Welcome to Fixes.
This is a series about solutions, or potential solutions, to real world problems. It focuses on the line between failure and success, drawing on the stories of people who have crossed it.
Most of us tend to be better informed about problems than solutions. This presents two challenges: if we rarely hear about success when it occurs, it’s hard to believe that problems can, in fact, be solved. Also, knowledge about how to solve problems ends up being concentrated in too few hands. It needs to circulate more broadly so that it can be applied where needed.
Last week’s post highlighted encouraging initiatives in several states to implement a single payer system within a single state.
This was always a daunting challenge even before health reform. The Patient Protection and Affordable Care Act has raised the bar even higher.
ERISA and its preemption
Before PPACA a legal hurdle called the ERISA preemption severely hamstrung state health reform efforts. For those of us in the employee benefits profession, ERISA, including its preemption clause, is our bible or at least our Deuteronomy.
ERISA was passed by Congress in 1974 to regulate employee benefit plans. The preemption clause precludes states from regulating employee benefit plans. There were two exceptions to that preemption and both are instructive.
Insurance and not insurance
Under the McCarran Ferguson Act of 1945 states have the authority to regulate insurance plans. Under ERISA states still retain the right to regulate insured health plans.
After the law was passed, Congress figured out that the state of Hawaii had already established a law requiring employers to provide health insurance to their employees. I guess news travels slowly from Hawaii. Congress passed the first of many subsequent amendments to ERISA making an exception to the general preemption for Hawaii.
One reason for the preemption clause was the belief that Congress would tackle national health care reform soon and they wanted to protect that right at the national level, a theme that would reappear in PPACA.
The consequence of allowing states to only regulate “insured” health plans was the movement by many larger employers to “self-insured” plans. By taking on the risk of health insurance themselves, employers escaped the mandates imposed by state insurance departments. Companies operated in multiple states could establish uniform benefit designs for all of their employees. At least one source estimates about 43% or 53 million people with health care coverage are regulated by ERISA and not by state insurance departments.
When Congress exempted Hawaii from the preemption clause they only exempted the Hawaii law as it existed in 1974. Employers have since discovered the loopholes in Hawaii law for part time employees and contract employees. Now, even though Hawaii has always had the lowest rate of uninsured in the country, that number is increasing as more and more employers exploit that loophole.
The ERISA preemption prevents efforts by state to expand coverage by requiring employers to offer health insurance. Instead they are confined to a hodgepodge of confusing and complicated programs to expand state Medicaid insurance programs or offer subsidies to small employers.
Obama blocks states?
The PPACA does not make it easier for state single payer advocates. The Obama Administration vigorously opposed bipartisan efforts in the House Education and Labor Committee to give states more latitude as laboratories for reform.
Photo Credit: Maui-Tropica
Well, six hours anyway. I wouldn’t miss tomorrow’s health care political extravaganza. I’m planning to crack open a brewski and a bag of Cheet-Os, and splay out in front of the boob tube for the full six excruciating hours. C-Span on steroids.
What’s wrong with me? Don’t I know health reform is dead? Don’t I know the Obama administration was dumped into the dustbin of history following election to the Senate of Massachusetts Republican Scott Brown, which overturned what all viewed as a permanent Democrat/Kennedy lock on the ultimate safe seat?
Oops, there I go, getting wonkish. Well, that’s what it is with me. I used to cover health policy – wrote, edited and published a newsletter called “Health Policy Week,” for God’s sake – and I can’t get it out of my blood. The issues I covered during 1982-86 are, basically, the same issues as today. They weren’t resolved then – indeed, the solutions of the ‘80s and ‘90s (managed care, prospective payment) may have made things worse – and there’s a fair chance they won’t be resolved this time.
But that doesn’t have anything to do with my plans for tomorrow. Sure, I believe passionately that health reform must pass or this great nation will go bankrupt. And yes, in my opinion the current compromise pretty much stinks, may not work, needs the public option or something like it, yada yada yada. Health policy does indeed matter to me. But the reason I’ll be glued to the TV tomorrow has more to do with spectator sports. What NFL football and NBA basketball are to others, health reform is to me. Even if I had a full schedule, I’d cancel all engagements.
Now, as it happens, I don’t have any engagements tomorrow. The decks are clear for stultifying TV. I’ve been home from the hospital since last Friday, recovering from total knee replacement.
An improved patient delivery system is a necessary pre-condition for affordable and quality health care.
What do I mean by a “patient delivery system”?
Understanding patient delivery system means recognizing that people without health insurance do not receive treatment until they are in an immediate life-threatening situation.
I cannot back this up with a scientific study, only my daily experience. But that experience contradicts an oft cited myth that no one who needs health care is turned away. One of the most common reason that people call our office is because something happened to their health insurance that lead to a denial of treatment.
It may be as simple as the doctor calling the wrong number or it may be that the member has failed to pay their share of their health insurance premium. But the reasons don’t make the stories any the less heart breaking.
You have heard the arguments.
In the first corner: “We have the best health care system in the world. People travel to this country from all over the world to get the best health care. the parking lots in hospitals bordering Canada are full of cars with Canadian license plates.”
In the second corner: “There are 100,000 deaths per year from hospital infections and a similar number from prescription drug errors, and an equally horrific number of people who need to be re-admitted to the hospital for complications. And what about “Never Events”, those medical errors that are described as adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.
And there is a voice in a third corner: “We have the most expensive health care system in the world yet the United States is not ranked among the top twenty nations in infant mortality, maternal mortality, longevity, or hospital admissions avoidable with access to health care.”
It’s a bit like arguing who won the Super Bowl (this is Super Bowl weekend, after all) by comparing rushing yardage, passing yardage, first downs, time of possession. Unlike football, in health care there is no touchdown metric, no definitive “points on the board” that decides health care quality.
Which corner would you pick?
Is health care reform dead? Doubtful? What will it look like? Not nearly enough.
So I want to get a head start on the next round.
Because whatever happens in this round, round 2 cannot come soon enough. It is unrealistic to expect health care reform to be a once and done proposition. The Model T was not invented with 4 wheel anti-lock disk brakes or fuel injection.
So over the next few weeks, I would like to take a look at some of the issues that will still remain even after health care reform legislation is passed.
But first let’s give some thought to what we want from our health care system.
The next time you hear a Republican or a teabagger complain that President Obama is moving the United States closer to "fascism and socialism" (despite the two philosophies being ideologically opposite of one another), remember this: some of these same people are taking thousands of dollars in a form of "socialism" that we usually don’t think about: farm subsidies.
For those not in the know, farm subsidies are when the government pays farmers and businesses in the agricultural field to (a) supplement income, (b) manage commodity supply, and (c) influence commodity cost.
Here’s the dirty little secret: some politicians, mostly Republicans but also a few Democrats, figured out how to make tons of money off of this "socialism for the wealthy." It also comes as no coincidence that most of these particular politicians come from largely rural states.
Howard Dean says the health bill would do more harm than good.
Bill Clinton says “Don’t let the perfect be the enemy of the good.”
How did we get this close to health care reform legislation, but many progressives believe that it could actually do more harm than good.
Because the “progressive” position was already a compromised position?
Because “single payer” was never on the table. Because political operatives and policy makers didn’t trust the American people.
The current health care debate certainly demonstrates the power of money over popular sentiment. But could it be that the power of money was so intimidating to some reformers that they chose to misrepresent public opinion?
Dept. of Medicine
The health-care bill has no master plan for curbing costs. Is that a bad thing?
by Atul Gawande
December 14, 2009
In medicine, as in agriculture, efficiency cannot be achieved by fiat.
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PRIDE IN ISLAND!!! Cost is the spectre haunting health reform. For many decades, the great flaw in the American health-care system was its unconscionable gaps in coverage. Those gaps have widened to become graves—resulting in an estimated forty-five thousand premature deaths each year—and have forced more than a million people into bankruptcy. The emerging health-reform package has a master plan for this problem. By establishing insurance exchanges, mandates, and tax credits, it would guarantee that at least ninety-four per cent of Americans had decent medical coverage. This is historic, and it is necessary. But the legislation has no master plan for dealing with the problem of soaring medical costs. And this is a source of deep unease.
Health-care costs are strangling our country. Medical care now absorbs eighteen per cent of every dollar we earn. Between 1999 and 2009, the average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400, and the average cost per Medicare beneficiary went from $5,500 to $11,900. The costs of our dysfunctional health-care system have already helped sink our auto industry, are draining state and federal coffers, and could ultimately imperil our ability to sustain universal coverage.