Sunday, February 07, 2010

How to get enough votes in the Senate

When Hillary Clinton was running for President, she set forth a more modest agenda for health care reform than her competitor, Barack Obama. Maybe she understood better, based on her experience, how difficult it is to get a comprehensive bill through Congress in this field.

What is possible now that the President has lost the 60-vote majority in the Senate? I think the thing to remember is that he was having trouble even holding together the 60 votes he used to have. He had to agree to an assortment of give-aways -- to Nebraska, to Louisiana, to the labor unions -- to get the votes he needed. In part, that proved to be the undoing, as Massachusetts voters watched this sausage being made and sent a message through the election of Scott Brown that they didn't like what they had been seeing.

Now, it may be that the Republicans will act to kill anything that might come along. I don't think so. I think they are willing to be part of a bill, but it has to be a bill for which they can claim credit among their constituencies. What might it be?

Insurance reform: People, irrespective of party and political leanings, despise the practices of insurance companies that limit or take away coverage. The use of pre-existing conditions to deny coverage, lifetime limits of coverage, and rescission of policies are nasty and unfair. These practices remain as sources of insecurity among Americans, even those with insurance. There should be near-universal support to change them.

Tort reform: I think that most people feel that, while people should have a right to sue for medical malpractice, the process that exists today is inefficient and arbitrary for both plaintiffs and defendants. Any doctor will tell you that fear of such suits also leads to the practice of defensive medicine, driving up costs for all of society. Tort reform does not require limitations on payments. It could be accomplished with the establishment of specialized courts and procedures that would add greater certainty to outcomes and reduce the tensions and abuses associated with the system. This should not be a partisan issue.

Payment reform: Nobody likes the results of a system that systematically underpays primary care doctors and leads them to a life of 18-minute appointments and a role as triage doctors, a way station to referrals to higher paid specialists. If Congress were to order Medicare and state Medicaid plans to take the lead in establishing reimbursement rates for PCPs that reflected their value to families and patients, we would be on the way to a more rational system of care. Likewise, if physicians were paid for care delivered by telephone and electronically, millions of unnecessary and time-consuming office visits could be eliminated. If these steps were taken for Medicare and Medicaid, private insurers would follow.

Transparency: A national mandate for public disclosure of the rates paid by insurers to providers would help drive greater rationality in payment methodologies in the states. Disclosure of clinical outcomes in clinically important arenas would provide impetus to improvement in patient safety and quality. How can this be a partisan issue?

Now what about access? I fear that expansion of insurance coverage is the third rail in this debate. Why? Because it requires revenue to support the subsidies that would be required, and tax increases are really hard to achieve. The President made this issue more radioactive than necessary by proclaiming at the start that you could get access, choice, and lower costs all in one neatly wrapped package. Everybody in the field knew that you could not. This then resulted in sleight-of-hand revenue measures that became the undoing of the bill as Christmas tree ornaments were added to undo the effect on particular states or interest groups.

As I have stated here, a fair approach to generate the revenues for expanded access is to eliminate or reduce the pre-tax treatment of insurance premiums. Doing so would use the progressive income tax system in a way that would apply a larger percentage of these costs to more wealthy people. Could this approach gain a bi-partisan consensus? It could not gain support even among the Democratic majority, so I am guessing not. And the Republicans seem to express no interest at all in mandates for greater access. Maybe we have to accept as a reality the idea that expanded access is a casualty in this debate. I hope not, but I don't yet see an answer to this that can get 50 votes, much less 60.


Steven Horvitz, D.O. said...

While some of your comments are valid, especially concerning tort reform and ending pre-existing conditions, you still seem stuck in the notion that the third party payment system is the way health care should be paid for.
The third party system has been one of the major driving forces of healthcare inflation. Its continuation with pricing controls set by government would eventually decrease access, not increase it as many docs would take themselves out of the system.
I think the disagreement we have is you are in a hospital model, while many primary docs are not.

people need some individual responsibility to bring down costs.
governments have no individual responsibility and look how they run their budgets.

we need a paradigm change in the payment schemmes for healthcare, back to the individual and away from third parties, tied to catastrophic policies. I remember growing up as a kid, before insurers got so much power, that hospitals were a;ways expanding their services. It can happen again, if peopel would only demand it!!!


Anonymous said...

I understand that an amendment has been proposed that would provide that Members of Congress would receive their medical coverage under the bill. I've read that there is no interest in accepting this amendment.
Agreeing to this amendment would go a long way toward showing their enthusiasm for it.

Anonymous said...

Why don't you spearhead a group that can actually write the legislation that is required (come up with the right healthcare bill)

The problem with most legislation, is that it is written by legislators and their lobbyists. If the recent healthcare bill (with the give-aways to special interest) is any testament, they are not up to the task.

Why can't someone take this a step at a time and come to some consensus on facts - such as: is there any truth that 70% of healthcare costs are attributable to lifestyle choices, and if so there has to be some way to incorporate this, just like Life Insurance - why should i pay the same premium as someone who smokes, answer = I don't.

Another step is to take employers out of the process. Think thru it and it is absurd.

Health insurers do not invest in the long term health of their customers, because the average customer stays with them only 3.5 years (or something close to that)

How about coverage over state lines.

Tort reform (only the lawyers are against this, but almost all of the legislators are lawyers) talk of the fox guarding the hen house...

Just some thoughts, I know very little about the process.

Keith said...


The problem is that the republicans are too firmly rooted to the fantasy that the free market will fix everything if goverment keeps its hands off; something that is not likely to work for health care. And they seemingly gain more politically by opposing the presidents agenda, adding to their willingness to stick to their positon. Therefore, we can never raise taxes under any republican senario and thus can never broaden access to the middle class without adding more to the deficit. It is not fair to insurance companies to require mandates on covering presexisting conditions and such unless you broaden the pool of the healthy paying premiums through mandates on insurance coverage.

As a PCP, the payments for e-mail and phone calls would help greatly. How short sighted to have insurance pay only for a person to person office visit that inconveniences the patient and costs more, when an over the phone communication is so easy for all concerned.

I think your comments are spot on regarding the idea that health care reform was oversold in that we would get something for nothing, but this seems to be the only way the political process advances. After all, politicians learn early on they can make all kinds of promises to get elected while knowing they are not based in reality.

I am reminded that when the drug benefit plan was passed during the Bush years, that the CBO conveniently withheld the revised cost numbers for the program till after it was passed; otherwise it would have never survived (and maybe should not have). It seems a little deception is needed to get meaningful changes when the public expects goverment to provide for them, as long as someone else bears the cost.

Overall an excellent synopsis of what needs to change in health care.

Anonymous said...

I tend to agree that some legislation is likely, but hopefully nothing close to the original House or Senate bills. With regard to tort reform, it was apparent from the time that Mr. Obama addressed the AMA convention that tort reform wasn't even on the table (amazingly this organization fell into step with the proposed legislation minus tort reform). By dismissing what nearly every one except the tort lawyers would recognize as common sense, it was hard to take the Democrat effort seriously.
I lived in Germany for a couple of years with a judge as my next door neighbor. She presided over malpractice suits but with a set of rules that would make most tort lawyers here cringe - three judge panels (not juries) very knowledgeable about medicine and the concepts of malpractice, the ability for the judges to access expert opinion, no contingency fees, and losers paying court costs. Furthermore, if a lawyer brought forth a case that the judges considered "frivolous" there were significant penalties. It is so much more rational than the lottery that we have here.
BTW enjoy your blog very much.

Barry Carol said...

Labor unions vehemently oppose major changes to the tax preference for employer provided health insurance and trial lawyers strongly oppose tort reform that includes either specialized health courts or robust safe harbor protections for doctors who follow evidence based guidelines. Both labor unions and trial lawyers are key supporters of, contributors to and fund raisers for Democrats. Until the President and the majority leadership in Congress show a willingness to take them on, meaningful progress is unlikely on these two issues. While nobody likes to be denied access to insurance due to a pre-existing condition, the industry can’t eliminate that approach in the absence of a mandate to acquire insurance. Without a mandate, healthy people will just wait until they get sick knowing that insurers will have to accept them at standard rates. It’s classic adverse selection. At the same time, millions of lower income people would need subsidies to afford to buy insurance. As for price transparency, which I would love to see, insurers claim it could actually lead to higher rates as providers who are paid less agitate for more while those with significant local or regional market power will refuse to lower their rates.

At the end of the day, it’s hard to see how substantive health reform can happen unless and until all the major stakeholder groups are willing to take some risks and give up something substantive in money or power in the short term in order to achieve a more cost-effective and sustainable healthcare and health insurance system over the long term. So far, everyone is saying, in effect, reform the system but whatever you do, don’t cut me. It won’t work.

Engineer on Medicare said...

There is not yet enough pain to force the politicians to solve the problem. When it gets to that point, it should be a program based on the "Golden rule": He who has the gold makes the rules!

The people developing the program should start with a set of principles, perhaps along the following lines:

The whole health care system will be broken where necessary and reconstructed as a LEAN system where the patient is part of the system and bears some responsibility.

There will be no sacred cows with sweet deals: Not drug companies, insurance companies, trial lawyers, labor unions, health care providers, patients beyond the point of useful intervention, or anyone else you can think of.

The one with the gold will force competition for services or products and the losers can match the terms or do something else.

There will be evaluations of cost effectiveness and the one with the gold will not pay for ineffective care beyond the point of useful intervention. Medical providers and developers of drugs and devices will know that payments will be limited based on effectiveness of the treatment. The concept of "Cost is no object because someone else is paying." will not apply.

And there will be serious investigation and prosecution of fraud with mandatory prison for those convicted, and those convicted will be barred for life from participating in the program.

I'm sure that those in the health care industry will have more and better ideas but the guiding principle must be affordability and health care effectiveness.

Anonymous said...

Transferred from Facebook:

Susanne: I' m listening, BUT where in this list is the part that keeps insurers from dramatically increasing premiums once they can no longer deny coverage for pre-existing conditions or limit coveraged for the insured who are sick?

Michael: In the primaries, most found the Clinton health care plan to be more ambitious than Obama's, since it included a mandate and a strong public option ( Her plan was more expensive and less likely to pass, the only positive to Obama's was that it was far more pragmatic.

Of course, what is in the plan is entirely moot. It could be a voucher plan that eliminated Medicare and was named after Ronald Reagan and the Republicans in the senate (with help from the Landrieu, Lincoln, Nelson, and Lieberman wing) would still filibuster...

Engineer on Medicare said...

The government is paying for half of health care now. Providers want to get paid for all of the indigent care that they are compelled to provide. Insuring those with preexisting conditions is a problem and young healthy people are not paying into the system.

I'm satisfied with Medicare. I propose as a "Straw man" a Medicare model that is paid for by a Value Added Tax. I'm interested in seeing (a) refinements of that model, compared with (b) any alternative that someone can come up with. Incorporate some of the criteria that I described above or modify those criteria.

It should be possible to define a system, test it with "thought experiments", and refine it to something that meets the needs at reasonable cost.

Anonymous said...

Engineer on Medicare:

I'm afraid you are thinking much too logically. Politics is inherently emotional, and emotion is what's driving the "discussion" (if we can call it that). I am afraid that means nothing will be done until circumstances are truly dire for a large part of the population, similar to the jobless rate right now. Your satisfaction with current Medicare is part of why nothing is being done - Medicare covered people vote in large numbers.


Michael Kirsch, M.D. said...

Regrettably, I don't see much bipartisanship in the offing on health care reform. Both sides are viewing all issues through the November 2010 prism. There will be offers of bipartisanship, for sure, with each side accusing the other of pulling back. I agree with you re tort reform - a nonstarters. Couldn't pass it even when GOP controlled both branches. Need a health court, or some similar device to screen out innocent physicians from the outset. Caps (which I have supported reluctantly) would be less important if we had a filter in place. With regard to payment reform to pay primary physicians more, which specialists will be ready to willingly surrender their income to them?

Brenda RN said...

I have to disagree about the Republicans. They will not vote for anything. I think they agreed to kill this, regardless of what gets added to it.
I am all for bipartisanship, but both parties have to participate. Making concessions to win Republican votes, only to have them all vote no, is not bipartisanship.
If they are going to vote no anyway, then I think the Democrats should just focus on trying to get the best bill, and accomplish the goals of reduced cost and increased coverage. They will be lauded or blamed anyway, so they should just go for it.

Michael Kirsch, M.D. said...

Brenda, I don't think the Dems will take your advice after the Massachusetts election results. They would rightly fear that they would lose their majorities if they continued to push a plan that most Americans reject. This is why the Dems are pulling back.

Anonymous said...

There is a package of scaled back measures that they should undoubtedly agree upon rather than do nothing -- no doubt. It took 4 years to pass CHIP after the fall of health reform. They cannot make that mistake again.

However, having worked in the Senate for 10 years, I can assure you this analysis misses the 60 vote margin in the Senate.

* First, the Senate GOP is working to give this Admin nothing, even to the extent of voting against things they cosponsor (e.g., look at recent Debt Commission vote), so they are inclined to vote against even their own ideas right now.
* Adding tort reform loses you more votes than it gains (more Dems will walk than Reps voting for it -- note that Reps had the President and Congress and never passed it for years of the Bush Admin).
* The insurance reforms that you can get without mandated coverage would drive up costs, but "controlling costs" is the #1 issue for voters in health reform so they can only do limited things here
* Changing the pre-tax treatment of health reform is wildly unpopular -- psychology shows people have tremendous loss aversion and fear what they might lose far more than what they might get.
* Payment rates - good policy thing but voters aren't flocking to the polls on the issue..
* Transparency - same
* Strike access - "covering all children" is actually the #2 issue of importance to people with health reform and "covering all low-income people" also polls well.

So, why eliminate access to care and other things important to progressives and pass a package of "weak soup" instead that is more a set of GOP reforms that they won't even vote for?

Rather than start over, do what it takes to get moderate Reps. Thus, instead of starting over, which isn't viable, give moderate Reps the teacher's red pen and let them cut some. This would certainly scale back the package they have.

Thus, maybe you do need to postpone some of the subsidies in the exchange (saving hundreds of billions and taking off the table issues such as choice, immigration, and the excise tax). But, why wouldn't you go ahead with creating the exchanges, providing small business tax credits, covering everybody in poverty, doing some of the child health measures and effectively declaring victory on an issue that polls 87-11%, closing the Medicare Rx donut hole for senior citizens and people with disabilities (as well as some of the other things on his list) if Snowe and Collins would agree to it?

Anonymous said...

I think the President's idea of inviting the Republicans to a public meeting is just a stunt that is just as cynical as the stuff some of them are doing:

Picking up on your theme, though, why not find a few moderate Republicans to actually co-sponsor a bill? Or -- imagine this -- picking up Scott Brown to co-sponsor a bill, perhaps jointly with John Kerry. The new Massachusetts miracle?!

Brenda RN said...

If a moderate Republican would actually do that, Paul, it would be fantastic. I just don't see it happening. And Michael, I disagree with your statement that most Americans reject health care reform. I think they reject the process, the unseemly rewards for votes, and the scary lies spread by talk radio. But given the facts of what health reform would do, most Americans support it.

Michael Kirsch, M.D. said...

Brenda, I agree that the the public repudiated the Democratic 'sausage making'. No transparency and backroom wheeler-dealering. With each passing month, polling showed the public was increasingly skeptical about the substance also. Of course, it depends upon how you frame the country. If you ask if you 'support HCR', most folks will say yes. When they hear the details, however, their enthusiasim wanes.

Paul, your thought of a 'Massachusetts Miracle' sounds to me more like a 'Massachusetts Mirage'!

Anonymous said...

Paul, I disagree about Obama inviting the Republicans. If they have something constructive to say, let them say it and work to incorporate it into a bill. If they really just want to be the party of "no",then he will expose them. Politics is a dirty game all around. Kind of like you trying to run your hospital by different rules, and not reaping any benefit because Partners' has the gold. Sometimes you gotta beat 'em at their own game.....


Anonymous said...

Of course it is fine to talk, but public meetings just beget grandstanding. That's not how you build a legislative agenda. They goal here should not be to expose anybody. It should be to get the job done. One way is to give them a sense that they can share the credit for things that matter to their constituents. It is time for quiet negotiations, not theatre.

Anonymous said...

When the Senate was having quiet negotiations, Republicans criticized Obama and Democrats for not letting the public witness the discussion, so they basically forced Obama to hold this public spectacle. Democrats could give Republicans free rein of health care legislation and they would still vote against whatever bill they could come up with.

Anonymous said...

Transferred from Matthew Holt's page on Facebook, where a parallel conversation ins emerging:

me: If you are serious about reaching an agreement, you don't televise the meeting. This is a terrible way to proceed.

Jeff: Agree w/ Levy. This is theatre, designed to capture the reality that the Repubs don't have an affirmative agenda.

Renata: Both - seems to be the leadership style, which makes one wonder what the point is beyond being able to say - "I tried." I asked my McKinsey-er Xer daughter what strategy this was - and she and her friends laughed out loud. She said generally they put warring parties in separate buildings - and certainly NOT on television to PERFORM. So that's it. We have PERFORMANCE ART. Maybe the locale should be Lincoln Center.

Anonymous said...

Access --and especially access for the poorest in our country -- is the whole point of this bill. It is at the heart of "insurance reform" (which results in more access), and affordability (insurance costs go down when everyone has to participate in the system). Even the "special deals" were about access -- how could states fund mandatory Medicaid expansions with no cash? So Nebraska got 100%, while MA got 97.8% -- how awful!! A windfall! To cover poor people!! We should be ashamed!!! ...For failing to pass this bill.

Anonymous said...

I'm not sure why anybody is pretending that the Republicans have any interest in an agreement. I'm not saying this in a partisan way. Think about where they were a year ago - disorganized, despised for GWB's myriad failures and basically SOL. They decided to go with just blocking Democrat legislation as their only real option... and it's worked. The right or wrong of that is of course debatable, but the success isn't. How could anyone say with a straight face that they want to risk that success to wade into the morass of actually trying to pass something?

Michael Kirsch, M.D. said...

To the above anonymous commenter who remarked: "They decided to go with just blocking Democrat legislation as their only real option... and it's worked." Do you think it might have been that the Democrats' ideas were not accepted by the public as much as GOP obstructionism? I suspect the former and the results of Massachusetts supports this. There is no level of GOP plotting that could win Kennedy's seat in liberal Massachusetts. Scott Brown won because the electorate - not the GOP - said no.