Friday, October 30, 2009


I intend to post more later on, but I thought I'd note that the Richmond Times Dispatch finally posted my Op/Ed.

Saturday, October 10, 2009

If You Don't Believe Me, Believe Them

The Institute of Medicine is an independent, non-profit organization whose goal is to improve decision making on issues of healthcare. The Institute of Medicine's Committee on the Consequences of Uninsurance has proposed 5 key features that would be required of plans to extend health insurance. This list is from the Institute of Medicine's Uninsurance Checklist.

1. Health care coverage should be universal.

2. Health care coverage should be continuous.

3. Health care coverage should be affordable to individuals and families.

4. The health insurance strategy should be affordable and sustainable for society.

5. Health care coverage should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient centered and equitable.

A single payer plan--such as Medicare for all--is probably the best way to achieve this, but seeing the heartburn caused by the proposal of a public insurance option I doubt that single payer is in the cards right now. However, when you consider these key points, HR 3200 and the Senate HELP show the most promise. Both include the public option, which would stand to keep the costs of the private plans under control. The Senate Finance bill is probably not sufficient--state-based co-ops are not likely large enough to incorporate a pool of covered lives to adequately share the risk and keep costs low enough to be viable (especially if Republicans refuse any federal backing to ensure financial stability in the early stages).

So far, I have not seen conservative plans to reform healthcare in a way that would meet the criteria noted above. Plans like this from Gov. Bobby Jindal don't really seem to answer the call. I don't really see how they will address the cost issues. Even if HSAs and government tax credits make some form of coverage available to all in theory, how will the costs of insurance be kept in check? There is nothing in this proposal that would keep costs of plans contained. In fact, costs could rise quickly if patient costs are being subsidized in some way and the insurers can get away with raising costs some--overall patients might pay less, but the subsidy would need to cover more.

I'm sure Republicans would like to claim that the magic of the free market would work all this out--that competition between insurers would keep everyone in line. The fact is that, right now, insurers do not really compete among each other. Communities and states will have one or two insurers that dominate the market, to the exclusion of other companies. The free market is not working.

Free markets only work when consumers--patients, in this case--can reasonably refuse to purchase a product if the cost is not reasonable. I can choose not to buy a new car, a new TV, a new house, or a certain brand of mustard of the cost is more than I choose to pay. However, every single one of us will need healthcare. Maybe not much, and maybe not right now, but everyone will have to make use of this resource. With that being the case, consumers cannot really decline to pay for this product and therefore insurers have no real cost pressures to reduce the amount they charge.

So: real, honest healthcare reform that will meet the obligations listed above must include a public option to keep costs affordable. It also needs to have a mandated set of benefits in order to make sure that the affordable plans are actually worth something. Coverage must be available regardless of pre-existing conditions and regardless of your current employer.

Sunday, October 4, 2009

Do Physicians Support a Public Option?

Recently, an acquaintance brought this poll to my attention on Facebook, and claimed it shows that physicians don't trust a public option.

Interesting to note that this poll is from Sermo, a group whose founder posted this letter to discredit current healthcare reform efforts.

Remember: be careful how much weight you put on polls that are not randomized and that are not objective. Sermo is a self-selected group of physicians that does not favor the current proposals. If you ask this group if they like the current plan, the answer will be "No!". If you find this surprising, then you know nothing about research or polling.

As a counter-point, I'd like to re-post this link--from a top medical journal--showing the overwhelming support physicians have towards a public option (70%).

Remember: just because your favorite pundit says something is so doesn't make it so.

Saturday, October 3, 2009

Healthcare Co-ops

At this point, I am sure that everyone is aware that the Senate Finance Committee voted down 2 amendments to introduce a public healthcare option into their proposed bill. Opponents of healthcare reform have trumpeted this as a major victory, without realizing that this has not killed the proposal. The Senate is a much more conservative body than the House of Representatives and the public option was going to be a tougher sell in that group. What healthcare reform opponents don't seen to realize is that the key action of the senate is to pass SOMETHING out of the chamber. If they Senate passes a bill and the House passes out HR 3200, then they go into the reconciliation process where the public option can become the primary method of making healthcare accessible to all.

I wanted to say a few words about the Senate's proposed alternative: health care co-ops. The intent is for these member-owned organizations to be able to bundle people together and allow them to self-insure.

This sounds like a nice idea: let the members decide what benefits will be offered and decide the premiums, costs, etc. There are major problems, though, that have to be addressed:

--Insurance companies are only financially viable if they have a large enough risk pool that the money being paid in in premiums can cover the necessary costs and benefits being paid out. This means that you need a sizable member pool to get a large enough risk pool with enough relatively healthy people that you can achieve the needed net positive cash flow. I don't know the numbers offhand but it is a very large number of people that need to be in the pool for the co-op to work. If we are going to have the 50+ co-ops proposed in the Senate (at least one per state), how can that critical mass of members be reached? Around World War II, healthcare co-ops developed as a way to handle healthcare. Of these, only 2 remain. How will the Senate's plan provide for the longevity and survivability of their proposed co-ops?

--On a more political level, how will the start-up co-ops be funded? I, for one, would be reluctant to sign up to a co-op and start paying premiums into it unless I felt that the co-op was financially secure enough to be around for a while. I suspect many people would be worried about sending money on health insurance coverage that might not be around very long. So: co-ops would have an easier time signing up members if there was some form of assurance that the institution was fiscally sound. For example, government back-up (in the same way that the FDIC protects our bank deposits) would provide the earliest members of healthcare co-ops assurance that their money would not be lost if the co-op is unable to sign up enough members. The political problem: Republicans will not support this sort of start-up assistance or other forms of federal money to ensure solvency.

--Finally, in order for alternative health insurance structures to be successful, they need to be able to compete with the large private insurance companies that are flush with money. How exactly is a Virginia Health Co-Op supposed to compete with Wellpoint (Athem) or Aetna or the like? If you had a nationwide health co-op then this might work. Funny...that sounds familiar...sounds a lot like a national public option...

So, the co-ops are unlikely to make a dent in the costs of healthcare, will have a terrible time enrolling enough members within an individual state in order to have the covered lives to be fiscally sound, and will have an even more difficult time starting up if there is no federal back-up to provide financial security for the early co-op members.

The Finance Committee's proposal for co-ops is probably planned to be a soft alternative that will not scare away conservatives and on the surface might appeal to liberals. However, at the heart of the matter, co-ops that are not structured at the national level and that do not have federal backing at the beginning will probably not make any difference.