid, which pays for long term care services (nursing homes) for elderly and disabled persons. The acute care portion of Medicaid could be transitioned into premium support to allow persons to buy private coverage underneath the catastrophic cap. This would mainstream these folks. States could decide what extra help and services such low income people might need; some states might prefer to keep Medicaid as the provider of underneath cover. The long term care portion of Medicaid would remain unchanged as these persons are the amongst the most vulnerable members of society.

• Medicare purchasing. The Independent Payment Advisory Board (IPAB) set up by the ACA could play an important role is addressing health care cost inflation if it implemented, and particularly if it is expanded as suggested by the Deficit Commission. Most interestingly, the first suggestion of such a Board during 2009 was made by Republicans: The Patients' Choice Act (PCA) was introduced on May 20, 2009, around one month before the House of Representatives passed any of their reform bills. Republicans criticizing the IPAB have conveniently forgotten that the PCA proposed a similar commission that would apply cost effectiveness research and use this to make coverage decisions. Co-sponors of the PCA include Rep. Paul Ryan and Sen. Tom Coburn, leading conservatives in the Congress (and my senior Senator, Richard Burr). Of course, Rep. Ryan is the incoming chair of the budget committee, a key health care committee. We have got to be able to ask hard questions about what we pay for, when and how in the Medicare program. The existence of the IPAB in the ACA is an example of a Republican-initiated idea being folded into the final bill. Again, we will only be able to do the hardest things if both parties work together.
  

The Democratic party invested much political capital and time to pass the ACA. The Republicans have talked about many of the ideas above over the years, but it is worth remembering that they passed none of this when they controlled both Houses of Congress and the White House from 2002-2006. No federal bill to expand insurance purchase across state lines; no medical malpractice reform; no changing of the tax treatment of employer paid insurance. Now that they control the House of Representatives, I hope they will work to pass some health reform legislation, and thereby continue the health reform discussion that is needed if we are to ever develop a sustainable health care system.

More on individual mandate and the options

Mark Hall with a very nice, succinct piece in the New England Journal of Medicine addressing the constitutionality of the individual mandate. He does a good job of addressing the legal/constitutional, political and health policy dimensions to this question.

Universal coverage or something close is a necessary, but not sufficient condition to deal with our health care cost problem. There are three basic ways to expand insurance coverage toward anything resembling universal from our current point of 50 Millionish uninsured.

• Government insurance, such as Medicare, Medicaid or a new plan in which government acts as the insurer. Such government insurance needn't be expansive, it could be catastrophic like what I wrote here.
  
• Employer mandate, in which employers are compelled to provide insurance or pay a tax to support such coverage if they do not. Hawaii has had one for 30 years and has the second highest rate of insurance (after Massachuetts, that has an individual mandate).
  
• Individual mandate, which is what the Affordable Care Act proposes.
  

A fourth option is direct government provision of care, like in the Veterans Administration in the U.S., or the National Health Service in the U.K. This would be an actual takeover of the health care system, and I list it as a possibility in the interest of completeness since some of my students read this blog.

If the Supremes rule that the individual mandate is unconstitutional, then I see only two other options left. If there are other ways to move toward universal coverage, which is a necessary but not sufficient condition to addressing costs, we need to see this laid out in a bill that is marked up in a House committee, scored by the CBO and subjected to the debate and discussion that was afforded the ACA. There are some good ideas hidden amidst GOP talking points on health policy, but they have to come together in a piece of legislation for the Republicans to be taken seriously on the health policy front.

Offense is harder than defense

Dave Leonhardt with a nice piece placing opposition to health reform in historical context. One take home from this long history is that you might as well try something radical because any new health or social policy will be called radical even if it is not. The Republican alternative to the Clinton Plan became the end of the Republic 15 years later. It will be fascinating to see what the House Republicans do on health reform in the new Congress beyond passing a repeal bill that has no consequence. Will that be it, or will they move to pass an alternative vision?

One thing I learned from my experience coaching my 10 year old's little league football team this past Fall is how much harder offense is than defense. On defense, one player can make a great play and the entire team looks great. On offense, 10 players can make a great play and one player messes up, the play fails and the team looks terrible. In the House of Representatives, the Republicans are getting ready to shift from defense to offense. Do they even have a health reform offense?

I don't believe that they do have an offense on health reform. That does not mean they don't have ideas, but they are mostly expert in using them to argue against things. I would love to see Paul Ryan's budget committee mark a bill along the lines of his roadmap proposal. I suspect he cannot pass it through his own committee, much less the entire House, but who knows? The default of our health care system with no changes is future fiscal disaster for our country, so we have got to do something. Offense is a whole lot harder than defense...I think the House Republicans owe it to the country to lay out their vision for health reform, and to go on offense.

Is the individual mandate unconstitutional?

The practical definition of what is constitutional these days is whatever Anthony Kennedy thinks. This is the clearest, simplest treatment of the constitutional issue I have read, and makes me think the individual mandate will be upheld eventually (as does private convos with a couple of constitutional lawyers). Here are lengthier discussions of the issues. However, I will leave the constitutionality decision to the Supremes and focus here on what happens to the health system if the individual mandate in the ACA goes away.

The three biggest problems with the health system are: it is unsustainable due to cost; there are many uninsured persons; and there are quality problems in the system. These problems are not isolated from one another, but they are distinct. The Affordable Care Act is mostly a coverage expansion bill with some steps toward dealing with costs; we need many more steps to effectively deal with costs.

While it may seem paradoxical, expanding insurance coverage beyond the 50 odd Million uninsured persons in our country is actually a necessary, but not sufficient condition to addressing costs. [Update:@IncidentalEcon with more on this from Len Nichols]. So, if the individual mandate is unconstitutional and the ACA unwinds, we will be left with a status quo that is not so good. And little hope of addressing costs. Likewise, if Republicans somehow get the repeal they say they want, perhaps after the 2012 election, where would that leave us?

• 3 in 6 Americans covered by employer based private insurance
• 2 in 6 will be covered by government insurance
• 1 in 6 will be uninsured
  

With the 3 in 6 getting smaller over time as the link between employment and insurance breaks down, and the 2 in 6 gets larger due to population aging. And the plight of the uninsured is familiar: getting some care, albeit delayed, typically of lower quality, and often delivered in the most expensive setting, with the costs shifted to persons with private health insurance via higher premiums.

There are three basic ways that health insurance is financed across the world:

• Government
• Employers
• Individuals

No country has gotten anywhere near a universal coverage system without some type of a mandate, or a mix of mandates, and neither will we. Medicare, for example, is a type of mandate because you must pay payroll taxes, and then you are eligible for insurance.

The reason we have uninsured persons is because the link between employment and insurance is imperfect and some employers don't provide it. The link is likely to continue to break down over time because insurance is so expensive. Others slip through the cracks because they lose their job, but are not eligible for any governmental insurance. Some may want to purchase insurance but it is very expensive if you are priced as an individual and not as part of a large risk pool, and others will be denied because of their health without the insurance reforms of the ACA (the only thing I can think of worse than nothing is no individual mandate but guaranteed purchase, updated with stuff from Austin Frakt via Ezra Klein talking about Jon Gruber). And some choose not to take up offers of insurance, mostly because they are young and don't think they will get sick. They will probably be right unless they are wrong. If they are wrong, we all will pay.

So, if Republicans get their wish and the ACA goes away either via the courts or repeal, then what?

• Republicans are opposed to government expansions of health insurance. They don't like the expansion of Medicaid in the ACA and certainly don't want an expansion of Medicare to cover younger persons, for example.

• They are opposed to an employer mandate, and don't like the penalties in the ACA to larger employers who don't provide cover if their employees subsequently get subsidies to purchase insurance coverage. The Clinton Plan and other options in the early-mid 1990s were based broadly on an employer mandate, or so-called 'pay or play' in which employers had to provide coverage or pay a tax to fund government insurance for their workers. Republicans were deathly opposed to this plan, and in their opposition they proposed an alternative: an individual mandate.

• Now they are opposed to the individual mandate, what has heretofore been their idea. The pragmatic solution that focused on individual responsibility is now a threat to the Republic. It is not clear when they changed their mind, but it seems to have been sometime around Noon on January 20, 2009.

If you are opposed to government insurance, to employer mandates, and to individual mandates, then you have no credible policy to attempt to expand health insurance coverage. And no hope of addressing costs. There are plenty of inconsequential policies that sound great but won't do much, such as selling insurance across state lines.

Maybe there is another way that I just can't see. Maybe the House Republicans will pass a bill in the next Congress that provides their vision for how we can expand insurance coverage and address costs and people will be sold. They control the House and all the Committees. I would love to read their vision for the future of the health care system. They need to move beyond what they are against and lay out what they are for, meaning written in legislative form, marked in a committee, scored by the CBO and so on. We know what you are opposed to in health policy, now show us what you are for.

*I updated this post around 7:00am on 12/14 with posts that made some of my points much better than I had done. Update 12/14, 4:45pm. Ian Crosby of @IncidentalEcon with another good post on the legal arguments.