Friday, July 31, 2009

Doctor sees insurance remedy in health reform

Dr. Scott Nelson has found a growing problem among his patients in rural Mississippi, and it's not related to a disease.

More and more patients, he says, have extremely high deductibles in their health insurance plans. As high as $5,000. So they must pay that amount out-of-pocket in a year before insurance kicks in.

Nelson, a family physician in Cleveland, Miss., treats many people with chronic medical conditions such as diabetes and hypertension. They require ongoing care for those conditions, but it's out-of-pocket costs – amid a recession -- that lead an average of two patients a day to walk out of his clinic without getting needed tests, he says. "A lot of sick people need a lot of monitoring,'' he says.

Such insurance problems have helped convince Nelson to support the movement to overhaul the nation's health care system. Not only would reform help patients receive proper care, he says, but it also could boost his practice financially.

Doctors are far from united on health reform. Some major organizations, though, have moved to support the proposals coalescing in Congress, a shot of adrenaline for President Obama and advocates of an overhaul.
The American Medical Association earlier this month endorsed legislation moving through the House. The American College of Physicians and the American Academy of Family Physicians have also backed reform efforts.

Nelson, 45, looks upon reform from his rural Mississippi perspective. He has been a doctor in solo practice for the past four years in Cleveland, his hometown. Office overhead, though, is higher than he anticipated -- rent, salaries, malpractice coverage, equipment, insurance hassles. His business is marginally profitable.
"Cash flow is pretty sporadic,'' he says.

Health reform as it now stands is a confusing, elusive target. Nelson welcomes the talk of bonus pay for primary-care physicians like himself, but he's not sure what final legislation will actually produce. "I don't think I've met a physician who really has a good grasp of it,'' he says.

He wants any legislation to preserve patients' ability to choose their doctor, and physicians' autonomy to order medications and tests.

Extending coverage to people without insurance -- about 5% of Nelson's practice -- ''would help tremendously,'' he says. People with chronic disease need care early before medical conditions worsen -- when treatment becomes more expensive.

And he would embrace a prohibition on health insurance companies from rejecting people with pre-existing medical conditions. ''An ongoing nightmare for patients,'' he says.

But the under-insured situation needs fixing, too, Nelson says. These people have coverage, but their deductibles and out-of-pocket costs make affording medical care difficult, if not impossible.

"Deductibles have skyrocketed,'' he says. Employers and individuals have not been able to maintain the same coverage, he says.

With a $5,000 deductible, few patients are going to reach that point where their medical spending triggers their insurance coverage, Nelson says. About half of his patients with private insurance have high deductibles.
His patient volume is decreasing by 10%, which he largely attributes to insurance problems. Better coverage for more people could help his practice revenue, he says.

Currently, Nelson says, "I have no choice but to ask to be paid at the time of service. My profit margin is slim. That puts a patient in a difficult position.''

Such concerns about patients' access to care have driven many physicians to consider the positives of health reform, Nelson says. He adds: "Virtually everyone realizes that something's got to be done. ''

Senate Republicans: No deal on health care

posted at 12:15 pm on July 30, 2009 by Ed Morrissey
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With most of the focus on the House in the health-care battle, the Senate has tried to independently reach a bipartisan deal on health-care reform — by actually engaging Republicans. At least for now, Democrats in the Senate have has as much luck with the GOP as they have with their own Blue Dogs. The three Republicans on the panel have announced that no deal will come before tomorrow’s recess — and it doesn’t look like they’re getting closer regardless:

Two of the three Senate Republicans negotiating a bipartisan deal on health care reform said they consider an agreement out of reach before the Senate goes on its August recess.

That likely dashes the hopes of Democratic leaders and President Barack Obama for a deal among the so-called Gang of Six negotiators that could deliver critical momentum for the stalled health care overhaul.

Sen. Charles Grassley, R-Iowa, and Sen. Michael Enzi, R-Wyoming, dropped the bombshell news to CNN and two other reporters in Capitol hallways Wednesday night. They have spent weeks behind closed doors, trying to hammer out an agreement with their Democratic counterparts on the Senate Finance Committee but said too many issues remain unresolved, making it virtually impossible for them to sign on to a deal before the break.

Harry Reid postponed consideration of health-care reform until after the break, but he had hoped to get some broad framework of agreement before everyone left Washington. In this case, Reid at least tried to play it smarter than Nancy Pelosi, who has put herself in the worst-case scenario of having a firm bill with only Democrats supporting it (and not even all of those), hanging in public like a pinata for the GOP to hit for the next several weeks. Reid wanted to get Republicans on board before the recess to alleviate the pressure on his caucus from constituents during the recess.

Even if Reid failed, the strategy made a lot more sense than what Democrats are doing in the House:

A leading Blue Dog said today that Democrats aren’t working with any Republicans to pass healthcare reform.

Rep. Barron Hill (D-Ind.) admitted that healthcare efforts so far have focused entirely on rounding up the Democratic caucus.

“We’ve not had any discussions or negotiations with Republicans,” Hill said on MSNBC’s Morning Joe. “We invite Republicans to be a part of the solution to our healthcare problems that we have, but we’ve not had any negotiations with them.”

Why Health Care Isn't Going Away

Doctor's visit.
(Photo: Joseph Rodriguez / Gallery Stock)

Watching the Dixiecrats supposedly impose fiscal responsibility on the "unrealistic liberals," who, in theory, would go off and provide health care to all Americans if someone didn't put a stop to them, you have to wonder if this isn't all for show.

Speaking of shows, the mainstream media is in full-onslaught mode on health care reform now. They're going after Obama and his health care, trouble-making with everything and the kitchen sink. One more poll published today illustrating how "the public" is turning against Obama on health care reform will make an even hundred. How informative, so impressive.

In fact there is some real news out there that mattered: A quick read of the independent press might reveal, as David Swanson reports, "Nine More Go to Jail for Single Payer". [1] These were not hooligans or persons of low moral character; they were doctors and Catholic workers, an 11-year-old child and ordinary citizens who cared enough that all Americans would be entitled to health care that they voluntarily forfeited their liberty.

Or, as Nayla Kazzi reports, "More Americans Losing Health Insurance Every Day". [2] To wit: 46 million Americans are currently uninsured, but that the number is rising at an alarming and accelerating pace. Further, Kazzi reports that many of the uninsured are currently working.

The US Centers for Disease Control (CDC) reports, "Percentage of Americans With Private Health Insurance Hits 50-Year Low". [3] So, that's a drop in the percentage of insured Americans from an estimated "nearly 80% in the 1970s and early 1980s", to a 2008 estimated level, according to the CDC, of 67 percent of non-elderly Americans. That's down 2 percent in the past year alone apparently, according to the report.

Health Care as a Wedge Issue

If the corporate news machine isn't good for anything else, they're good at shaping public opinion in favor of corporate profits, even at the expense of the public's best interest. To be sure, Alabama Rep. Mike Ross and his Dixiecratic associates are well aware of the facts laid out above, well aware of the toll of human suffering generated by them and just as well aware of the losses meaningful reform of the health care industry would mean to industry bottom lines.

But how do you convince an ordinary American that health care reform that clearly stands to benefit them, at least to some extent, is something they should oppose, and oppose its advocates as well? First, you need a powerful medium. Broadcast television is a good start, commercial print media helps as well and talk radio really saturates the market fully. But you still need a wedge, an issue that divides.

What if you could convince the majority of Americans that health care reform would actually cost them money? Well. that would sure do it; yes, it would. The reality is a bit different: The American health care industry enjoys not only the staunch protection of US lawmakers, but the enormous financial benefits that follow. The numbers are staggering. [4] These are Fortune 500 people, and they absolutely, positively intend to keep it that way. Take away the enormous profit and health care would serve no other purpose than to ease human suffering.

So, sure, Barack Obama's popularity can be tarnished by a media onslaught and, sure, public opinion can in the same manner be panic driven to a profitably convenient conclusion. People, however, are dying and being left to die in staggering numbers as the Fortune 500 priorities are writ large by the nation's lawmakers.

Let there be no mistake, health care isn't going away.

The Heavenly Host of Health Care Authors

The health care bill is 1,000+ pages. As long as the Old and New Testaments, with a few centuries of The History of the Decline and Fall of the Roman Empire tacked on. That in itself raises justifiable suspicions as to what is in it. All conceivable explanations for such unseemly length suggest that these doubts are well founded.

The legion of authors is one reason. Most all congressmen, their armada of staffers, armies of lobbyists, and even the occasional White House operative have had a hand in writing this opus. Unhappily, the all too common motivations of ego satisfaction and promotion of self-interest are a lethal combination as far as the public interest is concerned. That's one. Then there are the myriad of qualifiers, addenda and exemptions incorporated at the behest of some special pleading party or other. That's two.

Complexity and rephrased repetitions similarly serve to open opportunities for dispute as to what exactly has and has not been stipulated. Multiple interpretations can be a form of compromise between drafters and/or a way for legislators to put their own spin on the bill when defending it before constituents. That's three. Confusion as to specific aims and purposes also can be the more or less innocent outcome of a turgid, wearisome process. To quote the prophet Isaiah, "Take counsel together and it shall come to nought." Protracted deliberations on this scale pretty much ensure that we have gone beyond 'nought' and passed into negative territory. Amazingly, Isaiah had this blazing insight without ever serving on a Congressional committee or having attended a faculty meeting. That is four.

A persuasive explanation can be compounded of all four hypotheses. That is not reassuring, especially for those who doubtless will encounter the hardships of trying to obtain affordable medical care -- the point of the exercise, supposedly.

Those of a more positive frame of mind will be free to celebrate the modest signs of bipartisanship that marked the bill's tortuous odyssey. No small thing; after all, even the Good Book is bipartisan. Consider the fair and balanced admonitions of Matthew (7:7): "Seek and you shall find," he counsels Republicans while comforting Democrats with the words, "ask and you shall be given." Perhaps reflections on Scripture will give Barack Obama peace of mind on his holidays.

Defending Canada's Health Care: Truths and Lies

Last week a new study showed that 92% of Canadians would recommend their doctor to friends and family. Two-thirds have had their doctor for over five years and 85% of Canadians have a regular doctor.

Does that sound like the health care system depicted in the right-wing Republican-backed smear campaign against Canada?

No care for life-threatening conditions, no choice, exorbitant costs, bureaucrat control, poor outcomes -- these are the bogeymen of the right-wing smear campaign. And like all bogeymen, once you look under the bed they don't exist.

Our system does have flaws. We need better prescription drug coverage, better remote access to care and better practices in hospitals and clinics. No honest advocate for our health care system would dismiss these things. But Canadian health care works -- and works well.

If you face a medical emergency -- you get the help you need. An admitting nurse doesn't check your credit card -- she checks your pulse. Across Canada innovative best practices in hospitals and clinics are cutting wait times for emergency treatment and elective surgery alike.

Costs are under control in Canada. We spend similar amounts on public care - around 7% of GDP. For that price, Canada covers everyone, the U.S. just one third of the population. In case you're worried Canada wastes money on bureaucracy, know that just 2.4% of our total costs go to administration compared to 7% of what your government spends. In end, Canadian care costs $2,500 less per capita - and covers everyone.

Our outcomes are excellent too: infant mortality is lower, people live longer and we are less at risk of cardiovascular disease than Americans.

Does all this mean that the United States should adopt Canada's health care system?

No. America can no more adopt our health care system than we can swap hockey for baseball as our national pastime. A good health care system reflects a country's values, and each country's values are different.

But a system with 47 million uninsured, coverage denied due to pre-existing conditions and people thrown off plans when they become ill? That doesn't reflect American values.

Fixing the health care system won't be easy -- from Truman to Nixon to Clinton presidents have tried and failed. But it wasn't easy in Canada either.

Sixty years ago Canadians families shouldered their own medical bills. Those with the money got the care they needed, but those without struggled -- they sold their farms, mortgaged their homes, or went without care, suffered, and even died.

Tommy Douglas, one of my predecessors as leader of the New Democrats, believed everyone should get the health care they needed, regardless of income. So in 1947 Tommy and his supporters launched a decades-long battle for Canadian Medicare.

The forces of the status quo -- like those in America today -- fought back. Small and big business, patients and doctors groups -- at different times they all fought reform. Doctors even went on strike, leaving sick women, men and children without care. But by 1984 the Canada Health Act had secured a national public health care system that has become part of our identity. It's not a perfect system, but it works.

With health care reform in the U.S. closer to success than at any time in my life, our hopes are with you. Don't let right-wing lies about Canada help derail health care reform in America.

FIU professor and humanitarian Dr. Pedro José “Joe” Greer to receive Presidential Medal of Freedom

MIAMI (July 30, 2009) – Dr. Pedro José “Joe” Greer, chair of the Department of Humanities, Health & Society at Florida International University’s Herbert Wertheim College of Medicine, has been chosen by President Barack Obama to receive the Presidential Medal of Freedom, the highest recognition given to civilians by the United States.

“I am deeply humbled by this incredible honor,” said Greer, who will accept the award at a White House ceremony on August 12. “I love medicine and what it can do for our community, particularly those in need. This is our country, this is our community and it’s our responsibility as physicians to make sure we take care of those who need it most.”

The Presidential Medal of Freedom is designed to recognize individuals who have made “an especially meritorious contribution to the security or national interests of the United States, world peace, cultural or other significant public or private endeavors.”

Greer has pioneered medical delivery and education in areas of homelessness, poverty and its relationship to policy and ethics in medicine. At the FIU Herbert Wertheim College of Medicine, he is the chair of the Department of Humanities, Health & Society, which incorporates ethics, medicine and society and family medicine in concert with the College of Medicine’s unique curriculum.

That curriculum, called NeighborhoodHELP™ (Health Education Learning Program) and operated under the Green Family Medicine & Society Program, will place each medical student in a team that will include students from nursing, social work, public health, and others. Each medical student will spend three years working with a household in North Miami-Dade County. The interdisciplinary cooperation is similar to the model that is taking shape in modern medicine, as doctors collaborate with counterparts, such as social workers, to address a patient’s needs.

“Our students will have the privilege of learning about the social aspects of medicine from a recognized leader in this field,” said Wertheim College of Medicine Dean John Rock. “The energy and the vision of professors like Dr. Greer will inspire our students and propel this young college of medicine into a leadership position on the national stage.”

The Wertheim College of Medicine welcomes its first class of 43 students on Monday, Aug. 3.

President Obama on Thursday praised Greer and his fellow honorees for “their relentless devotion to breaking down barriers and lifting up their fellow citizens.”

“These outstanding men and women represent an incredible diversity of backgrounds. Their tremendous accomplishments span fields from science to sports, from fine arts to foreign affairs,” said President Obama in a statement. “Yet they share one overarching trait: Each has been an agent of change. Each saw an imperfect world and set about improving it, often overcoming great obstacles along the way.”

Added FIU President Modesto A. Maidique, “Dr. Greer represents the best that our community has to offer. This great honor is testament to the caliber of doctors that FIU’s Wertheim College of Medicine has attracted. We are honored to call Dr. Greer one of our own.”

Greer has been awarded the prestigious MacArthur “Genius” Fellowship, the Doctor of the Year for Teaching by the Magazine Hippocrates, and has received the Presidential Service Award from Presidents Bill Clinton, George H.W. Bush, and Jimmy Carter. Dr. Greer also was named the Health Care Hero of the Americas by Pan American Health Organization in Washington DC in 2005. He has advised both the Bush Sr. and Clinton Administration in issues of healthcare and poverty. He has published articles ranging from digestive and liver disorders to policy and poverty in America, as well as the book, Waking Up in America.

He did his undergraduate studies at the University of Florida and earned his medical degree from the Pontifica Universidad Madre y Maestra in Santiago, Dominican Republic. Greer did his internship, residency and was Chief Medical resident at JMH/ VA in Miami as well as two fellowships in Gastroenterology and Hepatology there. He is a Fellow of the American College of Physicians and the American College of Gastroenterology.

Custom Search Control Web Medical interns supporting doctors strike in Gujarat resume duty

As many as 550 final year MBBS interns in various Gujarat hospitals who were supporting the resident doctors on indefinite strike since July 23 resumed duty Thursday.

However, at least 1,200 resident doctors who are postgraduate students serving with various government hospitals in the state are continuing with their strike to demand a higher stipend.

The interns were warned by the state government that their support to the resident doctors and their absence from hospitals would be taken seriously and expulsions ordered for absentee interns from Thursday onwards.

"There had been some respite for the government hospitals with the 550 interns deciding to resume duty today (Thursday). As of now, there are 633 resident doctors out of 1,200 whose services are likely to be terminated from today (Thursday) evening," a senior health department official said.

He said that the resident doctors have been warned against going on a hunger strike across the state.

The state government had already told the resident doctors that the government would not bow down to their demand.

A statement issued by the Gujarat Association of Resident Doctors (GARD) said that none of the resident doctors will resume duty till their demands are met.

Health care reform, part III

Physician-related problems

  • Medical education: It is long and very costly. In the U.S., we do not follow a vocational model as many other countries do. Here you must complete a four-year university degree, a four-year medical degree, and a residency program (at minimum). This is payed for by the students themselves, so that it is not unusual for a student to enter residency with 200K in debt. Residency, which is a minimum of three years, usually pays about 40K, so not much debt is being repaid (but interest is accruing on some loans). This means that an average doctor in the US needs to be paid A LOT just to maintain loan payments. Starting up a practice often isn't an option, as there is no money left. This leads to additional problems/solutions.

  • Reimbursement: Doctors' fees make up a small percentage of health care costs but it is often seen as low-hanging fruit. Remember though, that doctors are repaying enormous personal debt in addition to the usual work of raising a family and creating a career. Remember also that once a doctor is committed to a house, a debt payment, the costs of a practice, then drastic changes in payments will collapse the system. Doctors will lose their homes (yes, really), default on debts, and be unable to sustain their practices.
  • Financing education: unless the country decides to significantly subsidize medical education, including retroactive debt forgiveness, there is no way to significantly lower physician reimbursement. Most countries do this, and many, in return, demand a year or two of public service. Public financing of medical education, with a built-in expectation of military or public service, would mitigate the problem of underserved areas and the massive debt-burden of doctors.
  • Bureaucracy: If medical bureaucracy is overly burdensome, as is seen with many insurance companies, doctors will find new careers or refuse to accept insurance and demand payment out-of-pocket. My private practice does not accept HMO patients because we would have to hire more people just to do the paperwork involved with referrals and prior authorizations. It's just not worth it.

There are no easy solutions to our health care problems, and we do have problems. Any person who is covered by decent insurance is going to be hesitant to risk a change, but we have to decide, as a nation, what we value. If we value our economic and physical health, we need a system that gives everyone access to preventative care, that encourages practices based on evidence, and that encourages our best people to practice medicine. Right now, we pay a huge amount for health care, so arguments that any change will cost more are ridiculous---it doesn't have to cost more, and shouldn't. It should cost different. If businesses are relieved of the burden of paying insurance (like overseas businesses), if less money is spent on administration, we will all benefit.

Whether a system is a patchwork of private insurers with citizens given tax-incentives or vouchers, or whether it is a single payer system, or whether it is the same system we have now with minor tweaks (which seems likely), we need to get comfortable with change, and do it soon. Any real change, change that actually accomplishes something, is going to hurt. It's not going to be easy. Before you reject certain options out of hand remember this: our largest insurer in Medicare. Medicare is unassailable as a program beloved by people enrolled, and they are pretty easy to work with as a provider. Medicare for all is not such a bad idea. It would require giving up some things to gain others. There is no system that won't require some sort of sacrifice. It's time to step up.

Eastern Medicine in Western Culture

About a quarter of all Americans are obese. This week the Centers for Disease Control (CDC) announced that obesity-related diseases account for an estimated 147 billion dollars in medical costs annually in the United States. That's 9.1 percent of all medical spending, up from 6.5 percent in 1998.

If you do the math, the report suggests we could pay the entire ten-year trillion-dollar bill for health care reform by lowering our obesity rate from 25 percent to 8 percent and thereby saving 100 billion dollars annually. And after ten years we'd have 100 billion dollars a year left over.

Obviously, we're failing miserably to curb the obesity epidemic. But is there a country with a low obesity rate that we can look to as an example? China comes immediately to mind. In recent years the obesity rate in China has soared as urbanization and Westernization have introduced an unhealthier diet and more sedentary lifestyle. But traditional Chinese culture still serves as a model we can study, leading to an obesity rate of only 2.6 percent in 2002. Just as experts are looking to countries around the world for ideas on how to fix our broken health care system, we should be exploring the traditions of other cultures -- now and in the past -- for ideas on how to follow healthier lifestyles.

During this week's CBS Doc Dot Com, I visit two Chinese physicians practicing in New York City who are trying to integrate the best of Eastern and Western medicine.

President Obama's Health Care Reform 2009

President Barack Obama noted during his election campaign for the 2008 presidential election that the health care system in the United States was at best inadequate. Many times he spoke about the system, the many uninsured and under-insured people throughout the country and how it was time for health care reform. He promised that if elected, he would make the issue a top priority for the nation.

Planning Health Care Reform

In the years prior to becoming elected as the President of the United States, Mr. Obama researched and consulted with experts all around the country looking for help in devising a new plan for health care in the US. He knew that it was time to fix the failing system that was in effect and drew up plans for his health care reform which were viewable on his website.

On July 14, 2009 a healthcare reform bill, written by Chairmen Charles B. Rangel (D-NY), Henry Waxman (D-CA) and George Miller (D-CA), the chairmen of the House Ways and Means, Energy and Commerce and Education and Labor Committees in conjunction with President Obama's plan, was introduced in the House of Representatives. This bill included an attempt to control the costs of health care by trying to eliminate fraud and waste and promote quality and accountability. It proposed that it would save $500 billion over 10 years and strengthen Medicare. In a statement by the President he also claimed that with this proposal, "Americans can receive the best care, not the most expensive care. And it will offer families and businesses more choices and more affordable health care."

Pre-Existing Conditions and Changing Jobs

They propose to disallow insurance companies to deny coverage for pre-existing conditions and to cover workers themselves, not hinging insurance coverage on whether or not they keep the same job. One of the problems facing workers under the current system is that if they change jobs, are laid off or start their own businesses, they will lose their health care and if they already have a health condition, they stand a risk of being denied coverage.

The biggest change in the way that company coverage would work is that the individual consumers would be choosing their insurance and their employers would help pay for it instead of the current standard in which the business chooses the insurance and they help their employees pay for it. At this time, if that employee leaves the company, he is no longer insured until he either purchases his own or has been employed at a new company for a certain period of time. Usually this time period is about 90 days, but it can be up to a year.

The proposal suggests that it will be able to cover an estimated 97% of Americans with it's system that includes a public health care option and an insurance exchange that would allow families to review pricing and quality to let them choose the plan that best suits them.

An Ounce of Prevention is Worth a Pound of Cure

President Obama has, since the beginning, endorsed a preventive maintenance attitude towards health care, stating that if more emphasis was put on preventing disease and crippling medical conditions, less money would have to be spent on trying to cure. Through education and preventive measures such as early diagnostic testing, learning healthy habits, and investing in the future of scientific research President Obama is looking to the future and hoping, as he does with many of his programs, that what we do today will benefit society as a whole tomorrow.

The Senate Draws a Similar Proposal

The Health, Education, Labor and Pensions (HELP) Committee released 615 page document (not yet in it's final form) on Tuesday Jun 9, 2009. The Committee chairman is Senator Ted Kennedy but Senator Chris Dodd has been filling in for him and drafting much of the bill while Senator Kennedy has been dealing with brain cancer.

Opponents of the Proposals

Opponents of this reform plan spend as much as $1.4 million every day sending lobbyists around Washington D.C. hoping to spoil the plans of this reform. The White House says that some opponents are going so far as to spread mis-information about items in the bills such as a rumor that the bill requires older persons on Medicare to be forced to discuss options of how to end their life. Republican congresswoman Ginny Brown-Waite was quoted as saying, "'It doesn't say that they're going to receive counseling on euthanasia, that's not what it says,' but some people fear that the government is trying to control every aspect of their lives and that this reform bill is just one more step closer to a Socialist regime.

House Republican leader John Boehner said that the plan will “increase healthcare costs for families, small businesses, and seniors, destroy jobs, and reduce access to quality healthcare.”

Supporters of President Obama say that nothing could be further from the truth and that bringing about this health care reform is a necessary step for a better future for the US.

Chart of the Day: More people think Obama health plan is bad idea

More people believe President Barack Obama's health care plan is a bad idea, according to a recent WSJ/NBC poll.

In the poll, conducted July 24-27, 42 percent of respondents said the plan was a bad idea, while 36 percent said it was a good idea. The number of people with a negative opinion of the plan increased by 10 percent from last month and is up 16 percent from April.

According to the WSJ, among respondents with private insurance, the proportion of people who think the plan is a bad idea increased from 37 percent to 47 percent.


U.S., Mexican health experts meet to plan flu strategy

— Health experts from the United States and Mexico, countries that together have accounted for about half the world's swine flu cases, are shoring up their defenses ahead of a second wave of infections expected this fall.

They're stocking up on supplies such as masks and antiviral medications, encouraging one another to rest up before flu season hits and considering the postponement of elective surgeries to deal with any surge in flu patients.

These strategies emerged Thursday at the Courtyard Marriott in Old Town, site of a two-day workshop on the H1N1 virus that drew about 80 public-health officials from southwestern states and Mexico.

Participants also reflected on their experiences in dealing with the initial outbreaks of swine flu that would gradually broaden into a global pandemic. San Diego County reported the world's first cases in April, and Mexico became the epicenter of infections and deaths during the peak of the crisis.

“We learned that we need to be very nimble in terms of geting resources to the table,” said Dr. Gilberto Chávez, California's top epidemiologist. “A response like this is like fighting a fire. You need to be involved 24 hours a day.”

Dr. Leticia Wong, the surveillance epidemiology coordinator for Baja California, said the United States recorded 36 percent of the world's confirmed swine flu cases and Mexico logged 14 percent as of mid-July.

Epidemiologists stress that reported cases of H1N1 pale in comparison to actual infection figures because of inadequate specimen collection, limited lab testing and other factors.

Looking ahead to the regular flu season, the U.S. Centers for Disease Control and Infection estimate that 40 percent of Americans could come down with swine flu in the worst-case scenario.

Scientists are working on ways to manage a resurgence of H1N1 until improved response plans are in place, a vaccine is ready and hospitals are better equipped for an influx of patients.

“We live in a global village and have no choice but to work hand in hand at every level,” Dr. Martin Cetron of the CDC said during an introductory panel at Thursday's workshop.

People in attendance suggested ways to improve on the generally well-regarded work by public-health agencies during the spring outbreaks of swine flu, which took the world by surprise with the speed if not the severity of its spread.

Several health officials said the best cooperation would include the sharing of epidemiological information, surveillance techniques, diagnostic tools and lab technology. They also discussed how to streamline operations, such as how to deliver lab supplies and pick up lab specimens more efficiently.

At the workshop were epidemiologists, lab directors and managers of programs that provide early warnings about infectious diseases. They belong to federal, state and local agencies in the United States and Mexico.

They came from California, Arizona, New Mexico and Texas, and from Baja California, Sonora, Chihuahua, Nuevo Leon and Tamaulipas.

Chávez said the only northern Mexican state with no one in attendance was Coahuila.

A major message of the workshop was that while swine flu is widespread, it's not following the same infection and virulence patterns everywhere.

For example, cases of H1N1 continue to mount in San Diego County this summer, but not so much in Imperial County. And while there was a lull in Tijuana in recent weeks, new cases cropped up just this week.

By now, health officials said, it's more important to count the number of hospitalizations, deaths and patients who are resistant to antiviral medicine than to tally the overall total of confirmed cases.

Two interpreters stationed in a glass cubicle in the hotel's main ballroom allowed those who weren't bilingual to understand all that was said. It was one small reflection of how these cross-border health officials are collaborating.

Echoing essentially every speaker's theme, Dr. Michele Ginsberg, chief of community epidemiology at San Diego County's Health & Human Services Agency, told the crowd just before lunch that continued teamwork is crucial.

“Anyway you look at it, we're all in this together and hopefully we'll be able to share our strengths and deal with this appropriately,” she said.

The Health Debate, at a Fever Pitch

We should be ashamed of ourselves for allowing the message of those who are driven by the powerful insurance lobby, and those who oppose the president’s plan for purely political reasons, to shape our opinions.

They have offered no alternatives to the president’s health care reform plan, and in fact have done nothing except muddy the waters of reasonable logic with relentless, misleading and scary commentary and whisper campaigns, often verging on outright nuttiness.

If we can’t see through that for what it is, especially after the last eight frightening years, we deserve whatever pathetic health care reform rises from the ashes.

In November, we voted for change, and we got it, and it can be said that in many ways, it is not the same old government of the last eight years. Unfortunately, it is the electorate that remains the same — susceptible to fear tactics and misleading innuendo. When will we ever learn?

Join Our Health Care Tele-Town Hall

As DCCC Chairman and Assistant to the Speaker, I read the e-mails that you send to us. I wanted to address a recent e-mail from Barbara, who is a retired teacher in California. She expressed concern that Democrats aren't one hundred percent behind President Obama's health care reform plan. I want to address that concern.

While having a strong Democratic Majority is something we should celebrate, we can't forget that bringing real reform involves making very tough decisions. As President Obama often says, if bringing change were easy, it would have happened a long time ago.

After decades of struggle, we are now closer than ever to providing quality, affordable, and accessible health care for every American. Grassroots Democrats should feel pride in getting us to this point by creating a great force for progressive change.

In recent weeks, the Republicans have deliberately spread misinformation about the President's health care reform plan. Right-wing talk radio and TV spew lies 24/7 about the plan. This campaign of distortion is designed to undermine support of the plan in the districts of our most vulnerable members.

The single best way you can help Democrats unite behind President Obama's plan is by helping us set the record straight. Our plan lowers costs, provides greater choice and competition, and puts an end to insurance companies making health care decisions for families.

Only our grassroots supporters have the power to fight back against these Republican attacks and ensure that President Obama brings real health care reform this year.

Thanks for all that you do and I hope that you can join me on Friday.

Pols vow to fight for health care

WASHINGTON — An increasingly intense battle over health care legislation in Congress will now shift to states across the country as lawmakers begin returning home for a month-long recess and outside groups prepare to flood the airwaves.

With polls suggesting that public support is sagging for President Obama's push to overhaul health care, House Majority Leader Steny Hoyer said the party will use the August break to make a strong sales pitch to middle-class voters.

"We're going to be on the air. We're going to be in the neighborhoods," said Hoyer, D-Md. "Our members are going to now have the opportunity to go home ... and say to their constituents, 'Look, this is what we're doing. This is why it's good for you and your family.' "

House members will return to their states after missing a self-imposed deadline this week to vote on health care after fiscally conservative Democrats demanded that their party leaders slow the process down and trim the cost of the House bill by $100 billion. The Senate's break begins Aug. 7.

A House Democratic memo obtained by USA TODAY shows the steps the party is taking to coordinate its message over the break. Lawmakers are encouraged to hold town-hall-style meetings, post videos on the Internet and find small-business owners "whose testimony can provide a powerful narrative," the memo states.

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Republicans, who have criticized the Democratic proposals as a costly government takeover of health care, said they will also be busy talking to constituents.

"It's safe to say that, over the August recess, as more Americans learn more about their plan, they're likely to have a very, very hot summer," said House Minority Leader John Boehner, R-Ohio.

A Gallup Poll conducted July 24-25 found that only 26% of Americans believe a new health care law would improve their care even as Obama has increased efforts to convince voters the proposal would reduce long-term costs and prohibit insurers from denying coverage because of pre-existing conditions.

Outside groups, meanwhile, vowed to turn up the volume with television advertisements that have already dominated the airwaves in some states.

Jacki Schechner, a spokeswoman with Health Care for America Now, said the group will focus on the fiscally conservative Democrats it believes are weakening the bill.

A group called Conservatives for Patients' Rights, which has opposed the legislation taking shape in Congress, budgeted $1 million to push its message in the first weeks of August, spokesman Brian Burgess said.

"I think you're probably going to start seeing a lot more pointed rhetoric," said Evan Tracey of Campaign Media Analysis Group, which tracks political advertising. "There will be a healthy clip (of spending) through August."

Strategies: Small businesses suffer on health care issue

Something must be done — and done now.

Here's what I wrote in 1993, the last time health payment reform was seriously considered:

"When it comes to the debate over health insurance, one thing is for certain: the current system is terrible for small business ... small businesses usually have the hardest time getting insurance, the smallest choice among providers, and pay the most for the least coverage. Many people who would like to start new businesses are stuck in jobs because they can't afford to give up health insurance from their current employer. So, please Mr. President and Congress Members, give us a break!"

Here's what's happened since. Things have gotten far, far worse.

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The percentage of small businesses offering health care coverage has withered, employees pay more and health costs have shot through the skyscraper's roof.

Market forces have not — and will not — work. We need government intervention and a public health insurance option. Or, trust me, five years from now, if you own or work for a small company, you will not be able to afford health insurance.

Our current system of health care payment developed in the 1950's and 1960's, when our fathers worked for big corporations and health care was cheap. It made sense that health insurance was provided by large corporate employers. Now Dad — and Mom — and you — are self-employed or work for a small service company or start-up that could be the next Google.

The system must be changed.

Here's how it really works for small businesses:

• You're interviewing two candidates for a job. One is in his 20s — he'll cost less than $200 a month for health insurance. One's in her 50s — she'll cost more than $700 a month. Our current health payment policies contribute to age discrimination.

• You look at your income statement. By far, your fastest growing cost is your health insurance. Small businesses pay nearly 20% more than big corporations. So, you decide to not hire, use independent contractors, or end health insurance altogether.

• You want to leave a lousy job and start a business, but you can't afford health insurance. You never launch the business that might one day employ others.

• You get laid off. You become self-employed. You can't afford COBRA, so you go without health insurance and pray you don't get sick or injured.

• You pay hundreds of dollars a month for insurance. But your co-pay and deductible is still thousands of dollars a year. You — or your employees — hesitate before going to the doctor. Your condition gets worse.

Small businesses need reliable, predictable health care costs that are competitive with big corporations and foreign competitors. A public health insurance option — whether at 8% of payroll or $750 a year per employee — gives us that. If you want, and can afford, to purchase private insurance or supplemental insurance (which, like with Medicare, I'm sure will develop), you should be able to do so.

Those who want the government to do nothing want you to believe that if the government gets involved you won't have your choice of doctors, your choice of treatment. What world are they living in? I have the same situation right now, and I have expensive insurance. My insurance company determines which doctors are in my network, must approve my treatments and negotiates how much and whether they'll pay for treatment. And these insurance companies are more beholden to their shareholders than their policy holders.

Something must be done — and done now.

In 1993, I saw the same groups line up against health care payment reform that are lining up against it now. They said market forces would keep costs down, legislation could address issues such as access and restrictions on pre-existing conditions. They were wrong.

Don't let them defeat health insurance reform again. The group Small Business Majority projects that, without significant health care reform, the cost to small businesses of providing health care will double by 2018. But who will be able to afford that?

Right now we have the best chance of getting meaningful — sweeping — health care payment reform. As a small-business owner, you have a vested stake in making this happen.

Health reform must address services for seniors and disabled

Larry Minnix

Health and Human Services Secretary Kathleen Sebelius has announced that any health reform effort should include a new program to help families struggling with the high costs of long-term services and support for aging or disabled loved ones.

The administration's support comes not a moment too soon. With America aging at an unprecedented rate and people living longer with disabilities, health reform and long-term care are inextricably linked.

Chances are, someone close to each and every one of us will require long-term services and support at some point in his or her life. In fact, among those turning 65 today, 69 percent will require some form of prolonged care.

Unfortunately, it's becoming more difficult to pay for such care.

Surveys have found that the costs of food, transportation, and medicine total over $5,500 annually for the average long-term caregiver responsible for a loved one. To cover these costs, 16 percent of seniors will need a nest egg of more than $100,000; 5 percent will need more than $250,000.

Many Americans aren't prepared for these extra extra expenses. People wrongly believe Medicare will pay for these services. It will not. They haven't saved enough. And they have no idea how much it costs to provide and receive care.

Making matters worse, the time and energy needed to care for the elderly costs the economy billions of dollars every year. One recent report found that American businesses lose $33.6 billion annually in revenue as employees care for loved ones.

Long-term services and support cost the government a great deal, too --

$116.8 billion each year for Medicaid alone.

Many seniors receive long-term services through Medicaid. But the demand on the program cannot be sustained-- even with the recent injection of $87 billion in funding from the stimulus package. By 2025, Medicaid's expenditures on long-term services and support will have doubled. By 2045, those costs are expected to increase five-fold.

The CLASS Act, which received bipartisan support from the Senate Health, Education, Labor and Pensions (HELP) Committee, sets up a fiscally responsible way for all of us to plan ahead for these inevitable expenses.

And, according to the Congressional Budget Office, it can trim the federal deficit by $59 billion in its first decade. Secretary Sebelius is smart to support its inclusion in health care reform legislation, as she wrote to the committee this week.

President Obama is right to insist that aid for long-term services and support be included in any health reform package.

America's seniors and those with disabilities -- both current and future -- are counting on it.

Monday, July 27, 2009

On Health Care, Congress Races Against Recess Deadlines

Congressional leaders this week are racing against the clock in hopes of making at least some progress in advancing major health care legislation before the summer recess.

A small group of bipartisan senators on the Senate Finance Committee, led by the chairman, Max Baucus, Democrat of Montana, hope finally to reach a deal on health care legislation that would let them issue a draft bill and begin committee sessions a week from Monday, with a goal of completing the bill before the Senate leaves town on Aug. 8.

But there are a number of complicated issues yet to be resolved, including final agreement on how to pay the roughly $1 trillion, 10-year cost of the legislation. This week, senators will be scrutinizing a proposal to tax high-end health plans. The idea has some support among White House officials and could raise $100 billion over a decade.

The House is scheduled to adjourn at the end of this week. And Democrats will push Monday to settle the outstanding reservations about the health care legislation among a group of fiscal conservatives in the Blue Dog Coalition – particularly seven Blue Dogs who have blocked work on the bill in the Energy and Commerce Committee.

The Energy and Commerce Committee chairman, Representative Henry Waxman, Democrat of California, has said that he hopes to resume the committee’s work on the bill by Tuesday. But after a tumultuous day on Friday during which Mr. Waxman and Blue Dog leaders traded recriminations, it is unclear how quickly the Blue Dogs’ concerns can be resolved.

Mr. Waxman said negotiators would be carefully looking at a few top issues, including how a proposed government insurance program would operate and whether the bill included sufficient provisions to help curb the steep rise in health care spending over the long term.

While the health care issue will dominate the agenda and the attention of Congressional leaders, the House also plans to take up its final appropriations bill, the annual military spending measure, which would allocate $636.3 billion, including $128.3 billion for war operations in Iraq and Afghanistan.

This is the first year that the full war costs are being included in the regular military budget and not in a separate emergency spending measure.

The Senate, which has been moving more slowly on the annual spending bills, is expected to begin work on the energy and water spending measure and perhaps also on a military construction and veterans affairs bill.

The majority leader, Senator Harry Reid of Nevada, has already said that the Senate will wait until after the recess to vote on the health care legislation. But lawmakers are eager to show forward motion by having the Finance Committee unveil its bill, which has the chance of being the one bipartisan health care proposal.

The Senate health committee approved a health care measure, but strictly along party lines with Republicans opposed.

Substantial differences remain. The House speaker, Nancy Pelosi, on Sunday affirmed her support and that of many Democrats, including President Obama, for a new government-run insurance program to compete with private insurers.

But the Senate Republican leader, Mitch McConnell, said that was a no-go for his members. “I think I can pretty safely say there aren’t any Senate Republicans who think a government plan is a good idea,” Mr. McConnell said on CNN’s “State of the Union.” “We have 1,300 health insurance companies now, robust competition among them. We know that if we create a government plan, there won’t be any more private health insurance companies and there won’t be any competition.”

The Finance Committee, as a compromise, is considering a plan to use private, nonprofit health care cooperatives instead of a government-run plan to compete with private insurers.

One big focus on the Finance Committee early this week will be a proposal put forward by Senator John Kerry, Democrat of Massachusetts, to tax high-end insurance plans.

Mr. Obama expressed a willingness to consider the latest version of the proposed tax on high-end insurance plans during his news conference about health care policy on Wednesday night.

David Axelrod, a senior adviser to the president, in an appearance on “Face the Nation” on CBS, said the proposal could meet Mr. Obama’s requirement that any new taxes to help pay for the health care legislation not fall on the shoulders of middle-class Americans.

“The president actually was asked this the other day by Jim Lehrer and what he said was that this was, you know, that this was an intriguing idea to put an excise tax on high end health care policies like the ones that the executives at Goldman Sachs have the $40,000 policies,” Mr. Axelrod said.

Mr. Kerry’s proposal would impose an excise tax on the insurers who issue such policies, with the expectation that the insurers would pass along most, if not all, of the cost to employers who purchase the plans – a potential point of conflict over who will actually pay the tax.

Leaders of the Finance Committee had long expressed interest in taxing some employer-provided benefits, a move that many budget experts say would help slow the steep rise in health care spending.

But a number of Democrats, including Mr. Reid, said they opposed the idea and urged Mr. Baucus to drop it. Negotiators began looking for other ways to cover the cost of the bill.

Senator Kent Conrad, Democrat of North Dakota and a key author of the Finance Committee’s health care bill, endorsed the idea of taxing rich plans during an appearance Sunday on the ABC program “This Week With George Stephanopoulos,” noting that the tax exemption for health benefits provided a government incentive for overspending on health care.

Asked if Congress would tax high-end plans, Mr. Conrad said: “I think we’ve got to. Again, virtually every economist that’s come before us has said you’ve got to reduce that tax subsidy as part of an overall strategy to really contain costs.”

Health care talk sinks Obama press conference ratings

MSNBC host Dylan Ratigan said Thursday morning that while President Barack Obama has “elevated the conversation” when it comes to health care, there’s a downside for cable executives and his fellow hosts: “Health care is bad for ratings.”

Discussing the previous night’s low-key news conference, Ratigan said that “cable networks’ ratings go off a cliff” during the health care debate, which eventually “forces the conversation out of the TV.”

It’s not as if the public ignored Obama entirely as he took questions in the East Room on Wednesday night. Indeed, 24.5 million viewers tuned in across the broadcast and cable networks. Still, that tally was the smallest prime-time audience of Obama’s presidency, dropping 50 percent from five months ago. And Fox’s decision not to air the presser paid off: The network won the 8 p.m. time slot with an episode of “So You Think You Can Dance.”

“It’s bad for ratings,” The Washington Post’s Jonathan Capehart told Ratigan, “but not talking about it is bad for the American people.”

Television executives, correspondents and pundits are quick to point out that health care is perhaps the most vital issue facing the country, and it’s their professional obligation to present the facts and arguments to the public. But doing so is similar to taking medicine — important, but not always fun.

While viewers may seize upon numbers that indicate the size and scope of reforming health care — 47 million uninsured Americans or costs in the trillion-dollar range — most eyes glaze over when terms like “public option” or “bundled payments” get tossed around on the air.

“It’s not only not a cable TV-friendly story; it’s not a journalism-friendly story,” said John Harwood, chief Washington correspondent for CNBC.

Harwood, also a political writer for The New York Times, explained that reporters need to first understand the intricacies and nuances of health care policy before they can then try getting the story across to viewers and readers. Last week, Harwood said, he was “trying to get [his] head around the issue of cost control” before penning a Times column.

“It’s incredibly complex to try and explain to people,” Harwood said.

“The problem with health care is that it’s so big and so complicated that the public is never really going to understand all the moving parts of this,” NPR health policy correspondent Julie Rovner said on air Wednesday.

“So the public is really always going to be sort of amenable, if you will, to demagoguery and arguments one way or the other that don’t necessarily link to what the substance is,” Rovner continued. “We saw this during the Clinton efforts.”

Health Insurance and Reputation

Here's an argument even I've found seductively appealing:

The problem with free-market health insurance is that if a customer develops a truly serious health problem, his insurance company will try very hard to weasel out of the contract. At best they'll deliberately give poor service to the people who need it most, because they know that none of their competitors want to poach customers with serious pre-existing conditions. At worst, they'll claim that you broke the contract somehow, and hope you die before your lawsuit gets to a jury.
It seems plausible, no? If your condition is truly catastrophic, won't profit-maximizing health insurers struggle to "contain their costs" at your expense?

The problem with this argument is that it proves far too much. The same argument applies to life insurance and home insurance. You dutifully pay your premiums for years. Then you suddenly die, or your house burns down. What's a profit-maximizing insurer to do? Say you died or the house burned down because you were smoking in bed, of course! Can you prove otherwise?

Yet in practice, people almost never complain about disingenuous disputes with life or home insurers. Why not? The obvious explanation is that life or home insurance companies that shirk their responsibilities hurt their reputation. It might seem profitable to reject expensive claims, but in the long-run, an insurance company that mistreats its expensive customers is going to have trouble attracting any customers at all. After all, what's the point of buying insurance from a company that won't pay when you need it most?

So why would the reputational argument be any less convincing for health insurance? I wouldn't choose an insurer that was known to abuse or abandon its sickest customers. Would you? And why would word of mouth, advertising, and other conduits of reputation be less potent here than in other lines of insurance?

I agree that there is a popular perception that health insurance is an unusually crooked industry. My main explanation is that customers of health insurance companies have more latitude for unreasonable demands. If your dad dies, the life insurance company owes you $X. If customers ask for $X+1, the firm refuses, and no one sees this as proof that the free market can't be trusted with life insurance. If you get sick, in contrast, it's hard for an insurance company to decisively prove that they've lived up to their agreement. You can always insist on another expensive test, even if the insurer knows it's useless.

Insurance companies want a good reputation for taking reasonable care of their customers. However, they can live without a reputation for paying for everything, no matter what. Some companies might want to be known as "generous," and charge their customers correspondingly higher premiums. But most insurers prefer a reputation for decent but cost-conscious care. If that means affordable premiums, customers will happily buy cheap - then complain if their budget insurer makes them wait or tells them no.

Am I saying that health insurance companies never play dirty tricks on their customers? Of course not. It's a big world, lots of bad stuff happens. What I'm saying, rather, is that reputation works well even in industries where firms have big, lumpy liabilities. There are plenty of examples. What reason is there to think that health insurance isn't one of them?

Health Insurance “Innovation”

The This American Life crew, once again proving that they can cover any topic they want better than anyone else in the media,* has a segment in this weekend’s episode on rescission of health insurance policies – insurers’ established practice of looking for ways to invalidate policies once it turns out that the insured actually needs significant medical care. (The segment is around the 30-minute mark; audio should be available on that page sometime on Monday.) The story describes a couple of particularly egregious cases, such as a woman who was denied breast cancer surgery because she had been treated for acne in the past, and a person whose policy was rescinded because his insurance agent had incorrectly entered his weight on the application form.

The legal basis for rescission is that when you sign an insurance application, you are warranting that the information on the application is true; if it turns out not to be true, the insurer can get out of your insurance contract. It’s particularly nasty in practice because the insurer does not immediately investigate your application to determine if it is accurate before selling you the policy (that would be impractically expensive); instead, the insurer waits – years, in many cases – until you actually need expensive health care, and then does the investigation, which at that point is worth it because of the payments the insurer could potentially avoid. Also, you can lose your coverage for innocent mistakes, which are easy to make since the application form asks you if you have ever seen a doctor for any one of a long list of medical conditions that you are certain not to recognize or understand. (In a Congressional hearing, the CEO of a health insurer admitted that he did not know what several of the conditions listed on his company’s application were.)

This reminded me of nothing so much as all of those “innovations” created by credit card companies, such as universal default, penalty rates, and double-cycle billing, which are really just ways to generate fees that you are unlikely to accurately estimate at the time you sign up for the card. It’s legal; it makes more money for the insurer (or credit card issuer); once one company does it, other companies have to, or they won’t be able to compete; it’s disclosed in such a way that customers don’t understand what they are getting into; it nails you when can least afford it; and it even has a plausible economic justification. Credit card issuers claim that their arsenal of hidden fees makes the cost of credit more closely reflect the riskiness of the borrower, and without the fees they would have to charge higher interest to everyone; health insurers claim that rescission is necessary to deter fraudulent applications, and presumably without it they would have to charge higher premiums to everyone.

Also, it’s definitely an innovation. I’m sure health insurers have always had fraud investigation units, which looked for red flags on new insurance applications to identify suspicious customers. But the idea that you should (a) target customers precisely because they get sick and need health care and (b) go after them for innocent mistakes is not an inherent part of the insurance business, and is something that some clever person came up with as a way to make more money – not a way to provide more coverage or better service to customers at lower cost.

And it’s terrible. Basically, anyone who had to fill out a medical underwriting application to get health insurance (this is basically the individual market, not the group market that people are in if they get insurance through their employers) is at risk of finding out that that insurance doesn’t actually exist precisely when he or she needs it most. The insurers claim that rescission is very rare; at the Congressional hearing, two of three industry representatives said it happens to less than 0.5% of policies per year. But that is a deeply misleading number. That means that if you are in the individual market for twenty years, you have a 10% chance of your policy being rescinded; 30 years, and it goes up to 14%. There is a big difference between health insurance and a 90% chance of having health insurance. And remember, insurers only try to rescind policies if you turn out to need them; so the percentage of people who lose their policies when they need them is even higher. (The denominator should exclude all those people who never need expensive medical care, at least not before 65 when they go onto the single-payer system.)

I know that rescission does not logically prove that some private health insurance system cannot work. For one thing, Congress could simply pass a law banning the practice except in cases of intentional misrepresentation (although the free marketers would complain about increasing government interference in the “free market”). But it is evidence that the private health insurance system we have does not work. Yes, it’s just the individual market, but it’s the individual market that’s growing, not the employer-based market. And the system we’ve got, like the credit card industry, is one where the name of the game is finding ways to make the product you sell worth less to the customer than the customer thinks it is worth. (The more common way this is done is by burying exclusions and limits in the fine print.)

This is the system that the politicians who are dug in against health care reform – and everyone knows who they are – are defending. I’d like to see them try to defend it openly, instead of hiding behind the tattered banner of fiscal responsibility.

* OK, that may be a bit of an exaggeration. I am really a huge fan, so I get carried away sometimes.

Update: Some days the Internet can be scary. I just peeked and noticed that The Huffington Post has sent over about 40,000 views to this post in the last few hours. The HuffPost excerpt focused on the two horror stories I mentioned at the end of the first paragraph which, I want to be clear, I did nothing to help uncover; they were raised in a Congressional hearing and then picked up by This American Life.

Since my late-night musings on rescission are getting more attention than they deserve, I want to point you to other discussions of the topic that probably got less attention than they deserve. First, the transcripts of the House Energy and Commerce Committee hearing that is quoted by This American Life are available here. The same committee is having another hearing on the topic today. Second, at least two bloggers picked up the story when it happened back in June: Kevin Drum and Ezra Klein. For those who don’t want to read all the hearing transcripts, Drum linked to this Los Angeles Times story. Finally, one expert on the topic is Wendell Potter; his appearance with Bill Moyers is excerpted by Mark Thoma.

Hillary and the Health Care Debate

President Obama's recent full-court press on health care began with an event in the Rose Garden last Wednesday featuring nurses. Obama had spent the previous week overseas and the previous days on other issues, so the White House was eager to kick off a sustained PR offensive. But it was noted by some that this kickoff was scheduled for precisely the same moment that Secretary of State Hillary Clinton, veteran of her own health care fight 16 years earlier, was attempting to jump start her new portfolio as the nation's top diplomat.

Such moments have fed nagging questions about just where Clinton fits in the administration of her one-time rival for the Democratic nomination for president. On Friday, the two sat down for a rare one-on-one lunch together as progress has slowed on Obama's top legislative priority. Did she weigh in?

“We talk about everything,” Clinton said Sunday during an interview on “Meet The Press.” She declined to say much more, citing her own policy not to “ever talk about what I talk about with presidents.”

Questions even putting "Clinton" and "health care" in the same sentence only seem to produce awkward reactions, or more often the case, deafening silence. Asked at one of his daily briefings this week if the two principals have ever discussed the issue thus far, Robert Gibbs said only: "I have not heard of any discussion recently on that."

A number of senators also professed to be unaware of whether Clinton and Obama have talked health care. "She's got her hands full with a lot of other things," Sen. Evan Bayh (D-Ind.) said. "Senator Clinton is busy trying to save the planet," Sen. Barbara Mikulski (D-Md.) added.

Asked how the current debate might be playing out had Clinton remained in the Senate, or been elected president, even those like Mikulski and Bayh who endorsed her in the primary were reluctant to answer. "That's speculation of no utility," the latter said.

More than a year ago, health care was one of the few substantive policy debates between the Democratic heavyweights in a campaign that otherwise was dominated by questions of electability, personality and delegate math. Clinton, aware that her past failure in this arena was still an issue in voters' minds, carefully rolled out a proposal in several stages, in full by September of 2007. Obama released his proposal in May of that year. In the months that followed, the two policies would be picked apart on air, in the mail and in multiple debates.

The primary difference between their plans was that Clinton's called for a mandate and pledged to cover all Americans.

"I have consistently said that Senator Clinton's got a good health care plan. I think I have a good health care plan. I think mine is better, but I have said that 95 percent of our health care plan is similar," then-Senator Obama said during a February debate in Ohio.

His campaign did spur a major confrontation over that 5 percent difference, though, in a direct mail piece that said Clinton's plan "forces everyone to buy insurance, even if you can't afford it." Her campaign and the candidate herself reacted furiously, prompting the famous, "Meet me in Ohio," declaration.

"My plan will cover everyone and it will be affordable. And on many occasions, independent experts have concluded exactly that," she said at that same February debate. "Senator Obama's plan does not cover everyone."

Despite the heated arguments, the campaigns would now acknowledge that the issue was not a decisive one. Now, White House aides say Clinton is busy with her own diplomatic portfolio, and profess not to be aware of whether the president and the secretary might touch on health care during occasional meetings.

But her influence is still being felt. Neera Tanden, who had a leading role in shaping Clinton's health care plan in the campaign, is now part of the Office of Health Care Reform in the Obama administration. And ironically, it now it appears that Clinton's mandate will be part of Obama's final health care bill.

"She was a little bit further to the left than he was on the mandate issue," a former Clinton campaign staffer said. "If anything she would have been pulling him more and more to the left if she had been in the Senate."

After Obama won the election, but before Clinton had been approached about a Cabinet post, she had hoped to play a lead role in the health care debate from the Senate. Sen. Ted Kennedy (D-Mass.), however, made clear he would be running the show. But he did announce three working groups to tackle specific components of a plan, and Clinton was chosen to work on insurance coverage.

Had Clinton been elected herself, it's unclear how she might have chosen to develop the legislation differently from the Obama path. The former campaign staffer said the debate might have unfolded largely the same way, but with one key difference.

"Obama enjoys significant personal approval ratings, which theoretically Hillary would not have had the comfort of," the staffer said. "It would have been a lot easier for the Republicans or the opponents of heath reform to tie to the issue of reform to the person of the president if Hillary had been in office. I think they're having a somewhat harder time demonizing the effort as an Obama-driven initiative."

But, the aide noted that in rolling out her plan during the campaign, she had emphasized the cost reduction component as much, if not more than the expansion of coverage.

"I think the White House, depending upon the week, have sort of been somewhat schizophrenic in terms of emphasizing one over the other," the aide said. "Hillary was very religious about emphasizing the cost issue. And Obama seems to be not as consistent - he does it, but just not as consistently as she did."

The unending parlor game that is speculation of the Clinton-Obama relationship will go on, much like, it seems, the reform effort itself.

How the Health Care Mess Affects Entrepreneurship

Scott A. Shane is a professor of entrepreneurial studies at Case Western.

In response to my earlier post on declining trends in rates of entrepreneurship in the United States, a lot of people commented that the cost of health insurance was a big part of the problem. So this week I am taking a look at the effects of health care on small business and entrepreneurship.

Clearly, health care costs have reached levels that are adversely impacting entrepreneurial activity. One result of the spiraling expenses is the inability of new companies to offer health insurance to their employees. The Kauffman Firm Survey, which tracks a sample of new businesses drawn from the 2004 cohort of start-ups in the United States, reports that only 29.5 percent of new employer firms and only 12 percent of all start-ups provide health insurance to their full-time employees.

A second effect has been to lead many older small firms to reduce health care coverage. According to the Kaiser Family Foundation, which conducts an annual survey of health care costs, the majority of businesses with three to nine employees do not offer employee health insurance; only 49 percent of these businesses did so in 2008. Moreover, the foundation data indicates that the provision of health care is much lower among small businesses than large ones. Only 62 percent of companies with three to 199 employees offer health insurance, as compared to 99 percent of businesses with more than 200 employees. According to the U.S. Small Business Administration’s Small Business Economy 2009, 25 percent of the 15.7 million workers in small businesses do not offer health insurance.

Self-employed people are much less likely than other people to have health insurance. The 2009 Small Business Economy reports that only 49.3 percent of self-employed workers have employment-based health coverage, as compared to 70.5 percent of wage and salary workers. Moreover, the S.B.A. publication also shows that approximately 3.7 million self-employed people aged 18 to 64, or 26 percent of the total, are uninsured.

Small businesses also pay more for health insurance than large companies. According to the Commonwealth Fund, small businesses now pay 18 percent more than large businesses pay to obtain comparable insurance.

A third effect of the tremendous rise in health insurance costs over the last decade has been to impose a huge financial burden on new companies. The cost for the average new company to provide its employees with family health insurance at the average cost for firms of its size (as reported by the Kaiser Family Foundation) is now $68,611 a year, more than double what it was 10 years ago. Granted, some of those costs aren’t paid by the employers, and some employees have individual coverage, making the actual numbers paid by employers lower, but it’s still a huge figure in comparison to new-firm revenue. According to the Kauffman Firm Survey, the average three-year old surviving firm generates only $152,000 in revenue annually.

Finally, because leaving a job to start a business causes one to give up employer health insurance, the employer-based health insurance system in this country is keeping some people from becoming entrepreneurs. A recent working paper by Rob Fairlie of University of California Santa Cruz estimates that workers with employer-provided health insurance have 2.5 to 3.9 percent lower odds of becoming self-employed than those without health insurance, suggesting that health insurance affects the start-up decision.

To all the readers who commented on my earlier posts and got me to look at health care costs and entrepreneurship, you’ve got me worried. The health care mess is clearly weighing down entrepreneurship in this country.

Some Details Emerging in Senate Health Reform Talks

ABC News' Z. Byron Wolf reports: The closed-door health care slog at the Senate Finance Committee continued today, without resolution.

But it does appear that negotiators have begun to tackle the treacherous issue of how to pay for health reform.

Both Sens. Olympia Snowe and Max Baucus talked on-camera to reporters after today's talks. They meet again tomorrow afternoon.

Baucus said he has been speaking to President Obama almost daily about the talks.

There is no deal yet on any issue, and all negotiators are careful to qualify that “we don’t agree on anything until we agree on everything.” But some themes of what a compromise could look like are starting to emerge.

And these are often riffs on controversial ideas. Instead of an employer mandate, there is talk of fees levied on "free rider" employers. The result would be similar – employers of people who can’t afford insurance on their own would either have to offer insurance or pay the government to offer it for them.

"Its not a broad based employer mandate," argued Snowe. She said the idea is to "encourage employers to continue their coverage."

Negotiators seem to be rejecting a so-called mandate for employers to provide insurance for employees, but there is apparent agreement that employers who drop coverage for employees should have to cover the cost of any government subsidy their employees would qualify for under reform.

This is modeled as a way to keep employers in the benefits game and discourage so-called "free rider" employers who would try to drop their benefits plans to save money.

Another contentious issue for Democrats is that of paying for health reform in part by taxing workers' high cost “Cadillac” health benefits plans. Many such plans are offered by unions, who have accepted better benefits in exchange for lower wages. The idea of taxing high-cost plans is painful for many Democrats.

Instead, there is talk of not taxing the people who receive the plans, but instead taxing insurance companies that offer them.

The idea here is to tax the companies instead of the recipients. Snowe suggested today that companies offering benefits worth more than $25,000 or more – a small minority of health insurance plans - would be taxed.

House Dems clear one health obstacle, others loom

WASHINGTON — House Democrats announced agreement Friday on far-reaching measures designed to rein in the relentless growth of Medicare, part of a drive to counter the impression that President Barack Obama's health care legislation is in deep trouble.

Speaker Nancy Pelosi hailed the agreement as a "giant step forward" for the bill that Obama has made a test of his leadership. Advocates said it eventually would turn Medicare toward a program that rewards quality, rather than volume, as well as alter a system that pays doctors and other providers more in some regions of the country than others.

Yet talks between the leadership and rebellious conservative and moderate Democrats demanding changes in the bill appeared deadlocked, and the second-ranking House Democrat said there was only a small possibility that the legislation would come to a vote before lawmakers' vacation scheduled to begin in a week. Rep. Steny Hoyer, D-Md., the majority leader, raise the possibility that the rank-and-file would be held in session into the first few days of August to vote.

The maneuvering in Congress came as Obama met at the White House with Senate Majority Leader Harry Reid, D-Nev., and Sen. Max Baucus, D-Mont., the chairman of the Finance Committee, who has been trying for months to produce a bipartisan agreement.

"I said to him (Obama) what I say to everybody. We are ready when we are ready," Baucus later told The Associated Press in an interview.

Obama has worked energetically in public appearances, interviews, meetings with lawmakers and a prime-time news conference this week to advance legislation he wants to expand coverage to millions without insurance at the same time it restraints the growth of health care generally.

Despite his efforts, Republicans have grown more emboldened as efforts in Congress stall, and some have suggested that defeat of the drive to remake health care could cripple his presidency, now in its sixth month.

Reid announced on Thursday that he was abandoning his timetable of passing legislation in the Senate before lawmakers begin their vacation, saying Republicans involved in the bipartisan negotiations had asked for more time. He said he expects Baucus to produce a bill within the next two weeks, though, and that the Finance Committee will vote on it in early August.

Across the Capitol, Pelosi virtually ordered a small group of Democrats from rural and urban areas to thrash out their differences Thursday night on Medicare issues that sound arcane, but matter enormously to individual lawmakers and likely will also lead to cuts in spending growth.

"This is just one piece of the puzzle, but we think it's an important piece," said Rep. Xavier Becerra, a Californian who played a key role in the discussions.

Lawmakers said the agreement would lead to changes in Medicare to try and reward doctors, hospitals and other providers for high-quality care. Critics argue the current system simply pays by volume — compensating providers regardless of whether additional medical procedures contribute to better health care.

Under the agreement, the Institute of Medicine would complete a study by September 2011 recommending changes in the current structure for determining reimbursement. The administration would have 45 days to submit the report to Congress, and it would go into effect unless Congress blocked it by the end of February 2012.

Separately, lawmakers agreed to call for a second study by the Institute of Medicine to investigate regional differences in payments to Medicare providers, to be implemented in 2014.

In general, rural providers are paid somewhat less under Medicare than their counterparts treating patients in urban areas, even though studies show there is no better-quality care delivered as a result. At the same time, lawmakers from sparsely populated areas wanted assurances that fees would be driven even lower for doctors in their communities as part of an adjustment.

Officials said the two steps combined were designed to control the steady increase in Medicare costs, although they said they did not have an estimate from the Congressional Budget Office.

Democrats suggested the agreement could allow Pelosi and the leadership to split a group of so-called Blue Dog moderate and conservative Democrats whose rebellion has stalled progress of the legislation this week. Many in the group represent rural districts, and greater cost-cutting has been one of the changes they wanted to have made in the legislation.

Yet Rep. Mike Ross, D-Ark., said attempts by so-called Blue Dogs to win changes had ended in stalemate.

"It pretty much fell apart this afternoon," he said.

The group has enough votes on the Energy and Commerce Committee to prevent the bill's passage there, and the chairman, Rep. Henry Waxman, D-Calif., raised the possibility of simply bypassing the panel and taking the legislation directly to the floor.

"We've got to get moving on this legislation," he said. "I hope we don't come to that conclusion."

He said that while negotiations with Democratic critics are continuing, "we're not going to let them empower the Republicans to control the committee." No House Republican has yet expressed support for the health bill that the White House is seeking.

As lawmakers continued to haggle, the White House said Obama will keep working on health care in August even if Congress goes home.

"Nobody in planning meetings decided we should just take August off," said White House press secretary Robert Gibbs. "For a long time we planned to continue the discussion of the issues that are important, be it the economy, health care ... education. That had always in many ways been priced into the scenario."

Obama envisions legislation that would, for the first time, require all Americans to be insured. A new government insurance program would compete with private insurers, and insurance companies would be barred from excluding people with pre-existing conditions. The goals are to hold down costs and extend coverage to most of the 50 million uninsured. The price tag: $1 trillion-plus over a decade.

Associated Press Writers Matt Gouras in Montana and Erica Werner and Ricardo Alonso-Zaldivar in Washington contributed to this report.

The health care debate

Dear Editor:

Don't we already have nationalized health care?

Some compelling reasons for supporting nationalized health care truly start with how you define profit, greed and corruption. I support our for-profit, free-market system in all areas except for health care and medicine. Yes, all who are associated with the industry deserve to make a good living. If you are compelled to become a doctor or a nurse it should be because you want to help people as your primary reason.

If you added up all the people who are already on our nationalized health care system I think we would all be astonished. If you are a taxpayer you may not be able to afford health care but you are paying for the health care of the following:

All senators, congressmen and their staff. All federal employees, all military and veterans, all state employees, all county employees and all city and town employees. You also must include most of the above who have retired through these careers. Then you have to add in Medicare, Medicaid, S chip and the prescription drug plan.

Let's not forget our prisoners and illegal aliens who are crowding your emergency room. What about our defense contractors and other industries that provide services and products primarily for the above mentioned — you might as well include them. I am sure I have forgotten many, many more. Most of these people are good people providing essential services and most are paying their taxes.

We also have to keep in mind that many of our tax paid for institutions have to get their insurance through “for profit” insurance companies. So what if we just cut the profit and greed out of the system? What could we do with all of that extra dough? Well, for starters we could provide health care for some of the people you really care about who can't afford to spend most of their income on high deductible health insurance scams. So before you call yourself a practicing Christian, Jew, Muslim, Buddhist, Hindu or just plain old good person you better double check your soul to see how you define who deserves to see a doctor or get medicine and who doesn't. You should also ask yourself, is the person who is preaching in support of “for-profit” health care truly on your side about anything?

Brad Larson

Basalt

Technology Award for Health and Medicine

Abingdon, United Kingdom, 23rd July 2009 - Toumaz Technology Limited, the leading provider of ultra-low power wireless infrastructure for body monitoring solutions, today announces that Toumaz Technology Co-Founder, Chairman and Chief Technology Officer Professor Chris Toumazou FRS has won the 2009 World Technology Award in the Health and Medicine category. Professor Toumazou, who is also CEO of Toumaz Holdings (AIM: TMZ.L), was named as this year's recipient at a gala ceremony on Thursday 16 July. The award ceremony was held at the TIME Conference Center, Time and Life Building, in New York, at the culmination of the two-day World Technology Summit.

The prestigious World Technology Awards are given in recognition of those individuals and companies doing innovative work of "the greatest likely long-term significance" in their respective fields. Nominees are proposed by Fellows and Founding Members of the World Technology Network (WTN) - a global community of the key players working in technology, from technologists, financiers and entrepreneurs to government officials, policy analysts and futurists. Other recipients of an Individual award this year include Facebook Founder and CEO Mark Zuckerberg and President Paul Kagame of the Republic of Rwanda. Corporate winners include YouTube (in the category of Communications Technology), Amazon (IT Hardware) and Facebook (IT Software). The corporate winner in the Health and Medicine category was the Mayo Clinic.

World Technology Network Founder and Chairman James P. Clark commented: "The World Technology Network was conceived to bring together the most innovative and impactful people and organisations in science and technology today. Professor Chris Toumazou is a great example of an extraordinary individual working tirelessly on technologies and businesses that are actively creating the future, as exemplified by the pioneering digital band-aid healthcare product now entering the market through Toumaz Technology. Professor Toumazou's achievements have been wholeheartedly endorsed by his peers through this award, and we are delighted to welcome him to the association."

Commenting on his award, Professor Toumazou said, "I am very grateful to the members of the World Technology Network for this honour. The focus of my professional endeavour has always has been to accelerate the development and adoption of technology that can benefit and improve the lives of people around the world. I am delighted to become a part of a community of innovators that share this vision."

Professor Toumazou (FRS FRS FREng FIEEE FIEE CEng PhD) co-founded Toumaz Technology in 2000 to exploit developments in ultra-low power silicon chip technology at Imperial College London. The patented core technology, Advanced Mixed Signal Processing (AMxTM), is the basis for Toumaz's SensiumTM technology platform for intelligent, ultra-low power wireless body monitoring.

Professor Toumazou currently holds the Winston Wong Chair in Biomedical Circuits at Imperial College London and is Director and Chief Scientist of the new Institute of Biomedical Engineering at Imperial. In recognition of his outstanding research, he was made a Professor at Imperial at the age of 33 - one of the youngest ever. He holds 23 patents, many of which are now fully granted in key territories throughout the world, and has published over 320 research papers in the field of RF and low power electronics.

In 2007 he was awarded the Royal Academy of Engineering Silver Medal and in 2008 was elected as a Fellow of the Royal Society - the highest honour in the UK scientific system.

Professor Toumazou led a major campaign to raise £22 million to fund the creation of the Institute of Biomedical Engineering at Imperial College London, which opened its state-of-the-art, purpose-built facilities in 2006. By combining the strengths of Imperial's world class research schools in engineering and medicine, the IBE draws together scientists, medical researchers, clinicians and engineers to drive major advances in key areas of medical diagnosis and treatment, including personalised healthcare, regenerative medicine and biomedical imaging.

For more information about the World Technology Summit and Awards and for a full list of 2009 Award winners, please visit: http://www.wtn.net/summit2009/nominees.html

About Toumaz Technology (www.toumaz.com)
Toumaz Technology Limited is the leading provider of ultra-low power wireless infrastructure for body monitoring solutions.

Toumaz's ultra low-power smart sensor interface and transceiver platform - the SensiumTM - enables non-intrusive, real-time wireless monitoring of multiple vital signs for a wide range of healthcare and lifestyle management applications. Based on Toumaz's patented ultra-low power Advanced Mixed Signal (AMx)TM technology, the Sensium provides the enabling technology to connect the mobile individual to healthcare providers - simply, affordably and unobtrusively.

For healthcare professionals, this transforms the possibilities for pro-active monitoring and improved quality of care. For patients, it delivers new opportunities for lifestyle-compatible, personalised healthcare, as well as better therapeutic outcomes.

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Press contacts:

Toumaz
Nicky Davis
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toumaz [at] evokedset [dot] com

Phone: +44 844 870 8025

Distributed on behalf of Toumaz Technology by NeonDrum (http://www.neondrum.com)
Nicky Davis
Tel: +44 7747 017654
nicky[at]neondrum[dot]com