POSTED AT 8:31 AM ET, 04/ 2/2010
Regardless of where you fall on the political spectrum, one thing is true: these are historic times. The singular issue of health has dominated the national political landscape for just over a year in unprecedented fashion--revealing our hopes and fears and testing our resolve. We can debate whether its high ranking on the national agenda was motivated by financial concerns (the rising costs of health care) or a moral obligation (health care as a right not a privilege)--but the essential point is that America is speaking about health. And all during a time of worldwide economic turmoil and uncertainty. History shows that during economic hardship, governments (local, state and federal) have chosen to dismiss health as a "side issue" or eliminate health services altogether, forgetting the direct link between health and economic stability. So credit must be given to President Obama, for without his tenacious leadership in keeping the nation focused on health through the spirited and grueling national health debate, its historic outcome might not have occurred.
This, however, is just the beginning. True reform does not stop with financing health-care delivery or covering millions of uninsured. It requires a broader discussion on health promotion and our individual and collective contributions to the health and wellbeing of this nation. It depends on the creation of opportunities for non-health sectors to perceive their work as an essential component of the health landscape and a willingness for non-health and health sectors to work together. It will be predicated on the development of action plans consisting of health-friendly policies and strategies for health promotion with the expectation that these will result in improvements in health outcomes across populations. Then, only, can we have a fully comprehensive and transformative movement on health and health care in America. It is with great foresight, then, that Congress included in the health care reform bill the creation of a National Prevention, Health Promotion, and Public Health Council comprised of leaders in non-health and health agencies in federal government. For the first time, top cabinet officials in Labor, Education, Transportation, Agriculture and other agencies will be sitting at the table with Health and Human Services to examine strategies for promoting health across all sectors. This is a tremendous feat and one that will yield great dividends if done correctly.
Cities and states across the country can look to emulate what the federal government and bring together various stakeholders to assess the impact of current policy on the health of communities and develop mechanisms to ensure the health (and some municipalities already have). If we want to be successful in transforming the landscape of health and health care in the U.S. and create healthy communities that can meet the demands of the 21st century, we must be unequivocal in visioning and creating these collaborative opportunities. In this manner, we can leverage the momentum generated in the passage of health reform and potentially improve the health of Americans for this and future generations.
POSTED AT 5:13 PM ET, 04/ 1/2010
It's been a wild ride over the past two years: first the campaign, then the stimulus debate, and finally passage of health reform. As I've written elsewhere, this has been the ride of a lifetime for me personally. This is probably the most significant thing I have ever done. A long list of delayed projects and papers awaits me.
Our charge is to describe the implications of this complex new law. I would say that the implications are somewhat indeterminate. Libertarian legal scholar Richard Epstein complains that a 2,500-page bill will require a 20,000 page rule book to implement it. I agree, though I am less bothered by this fact of modern life than Richard is. One page per $130 million of economic activity doesn't seem excessive to me.
I am gratified that this bill establishes -albeit imperfectly--the principle of near-universal health insurance coverage. I am gratified that this bill will curb discrimination against our fellow citizens facing serious injury and illness. I am gratified that we will provide about $200 billion every year to help poor and working people obtain health coverage. I am gratified that the bill includes important measures to help the disabled. I am immensely gratified that we have embraced the principle--albeit imperfectly--that people should not go bankrupt because they get cancer. That bill was worth every moment tens of thousands of people have spent over many years to get this done.
I am also gratified by the fine work done by so many people to design an intricate, complex, and politically feasible piece of legislation that could accomplish everything in the above paragraph at an acceptable cost. This wasn't in any way easy. The army of White House, HHS, and Congressional staff that made this happen receive less public credit than they deserve. So do the reporters. I think this was the best-covered domestic policy story, ever. Writers at this very newspaper are among the best in the business at explaining a complicated bill to an often-clueless and innumerate public. They did an amazing job.
To me, the most agonizing feature is no special interest deal barnacled to the bill, or anything left out. It's the simple timetable. For no good reason, really, we must wait until 2014 for critical measures to kick in. I met so many people on the campaign trail and in my public health work who need help: People with multiple sclerosis, people near retirement waiting for Medicare before getting their glucose and blood pressure checked, street drug users who need Medicaid, liver transplant patients on Medicare waiting lists. High-risk pools and other stopgap provisions will help before 2014. Unfortunately these measures are obviously inadequate.
We must do more now. Millions of people can't wait.
POSTED AT 12:25 AM ET, 04/ 1/2010
I am an optimist by choice - not by nature. I arise each day and metaphorically cloak myself in a robe of 'learned optimism.' But I have to tell you that it's sure been difficult for me to remain optimistic in the face of the partisan political rancor that marked the final chapters of the health care reform legislative process. So much so, I found that my muse had left me after my last washingtonpost.com posting in November. I'm back for the final weigh-in.
Now that the bill has passed, we've been left to figure out the ramifications of the myriad disparate pieces described in more than 2,400 pages. It's a mixed bag to be sure. As a Family Physician I feel that the bill offers some important validation for the critical role of Primary Care in the health care delivery system of the future. As a vendor of population health and wellness services delivered from an on-site clinic platform I see reasons for companies to still want to purchase my service offering. As an off-shoot of a large employer, I've come to the conclusion that overall, the bill is more negative for American businesses, and hence the American people, than positive. The new law missed its opportunity to address the anti-competitive burden that health care presently places on American businesses, now competing in a global economy.
Although the regulations are just beginning to be written, what we do know is this: access to insurance coverage has been expanded to 32 million additional lives. That's a good thing. But at what cost to American employers? The tax implications of this bill are just beginning to be appreciated; and in cases like Caterpillar and AT&T they're staggering. The bulk of the actuarial analyses I've read suggest that companies, like my parent company Quad/Graphics, will be paying more in a variety of ways such as the new long-term care tax, and providing benefits for part-time employees we never had to cover before. Our lifetime limits are now removed and we'll have to cover dependents to age 26.
If there's a glimmer of hope for me in this new law it's in the funding for pilot projects supportive of Accountable Care Organizations and Patient-Centered Medical Homes. Because, to paraphrase what I wrote in my very first essay in this space, the fundamental dysfunctional health care dynamic is this: excess costs are driven by the perverse incentives inherent in our disaggregated, piece-work delivery model.
Where do we go from here? The more-government-is-better crowd on the left see this as the first step to nationalizing U.S. health care and will continue to press their fight. The anti-entitlement folks on the right see this new law, foisted on them in so partisan a fashion, as a clarion call to close ranks and re-energize. Their hunt is on for a 21st century Ronald Reagan. This is just the first major battle in what's likely to be a protracted war.
For my part, I plan to continue to work to improve the health of the folks that have been entrusted to me - from QuadMed's empowered primary care delivery platform - one person at a time.
POSTED AT 3:25 PM ET, 03/31/2010
Unlike so many, I find myself being more impressed each time I delve into the new law. This is, ultimately, a piece of legislation that WILL achieve many stated and even unstated objectives:
1. It will extend the Medicare Part A trust fund for just long enough to allow BOTH sides to discuss meaningful reforms to make it truly sustainable.
2. It provides a real commitment to our nation's poor; and strengthens Medicaid at the same time. Here, too, there are opportunities for additional reforms, but this makes clear what our priorities are; and, importantly, demonstrates our national humanity and compassion for those less fortunate.
3. It dramatically reforms our understanding of and right to health insurance. We have never had a federal definition of health insurance and this begins that discussion in a meaningful way.
4. It is financially sustainable, as long as our elected officials do not undo the tax and revenue-generating items.
What do we need to wait for and hope for?
1. Tort reform and/or Malpractice reform. This should have been firmly part of this law, but will have to wait.
2. Sustainable Growth Rate legislative reform: This is universally recognized as necessary and putting it off, even for a few months, is a big disappointment.
3. Implementation of insurance regulation and insurance exchange regulation will be the first real tests of the success of the law.
4. Taking the Medicare savings and law changes as a first step; and not ignoring the very real legacy costs that we still have to address. AND working with the private (for-profit and not-for-profit) sector to develop a structure and process for improving the delivery of high-quality health care with consideration of cost.
5. Revisiting the notion of better patient education and not being scared off by hateful rhetoric. Discussions around end-of-life and compassionate care should not be politicized or used for pure political gain.
I remain very optimistic about this country and about seeing our elected officials, of both parties, come together around common goals and purposes. In the mean-time, I am proud of the many elected individuals (and their staffs) for having stood behind their promises and made this a reality.
POSTED AT 11:00 AM ET, 03/31/2010
"We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are life, liberty and the pursuit of Happiness." These famed words written on parchment in 1776 became more tangible with the passage of the recent health-care law. In expanding coverage to 32 million Americans we approached a more equitable union where all citizens have the opportunity to achieve the fullness of life. Quite obviously, it will not solve all of the complexities of the American health system, but it does represent a credible start and investment in our collective future.
Flawed as it may be, the current law narrows the health and well-being gap between the insured and uninsured. While it is not possible to legislate good health, rather, it is possible to legislate good health policy, and recent legislation, if it has done anything, has rendered a down payment on meaningful health reform. Among its successes are aggressive insurance reforms (to the benefit of those with preexisting conditions and chronic illnesses) and widened access or coverage options for the middle class, those on the individual market and small businesses.
Though the recent health-care law seems to have started a chain of events and seized the American electorate, and to some extent sent ripples across the larger health system, equally volatile issues, such as tort, health delivery and payment reforms and aggressive cost containment measures still occupy the to-do list. On top of that, protracted roll out of benefits, industry taxes that may trickle down to consumers, the individual mandate (a boon to insurers) and a largely unscathed pharmaceutical industry, serve as a mixed bag of incidentals. In essence we have only begun to solve the health-care conundrum. Health-care nirvana, we have not reached.
Pundits and politicians will weigh through the 2010 and 2012 election cycles and beyond, whether this particular bill and the manner in which it was enacted was the right political move for the President and the Democratic-controlled Congress. Though history remains the final arbiter, I believe both had a moral imperative to act, and to dodge this otherwise momentous occasion would have been cowardly and reckless given an already bloated system.
Fortunately, there is more to health than the political bottom-line. Indeed health policy, like all policy, is limited by what is politically feasible (given social and cultural norms), in addition to structural and economic realities. Still, as the document elaborates, "Governments are instituted among Men, deriving their just power from the consent of the governed" to act responsibly on behalf of its citizens. In a nutshell health-care reform constitutes responsible action.
The overwhelmingly partisan tone of the health-care debate and the intensity of public sentiment have made it increasingly apparent, however, that health care reform is proxy for a lot more. The undercurrent of who is "deserving" is scarily palpable, Thus, the march forward must not languish in victory, but press to articulate the next appropriate steps, fully addressing the social determinants of health, prioritizing prevention and wellness efforts, and tackling health disparities.
Health will continue to be the province of individual choice and responsibility, as it should be, but our next front is health literacy and health engagement to facilitate better patient-provider relationships in both a top-down and bottom-up approach.
When it is all said and done, though we have journeyed many miles, and hit major milestones, even so we have miles yet to travel.
POSTED AT 10:30 AM ET, 03/31/2010
For small business, the new health-care law begins a long struggle against cost increases, uncertainty and perverse incentives (see timeline here). Traditionally, small business produces over two-thirds of America's new jobs, but this bill jeopardizes that role.
Premium increases will dominate the near-term horizon. Insurers will no longer be constrained by an impending Congressional vote. Some insurers will see their days as numbered and will hike premiums before exiting the market. Surviving insurers will face fewer competitors and may increase their margins before the law limits their ability to do so. Millions of people will begin gaining insurance, with no commensurate increase in the number of doctors and other providers; this will push medical fees upwards, and insurers will have to cover the increases. The small-group market is always more vulnerable to rate increases, and this market will not change substantially until 2014.
Premium hikes won't be limited to small business. Based on only one of the myriad new tax provisions, AT&T, John Deere, Caterpillar, 3M, and other companies are setting aside billions of dollars for anticipated losses. They can't spend these dollars on jobs, products, and investment. Small businesses who sell to these companies will feel the secondary effects of this contraction. Governments will be similarly hit; Arizona just realized that the law hands the state an unexpected $3.8 billion obligation over the next three years.
Not only do individuals, businesses, and government have to guess HOW the new rules affect them; they also have to guess WHAT the new rules will be. A "Health Choices Commissioner" will define what constitutes an acceptable health insurance policy. Will everyone's policy have to cover single-occupancy maternity rooms, hair transplants, and liposuction? Only the as-yet unnamed Commissioner can say. Big businesses and unions will have in-house attorneys, accountants, and lobbyists watching their backs. Small businesses won't have that luxury.
Then there are the perverse incentives. Here's just one example: A business with 60 employees doesn't provide health insurance, but all of the employees are in households that earn too much to qualify for federal subsidies. Then, one day, an employee comes in and explains that his wife lost her job the week before. Since the couple's combined income drops below $88,000, they now qualify for a federal subsidy. Because of this one employee -- whose salary hasn't changed -- the firm now owes a penalty of $2,000 for each of its employees -- $120,000 annually. With dozens of similar perverse incentives, how is a business supposed to plan?
Small business will fight every day to survive this bill. As every high school commencement speaker says: "This is not an ending. It is only a beginning."
POSTED AT 9:53 AM ET, 03/31/2010
Despite the rhetoric, threats and backlash over health-care reform, the final legislation is going to make America a kinder and healthier place. For those of us who advocate for a universal system, it may not go far enough or fast enough, but the new health-care bill is a vehicle that is moving health care in the right direction.
The bill addresses areas of greatest need and ensures access for all Americans by providing support and options so families and individuals can purchase much needed insurance. It keeps employers involved and makes provisions for small business. It addresses the high cost of Medicare and reduces the gap in coverage for seniors needing drugs. It was a brilliant move to link affordability of education with affordability of health insurance. By Including legislation that cuts the cost of lending and financial aid for students the American people may come to see the benefit of cutting out business interests and profiteering from providing their most important services.
The first challenge was overcome when the insurance industry under pressure from the Secretary of Health and Human Services gave up efforts this week to challenge legislation that ensures children with pre-existing conditions will be covered. This move indicates that finally our health care is not governed by big business but rather by elected officials who represent us. It was a long journey and a hard fought process, but in the end the final health-care bill puts the power over the health of Americans where it belongs - with the American people.
POSTED AT 9:28 PM ET, 03/30/2010
The mainstream reform debate has been primarily focused on access -- the millions of Americans who don't have insurance. We heard heartbreaking story after heartbreaking story day after day for nearly a year. And this bill tackles that enormous problem!
But there are the other big problems -- skyrocketing costs, misaligned incentives, inferior and inconsistent care, and so on -- all stemming from the fact that our health delivery model has remained what is essentially an acute, episodic care business model from the 19th century; a traditional fee-for-service model based on patients visiting hospitals and physicians' offices when they're sick. We have a system that hasn't evolved to keep up with the way our nation's health has changed -- toward chronic care. Nor has it progressed to use health data in an effective way to drive better decision-making and improved methods. It's not set up to enable the kind of broad-scale innovation and consumer-focus that has transformed nearly every other industry that touches our lives. Nor is it poised to keep up with and take advantage of advances in medicine, especially to deliver on the promise of personalized medicine.
In the context of these massive structural problems, while the bill is a positive step forward, it seems like it's just the first mile on the marathon of reform.
There are other good "ideas" from "experts" in the bill besides access to address some of these problems -- an Innovation Center within CMS to pilot payment reform, a Patient-Centered Outcomes Research Institute to identify and carry out national research priorities to drive "evidence-based" medicine, a Medicare shared savings program to pilot cost-savings for accountable care organizations, and so on. But these will require doing a fundamentally better job of running pilot and demonstration programs in Medicare. Right now, we evaluate the reforms over 8 to 10 years. We need to lower that dramatically to accelerate the path for these ideas to 'scale' and become common practice -- driving the kind of wholesale transformation needed.
Most people recognize that it will take several years to get reform "right"-- we have an opportunity to do even more to drive innovation and shift the system to drive real value for every dollar spent. I hope that we will continue to work at driving the right combination of structural change, innovation, and use of technology to create a better system for our generation and those to come.
POSTED AT 6:19 PM ET, 03/30/2010
Is the health care overhaul perfect? Absolutely not.
From some angles, the work is just beginning. We have legislation now, but that legislation has to be put into policy. Patient advocacy groups will have a particularly important role in helping shape new offices and agencies like the Health Insurance Exchanges and the National Prevention, Health Promotion and Public Health Council. We've seen the sausage-making that went into the bill. Equally important is the execution that will take place outside the spotlight.
But the reason many in the cancer community are elated are the tangible benefits right around the corner and the elimination of the worst of the dirty tricks practiced by insurers.
Cancer survivors like me will no longer have to swallow the discrimination that so many of us face today. When I was diagnosed with cancer three times at the age of 19, I found out the hard way there would be no insurance company willing to offer me affordable coverage. In the future, other young survivors won't face that harsh reality.
Young adults across the country will also benefit from the flexibility of being able to stay on their parent's insurance plan until the age of 26.
And perhaps most importantly, within six months, insurers will no longer be allowed to use the dirtiest trick of all - terminating someone's coverage when they become sick. Over the years, the Lance Armstrong Foundation has heard countless heart-breaking stories of families driven into financial ruin trying to pay for a loved one's care while the insurance company waves goodbye. Luckily, those stories stop now.
Is it perfect? No.
Is it strong and welcome progress? Absolutely.
POSTED AT 8:57 AM ET, 03/30/2010
We're all Atlas's now, charged with taking on the mantle of health reform implementation. Whether we're health citizens, providers, payers, plans, suppliers to the industry or government agencies, our roles in health and health care will evolve over the coming months and years.
The heavy lifting will come in the forms of new payment mechanisms, for some involving bearing more tax burdens, and for others sorting out the logistics of buying and paying for new health plans. More lifting will be required for better understanding and acting on our responsibility as health citizens, to become more informed and smarter about accessing, buying and consuming health services.
For Washington and the states, being Atlas means moving ahead in new ways, designing and promulgating new models for incentivising health-care delivery for providers and utilization among health citizens. Quickly moving toward patient-centered medical homes and electronic health record adoption will drive better outcomes and economics for patients and taxpayers.
The message of personal responsibility so that Americans morph into health citizens, engaging in their own health and the health of the people they care for, can't be understated. There is no implementing health reform or health cost saving without citizens' full-on health engagement.
Even with that, there will be more heavy lifting as the largest single challenge driving up the Federal deficit -- Medicare -- remains to be solved.
POSTED AT 6:24 AM ET, 03/30/2010
There is no such thing as a perfect piece of legislation, especially on an issue as contentious as health care. This legislation had many positive components and it creates not only major insurance market reform, but transformational payment, delivery, access and quality reform. There are many good pieces in the legislation on prevention, long-term care and on addressing some issues with the senior citizens prescription drug program.
All that being said, I am deeply concerned that we have created a larger health insurance system prior to fixing what is broken in the current system. Because many of the fixes in terms of quality, delivery and payment reform depend on future actions by regulators and cabinet agencies, it is too tempting for special interests to fight to preserve what's wrong with our system. In a personal blog I posted today on www.mikecritelli.com, I used the example of a New York Times story about a poor quality hospital in New York that the state recommended be closed. Because it was a large employer and a major community resource, it was never closed.
To make this legislation work as intended, we must make politically difficult decisions to reallocate health care payments, expose badly-performing health care providers and to shift from putting too many resources into specialist care, wealthier communities, and complex treatments versus low-cost wellness activities. I have seen no evidence that we have the political will to make these decisions. I will try to be part of the solution, but this legislation, by building on the existing system before fixing it, has made transformational health care reform far more difficult.
Thankfully, there are many good transformational tools in the legislation, but our collective responsibility is to make sure they get used.