A good friend of mine, Jeff Goldsmith writes:

“It is possible that, for the second time in fifteen years, divisions inside the Democratic Party might doom health reform. President Obama will need all his skills and persuasive powers to save his Congressional party from itself. Rather than wasting scarce political capital on the public plan, health reformers need to focus on hospital and primary care physician payment reform, expanding Medicare coverage for the almost 11 million uninsured boomers and sensible design of a federal health insurance exchange. It isn’t going to take a miracle to get this important public task done, just focus and discipline…

In a 25 June New York Times Op-ed piece,  Alain Enthoven, a health policy veteran, argued persuasively that the ability to set health insurance market groundrules through a national health insurance exchange already hands the government sufficient power to curb private health costs, as well as to make covering the newly insured more affordable. This power, properly employed, makes the public plan completely unnecessary.

Enthoven is exactly right.   He proposed merely setting the maximum amount of tax-free pass through of health insurance premium costs to employers and employees at the amount of the least expensive exchange offering (a familiar remedy for those who have followed his work). People who want more expensive plans will be free to pay for them with after-tax dollars.    Since the exchange will also constrain underwriting practices and set minimum benefit levels, meet that price challenge by marketing only to the healthy or offering a stripped benefit will not be possible.

While health insurers and providers and the commentariat are engrossed in the contentious public plan debate, attention has been distracted from the crucial decisions regarding the shape of the federal regulatory regime embodied in the health insurance exchange.  This exchange will have immense power.  Health plans which do not adhere to its rules will be unable to serve their customers through the exchange and be locked out of access to a large fraction of their current market, as well as to the newly covered.

The exchange’s rules will likely include underwriting standards that limit pre-existing conditions exclusions, recissions of coverage, requirements of guaranteed issue, limits on the mark-ups for older and more costly patients, as well, crucially, the minimum benefit package and cost sharing provisions plans must meet.

These latter issues – benefits package and cost sharing- are both highly political and extremely important, as an excessively generous benefits package (containing ever-popular service mandates for chiropractic care, in vitro fertilization,  acupuncture, you name it) or elimination of high-deductible plans (another thing that happened in Massachusetts) could markedly increase employer costs, as well as the federal subsidies required to permit employers to participate.”

Kevin, MD:

Contrary to what you may have been led to believe, the United States has already tried its hand at a pseudo-single-payer system. The VA is one example. Another, albeit less highly publicized, is the Indian Health Service. (via WhiteCoat) Based on an agreement in 1787, the government is responsible to provide free health care to Native Indians on reservations. And, as you can see from this scathing story from the Associated Press, that promise has not been kept. The numbers don’t lie: American Indians have an infant death rate that is 40 percent higher than the rate for whites. They are twice as likely to die from diabetes, 60 percent more likely to have a stroke, 30 percent more likely to have high blood pressure and 20 percent more likely to have heart disease.American Indians have disproportionately high death rates from unintentional injuries and suicide, and a high prevalence of risk factors for obesity, substance abuse, sudden infant death syndrome, teenage pregnancy, liver disease and hepatitis. And, after Haiti, where in the Western hemisphere do men have the lowest life expectancy? It’s on Indian reservations in South Dakota. The primary reason, not surprisingly, is lack of money, compounded by a difficult time recruiting physicians and other clinicians. Indeed, many Indian health clinics cannot “deal with such high rates of disease, and poor clinics do not have enough money to focus on preventive care.” So, if you’re in the camp that supports a Medicare-for-all-type solution to our health care woes, consider how that same government, whom you’re entrusting to be the single-payer, has neglected the Indian Health Service.

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Andy Kessler writes:

Yet compared with other businesses, the health-care industry has been unmoved by the logic of lowering costs to increase profits. The truth is that these folks could have digitized the whole industry ages ago. The technology has been around for a long time: Wall Street began phasing out physical stock certificates over 35 years ago. Even the cash-strapped airline industry has gone ticketless, removing huge labor and overhead costs. These industries started using electronic records because they believed it would save money. The health-care industry simply has not followed suit.

The reason lies neither with cost nor with inadequate technology. Rather, the health-care industry’s reluctance to digitize its records is rooted in a desire to keep medicine’s lucrative business model hidden. Dangling $19 billion in front of a $2.4 trillion industry is not nearly enough to get it to reveal the financial secrets that electronic health records are likely to uncover—and upon which its huge profits depend. In those medical records lie the ugly truth about the business of medicine: sickness is profitable. The greater the number of treatments, procedures, and hospital stays, the larger the profit. There is little incentive for doctors and hospitals to identify or reduce wasteful spending in medicine…

An even bigger threat to the sickness industry’s business model is that by allowing automated tracking of patients over time, electronic health records would set the stage for early detection and preventive medicine. Currently, the entire industry is organized around treating sickness, rather than keeping people healthy in the first place. Three-quarters of health-care spending is devoted to chronic care, but the National Cancer Institute and the Centers for Disease Control and Prevention allot just 12 percent of their budgets to research on early detection. Moreover, the payment system is structured around reimbursement for treatment rather than prevention.

This is criminal. People are dying every day because life and death healthcare runs on handwritten notes. 100,000 people die every year due to medication errors. Of course! As the number of meds a person is on increases, the more likely a fatal interaction, overdose, or incorrectly written prescription will occur.

What if we “allowed” the airline industry to run on paper? Are we willing to tolerate 400 Air France crashes per year? Why does the medical industry get away with this?

I’d like to start a movement. Don’t go to doctors or hospitals that don’t use electronic medical records. They are simply unsafe and hazardous to your health.

idlaurenn:

“Faced with lower revenues and a growing number of citizens who lost their jobs and their health insurance, the state didn’t have enough money to pay for insurance subsidies for needy residents under the current plan”

“It’s a warning for the federal government as it looks to do something similar,” he said. “I’m not saying we can’t afford any of it, but it certainly doesn’t appear that we can afford all of it.”

Asked to picture healthcare in the twenty-first century, readers might imagine scientists applying the latest breakthrough in biotechnology as a radical cure for disease. But equally, they might also think of lengthy waiting lists, shabby wards and lumberingly bureaucratic administrative systems. This dichotomy is one of the biggest problems confronting policymakers and managers when they look at today’s health sector. Advances in medical science and technology have not been matched by innovation in healthcare management and processes. It is a failure that costs taxpayers and patients dearly.

The problem is not a lack of ideas, as cutting-edge medical research continues apace. Nor is it unwillingness to put money into healthcare, which consumes vast budgets. Rather, the difficulties lie in the diverse obstacles to new ideas finding their way into widespread and transformative change. But new approaches exist which demonstrate how healthcare systems could be improved.