Error: Unable to create directory /home/demockra/public_html/wp-content/uploads/2010/09. Is its parent directory writable by the server? Lost in Translation: Electronic Records and Health Reform

A typical day at work will invariably find me hunched over a piece of paper, staring at a jumble of illegible loops and lines, trying to figure out what on earth five loops and a squiggle is supposed to convey to the reader.

No, I am not a handwriting analyst, a historian of ancient writing, or a translator of foreign languages. I am a medical student, simply trying to read the paper progress note of another physician or resident in attempt to figure out what happened to my patient during his visit two months ago. This frustration contrasts to a recent gig at a VA hospital whose medical records and charts are completely computerized; a model system where I was able to breezily click through the past medical history of my patients. As an incoming medical professional in an already digitized world, I am constantly disgusted at the inefficiencies and difficulties that arise from using paper charts.

How Common are EHR’s?

Electronic medical record is one of the current buzz words in the health care field. A recent study published in the New England Journal of Medicine this past spring found that only 1.5% of hospitals have a comprehensive-electronic record system present in all units . Other recent studies have found that a small percentage of physicians’ practices currently utilize electronic health record (EHR) system or CPOE (computerized provider order entry) at all practice locations, leaving a larger majority of our hospitals and health care providers to sift through endless piles of paper every day to learn about their patients.

Costs and Benefits

Those who doubt the inherent benefits of comprehensive EHR implementation put forth the financial objection that estimates over hundreds of thousands of dollars for many physician practices to implement and maintain such a system. However, some studies show that the costs to the health care system created by the problems using paper charts have the potential to outweigh the costs of an EHR in the long-run. More importantly, even if ultimately shown to be cost neutral, effective use of electronic health records have been shown to improve quality and save lives. Many of these quality gains are realized with robust systems that include evidence-based decision support tools to providers.

The Scary Truth

The old joke of physicians having illegible handwriting holds true in my experience: for the majority of physician providers, their writing is difficult to read at best. At worst, it is plain illegible. This creates a multitude of problems in our health care system that is a huge detriment to the efficiency, safety, and the economics and structure of the health care system. The most obvious and feared complications of simple bad handwriting are huge mistakes that can needlessly cost a life.

In its landmark report, to Err is Human, the Institute of Medicine estimated that up to 98,000 lives are lost every year from medical errors.  Not surprisingly, one study found that approximately 90% of  inpatient medication errors occur at either the ordering or transcribing stage.  I see nearly every day how easy it can be to make a mistake with a life-or-death magnitude simply by misinterpreting the wrong word or number from a chart leading to a dangerous drug reaction or an incorrect treatment. Even if I finally correctly translate all of the scribbled notes in the paper chart, it will have taken me five times as long to treat my patient, increasing the time it takes to treat the patient and increasing the chance of an adverse outcome. Talk about inefficiency in health care!

Aside from the danger and inefficiency, medical errors due to paper charts can wreak havoc on many other players in the health care system by causing a high number of lawsuits. When a physician is sued due to a medical error, it drives up the cost of the already sky-high malpractice insurance that all physicians have to pay. While it may seem to the general public that all doctors are rich and live to play golf, many have high debts from school, don’t make the big bucks, and work horrendous hours. Add high malpractice insurance, and this causes financial difficulty for physicians in certain specialties that can cause shortages of some primary care doctors such as obstetricians.

Alternatively, physicians might be forced to cherry pick their patients, only accepting Medicare and private insurance patients, causing uninsured and Medicaid patients to use the ER as their only health care venue, thus shifting the burden of cost to taxpayer’s wallets in the form of hidden hospital fees to compensate for many cases of avoidable uncompensated care. Many critics of EHR within medical field fail to realize that in improving the efficiency and safety of medical records translates far down the line to many aspects of the health care system. Indeed, in a time of health care reform, the transition of paper charts to electronic medical records will play a large role in improving the health care system.

Reason for Hope?

Through the ARRA EHR stimulus, part of the larger stimulus bill, Congress recently set aside $19 billion dollars, or the equivalent of over $40,000 per physician in a practice, to assist in implementing electronic health records (EHR) that meet meaningful use definitions (e.g., CPOE). This is a huge step forward in the attempt to computerize medical records across the country.

As a health care professional, I am excited to see the dedication to the improvement in health care of the current administration and frankly shocked at those who refusal to consider any reform to this health care system that is so obviously inefficient, expensive, and backward compared to any other developed industrialized nation. An entire overhaul of our health care system is required, in which EHR are only one part. However, the same critics of implementing EHR because it is “too expensive” are focused on the short term in all areas of health care reform, battling reform not because they have a better idea, but because they have no idea. I challenge any EHR or health care reform naysayer to step into my shoes for a day to read handwritten patient notes in a paper chart and to make a life or death decision based on an illegible scrawl. Our patients deserve better.

The Case for the Obesity Tax

Recently, New York Governor David Paterson promoted a plan for legislation that would have levied a 15% tax on sodas and other drinks with high sugar content and containing less than 70% fruit juice. Proponents of the ‘Obesity Tax’ argued that the measure would help reduce the prevalence of obesity in New York State. The revenue generated was to be reinvested into public health programs and obesity prevention measures. Citing the success of other similar public health initiatives, including anti-smoking measures such as hefty sales taxes placed on the purchase of cigarettes, supporters were optimistic that this policy would have comparable effects in terms of reducing the consumption of soda and other high-sugar beverages, particularly in children.

Responses to the proposed ‘Obesity Tax’, however, were mostly negative and likely compounded by the Governor’s current negative approval ratings. The tax faced opposition from individuals, associations, and other organizations, including the New York State Restaurant Association and the National Restaurant Association. Disapproval took the form of the expected outrage over legislation which would dictate personal habits and beliefs that the ‘Obesity Tax’ would prove to be an ineffective public health measure. Others felt that, in contrast to successful cigarette taxes that have progressively increased the price of cigarettes by larger margins, a 15% tax on soda would fail to produce any changes in consumption. This latter criticism helped paint the Governor’s legislation as merely a disingenuous attempt to meet New York State budget shortfalls under the guise of a compassionate public health policy. And maybe that is exactly what it was, as the Governor recently performed an about face and replaced the “Obesity Tax” and other revenue measures with money from the federal stimulus package.

Yet the current political climate and unpopular governors notwithstanding, there is a larger point that can be gleaned from this debate. Public health measures that attempt to dissuade unhealthy behavior, whether through consumer tax or mandatory disclosure of nutritional information, are economically, politically, and morally justified. In addition to the promotion of healthy individual living, the basic goals of public policies like the ‘Obesity Tax’ include decreasing both the incidence of chronic illnesses and the amount spent on health care treatment for preventable diseases. In fact, as I will discuss below, reducing health care expenditures on the treatment of preventable chronic diseases should be a critical element of any plan aimed at improving the current health care system in the United States.

Independent of political, geographic, or economic backgrounds, many will agree that one of the tenets of improving the quality of and access to health care in United States is a decrease in rising health care costs. Health care spending has been trending upward and now makes up 17% of US GDP. This rise in spending is not necessarily problematic, particularly if it coincides with an increase in the total number of people receiving health care coverage. However, the percentage of individuals receiving health care benefits in the United States has been moving in the opposite direction. There are many contributing factors to this rise in health care spending, including, medical liability costs and superfluous medical procedures, an aging population, and an increase in the incidences of (and, hence, resources allocated to) chronic disease.

The rise in health care spending for chronic illness is staggering and can be attributed to just a handful of conditions. Although the scientific data varies, one study by Kenneth Thorpe, PhD, Chair of the Department of Health Policy and Management at Emory University and former Deputy Assistant Secretary for Health Policy in the Clinton Administration, found that just five medical conditions accounted for a 31% increase in health care spending in a period spanning from 1987 to 2000. All five of these – heart disease, pulmonary disorders, mental disorders, cancer, and hypertension – are conditions associated with obesity. Furthermore, a related study found that an increase in the prevalence of obesity accounted for a 12% growth in health care spending during a similar time period. It stands, then, that any public health policy attempting to reduce the prevalence of a chronic health condition – especially obesity – should be granted serious consideration. The policies’ potential benefit of reduced spending on preventable conditions is economically and morally compelling since resources could be redistributed to efforts such as improving access, quality improvement, and patient safety. Bearing these potential benefits in mind, critics of the ‘Obesity Tax’ should shy away from criticism based on futility and aimed at legislative defeat and instead focus on removing potential roadblocks, pitfalls, or imperfections within the policy in order to facilitate the policy’s desired outcomes.

Overall, despite the political realities surrounded Governor Paterson’s proposed tax, decreasing the amount of health care spending on preventable chronic conditions is required if current efforts at health care reform are to achieve goals such as raising the number individuals with affordable access to health care and improving the overall quality of care. Ideally, a measure such as the “Obesity tax” would reduce the cases of preventable chronic disease and contribute to the diversion of limited resources away from the treatment of preventable chronic disease to other critical areas, thereby making health care more cost effective and efficient. While Governor Paterson’s “Obesity Tax” as written may or may not effectively achieve these goals, as long as public health measures such as this one have reasonable and shared objectives – in this case, a decrease in health care spending through a reduction in overall obesity – criticism should be more constructive and aimed at improving a specific policy’s effectiveness rather than merely defeating it in the name of narrowly defined interests. We should not be satisfied with defeating a public health policy that has a laudable goal, but rather in ensuring that a public health policy effectively works to achieve that goal.

Error: Unable to create directory /home/demockra/public_html/wp-content/uploads/2010/09. Is its parent directory writable by the server? Health Care in America: A Way Forward

As previously stated, the purpose of this two part series is to set forth my views on changing health care delivery in America to make it more efficient, more effective, and, most importantly, more compassionate.

In Part 1 of this series, Health Care in America: A Time for Change, I laid out my personal experiences that led me to write this series and outlined the problem. In Part 2 of this series, I will explore ways of making health care better for all citizens of the US, starting with the concept of triage.

TRIAGE – WHERE IS HAWKEYE WHEN YOU NEED HIM

In the old sitcom, MASH, Hawkeye Pierce would perform triage for his MASH unit. His job in triage was to separate the injured into three groups:

1. Those who needed care immediately to deal with a life threatening or a rapidly deteriorating situation.

2. Those who needed care, but who could wait for a time period with little or no effect on the patients’ wellbeing.

3. Those who could not be helped by health care (either they were not sick or they were so badly injured and sick that normal health care procedures could improve the situation).

Hawkeye heroically performed triage for the MASH unit, and by doing so, used the unit’s limited resources for maximum effect. And why was he a hero? Because he made tough decisions about prioritizing the needs of patients based on triage. The system was not perfect, but decisions were made, and the doctors got on with the job of caring for the sick and wounded. And through appropriate triage, care was provided most efficiently given the limited resources at hand.

In the UK, this triage function is essentially how the national health care system works. Resources are indeed limited in the UK within the NHS, and everyone knows it. Indeed, this obvious limitation of resources does cause issues (e.g., waiting lists). However, it also forces the people and the doctors in the system to focus on what is important; it forces the doctors to make the tough decisions necessary to give care to those that are in most need. The classic triage function is returned, not to insurance companies, lawyers, or accountants, but rather to medical professionals. Indeed, this is what doctors are paid to do – not just provide care, but to provide care to the sick with recognition of the limitations of resources. They are not just health care technicians, but they also perform a much more important role – TRIAGE.

Indeed, in the case of my son’s broken arm and my cancer treatment, the triage system worked just as it is supposed to work. In both of these situations, the doctors recognized a problem that needed to be addressed quickly, and even though their resources were limited, we were cared for quickly and efficiently with the resources at hand.

In America, this triage system has been distorted by the market system – a market system which has less to do with medical priorities than it does with economics, litigation, and profit. The market system ensures that the ones with the most money get the best health care in a timely fashion. The ones without money get what they can get. The market system also ensures that those with access to lawyers will receive health care, often unnecessary health care. Large sums of money in America are spent on defensive health care, where diagnostic procedures or tests are performed for the sole purpose of defending against potential lawsuits. Finally, the market system, through the prospective payment system, ensures that many wasteful procedures, tests, and office visits will occur, not necessarily for the benefit of the patient, but for the benefit of the provider who will earn more money by performing more procedures and tests.

The table below is a simple demonstration of the inefficiencies of the US health care system

Country	$ Spent Per Capita on Health Care(USD)	Health Care as % of GDP	CT Units per 1 million persons	MRI Units per 1 million persons	Infant Mortality per 1,000 births	Life Expectancy (years)
USA	6,347	15.2	33.9	26.5	6.9	77.8
Canada	3,460	9.9	12.0	6.2	5.4	80.4
Denmark	3,179	9.5	15.8	10.2	4.4	78.3
France	3,306	11.1	10.0	5.3	3.8	80.2
Netherlands	3,156	9.5	8.2	6.6	4.9	79.4
Spain	2,260	8.3	13.9	8.8	3.8	80.4
UK	2,580	8.2	7.6	5.6	5.1	79.4

Source: OECD Health Data 2005

The first two columns of the table show how the US spends approximately twice as much on health care as comparable Western countries. The third and fourth columns are an indication on how that money is spent. The money is spent on fancy machines and diagnostic tools (CT and MRI); these columns show the US usage of MRIs is 3-6 times higher than other countries in Europe. Although these types of tests are a useful tool in diagnosing certain diseases, there use in the USA is certainly out of proportion when compared to other countries. Indeed, I believe the high use of such technology is not driven by patient need, but rather by profit motivation and the fear of litigation.

Finally, the last two columns show that for all the money spent and the technological advances (such as MRI and CT), the US lags behind other countries when it comes to two objective measurements of health care – infant mortality and life expectancy.

In summary, the market system of US health care forces costs to rise and rise and rise again with no objective benefit to the population. These costs are driven by all the players in the system:

1. Lawyers – who through the threat of litigation lead many doctors to perform unnecessary and non-cost effective treatments.

2. Managers (motivated by profit) – who want to provide more care (as long as it is covered by insurance, Medicare or Medicaid programs) because more care leads to more procedures leads to more revenue, which in turn leads to more profits.

3. Insurance Companies (and HMOs) – who tend to provide more care (more coverage) and increase premiums incrementally across its insurance pool. This is especially true since the costs of increased premiums are often negotiated with employers, and the costs are invisible to the employee (the actual customer). Ultimately, more care means more revenue, which usually leads to more profits for the insurance company or the HMO.

4. Doctors – who (bless them) want to provide more care because that is what keeps their patients healthy; but we also must remember that sometimes, doctors also have a financial motivation whereby more health care and more procedures will lead to more money in their pocket. In addition, the current system gives no financial incentive for doctors to coordinate care with other providers.

These four players in the system are all motivated to provide more health care and more expensive health care. The system is fixed to continually increase because there is no one in the system who is manning the brakes!

THE WAY FORWARD

The solution to these issues is simple in theory and more complicated in practice. This solution is a return to triage. Provide health care to the ones who need it, when they need it. The solution, however, given the ensconced positions of each of the players, will not be a quick fix. The US health care system has evolved and been shaped by the market, culture, and technology for over 100 years. A miracle cure will not happen overnight; any new law or system will need to be assimilated into the culture and have its own evolutionary process. However, change needs to happen, and that change must address the incentives and motivations of each of the constituent parties (the doctors, the managers, the insurance companies, and the lawyers).

However, the strategy for health care reform is simple: a return to triage – this entails three steps.

1. Define the resources (set the budgets): At a regional (manageable) level (state, county, or city) define the budget and resources which are available to each entity in any given year. Money, operating rooms, MRIs, hospitals, and all of the other resources available and the cost thereof must be defined and budgeted.

2. Define the health care needs of the population being serviced: At a regional level (state, county, or city), an actuarial study will need to define the health care needs of that particular population; any population of 50,000 persons or so can be studied from an actuarial viewpoint, and a very good estimate of health care needs of that population can be developed.

3. Allow medical professionals to make resource decisions: Doctors and medical professionals then need to make medical decisions on how to use these resources to best service the population. This will be a hard job; there is no doubt about it. However, it is the essence of triage and what doctors should be trained to do and, indeed, what they are paid to do. A limited budget means that not everyone can get an MRI; not everyone can have the expensive course of drugs that has a marginal effect. These are difficult decisions which need to be made, but without a budget limitation, the decision will not be made. These medical professionals, who should be appointed to significant staggered terms to avoid political winds, will have the flexibility to spend money on programs that provide more bang for the buck. They, in effect, will perform triage for the American health care system.

Finally, three other political decisions need to be implemented to allow this strategy to work.

First, health care must be universal and include all citizens. There needs to be an acceptance and realization that we as a country will take care of the basic health care needs of our citizenry. Patient finances should not be the determining factor when providing basic health care. This in turn will make it much easier to define the population and the health care needs of that population (because it is everyone, except those who opt out for private health care). This will also eliminate the universal problems of gaps in coverage when one changes jobs, issues relating to pre-existing conditions, and other problems caused by a private insurance system.

Second, all citizens will be allowed to opt out to a private system. If a person wants to spend his or her money for a special medical procedure, medical “gap” insurance or whatever he thinks is appropriate, he can. It is envisaged that only the relatively wealthy will opt for this type of coverage, but anyone who wants to spend his money on more health care can do so. (This would be analogous to a private school system whereby parents can opt out of the public system at their choice for a fee.)

And finally, and perhaps most importantly, we need to greatly reduce the dollars which are spent on lawyers and procedures performed only to placate the lawyers. Through major tort reform, we need to stop paying the lawyers to police the system. We must eliminate large litigation payouts and thereby eliminate most of the defensive medicine that today is necessary simply to provide an appropriate defense for many doctors. Fair reparation should be paid in certain cases where mistakes are made. However, the multimillion dollar payouts, and more importantly from a cost standpoint, all the waste which comes from defensive medicine in response to such lawsuits need to be eliminated.

These of course are only strategy statements. Work, work, and more work must be accomplished before this strategy can become reality. As such, these are no more than first steps meant to start a dialogue. I welcome discussion and debate which can lead to developing an American health care system which can be the best, the most efficient, and the most compassionate in the world.

Error: Unable to create directory /home/demockra/public_html/wp-content/uploads/2010/09. Is its parent directory writable by the server? Health Care in America: A Time for Change

The purpose of this two part series is to set forth my views on changing health care delivery in America to make it more efficient, more effective, and, most importantly, more compassionate.

In Part 1 of this series, I will explore my personal experiences that led me to write this series and outline the problem. In Part 2, I will lay out my solutions for a way forward to solve the health care problem in America.

My credentials for my views come from both my personal and professional experience. I have 20 years of experience as a financial executive and CFO in the health care industry in America and Europe. As a CFO throughout my career, it was my job to create value (i.e., make profit) through the marketing and delivery of health care to the general population. This involved understanding the rules and complexities of both private and public health care systems from a financial viewpoint. In the later stages of that career, I have founded, owned, and managed health care companies in both the US and the UK and have experienced firsthand how the corporate world prospers in both market-based and government-supported systems. In addition, while living in both Europe and America during this time, I have experienced health care as a patient on both sides of the Atlantic.

In 2005, my health care experience became more personal when I was diagnosed with cancer while residing in the UK. I was treated for the disease in both the UK and the US and directly experienced how each of these countries dealt with the diagnosis, treatment, and aftercare of a person with a major health issue. As a patient with a major illness, I suddenly had a very different perspective on what constitutes best practice when it comes to delivering health care. After one year of treatment and three years of aftercare, I am now a cancer survivor and am on a mission to bring about affordable, efficient health care to all citizens of the US.

Overall, I believe that my 20 years of business/health care experience gives me the expertise to help make a difference in health care delivery in America. My experience as a cancer survivor in America and Europe makes me want to make a difference

My Vision or (How I Learned How to Stop Worrying and Embrace National Health Care)

First, let me state my bias; I believe the UK health care system is better than the US system in many ways:

1. It is more efficient than the US system in terms of costs per capita.

2. It provides better outcomes than the US system (based on measures such as life expectancy and infant mortality rates).

3. It is more compassionate than the US system because all citizens are cared for regardless of income or net worth.

4. It allows for rich people to “opt out” and go private.

What’s not to like – better, more compassionate care for less money, and the ability to pay more to get an even higher standard of service?

My vision for US health care is certainly affected by my experience with the National Health Service (NHS) in the UK and Europe. The UK health care system is far from perfect, and the purpose of this series is not to critique that system. I also know that individual anecdotes seldom tell the whole story. Nevertheless, my health care experiences in a foreign country are worth mentioning.

In 1999, soon after moving to the UK, my son, aged 7, fell and broke his arm. I rushed him to the emergency room and I was in a fair amount of anxiety, not just because of the injury, but because I did not know how the medical system worked. He was in obvious pain, and upon arriving, the attending nurse quickly gave my son some drugs for the pain. After a 30 minute wait, the doctor diagnosed a broken arm, an x-ray confirmed the diagnosis, and after about 2 hours, my son left the emergency room with a cast on his arm. Both he and I were tired, but relieved that everything was going to be OK. While at the ER, we did not fill out forms, and there was no mention of money or insurance. The only thing that appeared to matter was that my son was in pain and injured, and the doctors acted on his injury. A light bulb went off in my head – this might be a better way.

Five years later, while still living in the UK, I was diagnosed with tonsil cancer. Six months of intensive treatment followed including two surgeries, radiotherapy, and chemotherapy. Three years of follow-up care (still ongoing) continued afterward. Interestingly, in terms of health care administration, my bout with cancer exactly paralleled my son’s broken arm incident. There were no forms, mention of money, or insurance and what was covered and what was not. More importantly, there were no discussions of employment gaps or pre-existing conditions or how future insurance coverage would be affected. Instead, the only thing that appeared to matter was that I was ill, and the doctors acted on that illness. I imagine there was some administration and paperwork somewhere, but I didn’t see it. All I saw was a focus between doctor and patient regarding the care, well being, and options of the cancer patient – me.

The light bulb in my head was now a spotlight in my face. This had to be a better way.

The Problem – Health care in America.

American health care, as in many other facets of American life, can lay claim to being the best in the world. America arguably has the best doctors, the best equipment, the best medical schools, the best research and development, and the best hospitals in the world. Many US hospitals are known throughout the world as “The Place” to go to ensure the best health care possible. The Mayo Clinic and the Sloan Kettering Institute are two examples of organizations which lead the world in health care practices. However, from the standpoint of efficiency, effectiveness, and perhaps most importantly, compassion, the US system falls well short when compared to other countries.

For example, studies have shown that the US spends about twice the amount on health care per capita when compared to other Economic Developed Countries (EDCs). (These other EDCs generally use a socialized or government sponsored health care system.) More interestingly, of the total US expenditure, about half is actually spent by the government that generally foots a large portion of the bill for over 65’s (through Medicare) and the “non-wealthy” through the Medicaid system.  (I put non-wealthy in quotes, because nearly 40 percent of the uninsured population in the US reside in households that earn $50,000 or more, so this group is not the indigent poor.)   So, even though there is a popular opinion that the US primarily relies on private health care, the US government spends about the same as other developed countries on a minority of its population even before one factors in private expenditure.  The US already has a national health care system whether it knows it or not.

So the issue is not whether the US should or should not have a national health care system–the US already has one. The issue is how the US as a country can spend twice as much on health care as other similar countries, AND

1. Obtain medical outcomes (as measured by key health care statistics) that are no better and, indeed, worse than many other EDCs.

2. Have approximately 1/6^th of its population (approaching 50 million people) with no insurance or health care plan other than a trip to the nearest emergency room when trouble occurs. This segment of population lives either in ignorance or fear of the liabilities which could occur if their health takes a turn for the worse.

But let’s put these statistics aside and get to the real issue – the human issues of people who are sick and suffering from not only sickness or disease, but also from the anxiety caused from the personal financial repercussions of injury or illness. When you or a loved one is sick and unsure if you have the financial wherewithal to deal with the sickness, the financial/personal issues can become more important than the sickness itself.

So what is wrong with American Health care? One thing that is not wrong is money – as stated previously, twice as much is spent in America on health care when compared to other countries. So what IS wrong is that this money is being spent on the wrong things, and I will sum that problem up in one word - TRIAGE. I will explore this and much more in Part 2 of this series.

Error: Unable to create directory /home/demockra/public_html/wp-content/uploads/2010/09. Is its parent directory writable by the server? What Daschle Means for Health Reform

Lost in the drama that always defines the Clintons, arguably the most important domestic appointment was leaked today and got relatively no attention outside of health care circles.  What was the news? Former Majority Leader Tom Daschle has apparently been offered and accepted the position of Secretary of Health and Human Services. In addition, Daschle will be President-elect Obama’s point man on all issues related to health care policy.

Make no mistake about it, this is a very important appointment. In fact, it is very hard to overstate its importance for anyone who cares about health care.  Daschle will be no Tommy Thompson or Mike Leavitt, picked to head a HHS that wasn’t a top priority for their President.  Daschle will also not be a Donna Shalala, who had no real power during the Hillarycare debacle. In his role as HHS Secretary, Dascle will be an all out Health Care Reform Czar for the Obama administration. In this role, Daschle will be charged to use his thirty-plus years of Washington experience and contacts to push comprehensive health care reform, including universal insurance, through the congress. And if successful, Daschle will be in charge of getting the new national health program (not to be mistaken with nationalized health care) off the ground running and through its first few years of existence. This may seem easier than the tasks awaiting the new Secretary of State or Treasury Secretary, but bear in mind that similar tasks to reform health care have failed many times over the past 60 years. I wrote more about this history last week.

With lessens from history as our guide, why does Daschle have a good chance to succeed where others, including Hillary Clinton and Harry Truman, failed?

• Daschle has the ability to get things done on the Hill. He served eight years in House and three terms in the Senate, including as Majority and Minority leader. In this capacity, he has the same core competencies that Lyndon Johnson, “the master of the Senate,” had when he ushered through such legislation as the Civil Rights Act and the expansion of the Social Security Act to include universal coverage for the elderly, disabled, and indigent (Medicare and Medicaid).

• Daschle, unlike Hillary Clinton, won’t be a divisive partisan crusader installed because of his or her last name. Daschle showed an ability to work well with Republicans during his time in Congress.

• Daschle by all indications has the full support of President Obama. Daschle was behind Obama early on in his Presidential race, and Senator Obama has returned the favor. Dashle was briefly rumored to be a potential vice president or chief of staff. However, I imagine Daschle would much prefer this new role. He is a smart man and realizes the potential impact and legacy of such a role, if successful.

• Key number: 58 or 59. With 58 or 59 seats in the Senate, his job will be much easier than Hillary’s was in 1993.

Any views expressed here do not necessarily represent the views of any organizations that the author is in any way affiliated with.

Error: Unable to create directory /home/demockra/public_html/wp-content/uploads/2010/09. Is its parent directory writable by the server? A Mandate for Health Reform?

Democrats have officially taken a trifecta or control of the White House, House of Representatives, and Senate for the first time in fourteen years. House Democrats have picked up over 20 seats and Senate Dems will likely have between 57 and 59 seats in 2009. These majorities with a Democratic President are the largest since the days of Lyndon Johnson. Like that time period, there is a real chance for a progressive window. In this type of window, which normally only happens once every 30-40 years, the Democrats will have the potential to pass landmark legislation.

What will be the policy priorities?

My guess is that there will be three top priorities: health care reform, environmental cap and trade, and  financial regulatory reform.

For now, I will focus on one of these priorities

Health Care Reform

The United States has come tantalizingly close to universal coverage several times in the last 60 years. First, in the 1930s, health care was left out of the original Social Security bill after much debate. Next, in the late 1940s, under President Truman, health care reform came within a few votes of passage. Next, in the last progressive window in 1965, Medicare and Medicaid were passed as a first step to what was thought to be universal coverage. However, other political realities, such as the Vietnam War, got in the way. Then in 1993, the last time the Democrats controlled the trifecta, came Hillary Clinton’s failed attempt at universal health care. The first two efforts were stymied in part by the strong opposition of organized medicine, in particular the American Medical Association. The insurance lobby helped put a stop to the latter effort. Ironically, the same Harry and Louise characters, who were famous for their 1993 commercial about government staying out of their medicine cabinet, have returned in a health reform commercial put forth by various leading health care associations and lobbying groups. Unlike the previous ads, these characters are now in favor of some sort of universal coverage as part of a comprehensive reform solution. In addition, one of the leading organizations calling for reform in 2008 has been the American Medical Association. While it is true that agreeing to reform in general will not necessarily lead to policy cohesion, having virtually all industry groups at the table is encouraging as long as reform does not become captive to these same groups.

There is general agreement that universal coverage must not only be for all, but must also be paid for by all. Thus, there is a sense of shared sacrifice that must take place in order to achieve universal coverage. With that said, it is important to note that universal coverage alone is only half of the solution. There must be cost controls and a continued increase in tying provider payments to performance and high quality outcomes. In addition, there must be incentives to correct the maldistribution of providers. Having insurance matters little if you cannot get high quality care and/or there are no health care providers in your area. Good luck finding a specialist in an under-served area. To solve this, there must be legislation to correct for the financial and cultural dominance of certain specialties of medicine at the expense of others.

Many health care experts believe that the states are the best laboratories. In this sense, the relative success of the Massachusetts health care plan in terms of achieving universal coverage should serve as a model for moving forward. However, at the same time, policy makers should be aware of the limitations of this model since it has not done enough to control costs.  According to the Massachusetts model, there will still be a private health insurance market, and no one will be forced to sign up for a government plan. (In fact, in Massachusetts there is no public plan at all, which may be part of the reason for the lack of cost containment.) Building on the successes and failures of Massachusetts and other states, regional health markets should be set up to help keep costs down and provide efficient coverage to every citizen.

What about mandates?

Unfortunately, Barack Obama was generally against mandates during his campaign for president. This is naïve from an economic standpoint. In order to control costs and avoid adverse selection, mandates must be in place so that all healthy individuals diversify the risk pool. Without a truly diverse risk pool, there is no way that universal coverage can be sustainable from an economic sense.

Overall, I think it is important to highlight the need for mutual sacrifice for the good of the country that will be needed in order to achieve the type of real health care reform that will be needed in order to lead to a fulfillment of the Institute of Medicine’s six health care aims–health care that is more safe, effective, patient-centered, timely, efficient, and equitable.

We must have a real call to all Americans do something for their country. Such a call hasn’t been made since JFK, and it’s been a long time coming. I hope that President-elect Obama will be able to issue such a call, because nothing less will be sufficient if we are to find a sustainable solution to our health care crisis.

Any views expressed here do not necessarily represent the views of any organizations that the author is in any way affiliated with.

Error: Unable to create directory /home/demockra/public_html/wp-content/uploads/2010/09. Is its parent directory writable by the server? McCain’s Health Plan: DOA

John McCain is fond of repeating the patently false assertion that Barack Obama would “raise taxes on the middle class.” FactCheck.org has had to re-iterate that Obama’s tax plan would absolutely not “raise taxes on the middle class,” unless people in the “middle class” make over $250,000 a year. Even though the ads have been thoroughly debunked, McCain continues to repeat this claim, which is not just an opinion, and not just “spin,” but an outright lie. In no way will an Obama tax plan raise taxes on the “middle class.” McCain knows this, and yet he continues to say that Obama’s tax plan will raise taxes on the middle class.

Ironically, McCain is himself preparing a tax on the middle class — in the form of his health care proposal. McCain, of course, wants to work within the broken confines of the broken health care system. This is his plan for “reform,” but to borrow a phrase from Barack Obama, McCain’s health care plan is still a pig wearing lipstick. There is no real reform: no attempt to bring costs — which have doubled (doubled!) since 2000 — down; no attempt to utilize the government’s bargaining power to get deals for patients; no attempt to get health insurance for people who are denied due to “pre-existing conditions.” McCain’s plan is this: throw a $2500 tax exemption ($5000 for families) at consumers and tell them to go get their own health care.

That’s it. Here’s some money, let The Market work things out.

The problem — as I’ve often said in the past — is that health care does not operate according to the Invisible Hand, since the respective interests of the health care provider and the health care customer are mutually exclusive. The insurer (provider) wants to provide the least amount of health care for the most amount of money. The customer wants to obtain the most amount of health care for the least amount of money. People who get health insurance through their companies get a break, since they get group rates. Because there are so many people in the insurance pool, the average cost of health care per person can stay low, and the pool can absorb the hit if any member of the group needs to cash in on that health care.

McCain isn’t even proposing that. Literally, he wants you to get your cash, go down to the UnitedHealthCare office, and sign up for a plan all on your own. No group discounts. No nothing. Regular retail price. Health care premiums in Ohio start at $300 per month. Even The Wall Street Journal agreed that John McCain’s health care plan was outrageous.

At the same time, McCain wants to tax the money that employers contribute to their employees’ health insurance:

The value of the typical plan provided by an employer to a family is $12,106, of which the employer pays $8,824, and the worker pays the remaining $3,282. The median household income is $44,389, which places most American families in the 15 percent income tax bracket.

McCain wants to add the employer’s cost — an additional $8,824 — to that middle class family’s income, then tax it. The hit to the average family is 15 percent of the McCain-added income — $1,323 more in income taxes.

This new tax would affect the 158 million Americans who are insured through their employer.

Now there’s a tax on the middle class! The Hill Blog goes into a little bit of conspiracy theory, though:

So if you choose to remain with your employer-based insurance, there’s no guarantee that you’ll ever see any benefit from that $5,000 payment. In addition, giving young healthy workers $2,500 to buy insurance on their own, where it won’t be taxed, will encourage them to leave employer-based plans, quickly raising the costs for everyone remaining and thus eliminating benefits of the tax credits. 

Republicans love to complain about how ineffective a particular agency or program is, intentionally staff that agency with idiots, and then, when the idiot-staffed agency messes up, point to that agency and exclaim (loudly enough for the cameras to hear), “See?! I told you that the government doesn’t work! Now, the private sector, that would have done things better!” Then, they outsource the previously government-provided benefit or service to a private company, most likely run by the personal friend of someone high up in the government.

The end result of the situation described in the blockquote above is that private health insurance companies would find their coffers pregnant with the cash generated by individuals buying insurance at the retail price rather than the discounted group rate. Why settle for getting income from group discounts when you could goad your consumers into paying full price?! That’s what I call reform.