Saturday, November 28, 2009

Health Reform (for a change)

OK, this is very repetitive, but I'm now restating my position on health care reform, as I wrote to my old mentor, Phil Lee:

Hi, Phil:

Hope you're having a good Thanksgiving and are hale and hearty.

A couple of decades ago you said to me that it seemed to you that there is so much money in the game that it's hard to change. I didn't have the wisdom to reply at the time. But it is just so obvious you were right then, and would be even more right now if you made the statement again.

It's pretty clear to me that should health care reform pass in its current state, and for Obama's and the Democrats' sake it had better do so, who would be sitting pretty? The same ones who are sitting pretty now. Pharma, no problem. Hospitals? All those newly insured patients and minor inconveniences of making their services non-infective, no new prohibitions on local and regional monopolies, no problem. Insurance companies? No more underwriting, continue to write up policies with big premiums, few if any assurances of breaking their oligopolies (I assume the retraction of insurance company immunity from antitrust will not go through), no problem. Training programs, with more money for nurses and more places for trainees? No problem. Nurses, now able to head medical home installations without physician direction or participation? No problem. FQHC's, with $1B growing to $4B increased funding over 5 years? No problem. Everyone with a strong lobby, no problem.

Primary care? Only a possible promise of a MedPac in the executive that might or might not dodge the specialty interests and help redress the RBRVS inequities. A policy to lure people in with debt forgiveness and more training slots, not to make the ultimate destination more palatable. No strong lobby, no place at the table.

And have you seen the plans for the Primary Care Extension Program? Pure public health, no involvement of the professional primary care givers at all! The Feds through AHRQ will dish out grants to states who will set up "Hubs" of the state health departments who will send out who, RN's and MPH's, to tell us in practice how to practice medicine in a medical home, with no money promised to fund it all, just another unfunded mandate? That'll sure be well received!

And patients, what kind of health insurance are they getting? The terrible kind of insurance that the insurance companies have come up with over the years, high deductible and high out of pocket costs up front, with no restraints on insurance payments at the back end, where the consults and the hospitals sock it to them, and will be fully funded. Reminds me of Goldmine Sachs and AIG - 100% on the dollar, while Main Street (Primary Care Street), takes it on the chin. I didn't know Larry Summers and Tim Geithner designed health insurance also.

There is so little about cost control, really. I don't know about funding the ACO's, but I would hope it could help. The biggest fights will be political -- who controls these babies, I guess. It would be great if they worked, just a muscled up version of the old DRG's.

Why is all this happening? Why is the government so weak? One, Senate representation of two Senators per state, no matter what the population. Two, election finances, with so much money necessary and corporate interests thus foremost except for the Obama national campaign. Three, the difficulty of fixing election finances, because of the First Amendment, and because of the long-standing confusion of treating corporations as persons with the same First Amendment rights as real persons. We can pin it on individuals, and on the weaknesses of the political class, but it's really structural.

What forces can be mustered for real reform? It's got to be the profession itself. Professional ethics really do exist, goodwill toward man really does exist in so many ways throughout the profession, if the professional societies and organizations could be mobilized. To me, that's our best hope.

I'm still for health reform on the basis that ethically, Americans need to be able to insured, and on the basis that at least the logjam will be broken. Breaking the logjam will be only the first step, but a necessary one.

Anyway, that's my hit on things.

Again, Phil, I hope this Thanksgiving greeting finds you well, and I would love to come down to Palo Alto and take you out to lunch.

Best as always,


Budd Shenkin

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