So on the one hand there will probably be downsizing in certain sectors of the health care system but, on the other, we may also be looking at some shortages. For example, as this article from the Times points out, people in Massachusetts are facing long delays before seeing general practitioners. Some of the problem is a part of a larger trend; nationally, particularly in rural and many urban areas, there is a widening gap between the number of general practitioners and the need for their services. But the situation is exacerbated in Massachusetts, where you suddenly have a large number of newly-insured people who are looking to make appointments with doctors when they previously would have gone to the emergency room or just forgone treatment altogether.
Once we have health care reform, any shortage of general practitioners/primary care providers is likely to become a bigger problem. It would be a tragic irony to trade a system where people can get in to see their doctor relatively easily (at least in part) because so many cannot afford health care for one where everyone can afford health care but no one can get in to see a doctor. The Times article touches on a few possible solutions: recruiting more foreign medical school graduates, student loan forgiveness for those who go work in underserved areas, and altering the reimbursement scheme for primary care providers. What are some other possibilities? Perhaps we could take some of the resources that are freed up as a result of having a more efficient system and reinvest in programs that would make sure there are enough primary care providers?
Oh, and speaking of job training programs, also noted in the Times is President Bush's proposal to eliminate $48 million in federal support for primary care training programs . . . .
As noted in the Times' article, reaction has been mixed. Groups representing employers and health care providers indicate approval because of the plan's proposal to lower costs. Union and consumer groups, however, expressed concern with the plan's underlying proposal to shift costs from a shared responsibility between employers and employees to one between consumers and taxpayers, which could cause employers to drop their health care plans.
I think both groups have it right: clearly, lowering the cost of coverage has to be a top priority of any health care reform. But I'm not sure if that will make as much of a difference in a system that from the beginning eliminates employer involvement. If employers were to dump their health care plans in response to the availability of the state-run plan, the result could be a (possibly significant) gap in coverage – at least initially.
This also raises a broader question: if we were to have a single, state-run plan (or, possibly, any well-regulated private market system) that has lowered costs so that they are affordable or subsidized for all, should employers still be a part of the equation? What do you think?
The last Review, hosted by Doug Williams of Health Business Blog, was chock full o' postings on health care reform. Over at the Health Care Blog, for example, Jeff Goldsmith writes that all of the political discussion about health care reform is focused only on two of our health care "systems" – public and private financing systems – but does not address the third system, the public care system (such as safety net urban hospitals and community care centers). Of course, there are two interesting posts making arguments for and against the health care reform topic du jour – mandates. And, just for a change of pace, Michael Millenson writes at Health Affairs blog that "Huckabee seems to be saying that fixing American health care is as simple as getting smokers to put their butts down and fat people to pick theirs up."
So, have you read any interesting postings out there on reform? Also, do you think there is any way to use these well-informed blogs and bloggers to push for or help achieve health care reform?
I am not a big fan of Wal-Mart because of its various, well-reported labor practices. I am willing to admit, however, that this is a step in the right direction. Of course, as pointed out in the linked-to article above, 7.3% of Wal-Mart's workforce still thinks it is better to have no insurance than to enroll in Wal-Mart's plan. This might be in part because some of the plans with low premiums have deductibles as high as $2000 for an individual – this equals 10% of the average Wal-Mart employee's $20,000 annual earnings. Still, a step in the right direction is always a good thing, as long as the company keeps working to increase participation.
The question is whether there is anything we can learn from what Wal-Mart has done. What do you think?
Two smaller points, though, deserve mention: first, data shows that spending on hospitals, doctors, and nursing homes grew at a slower rate in 2006 than it did in 2005, but that spending on administrative costs increased at a greater rate – almost twice as fast. "One reason [for this] is that private insurance companies have a larger role in Medicare, and they typically have higher administrative costs than the traditional fee-for-service Medicare program, federal health economists said."
Second, Medicare’s share of drug spending soared from 2 percent in 2005 to 18 percent in 2006, while Medicaid's share fell from 19 percent to 9 percent in the same period; this is because drug costs for six million people shifted from Medicaid to Medicare. As noted by the article, "[p]rivate insurers, which manage the drug benefit for Medicare, negotiate discounts with pharmaceutical companies. The discounts were generally smaller than those provided under Medicaid, the report said."
I call attention to these two smaller points because they implicate what tends to be a broader argument against health care reform that includes greater government participation: that the private market will be better at keeping health care costs and spending down. On at least a superficial level, these points appear to provide some evidence against that argument.
This is one of those things that seems kind of obvious but, when thinking about it in terms of the broader health care reform debate, it's implications are huge. If there is such success at staving off poor health after the uninsured person turns 65 (e.g., as noted by the article, "[u]ninsured people with heart disease and diabetes radically cut their expected rate of decline, to a point where they were almost as healthy at 72 as they were at 65"), imagine what could happen if coverage were extended to everyone? Although the article does not get into this, intuitively it would seem that the costs associated with reducing the risk of declining health would rise in accordance with the rising age of the uninsured individual.
Also from the article: “
Our findings provide some of the strongest evidence yet that expanding health coverage to the uninsured improves their health,” said Dr. J. Michael McWilliams, the paper’s lead author and a research associate at Harvard, particularly older people with “conditions like hypertension, diabetes and heart disease, for which there are effective therapies.”
This seems obvious but, for some, I guess it hasn't been. Food for thought as we enter a new year. Let's hope that, as 2008 comes to a close, real health care reform is just around the bend.
1) Producing and using better information: promoting health information technology, creating a “Center for Medical Effectiveness and Health Care Decision-Making,” and requiring providers to educate patients about alternative treatment options.
2) Promoting health and disease prevention: reducing tobacco use and obesity, and using federal funds and incentives to encourage individuals to engage in wellness programs and healthy behavior, and to cover preventive services.
3) Aligning incentives with quality and efficiency: establishing a hospital pay-for-performance program, transforming the fee-for-service payment system to an episode-of-care system, strengthening primary care and care coordination, and limiting federal tax exemptions for premium contributions.
4) Correcting price signals in the health care market: reset benchmark rates for Medicare Advantage plans, establish competitive bidding among Medicare plans, give the federal government the authority to negotiate prescription drug prices for Medicare plans, and limiting payment rate updates in high-cost areas.
As an interesting aside, one of the Fund’s suggestions for reducing obesity is to establish a nominal tax on sugar-sweetened soft drinks to help finance national and state obesity-prevention programs. The Mayor of San Francisco just proposed something similar, a surcharge for large stores when they sell sugar-sweetened sodas, for his city.
So, what do you think of the Fund's suggestions? What are some other ways to reduce the nation's health care spending?
This difference between the candidates' on individual mandates for adults has resulted in differences of opinion on several fronts, including: whether individual mandates are the best way to get as many people as possible covered (as opposed to, say, lowering health care costs to make insurance more affordable); whether mandates are actually enforceable; whose plan will cover the most people; and whether a mandate is even politically viable.
So, what do you think about mandates? Do you think they are good/bad, necessary/unnecessary? Is the "mandate issue" important, or much ado about nothing?
A little over a month ago, I wrote a post about medical tourism and how some in the health care industry are predicting that, within the next few years, U.S. health insurers will cover trips overseas for non-emergency surgeries. Thailand, specifically Bumrungrad Hospital in Bangkok, was mentioned frequently in the linked articles in that post as a popular medical tourism destination for Americans. Bumrungrad is, after all, a private downtown hospital, with a sushi bar, interpreters, and VIP suites with marble bathrooms.
Workers complain that they cannot afford high premiums for health insurance. Patients forgo recommended care rather than pay the out-of-pocket costs. Employers are cutting back or eliminating health benefits, forcing millions more people into the ranks of the uninsured. And state and federal governments strain to meet the expanding costs of public programs like Medicaid and Medicare.
The editorial is really just a jumping off point for a very important aspect of health care reform: how should we reduce and control health care costs? What should we prioritize?
To say choosing a plan is confusing would be an understatement. In Minnesota, for example, Part D beneficiaries will get to choose between a mere 151 plans! Investigating whether to stick with your current plan is important, though: as noted here and here, premiums for a lot of plans are going up this year. Other plans may be changing their coverage. There are resources on the web that offer advice on choosing a plan, including the official government site that lets you compare plans and what drugs they cover side-by-side. Some pharmacies are also going to help beneficiaries figure out which plans best serve their needs.
As noted in at least one of the above linked articles, Part D was controversial when it was passed as part of 2003's Medicare overhaul. Health Affairs, an influence health policy journal, has an interesting blog piece here examining renewed calls for a Medicare-run prescription drug plan.
So, as it is about to enter its third year of existence, what has your experience been with Part D? What has worked for you, what needs changing?
It is understandable that employers would want to cut costs associated with their employees' health care. But, in their effort to do so, to what extent should employers dictate or influence their employees' behavior?
This NY Times article discusses the recent trend of employers paying for "corporate wellness programs" to help employees quit smoking and lose weight.. Some even go as far as to provide monetary awards for employees who succeed. This can provide employers with big savings (compare the $900 in smoking cessation costs with the estimated $16,000 in additional medical bills the average smoker accrues over a lifetime). Plus, no one can deny that offering these programs provides a great benefit to employees.
Some employers go the opposite route: they penalize employees who engage in unhealthy behaviors like smoking, such as by charging them higher premiums or deducting small amounts from their pay. Some employers have even gone as far as firing smokers. A recent Wall Street Journal poll, however, does not find much support for these more punishing approaches. Only approximately one-third of the people polled think it is fair that employees who engage in "unhealthy lifestyles" pay higher premiums or deductibles, while there was barely any support for firing employees who smoke or are seriously overweight.
What do you think? Should employers be able to require higher premiums for employees who do not make healthy choices? Should they be able to require participation in wellness programs? Or should it be the employees' choice?
