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We are on the cusp of a historic agreement to control health care costs, improve the quality of care and patient safety, and cover most, if not all, of the uninsured. But such an agreement seems to be slipping away amid all of the charges and counter-charges. A compromise could be reached along these lines:
1. Trim the reach and cost of the new subsidies. A plan to make everyone living in poverty eligible for Medicaid, regardless of family status, has support on both sides of the aisle. Lawmakers could reduce the cost of the bills that have been brought out of congressional committees by not extending Medicaid coverage automatically to near-poor individuals as well, even though many would benefit. Further, current proposals call for sliding-scale subsidies for "lower-income" Americans who do not qualify for Medicaid and have incomes up to 400 percent of poverty, or about $88,000 for a family of four (not a figure that most believe is a low income). Lowering the cutoff for getting subsidies to 300 percent of poverty ($66,000 for a family of four) makes more sense and helps lower the cost. Massachusetts uses this level and provides a number of "hardship exemptions" for middle-income people a little over the threshold with serious illnesses and large medical bills. This system is working in Massachusetts, with 97 percent of the population already covered, and it can work for the nation.
2. Scrap the "public option." Liberals face a crucial dilemma: abandon the idea of a public plan, or risk losing health reform (yet again). Some national reform proposals feature insurance exchanges (like a new health care "marketplace" for those who lack affordable group coverage) but fail to give these exchanges the clear power to drive down costs. Some of these reform proposals would then throw in a watered-down version of a public plan (e.g. co-ops with little market clout) that still leaves us without much cost control. This gives us the worst of both worlds - a politically toxic public option that fails to control spending. A better approach is to design exchanges that can contract selectively with health plans, and lay out tough specifications related to cost control and quality improvement that must be met in order for health plans to get their share of this large volume of new customers. No insurer would have a guaranteed right to participate. This approach is also working in Massachusetts.
3. Build in real cost control. Congressional proposals on the table contain many good features to improve our health system, from more emphasis on wellness and prevention to investments in health information technology. But for the foreseeable future, these initiatives will not slow the growth of health spending, and could actually lead to more spending in the early years. Punting cost control to an "outside group," as some propose, does not assure that it will happen.
Real cost control could emerge from identifying the spending levels experienced by the best-performing health care systems today, such as Geisenger in Pennsylvania, Kaiser, and Denver Health, and setting Medicare payment rates in line with those levels. These systems coordinate and integrate medical care, reduce avoidable hospitalizations and emergency room use, control excessive medical tests, and reduce infections. Physicians and hospitals could be given a few years to reorganize along the lines of these innovative models before this requirement kicks in, and exceptions could be made for rural areas. Providers would not be forced to reconfigure their systems in this direction - but if they don't, their extra costs will not be paid for under Medicare. If insurance exchanges, Medicaid, and large employers that continue to offer health coverage follow the same approach, there will be "nowhere to hide" for those who deliver medical care in a fragmented and high-cost fashion, and they will bring their costs in line with best practices.
Make a deal on mandates. Conservatives must give ground on required participation in the health system. The important insurance market reforms with bipartisan support - no exclusions for pre-existing conditions, no higher premiums or denials of coverage because a person is very sick - cannot work if participation is voluntary. But the mandate to buy coverage could be phased in to follow, step by step, the successful implementation of new subsidies. Employer financing is also required if we are to keep our public/private system. The Senate HELP Committee provision to require firms with 25 or more workers to offer health coverage or pay an assessment is a good place to start.
People on the far right claiming that proposed health reform plans amount to a "government takeover" and "socialism" must be confronted and exposed for engaging in wild distortions and outright lies. No one is proposing that. At the same time, people on the left who are unyielding and make the perfect the enemy of the good (for example, no public plan, no health reform) must be confronted with this question: "If you bring down health reform, what will we be left with?"
We all know the answer to that: the current dysfunctional system that is unraveling before our eyes.
Jack Meyer is principal of Health Management Associates in Washington and a professor at the University of Maryland.
1. Trim the reach and cost of the new subsidies. A plan to make everyone living in poverty eligible for Medicaid, regardless of family status, has support on both sides of the aisle. Lawmakers could reduce the cost of the bills that have been brought out of congressional committees by not extending Medicaid coverage automatically to near-poor individuals as well, even though many would benefit. Further, current proposals call for sliding-scale subsidies for "lower-income" Americans who do not qualify for Medicaid and have incomes up to 400 percent of poverty, or about $88,000 for a family of four (not a figure that most believe is a low income). Lowering the cutoff for getting subsidies to 300 percent of poverty ($66,000 for a family of four) makes more sense and helps lower the cost. Massachusetts uses this level and provides a number of "hardship exemptions" for middle-income people a little over the threshold with serious illnesses and large medical bills. This system is working in Massachusetts, with 97 percent of the population already covered, and it can work for the nation.
2. Scrap the "public option." Liberals face a crucial dilemma: abandon the idea of a public plan, or risk losing health reform (yet again). Some national reform proposals feature insurance exchanges (like a new health care "marketplace" for those who lack affordable group coverage) but fail to give these exchanges the clear power to drive down costs. Some of these reform proposals would then throw in a watered-down version of a public plan (e.g. co-ops with little market clout) that still leaves us without much cost control. This gives us the worst of both worlds - a politically toxic public option that fails to control spending. A better approach is to design exchanges that can contract selectively with health plans, and lay out tough specifications related to cost control and quality improvement that must be met in order for health plans to get their share of this large volume of new customers. No insurer would have a guaranteed right to participate. This approach is also working in Massachusetts.
3. Build in real cost control. Congressional proposals on the table contain many good features to improve our health system, from more emphasis on wellness and prevention to investments in health information technology. But for the foreseeable future, these initiatives will not slow the growth of health spending, and could actually lead to more spending in the early years. Punting cost control to an "outside group," as some propose, does not assure that it will happen.
Real cost control could emerge from identifying the spending levels experienced by the best-performing health care systems today, such as Geisenger in Pennsylvania, Kaiser, and Denver Health, and setting Medicare payment rates in line with those levels. These systems coordinate and integrate medical care, reduce avoidable hospitalizations and emergency room use, control excessive medical tests, and reduce infections. Physicians and hospitals could be given a few years to reorganize along the lines of these innovative models before this requirement kicks in, and exceptions could be made for rural areas. Providers would not be forced to reconfigure their systems in this direction - but if they don't, their extra costs will not be paid for under Medicare. If insurance exchanges, Medicaid, and large employers that continue to offer health coverage follow the same approach, there will be "nowhere to hide" for those who deliver medical care in a fragmented and high-cost fashion, and they will bring their costs in line with best practices.
Make a deal on mandates. Conservatives must give ground on required participation in the health system. The important insurance market reforms with bipartisan support - no exclusions for pre-existing conditions, no higher premiums or denials of coverage because a person is very sick - cannot work if participation is voluntary. But the mandate to buy coverage could be phased in to follow, step by step, the successful implementation of new subsidies. Employer financing is also required if we are to keep our public/private system. The Senate HELP Committee provision to require firms with 25 or more workers to offer health coverage or pay an assessment is a good place to start.
People on the far right claiming that proposed health reform plans amount to a "government takeover" and "socialism" must be confronted and exposed for engaging in wild distortions and outright lies. No one is proposing that. At the same time, people on the left who are unyielding and make the perfect the enemy of the good (for example, no public plan, no health reform) must be confronted with this question: "If you bring down health reform, what will we be left with?"
We all know the answer to that: the current dysfunctional system that is unraveling before our eyes.
Jack Meyer is principal of Health Management Associates in Washington and a professor at the University of Maryland.
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The democrats already compromised on a single-payer. That compromise brought absolutely NO counter-offer from the Republicans. Now the democrats are now asked to compromise on a public option. That would again bring about NO worthwhile counter-offer from the Republicans. A bill without a public option would be NO MEANINGFUL REFORM since costs would not be controlled and it would give more power to insurers who got us in this mess in the first place. There is a good reason why liberals WILL NOT COMPROMISE on the public option. Almost every single poll has shown overwhelming support for a "choice" of a public option, if worded that way. The liberals are angry and demand their voice be heard. If Obama fails to support the public option, his support will decrease from about 55% to about 25%, costing him re-election and spurring a radicalization of the democrats. The democrats will likely move toward the Green party, feeling neglected by their own democratic party (which has essentially aligned with the republican party on most issues).
iel888 (09/06/2009, 10:25 AM )