Health reform debates during the Obama Administration’s first week
posted 1-28-2009 3:50 p.m.

 
In a week in which 10,000 jobs were lost in a single day, with more losses to come in the months ahead, the weak health care spending measures meant to cover more children and unemployed are already virtually moot. Unless Congress snaps to and suddenly realizes its gross underfunding, the monies intended to expand coverage won’t even give the states enough to maintain status quo. And the states aren’t waiting: they’re already cutting back.

There is a solution, but the Democrats would have to be uncommonly brave to take it on. And they’d have to push aside all but a mere handful of moderate conservative Republicans to get it done. The economic disaster is of great enough proportions to justify it; but that doesn’t mean the majority in the House and Senate will work up the nerve and twist enough moderate arms to get it done. And they're in too big of a hurry, as is the President.

Unemployment is up in all 50 states, says today’s Wall Street Journal. No job sector has been spared. States’ unemployment funds are nearly empty, if not already bankrupt. This is the worst unemployment situation inn the last 60 years. The economy is spiraling downward rapidly, and long before the federal funds in the stimulus package reach the states, considerably more money will be needed just to keep the current number of enrollees from being booted out of Medicaid. The funding being discussed now will only allow the states to tread water: it won’t in any way even begin to cover the people who are unemployed and uninsured now — never mind those who will become unemployed over the next 12 to 18 months. Congress is already losing the race.

Medicaid enrollment is bursting at the seams, doubled in many states compared to a year ago, just as state budgets are shrinking drastically. Having already cut provider reimbursements and delayed payments as much as they can, some states are now cutting Medicaid benefits and squeezing tight their eligibility requirements to reduce the beneficiary totals.

Bitter irony: there might have been enough to cover some of those newly unemployed applicants if it weren’t for the fact that more than three-quarters of the Medicaid dollar goes to cover care for the disabled and elderly. Translation: nursing home care, something that Medicaid was never supposed to pay for — but which Congress, in its cowardice about covering nursing home costs directly under Medicare, where every elderly person would be eligible, let slide into Medicaid instead, thereby eating away at benefits that otherwise would have covered more poor and uninsured children and their mothers. The reason there have to be separate children’s state health insurance programs is because Medicaid money gets diverted from its original purpose.

Now President Obama and the Congress want to let workers who get unemployment apply for Medicaid. Just when the states are actively trying to keep more people out of Medicaid because there’s not enough money to cover the enrollment increase during the last 12 months. Congress and the president must know by now that unemployment won’t stop next week just because they’ve passed a bill. Things are going to get still worse: the states that were first to feel the downturn — those heavily dependent on home construction and manufacturing — are getting worse, not better. The economy hasn’t bottomed out yet and may not for as long as a year..

Trying to provide coverage for the unemployed is a necessity — the nation needs this if we are ever to recover economically. But in being timid about amounts and means, Congress and the president are far behind the curve, will only dig themselves (and us) in deeper by taking half-measures, and are guaranteed to fail in their promises to the unemployed.

By trying to fold in health ‘reform’ measures into the stimulus bill instead of taking another month or so to think through what we really need and how much we have to pay to get there, Congress is rushing headlong and blindly into mistakes that may take us years to undo, if we can undo them later.

Now that there is huge pressure to get something done quickly, it will be, as I said earlier, likely done badly. Unless wiser heads than Secretary Daschle’s see opportunity in the chaos and are prepared to take a completely different approach, one that many in the health care and insurance industries won’t like but will be forced to swallow sooner or later. It’s just that, high as the cost may be now, it will still be cheaper to tackle now rather than later.

I am, of course, referring to honest-to-God national health insurance. For a debunking of the myths surrounding what universal coverage really means, see my earlier post on Getting the health care discussion wrong. We face an avalanche of unemployed and uninsured, whereas Mr. Daschle and his colleagues propose a flyswatter to fend it off. All sane analysts admit that the health system is broken and needs drastic revamping. To cobble little tweaks and massive IT spending onto the status quo is like pasting band-aids and Post-Its onto a building that is collapsing.

More to the point, there are two parallel systems that need fixing: the heath care financing system, and the health care delivery system. Getting everybody covered with health insurance is a necessary but insufficient condition to giving them actual access to care when and where they need it. Massachusetts and Vermont have previewed for us the backlog and waiting lists that can be expected if the needed care providers and resources aren’t in place. So there are some things that must be accomplished simultaneously first, then other things that must be done in order. And fixing the delivery system will take much longer than simply covering everyone.

So start in the logical place. Three things must be done at once:

First, get everyone into one, simplified health plan and give the reins of that program to an agency that is already doing the job fairly well: the Federal Employees Health Benefit Program. FEHBP contracts with HMOs and PPOs in every state, meaning everywhere there are federal employees. It already has performance standards for these health plans and knows how to negotiate with them; folding everyone into FEHBP will finally give it some real clout to hold down premium costs. In fact, this is the *only* way anyone can hold down premium increases: nothing else will do it. Moreover, FEHBP already has a sensible comprehensive basic benefit package that only needs to be amended slightly to bring it in line with the Federal HMO Act of 1974 and its amendments (the HMO Act is, by the way, the only decent basic benefit package that anyone would actually want; all it lacks is certain benefits for the elderly, like coverage for mammograms, and coverage for women’s reproductive services, including birth control and abortion services. And the conservatives who don’t like it can go hang: they lost the election and had to know this was coming; better to act fast and give the people what they need ). Fold all Medicaid beneficiaries, unemployed and uninsured persons in first (say, within the next two months), and four months after that, start folding in Medicare beneficiaries. Everyone who already has health insurance can be phased in over the following six to 12 months.

Second, while this is happening, you need to make sure there will be enough primary care doctors and nurses. There aren’t enough now, despite the fact that the medical schools have seen this coming for 20 years — so make the existing ones and the soon-to-graduate doctors and nurses a deal: stay 10 years minimum in primary care after you finish your internship and residency, and the feds will wipe out your med school or nursing school debt. Provide care in an undeserved area, like a rural town or the inner city, and the feds will also give you some cash toward your malpractice insurance premiums (but if you go into a non-primary care specialty before the 10 years is up, you’ll have to repay the school loan). Meanwhile, the president needs to call in all the medical school and medical specialty society presidents for a come-to-Jesus meeting and hand them an ultimatum: either start putting quotas on non-primary-care specialties, or the feds will do it for you. Primary care specialties include family or general medicine, pediatrics, obstetrics and gynecology, geriatrics and rheumatology, and, given the possibilities for epidemics, infectious disease specialists. Viruses and microbes mutate and evolve far faster than we do, and they trade genes with others of their kind, thus passing on immunities to drugs they haven’t been exposed to yet. It’s scary, and we need to be prepared to deal with that.

Third, we need more than just personnel in the right place: we have to fix regional trauma systems and put new ones in where they haven’t been for ages, because trauma systems in most states have broken down. Having health coverage is meaningless if nobody will bring you to the place where they can best care for you in an emergency within that golden hour that saves lives. And this is assuming that there IS an appropriate place the paramedics can take you within that golden hour. Luckily, once everyone is covered by health insurance, hospitals will no longer have to either turn away the uninsured or push that cost onto other patients — and hospitals will be able to afford to keep their ERs open and staffed for true emergencies. Which is why you’ll then *need* to designate as trauma units only those hospitals that are best situated and staffed for that purpose: we don’t need every hospital to have a top-level ER because that wastes money and doesn’t let the best hospital ERS get enough cases for their doctors and nurses to stay sharp and effective. Patient volume really makes a difference in how good a trauma unit gets; so do resources, which more top hospitals will have when they’re not trying to care for the uninsured. There may still be a small need for charity care for the few who fall through the cracks, but it won’t be anything like the dysfunction and financial deceit we have now.

Once Congress has accomplished this much with the financing and manpower situations, it can take another few months to think through reforms for the health care delivery system. Changes meant to improve the quality and effectiveness of care will take much longer to achieve, and this is the point at which we start to discuss electronic patient records. Computerizing patient records won’t save any money for years, because first you have to buy and implement the systems, and that takes time. But before that, the IT industry had damned well better solve the bigger problem: privacy and security. I’ve said it before: we really need a privacy czar in the Cabinet to make sure that neither people’s financial and credit records nor their medical records end up in the wrong hands. There are already way too many databases that have information they’re not entitled to, and we need an agency that can walk in unannounced, like OSHA does in factories, and force those databases to be purged, and fine those guilty very heavily for every day those records remain in their possession. Then the really hard part begins: making sure that nobody’s medical records get hacked. Just as there are professional hackers who steal credit records and sell them to others for illegal purposes, once your medical records are computerized there will be someone just as likely to steal those and sell them. Do you doubt it? Just wait.

By the way, letting Microsoft into this medical records computerization project is a really bad idea. Ever notice how many times evil hackers launch viruses, trojans and worms at programs just because Microsoft wrote them? What do you imagine they’ll do once your medical records are running on a Microsoft platform?? Yeah. Be afraid. Be very afraid. Microsoft shouldn’t be involved.

There’s already an agency within the federal Department of Health and Human Services that is dedicated to health care policy and research, including things like best medical practices, practice guidelines, and clinical decisionmaking systems. It’s called the Agency for Healthcare Research and Quality. Congress shouldn’t give Mr. Daschle yet another bureaucracy to spearhead reform efforts — give that job to AHRQ, seeing as how it’s doing much of the heavy lifting. Besides, once everyone is insured through FEHBP, the feds can get rid of the agency that runs Medicare and Medicaid, thus resulting in one less bureaucracy in DC and removing a financial burden from the states, all in one fell swoop. Simplify, ladies and gentlemen; don’t cobble more on to the broken Rube Goldberg machine we have now. Besides, Secretary Daschle really will have more than enough to do without adding more turf to his domain. Honest.

And that’s a good start.

With the majority leaders and whips holding all the Democrats in line and Sen. Reid and Speaker Pelosi making nice with the moderate Republicans, this could all squeak through without any help from the rest of the GOP. Let them squeal. Ignore them, gentlepersons of the Congress, and get to work with forethought, care, wisdom, and much boldness. You have a mandate: use it.

Waiting for bipartisanship is useless and a waste of time when the GOP has shown itself as intransigent and clueless as it has ever been in the last 28 years. The GOP had the last eight years to demonstrate that they could lead and failed miserably, giving us a year-long (so far) recession that looks headed for a depression. The Republicans now either need to follow President. Obama’s lead, or get out of the way. They’ve exhausted their other options. They just haven’t grasped that yet.

Time’s a-wasting.