A helpful account of a genuine political possibility, Joe.
Ted
----- Original Message -----
From: Anglo-American Health Policy Network <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Sent: Wed Oct 14 12:31:53 2009
Subject: Re: US Health Reform
A few comments... I wasn't restraining myself before, I just wasn't on e-mail. But this is it for the day from me!
* Basically I agree with Tim.
* And Ted, re. the public option and its current prospects.
* One real interesting question is what to think of the possibility of states having the authority to do a serious public plan. This has been proposed as a compromise and, separate from its substantive effects, makes sense for political reasons. It's harder for conservatives to fulminate against giving states choices, it allows Blue Dog Democrats to say that the public option in their state will only happen if the state's voters want it, so that voting for the provision doesn't violate their districts' views, and so on. If I'm from Tennessee, it seems to me not so bad to say, "hey, if Vermont wants it, let them try it. But I negotiated and took a strong stand and made sure nothing would be forced on the good people of our great state."
If I'm right about that, one question is what that state option should look like. Logically, once it's an option, states should have the authority to do much stronger versions than currently are on the legislative table. Such as including Medicare enrollees, and using the Medicare rates. I might well take the strong state option approach over the HELP bill approach, and maybe even the House approach. But what's needed then are both the provisions that allow that, and a way to make sure states don't get penalized for having more efficient systems. A state that has a strong public option might have lower insurance premiums which then would lead to lower subsidies!
* One thing that really bothers me about the Baucus design, but was not emphasized by Tim, is the focus of cost containment on Medicare spending. This is perverse as both policy (why whack providers with disproportionate shares of Medicare patients because costs for other patients are poorly controlled?) and politics (why give Republicans plausible reason to say the bill is financed by cutting the elderly?).
Back to the day-to-day. Thanks to all for good comments,
Joe White
-----Original Message-----
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On Behalf Of Michael Sparer
Sent: Wednesday, October 14, 2009 9:50 AM
To: [log in to unmask]
Subject: Re: US Health Reform
Perhaps I’m overly optimistic, but I see it a bit differently. Seems
to me we will end up mainly with a Medicaid/SCHIP expansion (combined
with a relatively individual mandate), which is hardly a surprising
ending and also is not such a bad ending.
For example, under the Finance bill, 14 million of the newly insured
will be on Medicaid and a million or so will be newly added to SCHIP.
Moreover, according to the CBO, of the 25 million still uninsured
(under the Finance bill), roughly 11 million will be eligible for
Medicaid but not enrolled, another few hundred thousand would be SCHIP
eligible but not enrolled, and roughly 8 million will be undocumented
immigrants. That will leave roughly 5 million uninsured who are
neither Medicaid nor SCHIP eligible.
My prediction is that in a few years Congress will do another bill
which will add these "gap" folks to the Medicaid/SCHIP rolls, along
with adding some of the others who will be floating along unhappily
with inadequate subsidies over the next few years on whatever
state-based exchanges are created. This is the path to national
health insurance in the US.
The keys then (and now) will be to figure out 1) how to get the
eligibles but enrolled to actually enroll, 2) whether the state-based
Medicaid infrastructures can handle the enrollment growth, and 3)
whether the ever growing “public plans” (Medicaid/SCHIP/Medicare) can
drive needed changes in reimbursement strategies, care management, and
the like.
I know there are many who have major problems with Medicaid
(especially among the provider community), but it seems to me that
Medicaid is the public program that will continue to drive efforts
around the uninsured. And as for the reimbursment issue, either we
eventually push for some sort of all-payer reimbursement proposal, or
we fix Medicaid's reimbursement approaches.
And at some point we will also need to decide as a society what we are
going to do about the undocumented.
Michael Sparer
Quoting David Wilsford <[log in to unmask]>:
> Well, I¹m thinking a Nobel Prize looks pretty good these days.
> But I shall forgo the temptation to throw my hat into that ring.
>
> I agree with Tim¹s analysis (as well as Jonathon Cohn¹s, who he cites), and
> with Ted and Michael. The major points bear repeating, because we will be
> living with them once the final bill passes:
>
> The premium subsidies are too low to make health insurance really affordable
> to lower and middle income Americans; the cost-sharing is excessive and is
> likely to continue to drive sick Americans into bankruptcy; the feeble
> state-based exchanges created by the bill add little of value; the
> individual mandate penalty is too weak and will leave many Americans
> uninsured and out of the risk pool; and the co-ops are dead on arrival.
>
> Unlike others, I do think that the major parts of the Finance bill will
> survice House/Senate conference, mostly due to the so-called Blue Dogs, who,
> no matter their vilification by the Kool-Aid left, are many of them running
> difficult reelections in moderate-to-conservative districts in the blink of
> an eye: next year! The Voodoo right will go after all these Blue Dog gals
> and guys with great force.
>
> Yes, ³we² will get a bill. Another over-learned lesson of the Clinton 93/94
> debacle is that the president and congressional Democrats believe that SOME
> bill must pass. Some bill, any bill, any bill at all. In this conviction
> has been lost the primary question about whether any bill at all, no matter
> its defects and dysfuctions, is truly better than no bill.
>
> The final bill that we get will NOT constitute non-incremental reform of the
> system. It WILL reward insurance companies and pharmaceutical companies,
> mainly by ensuring them large newly mandated markets, without any
> restructuring of incentive structures or any introduction of meaningful new
> competitive mechanisms to otherwise constrain pricing. They are the big,
> big winners here.
>
> The docs are protected by the bill, as well, because their payment systems
> go untouched, and their practice autonomy, such as they may currently have
> it, goes untouched. So they are definitely not losers. Hospitals,
> neither, seem to lose anything, especially after the ruckus they kicked up
> last week, which will scare off any remnants of wanting to do anything about
> their payment and operations structures.
>
> In the aggregate, the financial results of the final bill will be two-fold:
> € individuals will pay far more out of pocket for required insurance than
> they will think is reasonable, and they will vote their unhappiness,
> especially in 2012. (Huge swathes of the population will also escape
> mandate altogether, one way or the other, so that the perversions of picking
> up their emergency room tabs will continue unabated.)
> € The overall US GDP that goes toward health care will INCREASE rather than
> stabilize or decrease, and the RATE OF GROWTH will also increase, as a
> result of the final legislation. This macro-outcome will begin to become
> evident as 2012 approaches.
>
> In the end, very few macro- or micro-incentive frameworks in this system
> will have been changed in any way whatever, meaning that covering more
> people will drain immense amounts of new money out of the system. The US
> is already, far and away, the largest OECD spender on health care, in terms
> of GDP, with pointedly meagre results. The gap in the spread between the US
> as the the largest OECD spender and the next largest spenders will only grow
> larger each year as a result of this bill.
>
> The president¹s goals have always been impossibly mixed: increase access
> (this bill will do so partially) + restrain costs (this bill does not: in
> fact, it will significantly increase them).
>
> So, as Ted rightfully points us back to the iron triangle in health care
> dynamics of access, quality and cost: Access will go up a bit, but many
> will still be left out, either formally or effectively. Costs will
> skyrocket, making us yearn for the days of only 16 percent GDP. Quality
> what America does best: rescue medicine will remain intact, with all its
> functions (really good) and dysfunctions (really terrible).
>
> Yours
> David
>
>
>
>
> On 10/14/09 7:16 AM, "Oliver,AJ" <[log in to unmask]> wrote:
>
>> It might be interesting to hear whether David, Tim, Joe et al. now stand on
>> the likely success or otherwise of major US health care reform? Or you could
>> always stay silent, I suppose that way you might stand a good chance of
>> winning next year¹s Nobel Peace Prize.
>>
>> Please access the attached hyperlink for an important electronic
>> communications disclaimer:
>> http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm
>>
>
> --
> David Wilsford Ph D
> Professor of Political Science, George Mason University (Fairfax Virginia
> USA) and
> Visiting Fellow, London School of Economics (UK)
>
> [log in to unmask]
> French cell +33.6.11.16.50.93
> U.S. cell +1.224.522.0111
>
>
>
>
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