Editor’s Note: What follows is the transcript of a roundtable on public opinion and health reform that took place on October 13,  the day the Senate Finance Committee approved its version of health reform legislation. Participants included Bob Blendon, professor of health policy and political analysis at Harvard; Chad Bohnert, director of marketing and e-commerce at Zogby International; Mollyann Brodie, vice president, public opinion and survey research, at the Kaiser Family Foundation; and Bill McInturff, partner and co-founder at Public Opinion Strategies. Highlights of the roundtable are also available.

CHRIS FLEMING:  Thank you all for joining us. I’d like to address the first question to Bob Blendon. Bob, obviously this is a pretty momentous day in the health reform process.  The Senate Finance Committee is set to approve its version of the health reform bill.  Could you give us your assessment where you think things stand now in terms of public opinion?

BOB BLENDON:  My take is relatively simple.  The public expects some bill to be enacted.  There’s a real sense that something has to happen.  The problem is this: If you look at polls that were taken in the last eight days which asked about the legislation that was being considered before the Congress, or the president put forward, not one of them has majority public support. So what you have is the sense that the public wants a healthcare bill to be passed.  As a result, I can’t imagine something not coming out of this Congress.  But there’s a lot of concern about what’s included in these bills, and the concerns are around issues that are not all about if there is a public plan or employer mandate. They are about the cost of services for people, concerns about taxes, about the deficit, about Medicare cuts.  So I believe there will be a lot of public concern about the final legislation that emerges. The bottom line is we’re moving towards a final bill, but the desired content of it in the public’s mind is not settled. Read the rest of this entry »

Editor’s Note: Tim Jost wrote 3 posts analyzing the House health reform bill HR 3962. The first looks at financing reforms, the second post delves into the public option, health insurance exchanges, and more.

In this final post, I will explore the remaining 1600 pages of HR 3962.  Although these provisions have received less attention (except from the interest groups immediately affected by them), they will in fact work important changes in the American health care system.

First, however, I will mention a few provisions buried in the health care financing reform provisions—the first 400 pages of the bill—that are worth noting.  First, the “compromise” worked out on abortion in the Energy and Commerce Committee is included in the bill. Currently federal funds cannot be used to pay for abortion except in cases of rape, incest, or life endangerment.  But, according to some reports, most private insurance plans cover abortion. If private plans are to be more heavily regulated and funded through premium subsidies, what affect will this have on abortion?

HR 3962 prohibits the requirement of abortion as an essential service that must be covered by private health plans or by the public plan.  The bill also prohibits the use of affordability subsidies to pay for an abortion, although the bill does not contain the accounting procedures that the Senate Finance bill uses to implement this requirement.  The federal and state governments may not discriminate against providers or plans for refusing to cover, provide, or refer for abortions (although the government is not prohibited from discriminating against those that do).  Exchanges may not discriminate against plans that cover or refuse to cover abortions, but apparently are not obligated to offer at least one plan that does cover abortion, as the Senate bill requires.  Federal and state abortion and conscience protection laws are expressly not preempted.  In sum, the abortion issue is addressed but neither side of this contentious issue is likely to be satisfied. Read the rest of this entry »

In my first post, I described the major features and basic approach of HR 3962, as well as the provisions of the bill that would go into effect more or less immediately.  This post will look more closely at some of the bill’s basic insurance reform elements.  In a final post, I will discuss the bill’s other features.

To begin, there is the public option.  It is one of the most popular features of the bill—many polls find that it is supported by a majority of Americans—but the media continues to insist that it is a loony left-fringe idea and it terrifies the insurance industry.  Some analysts believe the public option to be the most effective cost-control mechanism in the reform legislation, as a public plan paying something close to Medicare rates could introduce competition into markets which a single or small group of insurers currently dominate.  This includes the vast majority of local insurance markets in the United States.

Insurers have little to fear from this public plan, however, it is in all likelihood a paper tiger. Read the rest of this entry »

Both the new House health reform bill and the Senate Finance Committee bill, despite their best efforts, have to impose some taxes on some taxpayers; they cannot get all of a trillion dollars of subsidies for insurance out of Medicare.  But they differ on what and whom to tax: the House proposes to tax well-off people by limiting their tax deductions for things unrelated to health care or insurance, while Senate Finance proposes to levy an excise tax on high cost health plans. 

As a card-carrying health economist, I am programmed to believe that the best choice for limiting health spending is to curtail the current open-ended exclusion of employment based health insurance premiums (whether nominally paid by employer or worker) and the flexible spending account loophole.  As an economist I am programmed to believe that a tax on insurers will be mostly shifted to buyers of insurance, who in turn are mostly employers—but who in turn will react by paying the higher premiums through lower worker wages and by curtailing the generosity of benefits to keep the tax burden on workers down.

Here I want to suggest a meritorious compromise: why not tax the high cost benefits of high income workers?  Read the rest of this entry »

HR 3962, the Affordable Health Care for Americans Act, hit the House floor with a thud Thursday morning at 1990 pages, almost double the size of the bill we last saw before the Energy and Commerce hearings at the end of July.  The bill incorporates, of course, amendments from the House jurisdictional committees, but also ideas from the Senate Finance bill and some new initiatives as well. In addition, far more than earlier congressional versions of health reform legislation, the new bill includes important initiatives that will impact the American public quickly, an important consideration both substantively and politically.

The intent of this post is to describe what is in the bill and the longer-term politics and policies that the bill’s contents represent.  The politics de jour of the bill are being amply covered by the media and will be given less attention here.

Most of the discussion over the summer and fall has focused on the health insurance reforms in the bill, and in particular on the public plan.  These reforms remain in the bill, and have indeed been expanded.  Over three-quarters of the bill, however, concerns other subjects.  The legislation would make major changes in the Medicare and Medicaid programs; establish a number of workforce, wellness, and prevention initiatives; significantly amend Native Americans health care legislation, establish a new voluntary insurance program for community living assistance services and support (CLASS) like that advanced by the late Senator Kennedy; revoke the insurance antitrust exemption, encourage certain state malpractice reform efforts, and enact a licensing pathway for biosimilars. Read the rest of this entry »

On October 12 America’s Health Insurance Plans (AHIP) released a commissioned report by Price Waterhouse Cooper (PWC), “Potential Impact of Health Reform on the Cost of Private Health Insurance Coverage.”   The study reported that health care reform as envisioned by the Senate Finance Committee would raise the cost of private health insurance by 23 percent above the costs projected for the current system from 2009-2016. 

The timing of the report–released one day before the vote of the Senate Finance Committee of its bill–brought an immediate and sharp response by the mainstream media, congressional Democrats, and the Obama administration.  Besides its timing, other issues impaired the study’s credibility.  First, the report did not include potential savings brought about by reform legislation in estimating the cost of coverage.  Second, the report provided limited information as to how cost estimates were derived.  Third, when methods were described, the assumptions at times seemed implausible.

Beneath the opaque and questionable numbers, however, AHIP calls to our attention an issue that should be of great concern to all supporters of reform and universal coverage: the destabilizing selection effects of insurance reforms without an effective individual mandate.  This blog examines evidence about reformed markets operating with and without mandates. Read the rest of this entry »

Narrative Matters recently brought together 80 writers, journalists, and academics to celebrate the Tenth Anniversary of Narrative Matters.  There was much to celebrate: over 150 Narratives published in Health Affairs that covered a spectrum of human stories set in the increasingly institutionalized health care system.  We came to celebrate the power of stories and storytelling in the human drama of health.  A diverse group of men and women from a variety of backgrounds attended; the common denominator was a dedication to the health narrative.

It was a needed function.  There is an often-unarticulated human side to every profession, but the healing professions have a special need for articulate writing.  No other profession is as complex; no other profession finds us as needy and vulnerable.  Health care delivery has gone from the family doctor of my youth to mostly large institutions and group practices.  It has gone from mostly touch to mostly technology. That doesn’t necessarily translate to indifference or uncaring, but it clearly challenges the human and humane side of health care delivery.

I had written one of the essays and was honored to be asked to attend and be on a panel “Stories and Policy: Policymakers’ Roundtable,” moderated by Susan Dentzer. I could sense the tenor of the conference on the way in from the airport to the site of the conference.  The van, after the initial awkwardness of strangers, was filled with narratives of the health delivery system, much of it on the tragedy of unmet need.  One woman told of the need for more translators in more languages in hospitals.  Another added a story of a deaf man who had an appendix attack and was not given a signer, another on the cruelty of health reform not covering illegal aliens.

I served as governor of Colorado for 12 years and was no stranger to unmet need.  Yet on that initial ride and all the way through the conference, as I listened to the human stories articulately told, I felt a growing frustration about my inability to articulate how difficult it is to balance a budget and draw lines.  How could I articulate the agony of decision making and the need to say both “yes” and “no” to need? No modern nation can provide all the “beneficial” health care to all citizens.  In a system filled with near-miraculous technology, need cannot automatically convey a duty to fund. Read the rest of this entry »

As Congress prepares for an historic floor debate over health care reform, those of us who have worked in the trenches to measure and improve the quality of care are watching with a mix of anticipation and concern. Reform has the potential to significantly improve the transparency and, ultimately, the quality of our system of care. But I worry that the provisions needed to achieve a transparent, high quality system could end up on the cutting room floor as lawmakers strive to finish the picture.

The unique perspective of the National Committee for Quality Assurance (NCQA) on the status of health care quality in the U.S. is based on rigorously audited data submitted annually by health plans according to specifications laid out in the Healthcare Effectiveness Data and Information Set (HEDIS®) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) information. Today, we publish the 13th in a series of annual reports known as the State of Health Care Quality and, for the first time, the results leave us little room to celebrate. In fact, performance across all three sectors of health care – commercial insurance, Medicare and Medicaid – was nearly flat, with only a few bright spots. Read the rest of this entry »

Editor’s Note: In addition to Arnold Milstein and Pranav Kothari (pictures and bios above), coauthors of this post include Rushika Fernandopulle MD, MPP, of Harvard Medical School and Renaissance Health in Boston, and Theresa Helle of the Boeing Company in Seattle. For more on health care delivery system innovations and reforms, see the Sept-Oct 2009 issue of Health Affairs, titled “Bending The Cost Curve,” and the Sept-Oct 2008 issue of Health Affairs, titled ”Overhauling The Delivery System.” 

A just-completed pilot project sponsored by the Boeing Company shows that enhancing care via a “medical home” designed explicitly for patients with severe chronic disease can improve quality of care and reduce per capita spending in well-led physician organizations without a long history of national clinical distinction. Although it was a small study, the pilot project’s findings align with other recently reported results from similar initiatives.   

Introduction

A handful of pioneering private purchasers are testing care delivery and/or benefit design innovations aimed at changing clinician and/or patient behavior. Of these, tests of re-engineered primary care models for the chronically ill are perhaps the most challenging, due to the small organizational scale of primary care and the consequent small number of any one purchaser’s chronically ill patients served by a single physician office. Read the rest of this entry »

As Senate and House Committee versions of health reform move toward unified legislation and floor votes, the most complex political challenge is how to resolve the “public option” controversy.  While one would have thought weightier issues such as the shape of Medicare reform, the taxation required to support coverage subsidies, or the presence or absence of mandates would have been pivotal in this debate, the seemingly peripheral issue of a Medicare-like “public option” might be the hill on which health reform dies.

The reasons are almost completely political.  The Democratic base wants to end private health insurance.  Single payer advocates view the public option as a down payment on an entirely public health financing system. Public option advocates believe that the plan’s bargaining power will drive private insurers out of business.  (I’ve argued in a previous blog posting that, without fully understanding what they are doing, these single payer advocates are probably right.)

Moderate Democrats, who will need independent and some Republican votes to be re-elected next year, cannot afford to be perceived as advocating a further expansion of government influence.  After deeply unpopular partial nationalizations of our banking and auto industries, public support for further expansion of government power appears to be waning.  Republicans appear ready to capitalize on the growing backlash against deficits and growing government power in the coming Congressional election cycle. Read the rest of this entry »