Senator Edward Kennedy came from wealth and privilege but believed in the obligation to serve the public—to give back to society and make it better. He will be remembered as the champion for the little guys–the people without a voice. But he spoke and acted for all Americans. He raised our consciousness. He channeled our outrage against injustice into solutions to help people live better lives. He reminded us of duty. He showed us the positive role that government can and must play in the lives of all Americans. He believed in equality and fought and won battles for social justice, health care, higher education, and labor. That was Edward Kennedy. There is talk of naming the health reform bill for him. He would not want the honor without substance—without health care legislated as a right for all. To remember one of the greats of history with a health care bill that does not live up to the ideals he fought for more than 50 years would be shameful. Kennedy wanted what was right for the little guy—not the rich, powerful, or corporate interests.
Archive for August, 2009
Health Reform Hysteria
The emotional and sometimes angry discourse seen at some health care reform town hall meetings reflects a disturbing combination of politics, fear, and misunderstanding. On one hand, there are the deep divisions within our country concerning the role of government. On the other, there is fear that something as intensely personal as health care might be made “less personal” and more bureaucratic. And lastly, there is confusion as to how our current health system actually works. So far, this combination is proving to be an important obstacle to health reform and perhaps lethal to a bipartisan effort.
Given the huge part of the economy represented by the health care sector, the interplay of economics and health reform is intense on many levels. Yet, I think many of these reactions speak to another aspect of the debate: the basic issue as to whether health care is perceived as a social entitlement that is part of citizenship or as a commodity that can be purchased if desired. There is a deeply reflexive reaction to what are perceived as handouts, and a strongly held sense of one’s just rewards for hard work. Against this backdrop, it is not that surprising that the U.S. is alone amongst highly developed nations in not having a system of universal health care. I would like to see the health reform debate focus more on the meaning of health care to American society and less on the paranoia of change.
Health care and jobs
The pressures to cut health care costs are enormous, but these cuts can also be a double-edged sword. Certainly, no one would argue against cutting fraud and overuse. But at a time when job creation is so important, the health sector is and will be a key player. These jobs are not just for a broad variety of health care providers, but also for a large range of administrative and management positions. A recent article points this out by focusing on individuals who cross over from other economic sectors to work in health care. As health care exceeds one-sixth of the economy and one out of every ten jobs, it becomes increasingly difficult to disentangle needed job growth from excessive health care spending in terms of driving the economy. This is especially true if there is some kind of health reform that increases access to a substantial number of persons who are currently either uninsured or underinsured. As we have pointed out in our report, Out of Order, Out of Time: The State of the Nation’s Health Workforce, we need to gain a more in-depth understanding of the kinds and numbers of health providers that are needed to take care of patients now and in the future. Perhaps by engaging in this discussion we can address the complex issues around “right-sizing” health care.
A Real Health Reform Issue to Address: Medicare’s Clinical Trial Policy
Let’s get some real issues on the table in the health reform debate—like Medicare’s clinical trial policy. The Medicare program is not only the key to current and future health care delivery in this nation but also the most critical link to all clinical research occurring throughout the nation.
Good science—and new cures and treatments for a host of diseases and illnesses–require that Medicare beneficiaries participate in clinical trials. That was the vision and purpose of the clinical trial policy, laid out in an executive memorandum signed by President Clinton in 2000. The goal was to provide increased access for Medicare beneficiaries to clinical trials—and that is not happening. During the Bush Administration, the policy was not fulfilling its intent and, in fact, was quite dismantled, creating a situation that discouraged participation of seniors in trials.
It’s not only seniors. The President had better check his health plan because many of the government plans do not cover clinical trials—as they should.
Health and Human Services Secretary Sebelius should be spending more time addressing this issue. She can provide the leadership to reform Medicare’s clinical trial policy, which currently:
- Compromises the quality and credibility of many research studies by discouraging enrollment of elderly patients
- Limits coverage for the elderly to potentially life-saving therapies and treatments
- Undermines the financial viability of the nation’s academic health centers where the majority of clinical trials take place
- Increases the likelihood of an adverse impact on the nation’s economy and job market as clinical trials continue to move overseas.
The Association of Academic Health Centers (AAHC) has been at the forefront in calling for reform of the policy. One of AAHC’s most important recommendations is for the HHS Secretary to establish the position of research coordinator at the Centers for Medicare & Medicaid Services (CMS) to oversee clinical research coverage policy. This position would ensure that an expert with knowledge of clinical research and trials processes and operations is providing needed leadership and making the issue a national priority.
President Obama and Secretary Sebelius need to signal that they recognize the significance of Medicare’s clinical trial policy. Appointing a permanent administrator for CMS would also be a good start. If the Administration can’t address clinical trial policy, there are many on Capitol Hill who will check their health plans, suddenly wake up and take notice, and address Medicare’s clinical trial policy so they can claim some real progress on health care reform.
Bambi, Ford, and Health Reform
I hit a deer the other day. Bambi is not supposed to gallop out of nowhere on a busy street and land on the hood of your car. Bambi got up and ran away but my car needed major repair. Which leads me to the Ford Focus, the only rental car available from the vendor used by my insurance company. One only has to drive two minutes in this car to realize why Detroit went under. What a piece of tin, I kept saying. From the design to the operation to the flimsy sunshade, the car is a disaster.
We blinded ourselves for years to the fact that American cars were terrible by blaming industry troubles on unions, high wages, environmental controls and lots of other diversionary issues. Many of us wanted to buy American but American design was no good.
Which brings me to health care. The design of the system—employer based coverage—is not good. It is not working because it is a model of a bygone era. We have to admit it—and move on to something better. All the hoopla at recent town meetings is diversionary from the real issue of health reform. It’s not a question of who pays for abortions; it’s not a question of death bed counseling or pulling the plug on granny. Wake up America. Think about cars. It’s a design issue.
Many in Congress—like the CEOs of the automotive industry–continue to promote a bad product–a health system that cannot fulfill current or future needs. What’s the answer? Stop the shouting. Americans are confused. They want to buy that American car but know that something is wrong with it.
The answer is to go back to the drawing boards. Mr. President– Take back control and call on Congress to create a special new committee for health care. Why are we using the old committee system for something that crosses the boundaries of so many committees? Start with a new structure and put out one plan from one committee—a plan that is understandable and creates a new delivery system. It has to be a new design for health care for the future.
Why so touchy about health care reform?
Why has the idea of health care reform provoked so much emotion? Why hasn’t there been a more reasoned debate over the important issues? I think part of the answer is two-fold:
- Economics – Health care represents more than one-sixth of our economy and about one in ten jobs, and the health sector is expected to continue to grow. With so much money and income at stake, it is obvious that there is a lot to lose (and win) with any substantive changes in the health system. So change raises issues and concerns at the level of the pocket book.
- Fear and Misunderstanding – Everyone is ultimately vulnerable to ill health and, on some level, harbors some fear of the unknown in terms of a future illness or health need. This in and of itself can foster reluctance to take a chance on changing the current system: better the devil that you know than the devil you don’t. In addition, health care delivery is so complex that it is difficult to get beyond rather simplistic paradigms when discussing meaningful health care reform. This makes it hard sometimes to really get at the issues. And, finally, when these fears and misunderstandings are coupled with rational (or irrational) concerns about the role of government, there may be little in the way of meaningful discourse.
What we need to do is take a deep breath and try to go back to basics. What are the principles that should guide our efforts in health care reform? How do these principles relate to the strengths and weaknesses of our current health system? And, perhaps lost in the current debate, what are our national aspirations for the health care of our citizens? Perhaps a back to basics approach can change the tenor and nature of the current health care reform dialogue.
Will employer-based health insurance rescue you?
For all those Americans worrying about health reform and fearing they will lose their current insurance, think about this. Sixty percent of all U.S. bankruptcies are attributable to medical problems, according to a study by Dr. David Himmelstein and his colleagues at Harvard and Ohio University, published this month in The American Journal of Medicine. The share of bankruptcies attributable to medical problems rose by 49.6 % between 2001 and 2007. “Medical” was based on debtors’ stated reasons for filing, income loss due to illness and the magnitues of their medical debts.
Here’s the kicker–Many families with continuous coverage found themselves under-insured and responsible for thousands of dollars of out-of-pocket costs (averaging almost $18K for all medically bankrupt families). Because almost all insurance is linked to employment, a medical event can trigger loss of coverage, say the authors. Nationally, 25% of firms cancel coverage immediately when an employee suffers a disabling illness (so much for your employer taking care of you); another 25% cancel coverage within a year.
The fear mongering currently underway to make Americans believe they will be losing the security of their current insurance coverage if the government steps into the act is truly intended to cover up the real threat. It seems to me that a real fear is the potential actions of employers (look at GM over the years–or how about the steel or airline industries) vis-a-vis health insurance. There’s no security there–and often they too are the victims of economic decline.
Finally, where do those people without insurance go? Answer: to the emergency rooms at academic health center hospitals throughout the country. How do policymakers think these institutions can survive? The Association of Academic Health Centers found in 2008 that AAHC institutions, on average, provided almost $44 million in uncompensated patient care each year, with one in seven institutions providing more than $100 million. It is not clear how the reform packages will help these institutions.
David Axelrod: Where am I in this debate?
Mr. David Axelrod , senior advisor to President Obama, may be the greatest strategist when it comes to getting candidates elected to office, but I am not sure about his credentials on strategizing on health reform. He wants Americans to understand that there are insurance market reforms in the legislation before Congress and has boiled the issue down to the following: “If you’re an American with insurance, you’re saying, Where am I in this debate?” He wants Americans to understand that there is “security and stability” in the plan.
Well, I am an American–with insurance—and so are almost all of my friends. A good many of my friends are the senior citizens and women that you say you are targeting, Mr. Axelrod. My friends know exactly where they are in this debate—trapped by the insurance industry. In fact, my friends call and email me every day to tell me this. They don’t want market reforms—they don’t want the insurers at the table. They tell me they want the insurers out of business—the sooner the better. I tell them to write to you, Mr. Axelrod, and the President, and the Congress.
On the Road With Health Reform: Where’s the Next Exit?
Speaker of the House Nancy Pelosi and HHS Secretary Kathleen Sebelius are using their August vacations to try to sell health reform. Unfortunately, no one really knows what they are selling. President Obama was elected in part because millions of Americans wanted health reform. They wanted change and a NEW health care system. What the Congress now has to offer—and Pelosi and Sebelius are trying to sell– is a warmed over version of the dysfunctional system we already have. It’s reasonable to expect that buyers might be leery.
Americans are attracted to all that is shiny, new, high tech, and different. But what are they getting with health reform? The proposed public plan is warmed over Medicaid, not Medicare—and no one is buying that. The insurers still get a big piece of the action—and no one is buying that. The timeline is too long for people out of work now—or fearing a layoff–and no one is buying that. People are wondering why the President is asking them to buy a clunker.
Mr. President, it’s time to take the next exit—turn around– and tell the Congress you want something better to sell on the road.
