The Republicans are saying that we need to start again, scrap the whole thing, and take “baby steps” towards a solution.  But I’m skeptical as to how that would work.  For the most part, congress in 2010 is made up of the same people that were there in 2009 (with some notable exceptions, like John Murtha and Ted Kennedy).  I find it hard to believe that starting again would result in a significantly different bill this time around.  Wouldn’t it just be a waste of another year of lawmaking efforts?  It’s unlikely that the people who came up with the first bill would be willing to make major changes if they did it again this year… we’ve seen resistance to compromise from both sides of the aisle over and over during this debate, including during the bipartisan summit last week.

As for the idea of “baby steps”, I don’t really understand the benefit that would be created by going slowly.  The current House and Senate bills could be considered baby steps as they are, given that most of their major provisions wouldn’t take effect for another three years.  For people who are uninsured and struggling to pay for health care (or not receiving any at all), I imagine that the prospect of a three year wait seems like an eternity already.

A lot of the provisions in the current bill make sense:  no pre-existing condition exclusions, no policy rescissions, subsidies to help people pay for health insurance, and a strong mandate requiring everyone to carry health insurance.  Americans are generally in favor of the idea of doing away with pre-existing conditions exclusions and policy rescissions, but tend to balk at the idea of requiring everyone to carry health insurance.  But I doubt that the former are possible without the latter… unless we all want to pay much higher health insurance premiums.

If we started over, do we really think that the same group of lawmakers would come up with a dramatically different bill the second time around?

This is definitely worth noting, and I think that this is a much more effective strategy than talking about numbers in the billions and trillions.  One of the main problems that I see when it comes to health care reform is the difficulty in getting everybody on the same page.  Nearly 60% of Americans get their health insurance from their employer, and are often totally unaware of the full cost of either their health insurance or their health care (since the employer pays for part of the health insurance and the insurance pays for a good chunk of the health care).  In addition, families that earn significantly more than $50,000/year may be unaware of how difficult it is to pay for health care on an average household income.

By looking at averages, and talking about numbers that are much easier to conceptualize, we can make it easier for people to understand the scope of the health care cost problem.  And looking at the problem in terms of averages shows why we can’t just increase taxes on wealthier families in order to make the problem go away.  There just isn’t enough money to go around.  As Brad Wright explains, even if we redistributed income and expenses completely, so that every household in American earned exactly $50,000/year and spent exactly $15,000 on health care, we’d still be struggling to pay for health care (only in that scenario, we’d ALL be struggling, rather than the way it is now, with some families crushed completely by health care expenses, and others unaware of how much their health care costs in the first place).

Until we address costs, we’ll never solve the problem.  But until we get the majority of people to really understand the problem of cost, we’ll never begin to solve the problem.

I found Ian and Brad’s articles via the Health Wonk Review, hosted by Brady Augustine at Medicaid First Aid.

What the report card basically shows is that things went downhill between 2003 and 2007.  Colorado was 3rd in the nation for childhood obesity in 2003, and 23rd in 2007.  It remains to be seen what effect recently-implemented programs will have on this number, but hopefully when the report card is issued with 2010 data a few years from now, we’ll have moved back into a higher ranking.

Governor Ritter signed an executive order last week that will make the application process for Medicaid and Children’s Health Plan Plus (CHP+) easier by implementing electronic data-sharing programs among state agencies.  There are still lots of children in Colorado who qualify for state-funded health insurance but continue to be uninsured.  There are plenty of reasons for this, including a sometimes complicated application process and parents who are unaware of what programs are available.  Anything that simplifies and automates the process is bound to result in more children being covered by some sort of health insurance.  I’m hopeful that the next Colorado Health Report Card will show a big improvement across the board, but especially in the area of children’s health.

In an interesting paradox, the people in Colorado are pretty healthy, despite having poor levels of health insurance coverage.  Our percentage of adults with health insurance is lower than 31 other states, and for kids, we’re nearly at the bottom of the pile, ranking 45th.  But our adults are a pretty healthy group (lowest incidence of obesity, and rates of diabetes and high blood pressure that put us in the top five states in the country).  Unfortunately this uninsured-but-healthy status doesn’t seem to be working for our kids.

One thing that I noticed about the report card is that it addresses some specific health issues for adults (mental health, diabetes, hypertension, and obesity) but for children this aspect of the report is limited to obesity.  The rest of the children’s health report includes things that have an impact on health, but don’t necessarily correlate exactly with how healthy a person is (for example, it’s possible for a child to be perfectly healthy despite living in poverty or not having a primary care physician).  I would like to see future editions of the report include statistics on the incidence of illnesses like cancer and asthma in children.  I’m curious as to whether our high percentage of uninsured children (relative to other states) is correlated with the actual health status of our kids.

For now, it looks like we have a lot of work to do in terms of getting Colorado’s children (and adults) covered by health insurance.  Even if it’s possible for a person to be healthy despite being uninsured, it’s a precarious position (both financially and health-wise) to be in, and not one that most people are in by choice.

But imagine if health insurance companies and the government (via Medicare) were to implement restrictions on screening tests based on a person’s overall health and life expectancy.  I’m sure there would be quite an uproar, with talk about death panels and pulling the plug on granny.  Regardless of the actual merits of such limitations, I can’t imagine that they would be well received by the general public.  And new guidelines would likely be highly distorted by people who have a financial stake in as many screening exams being done as possible, regardless of how helpful the exams actually are.

I can see the other side of the problem too – mainly that health insurance companies and Medicare/Medicaid could go overboard with regulations, refusing to cover screenings for people who might actually benefit from them.  There isn’t a clear cut answer to problems like this, but that doesn’t mean we shouldn’t look for solutions anyway.

David’s article was included in the Cavalcade of Risk this week, hosted by John Leppard at Healthcare Manumission.

The RWJF article details a program that has helped to curtail MRI costs by simply having treatment guidelines pop up on the doctor’s computer screen when a test is ordered – the doctor can go ahead and order the test after reading the guidelines, but apparently many times they change their minds, since the program saved almost $6 million in testing expenses in 2008.

These sort of reminders are good for both doctors and patients.  Remember a few years ago when there was a public ad campaign to teach people that antibiotics are not effective against colds, and that overuse of antibiotics leads to antibiotic-resistant bugs?  Perhaps we need something similar for diagnostic testing and imaging.  An ad campaign that encourages people to wait a few weeks and see if their pain subsides could be a good reminder that we don’t need to incur thousands of dollars in testing expenses at the first hint of pain.

Part of the problem stems from the fact that equipment like MRI machines is becoming more ubiquitous in medical offices.  According to a study detailed in Health Affairs, MRI utilization is directly tied to availability – so if an office has MRI equipment on site, their patients are more likely to receive MRIs.  This makes sense, as the doctor has to recoup the costs of acquiring the machine, and also stands to make a nice profit from doing the imaging tests.

Perhaps this is where we should start.  What if we implemented a system whereby doctors could not be compensated for ordering medical imaging for their patients?  The imaging equipment could be strategically located throughout each city and state, but not in doctors’ offices, and not run by doctors who order the tests.  If a doctor were to have no financial incentive one way or the other, we could probably assume that imaging would only be ordered when it was deemed medically necessary, and we would expect to see roughly the same rate of imaging use from one doctor to the next.

I’m not gonna get health insurance. I’m not going to inflate my bill by 35%. This cost me 30% less than had insurance been involved here. There was not one bureaucrat determining whether or not I was gonna get treatment. There wasn’t a death panel here. [...]

I don’t have insurance. “I’m sure he has insurance.”  No. I pay cash for it and it was less than the price of a car. And just as is the case with a car you could finance your health care coverage. You don’t have to come up with the whole lump sum, hospitals, doctors, work with you on this. [...]

A lot of people say, “Rush, you’re really running a risk here of sounding out of touch when you talk about how you can pay for this.”

I find it hard to believe that he paid “30% less than had insurance been involved“.  Yes, many hospitals will give a discount to people who pay cash, and Rush may have some extra pull – being a multi millionaire political icon.  But insurance carriers have the negotiating power of a large number of people.  The volume of clients an insurance company has as leverage is far more than any one person.

Regardless of how much his discount was, he still ended up with a five-figure hospital bill, which he describes as “less than the average car”.  Keep in mind that this was just chest pains, which didn’t turn out to be heart disease.  I wonder what the bill would have been if Rush had needed a double bypass?  What about a person who gets diagnosed with cancer and needs surgery and several months of chemotherapy?  What about a family who has a premature baby and two months of NICU bills?

When people think of the benefits of health insurance, they should be thinking past claims that are less than the average car.  They should be thinking of claims that cost more than the average house.

Rush Limbaugh earns about $33 million per year.  But the average American household has an annual income of just over $50,000.  So for Rush to advise going uninsured seems irresponsible.  He points out that hospital bills can be financed, just like cars.  While this is true to a point, it’s not as simple as he makes it sound.  Hospitals have begun sending clients to collection agencies fairly quickly, instead of dealing with the burden of waiting around for payment.

When Rush talks about how there weren’t any death panels involved in his treatment, perhaps he’s forgotten that the average uninsured patient faces a different kind of death panel – the kind that comes from not being able to afford any care at all.  Doctors and hospitals that need to get paid are the death panels to an average person without health insurance.

There are plenty of valid complaints against the current health care reform bills.  Those who say that the bills don’t do enough to address the root problem of ever-increasing health care costs have a very good point.  But take it with a grain of salt when a multi-millionaire with the ability to pay cash for any medical treatment he might need rails against reform that might make medical care more affordable for average people and talks about his death panel free medical experience.

I found Anthony’s article in the Health Wonk Review, hosted this week by Joe Paduda of Managed Care Matters.

“Although a mandate is the easist method of enforcing enrollment compliance by the majority of the population, a stiff pre-ex clause that was well publicized and understood could also be used to drive participation. If individuals who had gone uncovered for 60 days or more were subjected to a pre-ex. waitng period of 1 month for every month the spent without coverage(perhaps with a 24 month maximum),insurers would have protection from those wishing to game the system. They would then be better able to extend guarentee issue without being selected against.”

I really like this idea, and think that it could serve as a compromise between the people who are completely opposed to a mandate requiring everyone to carry health insurance, and the people (like myself) who feel that there is no realistic way to offer guaranteed issue, affordable health insurance unless everyone is required to be in the pool of insureds.

The people who are opposed to the mandate are usually either in the camp of not wanting to contribute to insurance company profits, or not wanting the government to tell them what to do.  And they make up a large percentage of the American public.

However, the idea of guaranteed issue health insurance is very popular, with most people supporting the idea that health insurance companies shouldn’t be allowed to decline applicants or exclude pre-existing conditions.  Yet without some way of making sure that people don’t simply wait until they get ill to buy coverage, a guaranteed issue system would not be sustainable.

Jim’s idea seems like a good compromise.   To be fair to all of the people who had not previously been able to buy health insurance because of pre-existing conditions or because they had no access to guaranteed issue policies, perhaps at the initial switch to guaranteed issue coverage, we could set up a three or six month window during which all applicants would be accepted without pre-existing condition limitations.  But once that window closed, we could use a system like the one Jim described.  That way, there wouldn’t be an incentive for people to remain uninsured and wait until they got sick to purchase health insurance.  The choice to be uninsured would come with consequences, but it would still be a legal choice.  This would allow people to make their own decisions, but would also protect health insurance companies and people who maintain continuous coverage.

Of course, there’s a bit of grey area involved with the pre-existing condition waiting periods that doesn’t happen with mandatory health insurance.  If a person feels ill but doesn’t go to the doctor to get checked out prior to getting health insurance, there wouldn’t be any proof that the condition was indeed pre-existing.  There would have to be some sort of leeway for discussion between insurance companies and doctors to try to determine how long a patient might reasonably have known about the condition.  This would be somewhat subjective, and would be a problem that would have to be addressed before a strong pre-existing condition waiting period could take the place of mandatory health insurance.  But overall, I think that the idea has a lot of promise.

Would you be more likely to support a mandate requiring everyone to carry health insurance, or a pre-existing condition waiting period like the one Jim proposed?

I understand the concern that if conservatives are involved, they might start up with the death panels and unsubstantiated scare tactics that were used last summer, and could just delay the reform process.  But even if the final revisions are left solely to the Democrats, why not open up the negotiations for public viewing?  Why not have C-Span cameras in the room?  Why not let the American people see what it going on?  By closing the doors and removing all pretenses of transparency, the process becomes fodder for speculation and conjecture, and automatically raises doubts.  People will start to wonder if back door deals are being made, or if special interests will trump the interests of the American people.

It remains to be seen what will come out of the negotiations that are underway, but I agree with Senators Udall and Bennet that we need more transparency in this final stretch.

Jaan Sidorov of the Disease Management Care Blog writes about the merits of employer-sponsored wellness programs and his reasons for supporting the language of the Senate reform bill that would   allow more financial incentives for employees who participate in these programs.  Employee wellness programs have been criticized by some who see them as a loophole that will ultimately allow for different health insurance premiums for employees depending on health, but I agree with Jaan on this one, and feel that these programs will do more good than harm.  I believe that most people who are unhealthy because of lifestyle choices would prefer to be healthier, but lack the tools, knowledge, time, etc. to get there.  Having wellness programs built into the workday make them much more accessible, and the financial incentives only provide more motivation.

Joe Paduda of Managed Care Matters has written a very interesting article about the relationship between health insurance status and workers’ comp claims.  The conventional wisdom is that people without health insurance are more likely to pretend that off the job injuries happened at work and file workers’ comp claims for them, but it turns out that this is not the case at all.  In fact, workers without health insurance are less likely to file workers’ comp claims.  But apparently it’s more complicated than that, and the likelihood that an employee will file a claim depends a lot on the nature of the company.  It does make sense that workers who don’t have employer-sponsored health insurance are be more likely to be in an intimidating work environment with low wages and little education in terms of employee rights.

John J. Leppard of Healthcare Manumission, explains why he isn’t impressed with the cost containment measures that are included in the Senate’s health care reform bill.  I especially liked his point about the individual mandate and his opinion that a $750 fine isn’t likely to encourage healthy people to spend several thousand dollars a year on health insurance if they don’t otherwise want the policy.  And it’s worth noting that the $750 fine wouldn’t go into effect until 2017.  When the penalty first takes effect, in 2014, it would be a mere $200.

David Williams of Health Business Blog brings us a podcast of an interview he did with Phil Lieberman, CEO of Lieberman Software.  The company provides solutions for safeguarding sensitive data – historically in the financial and government sectors.  But the push for electronic systems in health care, along with the stiff penalties that organizations face if protected data is compromised, have created more of a need for this sort of service in health care.  The interview touches on numerous aspects of information security in health care, and is a good reminder of the fact that implementing electronic medical records can be a complicated process.

Healthcare Economist’s Jason Shafrin explains why he thinks it’s a bad idea for the government to license tax preparers.  Licensing provides a revenue stream for government agencies, and to some degree it allows the government to keep an eye on licensed professionals to make sure that they are operating within the law and are adequately trained.  For health insurance agents in Colorado, that means passing our initial and continuing education exams, and adhering to the laws that govern our work.  Overall, licensing sounds good, but Jason makes a good point regarding people who volunteer their time to provide services for lower income families.  His argument could be applied to a variety of other professions too – it’s unlikely that volunteers are going to go through a licensing process, and more likely that they will simply stop offering their services.  Perhaps licensing requirements shouldn’t apply to people who provide services on a volunteer basis?

Jon Coppelman of Workers’ Comp Insider has a sad story about Iraqi translators working for the US armed forces – how little they’re paid, the risks they face, and the uphill battle they must fight in order to get benefits if they are injured on the job.  Their workers’ comp benefits are administered by companies like AIG, and payouts are apparently withheld in order to motivate injured workers to accept meager settlements.

Nancy Germond, writing at All Business, explains the benefits and process of building a strong safety culture.  Her post is a reminder that cutting corners when it comes to safety is likely to come back to bite you later on.  Despite budget cuts, safety still has to be a priority for every member of an organization, from the CEO to the part-time hourly workers.

InsureBlog’s Hank Stern explains how the less-than-great stock market performance of 2007-08 has  impacted variable products like annuities and some life insurance policies.  The new products don’t allow consumers to shift as much risk onto insurance companies, although they can still be a valuable part of a portfolio.

CJ Bowker, writing at The Life Of An Insurance Salesman, has an interesting article about how people react when faced with the risk of a door closing – or opportunity disappearing – even if the door didn’t hold much promise in the first place.  An interesting look at what drives us and when we might be wise to let something go.

Life insurance is a key component of risk management once we have other people in our lives who depend on us.  Jason at Redeeming Riches gives us Four Questions To Ask Before You Buy Life Insurance.

The Silicon Valley Blogger, writing at The Digerati Life, gives us a visual and written description of what stock market risk really looks like.  Nearly everyone lost some financial ground over the last couple years, and it’s been a good reminder that financial risks are real.

That does it for this edition of the Cav.  Here’s to the next decade.