Interestingly, the amendment wording does not make any attempt to reverse the provisions in the PPACA that require health insurance carriers to accept all applicants as of 2014.

If I understand it correctly, the backers of the Right to Health Care Choice Initiative want a health insurance system that would require health insurance carriers to accept everyone who applies (since they seem to have no problem with that part of the PPACA), but with no requirement that people purchase health insurance.  While I can understand the desire to be free from government regulations that direct how we conduct our lives, this particular freedom only works if the health insurance carriers can be free to determine which applicants they will accept and which they won’t (the way our system currently operates).

Most people I’ve talked to can see the problem we would have if we were to remove the guaranteed issue aspect of health care reform but keep the mandate portion (ie, require everyone to purchase health insurance but still allow health insurance carriers to underwrite based on medical history).  For some reason, the opposite scenario doesn’t seem as far-fetched to a lot of people.  But in reality, it just wouldn’t work.  I cannot see any conceivable way that health insurance premiums wouldn’t dramatically increase if all individual policies had to be guaranteed issue but people could come and go as they pleased from the health insurance system.

Regardless of whether amendment 63 passes or not this fall, federal law still overrules state law and Colorado will have to go along with the provisions of the PPACA unless there are changes to the law on a federal level.  But it will be interesting to see what the people of Colorado think about this issue.

But Maggie points out that this isn’t likely to be the case (instead, we’d just end up with continuing unchecked price increases for health care services, and correlated increases in health insurance premiums).  She makes a couple of very good points:  first, Medicare doesn’t cover everything (proponents of a single payer system often talk about “Medicare for everyone”).  In the case of a hospital stay that lasts several months, an insured with Medicare coverage who doesn’t have a supplemental policy would be facing a very large medical bill.  My father has kidney failure and was hospitalized for several months in 2004.  Medicare paid 80% of the cost, but if my father had not been covered by a supplemental private policy, my parents would have been on the hook for tens of thousands of dollars for the other 20% (even with the dramatic price reduction that goes along with the Medicare negotiated reimbursement rates).  Even a less catastrophic medical situation can get expensive for someone who doesn’t have a supplemental medigap policy.  20% starts to add up quickly.  Although Medicare is a great safety net for older Americans, it doesn’t provide as much coverage as the typical employer-sponsored group health insurance policy.  And it’s not free.  Enrollees pay premiums for Medicare itself in addition to private supplemental coverage if they choose to have it.  Once they tack on a supplemental policy, many enjoy health insurance coverage that is similar to what they received from their employers prior to retiring – but basic Medicare by itself is not as generous as the policies that most Americans get from their employers.

The other excellent point that Maggie made is that most Americans who have private employer sponsored health insurance like their coverage.  And they definitely like the fact that the employer pays a good chunk of the premiums.  If we were to switch to a single payer system, someone will have to pay for the coverage that employers are now providing, and it’s not likely that employers would continue to contribute as much to a single payer pool as they do to their own employees’ coverage now.  Basically, we’d end up with a single payer health insurance policy that would require more enrollee cost-sharing than current group plans, and with fewer benefits.

Here in Colorado, 56.6% of the population had employer sponsored health insurance as of 2008, which is higher than the national average of 52.3%.  I have no doubt that when the numbers come out for 2009 and 2010, there will be a drop in both of those numbers due to the recession.  But  most non-elderly Americans still get their health insurance through their employers.  And in general, as long as people are somewhat satisfied with the status quo, most of us tend to be a bit resistant to change.  Obviously, people who are currently uninsured are likely to support sweeping changes in the health care system.  But most Americans do have health insurance, and those who have generous policies – that are at least partially funded by their employers – might find themselves with less coverage if we moved to a single payer plan.

Maggie’s article was included in the Health Wonk Review this week, hosted by Joe Paduda of Managed Care Matters.

The idea behind the program is to reduce childhood obesity in low income families by giving patients vouchers (worth $1/day for each family member) that can be redeemed for fresh fruits and vegetables at farmers’ markets.  One of the biggest obstacles preventing low income families from eating produce is the cost – it’s a lot less expensive to eat from a fast food value menu than it is to shop for fresh produce.  So a program that subsidizes the cost of produce is likely to make it easier for families to add fresh veggies and fruit to their meals.

WIC has a farmers’ market program too, and it operates in 36 states.  But unfortunately, it looks like Colorado is not one of them.

WIC is funded by tax dollars, but the prescription veggie pilot program is being funded mostly by a charity organization.  It will be interesting to see if the program has any long-term effects for the families who are currently enrolled, and how they do over the winter when farmers’ markets are closed and the vouchers aren’t available.  If it goes well, I can see similar programs being adopted in the rest of the country.  Funding could be both public (like WIC) and private (maybe donations from organizations in the health care industry like hospitals and health insurance carriers).

I love the idea of making nutritious food more available to people who might otherwise be unable to afford it.  And I also like the fact that doctors are getting actively involved in their patients’ diets.  Hopefully this will have an impact on our obesity trend, and reduce the healthcare costs associated with obesity.

Although we could see it, we couldn’t get it out.  We tried briefly, but were afraid we would push it further in or that it would somehow wiggle it’s way into his sinuses, so we decided that the wise choice would be a trip to urgent care.

After our son’s finger incident last winter, he’s understandably wary of doctors, and as soon as we got out of the car at the urgent care clinic, he started saying “no doctor, no doctor”.  Hopefully he’ll remember that next time he thinks about sticking something in his nose.

We went to an urgent care that is part of Poudre Valley Health Systems on Harmony and Timberline in Fort Collins.  The receptionist greeted us, took our insurance card and id, and started filling out paperwork for us.  She asked us if we had attempted to remove the stone ourselves, and we told her what we had tried.  Then she mentioned that if we wanted to possibly save $140, there was one more thing we could try:  Hold his other nostril shut and blow into his mouth.

So Jay did just that.  And on the third blow, the rock came shooting out of our son’s nose.  We were thrilled – no need to sit in the waiting room at the urgent care facility, no need to subject our son to whatever instruments doctors use to extract stuff from toddler noses, and no need to pay for an urgent care visit (we have an HSA qualified policy with a $5000 deductible, so we’d have been paying for the whole thing).

We were in and out of the clinic in under five minutes, and it didn’t cost us anything.

A lot has been said about over-utilization of health care lately, and the need to reduce both cost and utilization in order to make our health care system sustainable.  But I wonder how many urgent care clinic front desk people would be willing to give out free advice like that, and how many would have just taken our insurance info and sent us in to see the doctor?

So he proposes an alternative:  an open source history and physical exam that would allow different doctors to access and add to each other’s notes without having to duplicate work already done by someone else.  It makes perfect sense, and does seem like a much better way to avoid errors in patient care.

Happy notes that such a system would work best with a bundled care reimbursement model, and that some doctors are nervous about such a system because they fear that they would earn less money overall.  But he goes on to point out that earning a little less money might be well worth it if your job is easier and you get to spend far less time repeating tasks that someone else has already done.  In addition, there would be less paperwork (electronic or otherwise) for health insurance companies to process, which should result in lower administrative expenses.

I love this idea.  I’m a big fan of technological advancements in health care billing, charting, prescribing, etc.  In an era when we can carry around phones the size of a deck of cards that double as palm-top computers, medical providers should be able to spend their days helping patients rather than worrying about getting their coding just right (and duplicating the work of six other doctors in the process) in order to get paid.

There are many reasons for the dramatic increase in c-sections over the last couple decades.  Too much medical intervention, a legal system that pushes doctors towards c-sections at the first sign of a hiccup in the birth, parental requests, ACOG’s recommendation against VBACs, etc.  Some have also pointed out that doctors make a lot more money for doing a c-section, and can do one a lot faster than it takes to wait for a laboring woman to give birth on her own.

It seems like that last one should be relatively easy to fix, if reducing the c-section rate is indeed a priority.  To make the math easy, let’s say that a surgical birth costs $20,000 and a vaginal birth costs $10,000 (these are completely random numbers.  The real numbers vary dramatically from one state to another, and from one health insurance network to another).  If we say that the goal should be no more than 15% c-sections, we can say that for 100 births there should be 85 vaginal deliveries (amounting to $850,000) and 15 c-sections (amounting to $300,000).  Add those two amounts ($1,150,000) and divide by 100 to get the average price of a delivery if we were to achieve a c-section rate of 15%:  $11,500.  In reality, the math would be much more complex than I’ve made it here, but the basics would remain the same.

Now that we have the average cost of delivery if no more than 15% of deliveries were surgical, that could become the standard payment for all births, regardless of whether a c-section were performed or not.  There would be no financial incentive for doctors to opt for c-sections, as they would no longer receive higher compensation for doing so.  The tough medical malpractice environment that OBs practice in would likely provide more than enough motivation for them to continue to do c-sections when there was a true medical emergency, despite the fact that they would know there would be no additional compensation for the birth.

The rising c-section rate is driven by a variety of factors, and obviously the problem needs to be confronted on many levels.  But it seems counter-intuitive to expect doctors to reduce their c-section rates when we’re paying them more to perform them.

Obviously this wouldn’t work for all seniors.  People who are living on social security without any other income would be hard pressed to come up with $375 to be seen by a doctor who doesn’t take Medicare.  And others might balk at the idea of seeing a doctor who doesn’t take Medicare, regardless of whether they could afford the care.  But for those who are open to the idea and able to afford the services, Dr. Dappen does make it sound like a good deal.  No hassle, no waiting, and the doctors will visit your home if you can’t go to them.

I’m curious what a procedure like this would have cost if the patient had opted to see an in-network Medicare provider in an office setting?  As Dr. Dappen pointed out, an ambulance with a stretcher and paramedics might have been needed to transport her to the doctor depending on the severity of her osteoarthritis.  That alone would have been more expensive than the procedure itself.

House calls are definitely still rare these days, but they are gaining in popularity as our population ages.  The Independence At Home Act of 2009 created a test program to see if money can be saved and outcomes improved for 10,000 of the sickest Medicare patients – people with multiple medical conditions, who have needed high cost health care in the previous year.  Time will tell how it works, but the idea is promising.  Keeping people in their homes helps to make them comfortable, reduces stressful transportation issues, and also avoids possible infections that spread easily in medical offices and hospitals.  Obviously for serious situations hospitalization would still be necessary, but for dealing with more minor illnesses and injuries, and especially preventive care, home visits make a lot of sense.

Private health insurance companies tend to take some of their cues from Medicare in terms of what they cover, so if Medicare eventually makes home visits more available, it stands to reason that people with private health insurance might also have access to house calls from doctors, even if they can’t afford to pay full price to a non-network provider.

Dr. Dappen’s article was included in Grand Rounds this week, hosted by Bongi at Other Things Amanzi.

The controversy surrounding homebirths (and midwives versus obstetricians) has been in the news again lately with the release of a new study that claims that homebirth is associated with a higher neonatal mortality rate than hospital births (registration required to view the Medscape article).  This has met with some fierce criticism from people who (rightly so, in my opinion) claim that the study results are politically and financially motivated.  The debate around whether births should be attended by OBs or midwives is much like the debate around health care reform.  People are very wrapped up in their own beliefs on the subject and become pretty fired up when talking about it.  It’s hard to distinguish real science and facts from hype and fear-mongering.  It’s difficult for me to consider points made by ACOG on the subject of homebirths as valid, because of their strict stance against homebirths and their obvious financial bias.   But I will readily admit that I have a bias in favor of homebirth.  Such is the way of human nature when it comes to controversial topics…. if we have opinions on them, we tend to hold tightly to them.

The US c-section rate rose by 53% from 1996 to 2007, although in Colorado and five other states the increase was a whopping 70%.  That trend doesn’t show any sign of reversing itself anytime soon.  As Jason noted in his article, there is a “cascade of interventions” in hospital birth settings that is steadily driving up the rate of surgical births.  In addition, we have a malpractice system that provides a strong incentive for doctors to perform c-sections at the first hint of a problem.  With a system like that, it’s hard to fault OBs for taking the c-section route, and intervening in general.  We can wring our hands all we want about how we need to reduce the rate of c-sections and medical interventions during childbirth, but as long as our malpractice system penalizes doctors for avoiding c-sections, we won’t make much progress.

Our own son was born at home following 45 hours of labor.  For almost nine of those hours, I had what would have been described in a hospital as “failure to progress”.  But I had competent midwives who checked our son’s heartbeat frequently, and patiently waited for me to give birth to him.  Had I been in a hospital, there is a very good chance that I would have had a c-section.  Yet our son and I both came through the birth unscathed, and a c-section would have been needless intervention.  I know it’s easy to say that in hindsight, but the problem is that when it comes to the over-medicalization of our country, we aren’t learning from our collective hindsight.

Dr. Welch also writes about late pregnancy ultrasounds doing more harm than good by finding tiny abnormalities and causing needless worry to parents when it’s far more likely that the abnormalities are nothing to worry about.  A good friend of mine went through this exact same scenario last year.  At seven months pregnant, an ultrasound revealed a problem with her son’s intestine.  She was understandably freaked out for the next two months, and was also subjected to weekly ultrasounds.  When the baby was born, he was whisked away to NICU and monitored for 24 hours (no nursing or bonding time in that first day).  The result of all that testing:  a perfectly healthy, normal baby.

I haven’t had personal experience with the over-medicalization of end of life care, but everything I’ve read about it indicates that we are doing way too much intervening there too.

Much has been said about how we need to reign in health care costs in order for health insurance to be universally affordable.   But we also need to figure out how to just use less medical care all around.  We need to find ways to support health rather than react to illness (diet is a good place to start).  And we need to question just how much we want our lives to revolve around medical intervention, pharmaceutical concoctions, and beeping machines.  As Dr. Welch noted, some medical interventions are absolutely essential and worthwhile.  But that is not the case for all medical care, and a “less is more” approach might create a healthier population and lower health care costs.

My guess is that people are starting to feel the real world effects of the bill and seeing the legislation in a more favorable light when it benefits them directly.  Seniors who find themselves in the “donut hole” in their Medicare Part D prescription coverage started getting $250 checks last month.  Colorado was one of the first states to get the new federally funded high risk pool up and running, but similar plans are coming online in all 50 states, and will make it easier for uninsured people with pre-existing conditions to get health insurance.  The early retiree reinsurance program application became available to employers last month, and will make it easier for businesses to provide health insurance to their retiring workers who are not yet eligible for Medicare.  Young adults are being allowed to stay on their parents’ health insurance policy until they are 26.  All of these programs are part of the health care reform legislation, and they all have a direct, favorable impact on individuals and businesses.

It will be interesting to watch public opinion of health care reform over the next few years.  I imagine a lot of it will depend on what happens to premiums.  If health insurance carriers can comply with the requirements of the new law without substantial premiums increases, we’ll probably see even more favorable public opinion of the law, especially once government subsidies kick in to help people pay for health insurance.