Wright on Health

Klein on Reconciliation on Colbert

bradwright@unc.edu — Wed, 10 Mar 2010 17:23:00 +0000

From last night's episode of The Colbert Report, here is Ezra Klein explaining the reconciliation strategy for health reform.

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Republican National Committee to Donors: "Love You, Mean It!"

bradwright@unc.edu — Wed, 10 Mar 2010 10:52:00 +0000

Politics is a pretty cutthroat business, especially in an election year. All the more so when your party has nothing to lose and pretty much anything to gain. So, in hope of regaining control of the House and/or the Senate in 2010, the Republican National Committee is pulling out all the stops. Ben Smith of Politico writes up a story about a recently held fundraising dinner at which the topic was, ironically, fundraising.

The best part of all this is the 72-page document that was the evening's presentation to attendees. What it makes perfectly clear is that politicians--well at least these politicians--look at donors the way mosquitoes look at bare skin. The document outlines strategies for striking fear into the hearts of the wealthy so that they will readily cough up large sums of cash. It almost feels like a mobster coming into your place of business and saying "What a lovely place you've got here. It would be such a shame if something were to happen to it."

I won't waste any more of your time, because the document is 72 pages long and I want you to read it.

Point of Clarification

bradwright@unc.edu — Tue, 09 Mar 2010 10:12:00 +0000

Ezra Klein nailed it the other day when he wrote the following:

"There's a difference between the statements 'America has the best health care system in the world' and 'With enough money, you can purchase the best health care in the world in America.' But that difference gets run over in political conversations....People should ask themselves a very simple question: Do they think they are likelier to lose their job and fall into the health care situation of the uninsured or become an influential politician [or extremely wealthy individual] and enjoy the health care options available to the most powerful people in the world?"

I'd go a step further. You don't have to lose your job to fall into the ranks of the uninsured. All you have to do is get really sick and have your annual and lifetime limits run out. Or have your coverage rescinded. Or have your employer stop offering benefits because they have gotten to be too expensive. Or continue to have coverage for which you can no longer afford your share of the out-of-pocket expenses. Or simply be underinsured because your policy lacks certain benefits you never thought you'd need until the unforeseen happened.

None of these scenarios should change the way you answer the simple question Ezra posed. But they do change the underlying odds substantially, and should make it even clearer that you and I are unlikely ever to find ourselves so wealthy as to have access to the best care in the world. Which is precisely why Ezra concludes the following:

"If you're a United States Senator, America may have the best health care in the world. But if you're an ordinary person with the same vulnerability to bad luck that we all have, you're better off being in Canada, or France, or Japan, or somewhere that doesn't take your insurance away when Wall Street causes the economy to crash."

County Health Rankings

bradwright@unc.edu — Mon, 08 Mar 2010 10:11:00 +0000

The Robert Wood Johnson Foundation together with the University of Wisconsin Population Health Institute has created the first ever county-level health rankings. The rankings, available online, include a variety of health outcome indicators (e.g., morbidity and mortality, low birthweight, health status), and factors that affect health ranging from health behaviors (e.g., rates of smoking and obesity), clinical care (e.g., uninsured rates, preventable hospital stays), socioeconomic factors (e.g., crime, poverty, and education), and the physical environment (e.g., air pollution, access to healthy foods, and liquor store density).

The site is a great way to see how your community rates within your state, or compare your county to other counties around the country. I strongly encourage you to check it out and spread the word. You might be surprised at how you and your neighbors come out in the end.

Counting House Votes

bradwright@unc.edu — Fri, 05 Mar 2010 17:24:00 +0000

Thanks to Jonathan Cohn for alerting me to Daniel Nichanian's blog "Campaign Diaries" where he has a post exploring the likely House votes for and against the Senate health reform bill. Go there and see for yourself who's in play.

Rules of the Senate

bradwright@unc.edu — Fri, 05 Mar 2010 10:02:00 +0000

Republicans are outraged that Democrats would use reconciliation to ram health care reform legislation through Congress--jamming it down the throats of the American people. Democrats were once outraged that Republicans would use reconciliation to pursue drilling for oil in the Arctic National Wildlife Refuge. It seems that whichever party is in the minority seems to think the filibuster's a great thing and the reconciliation process is terrible. However, as Republican Senator Judd Gregg clearly articulates, reconciliation is one of the rules of the Senate. "If you have 51 votes for your position, you win!" he exclaims. Well, the Democrats have 51 votes and then some right now, making the passage of health care reform through reconciliation a very viable option. Of course, Sen. Gregg opposes them doing so. It seems he--and I would argue pretty much every other member of Congress--wants to play by the rules only during those times that the rules benefit them.

As an aside, as boring as C-SPAN can be, it's the most unbiased information you're going to be able to get, because it isn't being passed through a mainstream media filter.

Baby Steps

bradwright@unc.edu — Fri, 05 Mar 2010 09:46:00 +0000

Another Fun Lobbying Tracker

bradwright@unc.edu — Thu, 04 Mar 2010 10:18:00 +0000

It's a given that Congressional action is influenced by organized interests. In fact, I think it's probably fair to say that the level of lobbying is directly proportional to the financial resources available to the interests and the degree of potential a piece of legislation has to influence those financial resources either positively or negatively. So, the least likely group to lobby doesn't have much money and operates in an area that doesn't happen to be on the radar screen of Congress. On the other hand, a wealthy group that stands to win or lose big will be paying legislators regular visits.

On the basis of this rule, one can easily conclude that organized health care interests are lobbying hard against health care reform (which they perceive as threatening their ability to earn unlimited profits).

Thanks to the Center for Public Integrity, you can go play around with a new online tool that lets you see just how much various organizations spent on health care lobbying. Their data reveal that there were nearly 8 "health-reform" lobbyists for each member of Congress, including representatives for atypical groups like Campbell's Soup and Dunkin' Donuts. You should read their report, but more than anything, you should explore a bit using their online tool. It is really fascinating!

Health Wonk Review: Kabuki Theater Edition

bradwright@unc.edu — Thu, 04 Mar 2010 10:00:00 +0000

A week ago today, literally dozens of people across the country were tuned into C-SPAN to watch the President's Health Care Summit being held at the historic Blair House across the street from the White House. Going into the event, a number of questions were raised, most having to do with the Republicans' response to being invited to a bipartisan summit: Will they attend? (They did.) What will they say? (Lots of things, including "Scrap these bills and start over.") Will they present their own reform proposal? (Sort of.)

Perhaps feeling threatened, the right raised some questions of their own: Will Democrats agree to drop their bills and start the summit with a clean slate? (They didn't.) Will rational discussion and compromise be possible, or will this just be Kabuki theater? (Kabuki what?)

Kabuki theater is a Japanese dramatic art form known for its elaborate costumes, make-up, and over-the-top performances. Like the Health Care Summit, most Kabuki plays last for the majority of the day, and are divided into five acts. They begin with a slow opening act to introduce all the key players (the President went around the room and greeted everyone), progress through three acts that build at increasing speed to a dramatic climax (they exchanged ideas stopping only for lunch and a vote in the House), and end with a swift conclusion that resolves the drama. (Oh, so close!)

The term Kabuki theater when used to describe the Health Care Summit, however, was pejoratively meant to describe grandstanding and rhetoric--political posturing not substance. Essentially, Republicans were warning that the air of bipartisanship being proposed by the President was an illusion, designed only to trade talking points in hopes of making Republicans look bad on national television with no actual aspirations of compromise.

While I think the President's effort paid off as intended, many others disagree. In fact, as soon as the Summit concluded, the analysis of winners and losers began and commentary from bloggers of all stripes has been plentiful. What is perhaps most evident is that all of the questions leading up to the Summit have been replaced by a host of new questions in its wake. This edition of HWR brings you a sample of what people are talking about now as the future of health care reform remains undecided.

Almost as if it were planned by Democratic strategists as a lead-in to the Summit, Wellpoint subsidiary Anthem Blue Cross of California announced a proposed 39% increase in premiums. It was all over the news and even elicited a strong response from DHHS Secretary Kathleen Sebelius and a report on cost growth from the agency. Dr. Roy Poses of the Health Care Renewal blog digs deeper by asking what lies beneath the increase. His conclusion is that the organization suffers from governance and leadership woes, but he doesn't think that that's an excuse. In fact, he thinks addressing such issues should be a central part of health reform. Louise, of the Colorado Health Insurance Insider, agrees, citing the Wellpoint premium increase as all the evidence that is needed for America to pass an individual mandate for insurance coverage. The logic is simple: Guaranteed issue without an individual mandate will make 39% premium increases the norm rather than the exception.

So, how does Congress keep that from happening? Jason Shafrin of The Healthcare Economist provides a summary of the many bad and few good ideas to emerge from the Summit. Chief among his list of bad ideas: Starting over. He writes "If you don’t like the current proposals, say what you don’t like about them. If you have suggestions on how to do it better, say them. Suggesting a 'do over' is not helpful." He makes a good point.

As for good ideas, Shafrin says we need sweeping reform, not incrementalism. Mad Kane's Political Madness author Madeleine Kane agrees, and takes Sen. Lamar Alexander to task in limerick form for even suggesting an incremental approach.

It's clear that obstructionist politics aren't going away any time soon. As the opponents of reform keep up their efforts to derail the process, they continue to appeal to the public's fears. First it was "death panels" and "socialized medicine." Now, as Gary Kaplan of Managing Disputes points out, there is talk of the increase in frivolous litigation that health reform will produce. Kaplan says that opposing reform because of the potential for future lawsuits is akin to closing hospitals to save electricity. In other words, it's hugely counterproductive.

And while we're on the subject of topics that are misconstrued for political gain, we can't ignore comparative effectiveness research (CER). CER is one of the more divisive issues in the debate. Democrats tout it as a means to achieving a more efficient health care system. Many Republicans decry it as yet more government-run medicine with bureaucrats getting between you and your doctor. In a post written for the blog of the Robert Wood Johnson Foundation, Bob Berenson of the Urban Institute and Beth Docteur of the Center for Studying Health Systems Change underscore once again the valuable uses of CER. The problem, they assert, is that people don't understand it, and their default response is to expect the worst-case scenario. On the whole, they present CER as just another useful tool for improving our health care system--it is in their opinion neither all good or all bad.

Fortunately, although Republicans and Democrats didn't find much to agree on during the Summit, that hasn't stopped many of my colleagues from investigating other alternatives ranging from value-based insurance to state-based reforms.

While there's still room for negotiation, Austin Frakt takes up the topic of value-based insurance over at The Incidental Economist. His post summarizes the findings of a study by Michael Chernew and colleagues that value-based insurance--"the reduction of copayments for some services (e.g. some drugs) for individuals with specified conditions to promote their use and obviate other types of care"--which finds that this strategy might actually have the potential to lower health care costs. As if we needed one more thing to confuse people! But it does sound like a promising strategy. The study appears in Health Affairs and you can access it here (subscription required).

Others are interested in the feasibility of state-based reforms. Writing at the Health Business Blog, David Williams takes issue with the notion that the states could possibly pick up the reform ball and run with it. He makes his case by agreeing with--while also critiquing--the arguments put forward by Sara Rosenbaum in a recent issue of the New England Journal of Medicine. The biggest obstacle (and one Prof. Rosenbaum missed) says Williams, is the enormous role played by the Medicare program, which establishes benefit and financing precedents, and over which states have no authority.

Williams isn't the only one batting around the idea of "letting the states do it." Jaan Sidorov of the Disease Management Care Blog read Prof. Rosenbaum's article in the NEJM, too, and he isn't having any of it. In fact, he wishes that the journal came with a mute button that would allow readers to cut through what he calls "faux hard science" to examine the underlying "subjective policy preferences." Maybe Mr. Williams and Dr. Sidorov need to hold their own summit to compromise on the proper role of the states in reform.

When it comes to the role of the states, one of the major ideas to emerge from the right is increasing competition by allowing the sale of health insurance across state lines (which is currently prohibited by law). It's a good idea in many ways, but there is reason to be concerned that insurers would choose to locate in states with the most lenient insurance regulations, undermining consumer protections that exist today. If you want an idea of what these consumer protections are like, Anthony Wright of the Health Access WeBlog has an excellent overview of the situation unfolding in California, where state lawmakers are already attempting to eliminate them.

In a slightly different take on the idea of consumer protections, over at the Workers Comp Insider, Julie Ferguson urges employers to re-examine their return-to-work policies and programs in light of a record workers comp related ADA payout being made by Sears to more than 200 former employees who alleged that they were kept off the job after suffering injuries and other health problems. The bottom line here: We need to stop discriminating against people on the basis of their health--an idea that was widely discussed during the President's Health Care Summit.

Of course, in closing out this edition, we must remember that all of this regrouping only became necessary when Republican Scott Brown won the Massachusetts Senate race. One wonders just exactly where he falls on the spectrum as a conservative from one of America's most liberal states. The Boston Health News' Tinker Ready writes a post entitled "Still wondering about Scott Brown and health reform." Of course Scott Brown campaigned on his opposition to the Senate bill, she says, but what exactly--if anything--does he plan to do about our ailing health care system? Might Sen. Brown make a name for himself by refusing to go along in lock-step with the GOP and supporting the legacy of Massachusetts' longest serving Senator? Unfortunately, it's hard to predict, because as Ready writes, "...we know what he's against. It would be nice to know what he's for."

And so, another act of the play comes to an end. After all the high drama, are we any closer to seeing meaningful health reform passed in this country? It's hard to say. Reconciliation is there if Congress finds the resolve to use it, but the conclusion is far from certain.

Perhaps we'll know more in a couple of weeks when Minna Jung at The Users' Guide to the Health Reform Galaxy hosts the next edition of Health Wonk Review.

Pot, Meet Kettle

bradwright@unc.edu — Wed, 03 Mar 2010 10:00:00 +0000

Jonathan Cohn had a wonderful piece on February 18th that did an excellent job of highlighting the hypocrisy--and often blatant promotion of falsehoods--that constitute the lovely game of politics. Basically, he outlined every criticism the right has leveled at the left--all things to do not so much with policy content as the political process--and countered these criticisms with the right's own committal of the same offenses during the passage of Medicare Part D. For anyone who cares to connect the dots, each time the right accuses the left of improprieties, it amounts to self-incrimination. Here are some excerpts:

"Everything that the Republicans accuse Democrats of doing now, the Republicans actually did then [in 2003]. And they did it brazen, shameless fashion.

You’re upset that the Democrats cut a deal with the drug industry? You should be: They gave the industry a more favorable arrangement than it deserved....[but] the drug industry arguably got a much better deal out of the Medicare drug benefit, known today as Medicare Part D. The Republicans (and, yes, some Democrats) working on Part D shelved every major provision that might have threatened the industry...Even some Republicans were aghast: One told 60 Minutes that "the pharmaceutical lobbyists wrote the bill." And it wasn’t just the drug industry that fared so well. The insurance industry did even better. Not only did the insurers win the right to administer the new benefit; the Republicans graciously agreed to give them huge subsidies that, in the years since, numerous experts and government authorities have ruled unjustified.

What about all the ways the Democrats are manipulating the legislative process? Yes, let’s talk about those manipulations. There haven’t been any. The Democrats put health care reform through five separate sets of committee hearings, which stretched out for weeks. At every step of the process, they posted legislation online so that members, their staffs, and other interested parties had time to read it before votes. They made arrangements to consider health care reform through the reconciliation process if necessary--an option Republicans have used repeatedly in the past, one that would merely allow a majority of senators to pass a bill. But Democrats also decided to pursue legislation through the regular order first.

If you want to see true manipulation of the legislative process, you have to go back to late 2003--and the push to get the Medicare drug bill through the House of Representatives. The Republicans famously waited until the last minute to release a bill and...did not bother to post a version online. When it came time to vote, the Republicans discovered they didn’t have enough support to pass the bill. Their solution? Hold the voting open past the usual fifteen minutes, until they could persuade enough members to switch their votes. An hour went by, then another, and then another.

At one point, then House Majority Leader Tom DeLay approached Nick Smith, a Republican congressman from Michigan, and offered to endorse his son’s congressional candidacy if Smith would vote “aye.” Smith would later allege that he was offered more than endorsement. Specifically, he said that somebody offered to dump $100,000 into his son’s campaign funds--a promise that might have constituted bribery...."

And that's just the start, folks.

Health Insurance and The Party of Free Market Competition

bradwright@unc.edu — Tue, 02 Mar 2010 10:34:00 +0000

The insurance companies are once again under fire thanks to the enormous 39% rate hike announced by Wellpoint (specifically its subsidiary Anthem Blue Cross of California). As a report from the Department of Health and Human Services notes, this is not necessarily a one-of-a-kind event. Similar and sometimes even bigger increases have recently been implemented in Connecticut (24%), Maine (18.5%), Michigan (56%), Oregon (20%), Rhode Island (16%), and Washington State (up to 40%).

A premium increase alone is not inherently a bad thing. The first question we must ask is why premiums went up so rapidly. This is where it gets interesting, because the insurers themselves have provided a justification, saying "Premium increases are necessary because health care costs are rising so much." It's like they have no choice but to pass on these rising costs in order to break even. I don't think people would demonize them for that. The problem is, they've not just held their own amid rising costs--they've seen enormous gains in profits--even as the rest of the country suffered from a deep and prolonged recession. It would seem that price gouging activity is undeniable and the American people are being exploited by the insurers.

Given that's the case, the second question is what permits this activity to occur? The answer is simple--an unregulated and non-competitive market for health insurance. Now, before you go disagreeing with me on that point, you should know that pretty much everybody is in agreement on this point--regardless of their political leanings. We need more competition in insurance markets so that consumers can make choices that will force insurers to be more accountable and that will simultaneously limit their ability to raise prices in pursuit of blind profit.

The political difference lies in how each party proposes we ought to increase competition in the insurance market. On the right, the idea is to allow the sale of insurance products across state lines. On the left, it's to set federal--rather than state--level regulations on insurers. In the Republican version, there will be a "race to the bottom" as insurers all flock to the state that offers them the most lenient set of state laws and regulations with which to comply. It's happened before with different industries and would happen again. Ezra Klein sums up both approaches nicely. I'll leave you with his comments:

Insurance is currently regulated by states. California, for instance, says all insurers have to cover treatments for lead poisoning, while other states let insurers decide whether to cover lead poisoning, and leaves lead poisoning coverage -- or its absence -- as a surprise for customers who find that they have lead poisoning. Here's a list (pdf) of which states mandate which treatments.

The result of this is that an Alabama plan can't be sold in, say, Oregon, because the Alabama plan doesn't conform to Oregon's regulations. A lot of liberals want that to change: It makes more sense, they say, for insurance to be regulated by the federal government. That way the product is standard across all the states.

Conservatives want the opposite: They want insurers to be able to cluster in one state, follow that state's regulations and sell the product to everyone in the country. In practice, that means we will have a single national insurance standard. But that standard will be decided by South Dakota. Or, if South Dakota doesn't give the insurers the freedom they want, it'll be decided by Wyoming. Or whoever.

This is exactly what happened in the credit card industry, which is regulated in accordance with conservative wishes. In 1980, Bill Janklow, the governor of South Dakota, made a deal with Citibank: If Citibank would move its credit card business to South Dakota, the governor would literally let Citibank write South Dakota's credit card regulations. You can read Janklow's recollections of the pact here.
Citibank wrote an absurdly pro-credit card law, the legislature passed it, and soon all the credit card companies were heading to South Dakota. And that's exactly what would happen with health-care insurance. The industry would put its money into buying the legislature of a small, conservative, economically depressed state. The deal would be simple: Let us write the regulations and we'll bring thousands of jobs and lots of tax dollars to you. Someone will take it. The result will be an uncommonly tiny legislature in an uncommonly small state that answers to an uncommonly conservative electorate that will decide what insurance will look like for the rest of the nation.

Human Nature

bradwright@unc.edu — Mon, 01 Mar 2010 09:20:00 +0000

A long standing difference of opinion about human nature centers around whether one believes that all people are generally good or whether all people are generally evil. In fact, the way they answered this particular question led directly to the way in which our Founding Fathers designed our government. My experience, however, has led me to another conclusion: Whether or not all people or basically good or basically evil, many people are incredibly stupid. Today's post is all the evidence you need. Just take a look at some of these protest/rally signs and judge for yourself:

And keep this in mind: Sure, anyone can make a mistake when creating a poster--switching letters around, leaving one out, or whatever else. The proof of stupidity is that these people proceeded to march with their accidents proudly on display for the world to see, rather than getting a new sheet of poster board out and starting over. That leaves me to conclude that they either 1) remained unaware of their mistake (in which case they are really stupid) or 2) they realized their mistake but thought it would be funny to show it off (in which case they are just plain idiotic). Hope these made you laugh as much as they did me.

Presidential Health Care Summit Re-Cap

bradwright@unc.edu — Fri, 26 Feb 2010 13:45:00 +0000

Yesterday was the big day. The President's Health Care Summit. I know this because I watched history unfold for a mind-numbing six-and-one-half hours....and because as I fell asleep last night C-SPAN was showing highlights like they thought they were Sportscenter. To keep it interesting, I flipped back and forth between CNN and C-SPAN. Actually, I didn't watch so much as I listened while doing other things around the house, like working with the data for my dissertation research. Before you give me too much credit for multi-tasking, let me just say that it was easy, because I heard absolutely nothing new from either side.

Here's my print-version dramatization of what transpired:

Pres. Obama: Thank you, everybody for coming. As I said before and I will say it again, I didn't decide to take on the issue of health reform because it was good politics. I did it because it's in the best interests of the American people. I want to talk today about the areas where we agree--and there are many--and then really take a long, hard look at the areas where we disagree so that we can find a way forward that works for everybody.

Camera cuts away from the President, and John Boehner looks like someone killed his puppy.

Important Republican #1: Thank you, Mr. President. You're right. There a lot of things we agree on. What we don't agree on is how to go about achieving those things. So, in effect, we disagree over the things on which we agree. It's a philosophical difference. The American people have spoken. They want us to start over. We want us to start over. You don't want us to start over. I think we can all agree on that. I hope you'll agree.

Pres. Obama: Those are some important points.

Important Democrat #1: Mr. President, the country needs health reform. [Insert substantive proof of the need for reform here.] That should not be the case in America. Our Republican friends say they want reform, but they have done nothing to move the country in that direction. In fact, [cite horrible CBO scores of Republican reform plans here], while the CBO has consistently scored both the House and Senate bills as greatly reducing the deficit over the next decade. If that's not enough, we've [refer to one of the many elements of the bills that are actually borrowed from Republican ideas] and they still won't support it.

Pres. Obama: These are all fair points.

John McCain: Back room deals. Kick-backs. Pork barrel spending. Shady politics. Mr. President, we both pledged to be open and accountable during the campaign.

Pres. Obama: The campaign's over, John.

Both sides toss talking points back and forth and make appeals in the names of people they know who have fallen ill and struggled with health insurance and health care they needed. Those stories usually go one of two ways.

Democratic version: "I know Miss Edna Mae Parker--a 47 year old woman from Springfield--who just last year got diagnosed with debilitating disease syndrome. Her husband lost his job, they lost their insurance, and she died because of it."

Republican version: "My friend, Robert Johnson, who has no health insurance, suffered from chest pains last June and went to the hospital emergency room where he was able to get the care he needed without any problem. He's alive and well today, because we have the best health care in the world here in America."

At the end of the day, nothing had changed. Reconciliation's still the way forward for the Democrats, and I wasted a few hours of my day. The only high points for me came when I recognized a couple of people in the room who I've met (Rep. Jim Cooper) or know personally (Jeanne Lambrew). Otherwise, it was the same old song and dance. But, be honest, did you really expect anything else?

"Government-Run" Health Care

bradwright@unc.edu — Fri, 26 Feb 2010 10:52:00 +0000

I don't like the pejorative use of certain words, especially when they're so incorrectly applied. Today, allow me to vent about the phrase "government-run" health care. Obviously, this phrase is used to evoke a knee-jerk response in people who are opposed to the government running anything. But what does it actually mean? Clearly, there are some cases where government-run is a more fitting description than others.

In the context of health care, there are two main concerns: financing and delivery. In a place like England, the National Health Service both finances health care and by owning the hospitals and paying the physicians on salary, mostly controls the delivery of care as well. That's about as close as you can get to "government-run." Still, the actual provision of care occurs between doctors and patients. It isn't as if there's a government bureaucrat in the exam room weighing in on treatment decisions--although there is a panel called NICE that makes some cost-benefit decisions that many on this side of the pond would frown upon. Still, they outlive us, so I'm not quite sure what we're afraid of.

Then, there's Canada, which people like to lump in with England as being "socialized." Or, as Wyatt Cenac of the Daily Show recently said, Americans don't want to become "Nazi Germany, or Nazi Russia, or Nazi Canada." In Canada, the financing of health care is a government affair, but the delivery is purely private. In many respects, it is no different from the U.S. Medicare program.

Which brings me to the United States. What exactly do people mean when they say Congress is proposing a government-run system? Well, based on my knowledge of what's in the bills, they can't mean a government owned delivery system, and they can't mean much in the way of a government financed system, because there's not much that would change from where we are today in that respect. Sure, there would be new subsidies, but we're not talking about Medicare for all. By and large, the private employer-based system would remain intact. So I really don't see how anything more than partially government-financed can be applied appropriately as a label for the proposed reforms.

Let me put it to you this way: Suppose it's your birthday. If your Grandma sends you a gift in the mail, that's Grandma-run. You had next to no say in what you received, where it came from, or how it was paid for. Now, let's assume she sent you a card with a check in it instead. That's Grandma-financed. You can choose to spend those resources anywhere you see fit. Of the two, I prefer the latter option. Of course, I suppose I could just buy myself my own gift, but where's the fun in that?

National Health Expenditures Update

bradwright@unc.edu — Thu, 25 Feb 2010 10:40:00 +0000

The newest numbers on U.S. national health expenditures are out in Health Affairs. In 2008, the estimated tab came to a little more than $2.3 Trillion. I really have very little concept of just how much money that actually is. I mean, how many McDonald's Happy Meals could you buy with that? The answer is a whopping 780 Billion. That's a lot of hamburgers, fries, and little plastic toys. In fact, it's enough to provide one happy meal a day to every person on the planet for about 4 months. It's almost enough to buy 1 of every 10 Americans a new Porsche 911 every year. The apples to oranges comparisons could go on forever. The bottom line is, while spending growth seems to have slowed, we still spend an insane amount on health care.

Right. Because It's So Simple Now...

bradwright@unc.edu — Wed, 24 Feb 2010 15:43:00 +0000

The big health care summit happens tomorrow. Literally dozens of Americans will be glued to their televisions to watch it. The President has released a plan--which is basically a guide for the House and Senate to push reform through using reconciliation--and it strikes a pretty fair balance between the two chambers' bills. I'll be writing up a more detailed overview of that later. But before tomorrow's pow-wow, I wanted--no, needed--to vent a bit.

It seems that a lot of people are threatened by the idea that they will lose their freedom, pay more themselves so that "the other guy" can have coverage, and generally suffer horribly at the hands of the socialicommunazis (because all three things are synonymous if you didn't pay attention in--or attend--school) who will institute "government-run" health care. I get that people are afraid of change, that they are distrustful of government, that they are inherently individualistic. These things are understandable. I happen to think that the hyperbolic assaults on reform aren't really necessary, though. You can state your position without fearmongering. Honestly, sometimes I think Rush Limbaugh is just a big, fat, blinding light for a nation full of moths. Okay, I'm getting off track. See, I told you I needed to vent. **Breathe, Brad. Breathe.**

Here's my beef: The health care system we have now my have familiarity going for it, but it is no walk in the park. The things people claim reform would mean losing are things we don't really have anyway. Look at it this way....

Insurance is regulated by the individual states. As a consequence entry into the market is limited, and insurers are not very competitive. (As an aside, permitting the sale of insurance across state lines is only a good idea if there is a single national standard put in place to prevent all insurers from heading to a state with lax standards. And when you do this, it's called "The Exchange.") So, where you decide to live often limits you to just a handful of insurers right off the bat. Are you free to move elsewhere? Maybe. If you can find work.

Speaking of work, that's how most of us get our insurance--through our employers. They have people working in human resources who may or may not have much experience in selecting employee benefits. Doesn't matter. You get the choices they offer you. Don't like it? Switch careers. Oh, wait. I forgot that no one's hiring in the recession. Just try not to get sick, okay?

Say you live in Georgia, and the three largest insurers (who enjoy 85% market share) are Blue Cross Blue Shield, United Healthcare, and CIGNA (this is just an example). You're down to three companies. You work for Delta Airlines. They offer you a CIGNA PPO--either basic or plus--so you really get just two options. Three if you think you can afford to buy non-group coverage. Four if you count being uninsured. Now let's say you work for a small employer who doesn't offer benefits. Your options just got severely limited.

All of these restrictions are just on access to an insurance product. They don't even begin to touch on the fact that the value of the products may differ substantially. They don't get into the fact that group-insurance is a much better deal than non-group insurance (with its smaller risk pool). Paying a higher premium because you smoke cigarettes makes sense, but why should what you pay for insurance have anything to do with where you happen to work?

By my own admission, this post is devolving. It is truly a rant. There are too many things for me to address them all in a few hundred or even a few thousand words. My overarching point, lest it be lost in the shuffle, is that people who are worried about the complexities of--and the limitations threatened by--"government-run" health care are ill informed of the current system's complexities and limitations. Otherwise, they would see that much of what's on the table would simplify the system and give consumers more--not fewer--options.

Digging Into the Dartmouth Atlas

bradwright@unc.edu — Wed, 24 Feb 2010 10:21:00 +0000

In case you're not familiar with it, the Dartmouth Atlas of Health Care is a decades long project started by Dr. John Wennberg to explore small area (i.e., regional) variation in health care utilization, spending, and the like. You can find out more about them here. They're the folks behind a lot of studies that you might have read about in the popular press, with the basic premise that there's a wide range of variation in utilization and spending that isn't easily explained.

In a recent article, Daniel Gottlieb and colleagues find that these regional differences in spending are primarily affected not--as many people thought--by differences in prices, but rather by differences in utilization rates. One has to assume that those differences in utilization are driven by the intersection of different patient populations and different physician practice patterns, but how much of the difference is justified and how much is wasteful has yet to be quantified.

The Paradox of Employer-Based Health Insurance

bradwright@unc.edu — Tue, 23 Feb 2010 10:52:00 +0000

A solid majority of Americans receive their health care through their or their spouse's employer, and for the most part, people are pretty happy with that setup. I'll put aside for a moment that most people don't know whether or not they are right to be happy about it--they typically don't know how generous their coverage is or how much it really costs--and I'll focus instead on the origin of the employer-based system and the paradox that it presents to those who strongly support the status quo.

Believe it or not, we didn't always have employer-based health insurance in this country. As a matter of fact, it's a relatively new invention. It began back during World War II, when the government instituted wage freezes because of the limited supply of available workers, but chose to exclude the provision of benefits from these freezes--and made them tax-free. Competition, like water, seeks its own level, and employers began to use health insurance benefits to attract workers, leading to the system we know today. You can read a succinct account of this here. You can also read Paul Starr's The Social Transformation of American Medicine, but it will take you much longer to get through.

Unintended consequences are a given in the policy world, and our accidental employer-based system is no different. Besides, there's evidence that group plans are a better deal than individual plans, because of the more efficient pooling of risk that they entail. Of course, that same principle would favor a universal single-payer plan over the patchwork we have now, but that's a different post.

There's an inherent paradox that those who support the employer-based system most strongly must subscribe to given its tax-free nature. Most opponents of reform, you see, would agree with these three statements: "We need less government taxation." "I don't want the government providing benefits to people." "People in this country who work hard deserve to get ahead and people who are lazy shouldn't get handouts."

The problem is that, while the tax-exemption of employer-based health insurance certainly aligns with the first and third statements, it flies in the face of the second one. By making health insurance benefits tax-free, the government is effectively subsidizing the coverage of everyone with job-based insurance, including the wealthy. In fact, because they are in a higher tax bracket, the wealthier people catch a bigger break from Uncle Sam.

So champions of the status quo clearly favor less taxation more than they oppose the idea of government giving handouts to people--at least so long as they're the ones getting the handouts. Otherwise, why not move to making employer-based insurance fully taxable? That would realign incentives "in a quick hurry" to use a good Southern phrase. Some people have raised this idea, but you'll notice it has very little traction. The closest we've come is the targeted tax on "Cadillac plans."

If we can't afford to subsidize the purchase of coverage for those who have none, why should we continue subsidizing the purchase of coverage for those who have something already? People should adhere to their principles more stringently, if you ask me. If you don't believe in government handouts, stop accepting them for yourself, and start paying taxes on all of your compensation. After all, you've earned it.

Why C-SPAN?

bradwright@unc.edu — Mon, 22 Feb 2010 18:17:00 +0000

The White House Health Care Summit is coming up in just a few days. The President has just released his own plan for reform and the GOP has agreed to attend. Best of all, the event will be televised live.........on C-SPAN. It's that last point that gets me down.

Your average person doesn't watch C-SPAN. They're not going to camp out in front of their television to watch this half day long event unfold live. That means that all that most people are going to get are the few snippets the media decides to show them--complete with their own framing of the issue. The story MSNBC tells folks will be quite different from the one heard over at FOX News, which is funny since only one set of actual events will have occurred.

I realize the networks don't want to devote such precious air time (and ad revenue) to covering the summit. After all, episodes of All My Children and Judge Joe Brown are far more important than the future of the American health care system. Still, I wish they would give people as many opportunities as possible to tune in on the mainstream channels. The stay at home moms and dads might actually watch for a bit and have some things cleared up. In fact, I daresay that--looking at the effect of Tiger Woods' televised contrition speech on the stock market--even folks who are working on February 25th would tune in if the event were targeted more to the mainstream and less to the wonks.

Who Supports Health Care Reform?

bradwright@unc.edu — Mon, 22 Feb 2010 10:13:00 +0000

When it comes to health care reform, chances are pretty good that you either support it or you don't. Not too many people fall into the "indifferent" camp these days. Chances are even better that you have seen a poll--from one source or another--that shows that the American people either do or do not support health care reform.

The fact that the polls aren't all in agreement--or even something closely resembling it--underscores a very important point: polling is a highly variable method of collecting information. While some polls are more methodologically rigorous than others, all polling efforts are subject to a variety of biases that can alter their findings.

For instance, how the questions are asked can change a person's response, even if the underlying point is the same in each case. So, too, can the length of the poll. People get bored easily, become impatient, and are more likely to answer hurriedly towards the end of a poll that is too long. Sometimes people don't really even understand what they're being asked. How can we really trust their responses in those cases?

Keep in mind that this has nothing to do with the margin of error polls typically report. That figure is simply an indication that the poll was conducted in a small sample of the population, and that the laws of statistics help us to project from the sample onto the larger population, but only within a given range of accuracy. If a poll is biased, it is simply biased, and its findings then fall anywhere from less accurate to meaningless.

David Brady and Daniel Kessler conducted a study that attempted to cut through the murkiness of the polling data. How did they do it? By conducting a survey, of course. But what they found was both predictable and fascinating. On the predictable side, people who were older, higher income, and Republican were less likely to support health care reform. On the fascinating side, income was the strongest predictor of support for health care reform. The authors write:

"[First,] the difference in support between a respondent in the top versus the bottom income bracket (more than $100,000 annual household income versus less than $25,000) is significantly greater than the difference between a Republican and a Democrat. In addition, income (and party affiliation) are much more important determinants of support than age, although older and middle-aged Americans are less supportive of reform than younger Americans. Second, the negative effects of income on support for reform start early in the income distribution. Depending on the reform, respondents with family incomes from $25,000–$50,000 are 19.7 to 21.6 percentage points less likely to support reform than those with family incomes under $25,000. Increasing income beyond $25,000–$50,000 reduces support for reform, but at a declining rate."

My take on their findings is simple: People are inherently white-knuckled and short-sighted. People with higher incomes feel more secure in their own right and simultaneously more threatened by the idea that reform means they will be forced to pay for those who have less. The fight over health care reform has less to do with political philosophies and differences of opinion over the role of government and more to do with greedy, selfish, self-centered people with an everyone for themselves attitude. If it didn't, income wouldn't be so negatively correlated with support for reform. That's the white-knuckled part--holding on to what's "theirs" for all they're worth.

The short-sighted part is that people fail to realize two very important things. First, that they may fall victim to misfortune and may suddenly find themselves without the incomes they now enjoy. In need of health care, but without the means to obtain it, they will suddenly be at the mercy of a public that doesn't care to lend them a hand. In an eye-opening moment of clarity, the proverbial shoe will be on the other foot.

But that assumes that some unforeseen circumstances befall the wealthy person. Such an event may never come to pass. Still, there is another way in which people are short-sighted. They miss the point that when the society as a whole is less than whole, all the people suffer in some way. We all shoulder the burden of the costs of uncompensated care, the effects of medical bankruptcies, and denials of insurance coverage through higher premiums, greater business expenses, and the rising cost of all of our goods and services. In short, our economy suffers as the maligned health care system staggers onward. There is a very real cost associated with doing nothing. As Brady and Kessler find, however, the wealthy have yet to feel those effects enough to do something about them.

The Blair House Summit

bradwright@unc.edu — Fri, 19 Feb 2010 13:43:00 +0000

I thought I had reached my saturation point on health reform--and that's pretty bad given that it's such a huge part of my life--because things seemed to be grinding to a halt ever since Scott Brown came along. Others were a lot more cynical than me, however, proclaiming health reform dead and moving on to anything and everything else. Perhaps I'm just a committed idealist, but I wasn't ready to let this opportunity slip away, which has proven frustrating given my limited capacity to affect the outcome at this point in my career. If I had Rahm Emanuel on a leash, for example, I'd have made him bite somebody by now.

But alas, there's a faint glimmer of hope on the horizon, or as Jon Cohn's metaphor labeled it, a weak but strengthening pulse. That hope is the half-day summit on health reform scheduled to take place at Blair House on February 25th. Now, there's already been a lot of talk about the event. It's supposed to be bipartisan, but many GOP leaders were refusing to go unless Congress scrapped both bills it passed last year and agreed to start over. The White House is stressing that the goal is to deal with the substantive issues and reach an agreement on the best way forward. Uwe Reinhardt is skeptical of any effort to solve the health care problem in half a day.

I'm inclined to agree. I don't think we'll see any startling new revelations during the summit, but that's because there aren't any. People like me--the people who do the research and study the health care sytem--already know what needs to be done. The ideas on the table aren't those of members of Congress. Sure, they're the ones who introduce the legislation and vote on it, but they are not experts in the minutia of our health care system. That's why they have staff who specialize in different substantive areas. But the ideas come from experts in the field. Each member of Congress chooses to listen to those experts or not as they see fit, but what has played out this--and every prior--time around has been one of politics interfering with what needs to get done.

I don't think the Republicans have any choice but to attend the summit. If they don't show, they look wholly uncooperative--not even willing to feign the appearance of helping to solve one of America's biggest problems. That won't wear well during election season. Strike one. I also don't think Republicans will offer anything substantively meaningful in the way of health reform proposals that aren't already in one or both of the bills passed by the House and the Senate. That's because they have good ideas and bad ideas, and their good ideas have already been included. If they raise their bad ideas, they risk having them exposed for what they are (CBO has already shown that many of their reforms would increase the deficit) all while televised nationwide. Strike two. Then I think that President Obama will clearly demonstrate that the Democrats ideas are the best ones out there on health care, and the Republicans will have little room to disagree. But they will stand in principled opposition, looking foolish in the face of a mountain of evidence collected over many, many years. Strike three.

So, I have hope. I also have hope that the House and Senate are very close to working out their differences and moving forward through reconciliation. And, before I leave you, let me make one other thing perfectly clear. This is not about politics for me. It is about understanding how our system works, where it is broken, and how it needs to be fixed. I appreciate that the reform legislation in Congress includes elements that should have bipartisan support--and would have if this hold thing hadn't devolved into a political pissing contest. I want to see things get better for the American people, and I believe that this is a step in the right direction. If an entire political party disagrees with that, I don't want them to tell me how idiotic my ideas are, I want them to offer a better idea on the right way forward.

Watch Jon Cohn on CNN

bradwright@unc.edu — Fri, 19 Feb 2010 08:04:00 +0000

Like me, CNN's Dr. Sanjay Gupta is trying to make health care reform accessible to the American people. Unlike me, he enjoys a noticeable platform for reaching them. One of his first guests was none other than Jonathan Cohn. Hear what he had to say here.

New Health Wonk Review Out Today

bradwright@unc.edu — Thu, 18 Feb 2010 13:35:00 +0000

Brady Augustine hosts this edition of Health Wonk Review--using themes from Dr. Phil's Relationship Rescue as a guiding force. If you don't follow HWR you should, because I don't have time to tell you everything you need to know on my blog alone, and it's a great way to sample the recent "best of" in health policy blogging. And of course, I don't mind pointing out that I have two posts included in this edition. What's more, I'll be hosting the March 4th edition of HWR here on Wright on Health. It should be a lot of fun!

America's Public Problem

bradwright@unc.edu — Thu, 18 Feb 2010 10:18:00 +0000

I've been doing a fair amount of writing lately that gets at the point that Americans are poorly informed about substantive issues in politics and that further laments the lameness of our political institutions. I don't like to write too much about such negative things, because it tends to bring me down and piss me off at the same time. So I'm not writing anything more on it for a bit, but I am giving you a few fun--and well-written--things to read. Is it an echo chamber? Perhaps. But I like the sound my thoughts make when they bounce off of smart people.

The first is Jacob Weisberg's piece that explains how our wishy-washy on-demand public attitudes are to blame for the lack of progress we're seeing in Washington. He nails it.

So does James Surowiecki who has pretty much the same thing to say about the absurdity of populism when the populace doesn't really know what it wants.

Ben McGrath will get you all caught up on the rise of the Tea Party Movement, which seems to be pushing for Sarah Palin to run for president in 2012, and to which my only response is "for president of what?!" Then again, after watching the commercials during the Super Bowl, maybe we don't deserve anything better than that.

And this is where it gets troubling. President Obama is planning to have a bipartisan summit on health care on February 25th. The idea is simple: bring everyone together--Republicans and Democrats alike--and carefully present all the ideas. Make the meeting transparent and the public will reach its own conclusions on the best way forward. Then, whatever Congress decides to do, the people will be in a well-informed position to hold them accountable. Oh, how I wish our politicians or our citizens were that rational.

Doing the Right Thing

bradwright@unc.edu — Wed, 17 Feb 2010 10:12:00 +0000

When he signed the 1964 Civil Rights Act into law, President Lyndon Johnson famously stated to an aide "I fear that we have lost the South for a generation." He was afraid--and history has borne out his fears--that the Democrats support of civil rights would alienate the southern states. Guess what? The law passed Congress and Johnson signed it anyway. Why? Because sometimes leading means putting politics aside and doing the right thing.

I don't see health care reform as any less important. The simple fact of the matter is that people die every day in this country who wouldn't have to given a different set of circumstances, and it is within our power to provide those circumstances to them. People want to argue that the market will take care of the problem, to which I must point out: It hasn't done so yet. It hasn't even taken steps in that direction. In fact, we're seeing just the opposite. The problem's getting worse every year, while the health care system builds a fatter and fatter bankroll at the expense of the people it is supposed to serve.

Other people will readily acknowledge that the market per se is less than ideal, but they are adamantly opposed to any form of government intervention. They know that a lot of people out there need help, but they still want to pursue an individualized approach to helping them. They say things like "There is a big difference between charity and redistributive taxation. I am happy to give of my resources as I freely choose to help my fellow Americans, but I do not want the government forcing me to contribute against my will." To those people, I would say: Your argument is awfully convenient. It allows you to ignore the reality of the uninsured, health disparities, and the like. Consequently, you say you'd be charitable, but how much have you actually given to support the uninsured? I'm guessing not much, because as long as the problem exists "out there" you can pretend that it doesn't exist at all. Most of you probably don't realize how many hard-working uninsured people you actually know.

Besides, the net effect to you of giving to charity or of being taxed is the same--it's just a philosophical difference you cling to--and the reason is clear: you don't really want to part ways with your money, and taxation robs you of that option, while pretending to be charitable does not. It's not necessarily wrong, it's just selfish.

My point in all of this is that, like it or not, sometimes there simply is a right thing to do. In this case, I believe that society should ensure a minimum acceptable existence for its people. Right now, we don't. We also don't consider ourselves a society. Americans laugh at the notion that no man is an island. We think we all are, and we are seriously wrong. When one of us suffers, the rest of us do, too. It's just that we don't often see the connection.

In the end, I would urge our elected officials to set aside partisan politics--and worries over re-election--and simply do that which is right and decent. To do otherwise is to look into the face of thousands of dying people each year and tell them "I'm sorry, but you just don't matter enough to do anything about your situation." I really hope we're not to that point as a country, but until I see some evidence to the contrary, I'm afraid I'm left little choice but to believe it.