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Health-care reform's grand bargain

PH2009111900371.jpg

There's nothing fun about reading legislative language. But spend enough time reading legislative language and it makes reading other things seem fun, like CBO reports. And so it was last night, where after hours spent digging through the legislative text the cool language of the budget analysis seemed as clear and crystalline as a Joan Didion essay.

There's not much in the CBO report (pdf) that surprises, at this point. The public option will serve three or four million people and have slightly higher premiums than private insurance. The co-ops will have such an insignificant effect that the CBO didn't both to estimate their impact. The exchanges will serve 25 million people in 2019, and Medicaid and CHIP will see a 15 million-member increase.

One actual surprise is that the Senate bill doesn't just pay for itself. It balances itself out. That is to say, the bill is not deficit neutral because it costs a billion dollars and then the government raises a billion more dollars in taxes. In that scenario, the government is spending more, but paying for it. Rather, "CBO expects that, during the decade following the 10-year budget window, the increases and decreases in the federal budgetary commitment to health care stemming from this legislation would roughly balance out, so that there would be no significant change in that commitment."

In the first 10 years, in other words, the bill improves the deficit a bit, but the government is spending $160 billion more on health care than it otherwise would have. In the second decade, however, that ends: The savings from Medicare and Medicaid, paired with the excise tax (which CBO says "is effectively a reduction in the existing tax expenditure for health insurance premiums") and a handful of other changes, leaves the government spending no more on health care than it otherwise planned to. That's impressive stuff given that some 94 percent of the country has health insurance. And it implies, of course, that in the third decade, the federal commitment actually goes down relative to expectations. The curve, as they say, is bent.

But it relies on the bill working, and being implemented. The legislation targets Medicare for continual reform and experimentation, with the goal being 6 percent, rather than 8 percent, annual spending growth. One reply to that is to judge it impossible, and call the bill a farce. I'm not quite so pessimistic. Six percent is lower than current growth, but neither unheard of nor unattainable. In any case, it's necessary. At some point, we have to get Medicare to 6 percent growth. The alternative is federal bankruptcy.

This is how health-care reform controls costs. It is, at its base, a grand bargain: The coverage expansion gets liberals to agree to, and even advocate for, cost controls they would never otherwise consider. A 6 percent growth target? A super-MedPAC -- now called the Independent Medicare Advisory Board -- that reforms Medicare to save money and whose recommendations are fast-tracked and protected from the filibuster? Hundreds of pages of changes to payment rates and experiments in value-based purchasing and coordinated care efforts? This stuff is very, very real, and it goes into effect very quickly. You may think it's impossible for Congress to cut costs in Medicare and the government will just go bankrupt, but even you'd have to admit that this is what it would look like if the government was cutting costs in Medicare.

If this piece of the bill was passed on its own, it would be the most important cost control bill ever considered by the United States Congress. But you could never have passed it on its own. You needed the coverage to make the grand bargain work. Republicans like to call this bill a trillion-dollar experiment to expand the health-care system, and in some ways, it is. But it's also a multitrillion-dollar experiment to cut costs in the health-care system, and it deserves credit for that, and support from fiscal conservatives. It's easy to talk about cutting costs, but this is the chance for people to actually do it.

Photo credit: AP Photo/Manuel Balce Ceneta.

By Ezra Klein  |  November 19, 2009; 9:09 AM ET
Categories:  Health Reform  
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Comments

"but even you'd have to admit that this is what it would look like if the government was cutting costs in Medicare."

Cutting costs in Medicare would involve benefit restrictions and targeted cost-sharing. Period. Neither are in the bill.

And I'm glad that with your "grand bargain" comment you make it explicitly clear that liberals don't actually care that we're heading towards bankruptcy due to health care costs-- but rather they'll concede cost control to get what they want-- which isn't the financial health of the country.

Posted by: wisewon | November 19, 2009 9:25 AM | Report abuse

"But it relies, as you might imagine, on the bill working, and being implemented. The legislation targets Medicare for continual reform and experimentation, with the goal being 6 percent, rather than 8 percent, annual spending growth."


i haven't read the CBO report and only got through basically about 500 pages of the bill so far.

Do you really believe that its attainable with our government when Democrats continue to push the "doc fix" which is set for a vote today in the house? I understand that politicans need to "pay off" supporters of reform but how can you with a straight face say that it controls costs in one breath and the next allow that to go on. Again I say this ALL needs to be taken out of politicians hands because they can't be trusted.

And the shell game continues. The question is what will they need to do to buy off Landrieu, Lieberman, Nelson and Lincoln and how much will it cost us all??

Posted by: visionbrkr | November 19, 2009 9:32 AM | Report abuse

To be add a little more-- this legislation is what cost control looks like when you believe that only government can fix the problem. Not individuals, not market solutions, ONLY government. And therein lies the problem. Everything offered up in this bill for cost control is helpful. But its simply wrong to think that our political process will enable successful cost control with ONLY government having a role.

So instead of pushing for a robust comparative effectiveness group generate "official data" that could provide political cover for insurance companies to make benefit decisions that are medically appropriate, we instead have an IMAC that will have its recommendations tossed just like we saw with mammograms this week. The mammograms is the EASY STUFF. We need government focusing on the gaps in the current market, and instead we have government providing the full solution. Ignoring the political realities that will prevent government from being a successful solution. This has been one of my core frustrations. Folks in DC don't really understand the nitty-gritty that has led to the downfall of the system. So they instead choose a "government as savior" path. And even that is too timid.

Posted by: wisewon | November 19, 2009 9:44 AM | Report abuse


I just read through the sections on delivery system reform projects. You may be impressed with demonstration projects, but there's frankly enough data existing in established Integrated Delivery Systems to know that the savings will be there. Kaiser. Projects between Partners HealthCare (Harvard) and BCBS. Mayo. Intermountain Health Care. We know what the benefits of integrated care are-- at least to the same degree that will come out of the pilots. Do you know what networks will be part of the pilots? Kaiser. Partners. Mayo. They're the only ones capable of participating! So we're just going to replicate the data they already have! The tough part is getting self-autonomous physicians to give up their practice and become employees of a hospital-centered network. No one is doing that for a pilot. So in 2016, we'll see data confirming what we already know, and we'll then have the tough problem of pushing the health care system to integrate in ways they don't know want. So we're just simply punting the tough issue-- forcing actual structural change to the system-- down the road another 7 years.

I'm supposed to be impressed with delivery system reforms because the have pilot projects replicating stuff that's already happened on the private insurance side? Sheesh Ezra.

Posted by: wisewon | November 19, 2009 9:45 AM | Report abuse

Wisewon nails it yet again.

Posted by: novalfter | November 19, 2009 9:48 AM | Report abuse

"...but even you'd have to admit that this is what it would look like if the government was cutting costs in Medicare."

Sometimes I wonder how you can write this stuff Ezra. Cost cutting in Medicare would look like this:

1. Medicare would be permitted to negotiate with pharmaceutical companies for drug prices. Starting Jan 1, 2010, the already prices already negotiated by the VA would apply. Medicare could improve on those over time.

2. Direct consumer marketing of prescription drugs -- which is designed to push patients to demand more expensive drugs of marginal (if any) medical benefit -- would be banned.

3. Cost saving programs that have *already* been identified through demonstration projects only to be stymied by Congress would be approved for immediate implementation.

In other words, cost cutting would...implement known cost cutting strategies immediately.

Posted by: Athena_news | November 19, 2009 10:04 AM | Report abuse

If the Dems are actually able to pass legislation that qualifies as a grand bargain, granted, a massive "if", won't that make the Republicans the public policy equivalent of the spleen?

Posted by: lostinthemiddle | November 19, 2009 10:11 AM | Report abuse

Ezra - You say a couple things that could be misconstrued. You're right that according to CBO, gov't spending on HC would be less under this bill than under current law -- albeit in the 2nd decade of the bill.

But your comment that this would bend the cost curve is misleading, if not outright wrong. CBO does not score the increase in private sector spending on health care that this bill would force on the American public.

In other words, the cost curve for gov't MAY be bent but the private sector will be spending more on health care. This is an incredibly important point. There's nothing in the Senate bill that makes me think that it will reduce overall HC spending as a % of GDP. In fact, if and when CMS gets down to analyzing this i think they'll arrive at the same conclusion.

And as for the "grand bargain" i think it's a bargain that the public doesn't want to make.

Posted by: MBP2 | November 19, 2009 10:14 AM | Report abuse

I think that the public option was part of the bargain as well.

Wisewon: you left the VHA out of your list of coordinated care institutions that achieve great results. Their IT program, VistA, is available to any hospital that wants it.

Posted by: eRobin1 | November 19, 2009 10:27 AM | Report abuse

I'm confused.

The CBO report says "The public option will serve three or four million people and have slightly higher premiums than private insurance."

The public option will have higher premiums than private insurance? How is that affording "competition"? I thought the public option was going to be cheaper and, therefore, cause private insurance to have to come down in order to compete? If the public option costs more, how are those uninsured going to afford it?

Something about that alone just doesn't make sense.

Posted by: boosterprez | November 19, 2009 10:40 AM | Report abuse

People misunderstand the "doc fix". The flawed SGR calculation for reimbursement through Medicare have caused annual decreases in reimbursements (though they have been stopped every year but one), while the costs to provide the care continue to increase. You cannot sustain a business where you are providing your services at or below what it costs you to provide those services. Moreover, when Medicare says they will now only pay 65% of the cost for a service, private insurers bring their reimbursements down as well.

The doc fix is about making a rational calculation for reimbursements so doctors are not faced with the choices to either a) not accept Medicare/Medicaid patients, or b) Shove way too many of those patients into one day just to make a profit - leading to shoddy care.

Doctors have to pay for high overhead costs, and they HAVE to make a decent profit too.

Posted by: Jodigirl | November 19, 2009 10:46 AM | Report abuse

jodigirl, the "doc fix" may be necessary, but it's still not paid for. And since it's part of health care, and Obama said health care would be deficit neutral going forward, it's tough to still claim that that's the case if you pass the doc fix. If they include the doc fix, they'll have to give up something else or tax something else...neither of which are politically popular.

I'd like to add that cuts in Medicare, as touted in the plan, haven't taken place since 2002. Congress has not had the political will to make those cuts because seniors are such a reliable voting bloc. So they can *say* these cuts are going to happen, to pretty up the CBO score and get passage, but the cuts are not likely to actually occur.

Democrats are ONLY considered about passage at this point, so they'll promise whatever it takes. After that, it'll be status quo. Which means continued rising deficits...and many more disenchanted independent voters.

Posted by: boosterprez | November 19, 2009 10:55 AM | Report abuse

This legislation boils down this:

Doctors: Amidst a physician shortage get MORE work with MORE patients, LESS pay, GREATER RISK for lawsuit due to poorer work conditions and a continuation of our current tort laws.

Private Insurers: MORE policy holders, LOWER reimbursements to providers, HIGHER risks.

Patients: Currently with insurance = INCREASED premiums, LESS physician access, pushed into inpatient settings for imaging studies, LESS benefits. Without insurance = Forced to pay or pay a penalty, while receiving bottom of the barrel services with difficulty finding providers able/willing to accept their Medicare/Medicaid or public option insurance.

Drug companies: Painless gift of not raising prices on some Medicare drugs to the tune of $80 billion over 10 years, while being free to gouge the American health care consumer in every other drug they offer.

Trial lawyers: Give NOTHING, GET MORE CLIENTS due to increase in patient pool, and decrease in physician pool creating greater likelihood of error.

Posted by: Jodigirl | November 19, 2009 11:01 AM | Report abuse

jodigirl, I'd say you sum it up pretty nicely.

Seems the lawyers are the best taken care of here...

I'd not have even given them a thought in the big picture, but you're absolutely right. They seem to be the class of citizens most cared about it.

Posted by: boosterprez | November 19, 2009 11:04 AM | Report abuse

"I thought the public option was going to be cheaper and, therefore, cause private insurance to have to come down in order to compete?"

Difference between absolute and relative. CBO is essentially calculating that private insurance WILL compete on cost by reducing it to just enough below the PO to continue to maintain market share. The PO just by existing and running with efficiencies on the order of Medicare can drive down the average premium even if it ends up the most expensive plan when the dust settles.

And I don't see how anyone can says there are no cost controls in this bill. Short version: bill eliminates savings in physicians reimbursements under Part B that realistically were never going to happen, in turn bill goes after the huge amount of waste from providers billing Part A for services that are not in fact covered under Medicare to start with or are never actually delivered at all. For a big net savings that shows up in the CBO score.

http://cbo.gov/ftpdocs/107xx/doc10731/Reid_letter_11_18_09.pdf

CBO breaks it down by line item in Table 4. Try lines 3131, 3131, 3201 for the big numbers. Or consider the $800 million in savings cutting back on motorized scooters (those things are a God send for people on oxygen and the like, but too many people seem to be using them as a tax-payer paid indoor/outdoor golf cart).

Anyway the big savings in the bill are not in demonstration projects, that is why they are called 'demonstration'. The big dollar savings come from reforms in the supply of inappropriate medical equipment and Medicare Advantage payments that are not actually delivering health care services. (Yes exercise is vital, no we don't have to deliver it via Gym Memberships).

Far from 'nailing it' certain readers seem to have been looking for evidence to support their pre-disposed views. Or do you all have quarrels with any particular line item of the CBO score?

Posted by: BruceWebb | November 19, 2009 11:07 AM | Report abuse

so the public option actually covers LESS people than the republican proposed health care bill would?

given its responsible for a small fraction of the coverage impact of the balance of the bill, the only plausible reason why it dominates 90% of liberal talking points about the bill is that it is a foot in the door, small foot but a foot nonetheless, for the government in the health care insurance market for non-vulnerable populations and the big things liberals see from this foot in the door lay down the road 10 or 15 years.

afterall, why insist on the public option so much if its present affect on coverage expansion is less than the republican's bill?

very very telling.

Posted by: dummypants | November 19, 2009 11:09 AM | Report abuse

The idea that these bills will cut the deficit is one of those very big lies advocated by propagandists in the great despotisms of the twentieth century - Goebbels, among others. Lies that big, that much against what one knows intuitively, have the effect of stupefying the public. It's hard to believe our leaders could lie so boldly, on such a large scale, and so oddly these lies are more successful than smaller ones.

Posted by: truck1 | November 19, 2009 11:10 AM | Report abuse

People misunderstand the "doc fix". The flawed SGR calculation for reimbursement through Medicare have caused annual decreases in reimbursements (though they have been stopped every year but one), while the costs to provide the care continue to increase. You cannot sustain a business where you are providing your services at or below what it costs you to provide those services.

Posted by: Jodigirl | November 19, 2009 10:46 AM | Report abuse


Oh i understand FULLY. The "doc fix" will increase costs by $200+ Billion over 10 years directly into doctors pockets. Should it be more set up towards primary care and away from specialty, YES. Should it be less expensive for docs to go to medical school, YES. Should doctors be allowed to practice freely without the threat of lawsuit and be forced to practice defensive medicine, YES.

Fine if you don't like the doc fix I'd rather move to capitation anyway. Maybe that suits you better.

Its funny how doctors are told they can make a profit but insurers can't. Listen I'm all for forcing insurers to be 100% non-profit. But doctors need to be held accountable for what they do to turn a profit (ie owning stakes in CT scanning facilities that they send patients to and don't bother to tell patients about, owning surgery centers where they do the same thing etc). People love to tout the lower costs of the other countries systems of care but conveniently forget that doctors in those countries aren't the profit mongers that a portion of doctors in this country are. Its a shame because the majority of doctors I find aren't like this but as with anything else a couple bad apples spoil the bunch (same can be said of insurers in regards to profit vs non profit).

Posted by: visionbrkr | November 19, 2009 11:10 AM | Report abuse

Far from 'nailing it' certain readers seem to have been looking for evidence to support their pre-disposed views. Or do you all have quarrels with any particular line item of the CBO score?

Posted by: BruceWebb
__________________

Actually, I have a problem with CBO scoring in general. The CBO scores whatever Congress tells them to score...doesn't mean it's actually going to happen. For example, the CBO doesn't consider whether people will opt to pay the penalty instead of buying health care coverage. This is a very real possibility, now that people don't have to worry about pre-existing conditions preventing them from getting a policy when they get sick. Nor do they have to worry about paying more for that coverage, thanks to "community rating" and the non-discrimination clauses. I liken it to being able to buy homeowners insurance WHILE my house is burning down, yet paying what my responsible neighbor pays.

CBO can't determine or consider unintended consequences or the behavior patterns of people, both of which could significantly alter the cost landscape of healthcare.

Posted by: boosterprez | November 19, 2009 11:18 AM | Report abuse

boosterprez:

Again, you cannot escape the fact that physicians cannot run their businesses by giving away free health care. Just because Medicare reimbursements have not been CUT since 2002, does not mean they have been RAISED to meet up with the fast pace of health care inflation. Provider reimbursement rates and health care inflation are going in the opposite directions (private insurance follows Medicare's lead on reimbursement - so when Medicare lowers reimbursements, so do private insurers) Providers are bound by enormous and fast rising costs to provide health care too. Yet, they are facing further reductions in their reimbursement from the government and private sector. This will not create a better system, and not will not lead to better access or more providers.

The fact that the doc fix is not paid for is a reason the government should not be running huge things like health insurance. There is a conflict of interest with a politician needing the necessary funding to support these expensive public goals, and do it appropriately such that it is adequately funded. Politicians cannot mandate higher taxes AND stay in their elected position. People don't vote for politicians who raise their taxes to support these very costly public entitlements. SO, the politicians do not raise the necessary taxes, but instead run these things extremely poorly - just like Medicare has been run.

Posted by: Jodigirl | November 19, 2009 11:20 AM | Report abuse

Jodigirl:

Just so you don't misunderstand, we are on the same page in this health care debate. You are preaching to the choir!

:)

Posted by: boosterprez | November 19, 2009 11:23 AM | Report abuse

boosterprez,

I was worried about that too (CBO scoring relating to people opting for the penalty) although from what i can tell the rules of open enrollment still seem to be in place so I'm a little less afraid today as compared to yesterday of people jumping from coverage to penalty based upon month to month cost and illnesses that could occur.

Posted by: visionbrkr | November 19, 2009 11:27 AM | Report abuse

visionbrkr:

We do not live in another country. We live in the wealthiest nation in the world!! Yet, we would expect our youth to incur the biggest personal debt for education, with the longest and most difficult training (intellectually difficult, emotionally difficult, and physically difficult), for a job that carries more liability than any other, demands on-call time away from family during nights, weekends, holidays, etc. but not allow them to attain any part of the wealthy dreams that this country inspires??? We will allow and encourage wealth, but NOT for the ones who have to face the biggest hurdles and hoops to do what they do, and those who have the level of intelligence it requires, AND for those who society needs the MOST to be the BEST!!! Yet, we leave lawyers, CEO's, etc. to be free, with their half the time of education/training and even less than half the cost for that training, and NO liability to become mega multi-millionaires.

That does not make any sense to me.

I am not a doctor so I didn't go to medical school, but I know some who did. NO OTHER CAREER choice in this country REQUIRES the amount of time and intellectual capacity that being a doctor does. Doctors are NOT getting rich seeing patients in this country. There is not ONE doctor who got anywhere near as wealthy off the health care system as trial lawyers like John Edwards who became a multi-millionaire from suing doctors with bogus science. There is not ONE doctor who got anywhere near as wealthy as the Humana regional director in my area who lives in a multi-million dollar mansion.

The doc fix is NOT money going directly into doctors pockets. AGAIN, it is to fix a flawed calculation (all in government agree it's flawed) that keeps physician reimbursements through Medicare stagnant while their costs to provide services continue to rise. They are NOT getting a huge sum of money, they are getting FAIR reimbursement rates that keep up with inflation. They are getting the ABILITY to see Medicare/Medicaid patients without it COSTING THE PROVIDER MONEY. Why is it unfair to allow providers to profit?

Posted by: Jodigirl | November 19, 2009 11:34 AM | Report abuse

I should correct myself:

Doctors cannot get anywhere near as wealthy from seeing patients as trial lawyers do suing doctors.

Doctors do not become millionaires seeing patients. Some may attain the status of half-millionaire, but not many.

Millionaire doctors are not millionaires from treating patients. They are millionaires through hospital investments or inventions, not seeing patients.

No doctors I know NEED to be millionaires. But they SHOULD be very wealthy.

Posted by: Jodigirl | November 19, 2009 11:55 AM | Report abuse

The public option will cost more. What a fine bill our boys have constructed. And their final argument? Better a bad bill than none at all. I disagree.

The Democrats have a death wish, and I think that their wish is about to come true. What next? Oh, of course, legalizing the illegals.

Posted by: rusty3 | November 19, 2009 12:07 PM | Report abuse

Jodigirl,

Don't get me wrong, doctors provide a very valuable service much more than anyone at a health insurer but there are many of them profiting off the current FFS system. You may not know them but I do. I know doctors that have multiple homes, cars etc. I know doctors whose offices feed off the insurance system as it is now. Just yesterday I had a client call me who is stressing because he got a bill for $5,000 and he has insurance. He could eventually be a medical bankruptcy case but his case is not an insurers fault for denying coverage. Its for paying coverage out of network. He went to this doctor in NYC who participates in his healthplan for the express reason that it would only cost him $10. But the doctor recommended a surgical procedure and told him that it would be done at St. Vincent's Medical Center in NY. He checked with me and I confirmed that St Vincent's partiicpated with his insurance so he'd be covered at 100% if he went there. Then the day before the procedure it was moved to the surgical center that the doctor owns (across the street from St vincent's) that does not participate with his insurer and that's done on purpose by the O/P surgery facility. The doctor owns the practice. The office staff called the insurer to see if the procedure require pre-certification (which it did not) and they then asked if it needed pre-certification EVEN IF they (the facility) didn't participate because they did not. The insurer told them it didn't need a pre-cert but yet never told the patient that they were out of network. Now the facility is sending them a bill for $4,000 and eventually the anesthesiologist will send them a similar bill for around $1500. That's an extra $5500 that will be due from this patient because a procedure was moved to make that one doctor more money to feed his practice and surgery center. On top of that, the out of network reimbursement is much greater than the contracted rate that a doctor would have received so it costs the system more. So please don't tell me doctors aren't profiting off this system.

I'm not saying doctors can't profit. Just be honest with us when you do. That doctor's office should have told the patient that the move from the hospital to THEIR surgery center increased his cost by over $5000 and made the doctor more money. But again there's no transparency in medicine so that won't happen.

I see this thing happen almost daily. Don't get me wrong, its not all doctors and I'd bet (and hope) that its a fairly small percentage, but it absolutely does happen. Its a vicious circle of cost that someone needs to break.

I'm all for getting rid of all the lawyers and the regional directors at Humana or any other insurer. I'd be fine with the Ken Feinberg of the world's capping their executive compensation but you're burying your head in the sand if you think docs aren't profiting off the current system and also destroying it with that profiteering.

Posted by: visionbrkr | November 19, 2009 12:07 PM | Report abuse

visionbkr:

You said your friend/client confirmed that the original surgery site was a participating provider....why didn't your friend confirm that the new surgery location was a participating provider? Is it the doctor's responsibility to confirm whether they're in the network, or the patient's?

I sympathize with your client. I know someone who experienced a similar situation. They assumed that, because the doctor was in the network, the location he'd be working out of would also be "in network"...

Of course, we all know what happens when you ASSUME.

Patients need to better educate themselves on the intricacies of their insurance policies. When the employer makes the decision for the insurance his employees will be offered, it seems to take the responsibility OUT of the hands of the insured.

Which is why I'd prefer to see our country move away from employer-sponsored plans. We are taken advantage of by insurers and employers when the real choice is NOT in our hands.

The Wyden-Bennett plan moved in this direction.

Posted by: boosterprez | November 19, 2009 12:26 PM | Report abuse

visionbrkr:

Doctors SHOULD be profiting, and they SHOULD be a part of the wealthy group in this nation (please re-read my earlier post). They should be allowed to be wealthy enough to have several cars, or a vacation home. IF any career should afford that, it is DOCTORS.

Removing the conflict of interest with physician owned facilities is on the list to fix the kind of problem you mentioned. But penalizing ALL doctors because of the behaviors of those few is counterproductive to everyone in the system.

I am a critical care nurse. I have worked in many ICU's at several different institutions and for a private practice group. EVERY area that I have worked in is opposed to the FFS model. It's NOT doctors trying to protect the fee for service model!! Doctors do not even get reimbursed for over 50% of their services anyway. Unlike a lawyer, a doctor cannot start a stop-clock to see how long they are on the phone with a patient, insurance company, or pharmacy. They do not collect a specific fee for the onslaught of overnight phone calls from ICU nurses needing medication tweaking. They do not get paid a specific fee for rounding on their patients on holidays and weekends, or if they have to see a patient 5 times on a Saturday, versus one time on a Saturday.

Doctors I know are ALL for a system that pays more for quality. The practice group I work for already went to PQRI years back. They are not afraid of getting paid more for providing better quality service. What they are NOT for is a system that penalizes the providers when outcomes are not reached, when they could not control the outcome.

For example, HR 3200 said reimbursement would be lessened for preventable hospital readmission. But, it failed to specify preventable by whom. As such, physicians and hospitals could face loss of reimbursement when a congestive heart failure patient is discharged, and then against medical advice consumes too much salt in their diet, causing worsening symptoms and difficulty breathing - leading to early re-admission (I have seen this MANY times). As long as providers are not penalized despite quality, they are all for it.

Doctors that I know are in the hospital repeatedly during nights, weekends, and holidays. They are bombarded with nighttime phone calls, or they have to come in to perform emergency angioplasty, or emergency brain surgery to prevent death from an aneurysm. These people NEED TO BE THE BEST OUR SOCIETY HAS to do these things. It is not realistic to ask people in this country, who are born surrounded by wealth and the American dream to attain it, to do what it takes for them to do, and not be a part of the wealthy American lifestyle.

Posted by: Jodigirl | November 19, 2009 12:38 PM | Report abuse

boosterprez,

I agree my client when it was moved should have checked again with us or the insurer directly but he was told that the new site "accepted" his insurance. Acceptance and participation are two totally different terms. My clients problem is that he is from another country on a visa (H1 I beleive) and doesn't get the inner workings of our system here and how one word change like that can affect his costs so dramatically.

I've also got another example that couldn't have ever been helped. Another client (a US born citizen) went to a doctor that had just left his practice he had been with for years and the insurer for all they knew he still participated (still shows up today on their website as participating but under the other office location). The different office address should have been what clued in the patient as to a potential problem. The doctor's new office was not contracted yet with the insurer but he still saw patients and the office manager said "after the fact" that they were working to resolve the issue even though the patient wasn't told that at the time of service the doctor wasn't participating yet because they billed under a different tax ID number. You can blame the insurers if you want for these examples but they're not their fault. A doctor's office should be honest with a patient if they participate with an insurer and should tell them up front that they do or they don't and then let the patient decide. These are all examples of why medical bankruptcies are as high as they are with people WITH insurance. Sure there are plenty of examples of recision and denial of coverage for pre-exisiting conditions that need to be addressed and resolved and thankfully this legislation does that but that's not the whole picture.

And Wyden-Bennett (which i'm highly in favor of) wouldn't help this. Its an issue that revolves around doctors. The only way to resolve it is to go to single payer (either through insurers or the government) and require doctors to accept all comers at a set rate. I don't think we'll get there any time soon with anything that's going on now.

THe problem is that insurers are easy to blame. Doctors help patients and they make them better. Insurers are just looked at as someone who didn't pay a bill irregardless of whether the bill was their responsibility or not and they're a nameless, faceless bureaucrat many of whose CEO's make ridiculous salaries. I don't blame people for blaming them but to me, they're not the only one to blame. There's plenty of blame to go around.

Posted by: visionbrkr | November 19, 2009 12:43 PM | Report abuse

jodigirl,

I appreciate your passion and also appreciate what you do. I know several ER nurses and there's not nearly enough of them. We agree that the FFS model needs to go and also that insurers need to be held accountable to their costs and I'm honestly upset that the MLR is as low as it is and isn't held after the exchanges open. That's a giveaway to insurers that shouldn't be in there.

Let me tell you one last story (then i need to get back to work). I have a client who wife was being treated by a maternal fetal medicine doctor in Northern NJ. She was admitted to the hosptial on bedrest at around 20 weeks. The doctor that the hosptial called in to treat the entire floor did not participate in any insurance. He billed the insurance $3000 each day for what the patient told me was 5-10 minutes a day where medications were adjusted. Now the insurance only paid the UCR rate of $600 but that went on for months. About 3 weeks in the patient asked the doctor (because the first explanations of benefit came in that showed the big discrepancy between what the insurer paid and what his office billed) if he would be responsible for that. The doctor said he didn't know (and i absolutely believe that) and that he'd have to speak to their office. Originally the office said that he wouldn't be billed for the differential ($2400 per day) but after a month he started getting a bill. He thankfully came to me, spoke to the doctor and the doctor was very upset with his office staff for billing him but what would that patient do if they didn't question it? How many other patients on that floor were in the same predicament that didn't ask the doctor the same questions my client did and just started to pay the bill for fear of "collections and medical bankruptcy?"

Again these are thankfully the exceptions rather than the norms but they absolutely do happen and insurers (rightfully or wrongfully) get blamed for them because no one wants to blame who is helping them get better and I don't know that they should.

Again my goal is capitation or a fair model that pays providers a more than fair income. You're right they should be among the highest paid because many of them do things most of us never could but at some point cost has to become an issue if its to be affordable for all.

Posted by: visionbrkr | November 19, 2009 12:55 PM | Report abuse

BAck to the "deficit-neutral" claim of this bill....

I hope people realize that the only reason any of these bills are considered "deficit neutral" is because there are ten years of taxes and cuts to pay for 5-6 years of medical care. Of course the bottom line will be favorable!

I crack up when I hear left-wing pols clamor on about how "we need health care for the uninsured RIGHT NOW"....yet the plans don't take affect until 2013! The only thing that will be happening RIGHT NOW is that taxes will go up, and the premiums of the currently insured will go up, to pay for what's to come.

Posted by: boosterprez | November 19, 2009 1:15 PM | Report abuse

The baby boomers are retiring in records numbers, the democrats are adding 55 year olds to Medicare, and they expect to lower the growth rate?

This is why liberals fail math. This is a jobs killer. I know two companies that have never had layoffs in their entire history who are letting employees go because of the increased taxes related to this bill.

I guess the democrats are picking nominees that cheat on their taxes, they can't run the FAA or the Post Office, Recovery.gov looks like a 1st grade practical joke (only cost $18 million), and now they are going to bankrupt states (except Nevada, they don't have to pay like everyone else) with 1/3 more in Medicaid.

Pathetic. Shameful day in US history. The pork in this thing is disgusting.

Why isn't Nevada required to pay for their new Medicaid participants? Why are Virginia and Delaware and Alabama expect to pay, but Nevada is not!

Posted by: Cornell1984 | November 19, 2009 1:34 PM | Report abuse

boosterprez,

ya sorry about that. I sometimes go off on a tangent and need to be slapped back to reality. I've said all along that the Democrats are in serious trouble in 2010 and 2012. As you say the negative points (costs) of the bill take place almost immediately and the positive ones (if they're really positive) don't start for 5+ years and even then only positively affect 10% or so of the population (until they open the exchanges to all).

The thing is though that they don't seem to care. They've fought for 70 years for universal healthcare and they're going to do it no matter how little it helps and how much it costs. Independents are kicking themselves for believing in them. If the Republicans ever stuck to their ideals of a strong national defense (without overstepping into wars) and a small central government they could be the ruling party for the forseeable future. Problem is most of them are idiots.

Posted by: visionbrkr | November 19, 2009 1:42 PM | Report abuse

visionbrkr:

I could not agree with you more on many things. I am a VERY disillusioned independent voter. I have many regrets about my votes a year ago. I would really like to get on-board with Republicans, as soon as they are more cohesive (and perhaps lose some of their crazies, like Palin, sorry to those who like her). However, even if the Republicans do not fix their party, I will likely still be voting Republican for a while to come. Seems to be the lesser of two evils, at this point.

I have tried to post a response to your earlier reply to me, but seem to be having trouble. May try again later.

Posted by: Jodigirl | November 19, 2009 1:59 PM | Report abuse

Jodigirl,

I'm not a Palin fan. Beck either. She really doesn't have a clue about much of anything. She really seems like a "hockey mom" as they put it with power gone horribly wrong and Beck is just a loon with way too much influence although you can't imagine how many people actually listen to him and thinks he speaks gospel truth. Its scary. And not dumb people either. CEO's of big companies.

I've been screaming (as have others on here) for a fiscally conservative and socially moderate to liberal party to step up and get rid of these two parties that don't have a clue as to what the majority of Americans want. I really hope and pray that someone steps in to fill that void.

Look forward to your response getting through. Sometimes I get so long-winded i need to put them into two posts.

Posted by: visionbrkr | November 19, 2009 2:14 PM | Report abuse

visionbrkr:

Your earlier story is unacceptable, for sure. But just paying providers less will only make doctors like that more devious and force good doctors into early retirement or away from patient care. Good doctors don't scam the system, so when they can't get paid adequately for what they do, they will leave and continue to tell others not to go into medicine because the burdens outweigh the benefits (people rarely look at the emotional stress of doctors jobs, laying awake at night wondering if they should have done this or that, etc. Watching patients die and families grieve is difficult, for any good physician. Not being able to help is emotionally painful. Not to mention being yelled at and threatened regularly by people who are acting out of their norm from acute medical crises).

Moreover, I guarantee you this, even fewer people will choose the grueling path to medical careers in the future (MINIMUM 11 expensive years post high school for primary care, 14 to 15 years post high school for specialties - this puts them into their THIRTIES before they even make good money and start paying off debt, saving for retirement, saving for their kids college, etc. Meanwhile, their professional counterparts will have been done with school for many years, been making money for many years, paying debt off for many years, saving for college and retirement for many years, etc.).

It is no wonder to those in the medical field WHY we have had so many empty residency slots in this country, going unfilled each year. We do not wonder why our physician population is increasingly more from doctors coming to work here from other countries. Now, we are on the path to making our doctor shortage even worse, while we simultaneously increase the overall consumer pool.

Doctors may make less in other countries, but so does EVERY career.

Posted by: Jodigirl | November 19, 2009 2:21 PM | Report abuse

cont. from above:

I am passionate not for the sake of the doctors I have worked with. I am passionate for MY OWN sake. I WANT the best of the best doing what I see these people doing. In five to ten years, I don't want medical schools and residencies filling their empty slots with people who earned a B+ average because too few with the highest achievement chose medicine.

Anyway - I have my own story, about insurers.

Like your friend, I was helped along with fertility. I finally achieved a pregnancy with triplets and then began having complications at 15 weeks gestation. The standard of care in this area is a drug called Terbutaline that requires a small medication pump. However, our insurer denied coverage of this. My perinatologist and obstetrician both talked to our insurance regional director, and we petitioned twice for it to be covered. The regional director said it was "experimental" for that use, despite the fact that it had been standard of care for over a decade (most drugs are used "off label", which creates an avenue for denying coverage of them).

I took the drug anyway, deciding we would remortgage our home if we had to.

Interestingly, a few months later (a few months of using this drug) a nurse I know said that she knows one of the reps for that insurance company and they have patients using that drug all over the place. She told me how they have a contract with the pump provider of that drug and are required to cover it!! Armed with that new information, we got it covered.

Had we not gotten that information, we would have had to remortgage or borrow the money elsewhere. How often do insurers do that kind of thing to avoid paying for something, and how often do people NOT find out the kind of thing we found out?

I do want to point out another thing on this topic, in a later post.

Posted by: Jodigirl | November 19, 2009 2:22 PM | Report abuse

I don't like Sarah Palin AT ALL, but count me as one of the crazies who watch Glenn Beck. I'm a fiscal conservative, and have few opinions on social issues. Glenn Beck opens people's eyes, if you'd just give him a chance. Why do you think Van Jones is gone from this administration? Beck almost single-handedly "outed" that guy!

His program last week with black Republicans was amazing. Anyone catch it?

Yes, he's a little over-the-top at times, but he speaks with passion and coherency. He's doing his darndest to try and inform people about money, deficits, debt, policy, etc. Many people don't even understand the difference between deficit and debt. What we don't understand, we don't question. He wants us to question EVERYTHING....

Posted by: boosterprez | November 19, 2009 2:33 PM | Report abuse

"One actual surprise is that the Senate bill doesn't just pay for itself. It balances itself out. That is to say, the bill is not deficit neutral because it costs a billion dollars and then the government raises a billion more dollars in taxes. In that scenario, the government is spending more, but paying for it. Rather, "CBO expects that, during the decade following the 10-year budget window, the increases and decreases in the federal budgetary commitment to health care stemming from this legislation would roughly balance out, so that there would be no significant change in that commitment."

And after 10 years?

Funny how National Review came up with a completely differnent take on the situation:

"It is fiscal madness, for one thing. CBO’s 10-year projection scores its cost at $848 billion, since CBO is required to use a 10-year window that starts at enactment and the bill is designed to start collecting taxes well before it starts spending money. If you look at the first 10 years of actual implementation, when both the spending and the taxes are in effect, the 10-year cost is $2.5 trillion. The Democrats are proudly pointing to the fact that even with its high cost the CBO says the bill will not increase the deficit in the first ten years, but what that actually means is that in the midst of an economic downturn it raises taxes (and also cuts Medicare for the elderly) enough to cover the gargantuan cost. In fact it raises taxes by almost half a trillion dollars over ten years (including taxes on employers, on the uninsured themselves, and on drugs and medical devices and more), and cuts Medicare by nearly as much. And of course, the deficit neutrality calculation assumes things that will never happen (which, as usual, the CBO does its best to signal to readers of its analysis of the bill, even if it cannot say it outright.) It is based, for instance, on the bill’s claim that some key Medicare physician payments would be cut by 23% in 2011 and would not be restored—which will happen well after hell freezes over."

What to believe? Government will come in on budget and make the politically unpopular fiscal choices? Or fiscal nightmare? As the simplest explanation is usually the right one, we'll go with the nightmare.

Posted by: NoVAHockey | November 19, 2009 2:39 PM | Report abuse

boosterprez:

I confess I'm not into Glenn Beck, but I also confess I haven't really watched him. However, I did happen to catch something he said yesterday, which is something I pointed out from an interview on Meet the Press with Larry Summers, months ago.

In the interview Larry Summers started out with, "we save this economy from diving off a cliff". Then, later, when he was put on the spot for why jobs are continuing to be lost, he said, "nobody knew how bad things were."

So, they saved us from a nosedive off a cliff, but it was worse than anybody thought?

Glenn Beck pointed out the same inconsistency with Obama yesterday, playing clips of him saying almost exactly the same things...."We saved this country from a potentially unrecoverable depression", then later when talking about why unemployment above 10%, "nobody knew it was this bad".

Posted by: Jodigirl | November 19, 2009 2:48 PM | Report abuse

I am an Independent who strongly supports a very strong Public Option and Universal Health Care. I will never return to join GOP for the rest of my life, but I respect Gov. Romney, Senator McCain, and Dr. Ron Paul for their contributions. The only Republican that has solutions for health care reform is Gov. Romney. All others don't suit for the 21st century, when they still talk about health care as a commodity in a free market. I am fully insured and offered more care than I want. But we need to expand coverage and seriously lower health care costs.

Health care in the US is like our public education. We spend the most and reap the least. Look around the world. Germany is recovering from this recession well. Why? Their public education has been a huge success and their people elected a smart quantum chemistry Ph.d. for chancellor, while we are joking about electing Sarah Palin for the White House.

Moreover, Germans respect social conscience such that German companies do not lay off workers like fleas when the economy tanks. They cut hours or days so workers get paid less but remain on the job. This stops the domino effect of a collapsing economy, which occurred in the US. When American corporations only think of their bottom lines, not their social responsibility, they laid off as many workers as possible, which caused chain reactions to other sectors of the economy as consumers (workers) disappear. This cut-throat strategy is killing our economy and just like those long term unemployed workers, our economy will take much longer to revive.

Germany has the oldest universal health care system in the world and it again shows having social conscience pays for everyone. As we Americans continue down our greedy path without regard to our education and national health, we will become nothing but a barbaric country. I wonder how I have turned from a GOP conservative, to a fiscal conservative, and now a liberal Independent. I don't believe in partisan politics any longer and will remain Independent forever. I did not vote for Obama, but he will have my vote in 2012 unless there is a viable Independent candidate.

I am all for health care reform with a strong Public Option for our economy and national health. Please read the Senate Health Bill in pdf no matter if you like it or not. Criticize it as much as you can before it goes to the next stage, joint Senate and House debates. Thanks!

Posted by: dummy4peace | November 19, 2009 2:49 PM | Report abuse

wisewon wrote, "this legislation is what cost control looks like when you believe that only government can fix the problem. Not individuals, not market solutions"

______________________________________________________________

Market solutions have been obscene hikes in premiums. Is that what you call a "solution?"

Posted by: edanddot | November 19, 2009 2:53 PM | Report abuse

Jodigirl,

maybe you're right on doctor pay which is why i favor capitation to just reducing what docs are paid but something has to be done to reduce costs. Evidence based tools seem better than that. I'll agree that insurers are way too stingy on covering what's required to be sometimes. Got another story for you. My accountant whose account we handle has Aetna. He adopted two children from impoverished countries(he's in his late 50's with grown children) and both ended up having autism related disabilities (one had fairly severe autism and the other Asperger's (sp). He searched nationwide for treatment for them and eventually found providers that did ABA therpay. Its a highly intensive miraculous treatment that really gets through to autistic kids and helps immensely with their development at early ages (they were 2 and 4 at the time). Aetna didn't cover it. We had to fight for 2 years to get them to cover it but eventually they did. Now, thankfully autism is required coverage in NJ where its so prevalent.
But the morale of the story is insurers should cover things quicker that are listed as experimental but then again if they did that then costs would skyrocket. They're caught (as we all are) in a catch-22.


The big question will come is when the biologics with serious expense come along and they can't be afforded for all who decides who gets the life saving cancer treatments and who doesn't. I'm afraid these problems and decisions are just going to get worse. Cost says we can do it but the human being in us says we have to.

oh and boosterprez,

i just lost all respect for you! just kidding!!

Posted by: visionbrkr | November 19, 2009 3:03 PM | Report abuse

dummy4peace:

First off - You think education is run poorly, and it's run by the government, and NOW you want the government to run health care too?

Again, politicians should not be running very costly public things like education and health care. A politician has a conflict of interest: They want to stay elected and cannot do that by mandating the taxing necessary to run these things well. So, they don't get the taxes, and instead just run things poorly (Medicare and education, PRIME examples). I'm not advocating they raise taxes to adequately pay for these things, I'm advocating they NOT be running these expensive things!! Like education and Medicare, they'll waste billions and run health care poorly and into the ground.

Secondly: If you are going to compare us to Germany, do it entirely:

We are the most obese nation IN THE WORLD. Obesity imposes huge costs to manage chronic illnesses over and over and over, when the "cure" lies more in the possession of the patient than the health care system. Germany does not deal with that much chronic disease from obesity. Not only do we HAVE to pay more because we NEED more due to these kinds of things, but the battle is uphill because the outcome cannot change unless the patient behavior changes. That's not up to the health care system alone!!

We are the largest consumers of alcohol, tobacco, cocain and heroin, according to the World Health Organization in 2008. These also carry with them large amounts of chronic illness, again, more able to be controlled by the patient than the health care system. Again, more very costly uphill battles for our health care system to be able achieve good outcomes. Germany doesn't have that.

We have the most ethnically diverse population to treat in our health care system, and different ethnicities deal with different genetics and lifestyle obstacles. Germany doesn't have that battle.

What about Germany's legal system? Can't we have a "loser pays" legal system too?

How much do doctors, nurses, techs, etc., go into personal debt to do what they do?

How many unions does Germany have, forcing hospitals into unreasonable corners and making them keep bad staff on their employment roster?

What about their drug companies? They are not free to gouge their public like ours is.

Their health care system is NOT the oldest. They just had reform 15 years ago!!! And they are now having a hard time paying for it!!! They don't want to ask their citizens to pay more through taxes, so instead they have begun borrowing from banks. How sustainable is that?

Their doctors are brutally unhappy and have gone on strike. When their monthly stipend runs out each month, they close their doors and go on vacation for a week or two, leaving patients without care - because they don't get paid. Their doctor shortage is going to be staggering.

Posted by: Jodigirl | November 19, 2009 3:18 PM | Report abuse

Jodigirl,

I agree 1000% with everything you just said there but I do think the government COULD possibly do it (even though it would put me out of business). The only way though is if we had term limits. And the Democrats would NEVER do that. Many republicans wouldn't either and although I think Senator Demint is an idiot for what he said about Obama's "waterloo" earlier this year (its ok if you think it, just be smart enough not to say it) his proposal for term limits makes a lot of sense. I also think many Republicans for all the hate the left spews about them do actually do that. Several Republicans are stepping down in 2010 because of self imposed term limits. That's noble of them but I hope the country doesn't go to "$($(" because of their principles on the issue. Of all their issues they pick this one to stand up for what they believe is right! SHEESH.

Posted by: visionbrkr | November 19, 2009 3:34 PM | Report abuse

visionbrkr:

I have thought of term limits too!! A pipe dream, likely. Not only term limits, but I think we have to get away from lobbyists controlling legislation, and we should make fund raising unnecessary in order to attain political appointments. I don't know how, but somehow once a person gets far enough to be in any primary, the funding should be equal automatically and not require it being "raised" (ie., legislation purchased). I would be willing to forfeit some tax money to pay for politicians to run for office, if it means removing some power from lobby groups, etc.

Reducing costs in health care HAS to include patient behavior, and in a big way. People want to pay less, but they will still need their expensive chronic illnesses managed. You can't just keep costs low by lowering what you will pay for services. You have to decrease the NEED for services and help to contribute to decreasing the REASONS services are so expensive to provide (drugs, malpractice, equipment/devices, education expenses, high administration costs, etc.). This administration has put the bulk of their reform into....we'll just STOP paying for it altogether. They fail to address many of the reasons WHY it's so costly.

Did you happen to notice how the Obama administration loved to tout their deal with the drug companies as a huge score for health care savings. Meanwhile, they look to the CBO's 2% estimate for cost savings through tort reform.

Let's look at that more closely:

Drug companies - $8 billion savings a year maxed out in 10 years. In return, they are free to charge whatever they want for other drugs.

Tort reform: 2% is over 50 billion dollar savings, a year, does not max out in 10 years. I don't know if that includes estimates for defensive medicine (which I think is impossible to measure anyway).

Somehow the drug companies $8 billion a year is a huge score for savings (at a HUGE cost to consumers). Yet, tort reform is too measly a savings to consider?

Obama said a long time ago...."Everybody has to give a little and make sacrifices". He failed to say what he really meant, "everybody EXCEPT trial lawyers". Trial lawyers are the only group NOT giving up ANY piece of their pie in this reform. Trial lawyers will make more money when there are more consumers in the system, treated by fewer and even more overworked doctors.

Welcome to Obamacare.

Posted by: Jodigirl | November 19, 2009 3:56 PM | Report abuse

Jodigirl,

I went to an insurance industry meeting about 6-9 months ago right about when that deal was talked up and everyone was screaming that PharMA was doing it because they were in the process of already jacking up their prices. Problem is that no one will listen to insurers. THey're the ones that know how to control costs. The ONLY plans they offer is HSA plans to their employees. They control costs but this administration won't go near them in fact they're limiting them. Now I get that many people can't afford a $2000 deductible in network but that's why you adjust it to what people can afford. What they should do is tailor it to a person's salary structure. The higher the salary, the higher the exposure.

And your take on obesity is dead right. 30% in the USA vs 20% in many other countries and the countries that the US is being compared against as far as health statistics are around 10%. Well DUH. Of course we're not healthy and our statistics suck. Look at all the crap we shovel into our mouths. Look at all the addatives, preservatives etc. Do they have those in Europe? I don't know but I doubt it. But please don't tax our sodas. give me a break.

I agree about the trial lawyers. They NEVER give their share. That's what happens when the lawyers make all the laws though.

Posted by: visionbrkr | November 19, 2009 4:11 PM | Report abuse

Remember, when REPUBLICANS propose a 6% rate of growth for Medicare instead of 8% growth, it is called "cuts" and there are cartoons of George Bush pushing Granny's wheelchair down the stairs. If Democrats propose the same thing, it's called "savings," and anybody who dares to disagree (like Humana) gets investigated by the FTC.

Posted by: SWSomerville | November 19, 2009 4:21 PM | Report abuse

HAHAHA!!!

So Ezra, you are now eating "CROW". I would send you more "CROW" to eat. The public option is in both bills. You predicted that it would never be. You see why your corporate news media outlets are not making money. You pundits recycle too much intellectual voodooism that a lot of people are no longer taking you serious.

Nobody can tell us exactly how many people would register under the public option because the whole science is based on extrapolations and estimates. How much it would cost and what the premiums would be cannot be exactly estimated. It is just like trying to fiqure out the cost of a can of soda in 3 to 4 years time. In Washington DC, from U Street to 14 Street, you can buy a can of soda at 4 different prices. At various places the same can of soda can be 60 cents, 75 cents, 89 cents, and 90 cents etc. Just try to fiqure out what these prices would be in 3-4 years and your work is cut out for you.

All these cost curve extrapolations are just just that, so Ezra just keep on eating crow.

Posted by: ameys1msncom | November 19, 2009 4:22 PM | Report abuse

I don't really know how the health savings accounts work. Honestly, I don't know anything about how insurance works, really. I am in health care, and that's all I know, really.

What kinds of things do insurers think will help keep costs down? I mean, besides just not paying providers anymore?

Posted by: Jodigirl | November 19, 2009 4:23 PM | Report abuse

BUT - That brings me to another patient behavior that must change....Patients have to understand, and somehow feel, the money they're spending in health care. Otherwise, people don't see the dollars they're spending and just keep spending away.

Posted by: Jodigirl | November 19, 2009 4:24 PM | Report abuse

Thanks, Ezra

We're close. If I understand the bill and the CBO correctly, there will be a public option, but because insurers will seek to protect their own market share, those in the public option are likely to pay more than those in employer-sponsored private plans. Is that true? Or, is it that the public option is available to so few that only the sick and the higher risk folks will be in the pool, driving up cost?

Posted by: teoandchive | November 19, 2009 4:41 PM | Report abuse

The article is somewhat misleading. The CBO says the senate 1362, health insurance reform, will reduce the deficit by beteen 60 and 120 billion per year after the first ten years which will cost 880 billion. The CBO came out later and said that if Senate 1361, the Dr Fix, is passed in conjunction with 1362 it will add an addition 200 billion to the deficit per year. In an effort to show the reform as a financial positive they seperated out the Dr. Fix which is what Obama promised to to AMA for support of his reform agenda. The two are tied together but seperate so people wont see the real cost.

Posted by: PSOG | November 19, 2009 5:19 PM | Report abuse

Teoandchive, CBO says that the public option will cost more because it will do less utilization management (i.e., "saying no") and will have a less healthy pool of enrollees. Has nothing to do with insurer market share.

Read it here, page 9, first bullet:
http://www.cbo.gov/ftpdocs/107xx/doc10731/Reid_letter_11_18_09.pdf

Posted by: Policywonk14 | November 19, 2009 6:33 PM | Report abuse

KLEIN DOESN'T GET IT - THERE IS NO, AND I MEAN "NO" AS IN "NONE", COST CONTROL IN THIS BILL.

This is fantasy budgeting... designed to fool americans, and payback Obama's liberal supporters. Let's just be sure to accurately record votes on this monstrosity...

Payback will be 'unpleasant' - VERY unpleasant.

Posted by: wilsan | November 19, 2009 6:53 PM | Report abuse

"it deserves credit for that, and support from fiscal conservatives". Are you kidding me? It also raises taxes enormously. I don't think fiscal conservatives will support that. You've lost all objectivity Ezra.

Posted by: dixon7408 | November 19, 2009 7:13 PM | Report abuse

Cost Control Bill? :-) ha ha ho ho!!!! Ezra Klein is way to smart to believe that for a 2nd. He knows as anybody with an IQ of more than 2 that the information submitted to the CBO was a corrupt joke. Congress will never do most of what they told the CBO they would do. I'm not sure as long as they were spinning a whopper this big that they didn't just make it look like passing Obamacare would cover every man, woman, and child with 100% total cadillac coverage and save so much money we could pay off the total national debt in 5 years after passing it and cut the income tax for everyone including the rich to 0. The fantasy really wouldn't be much bigger than what they are trying to pull. And Ezra Klein knows it because he's too smart not to know it, but he wants Obamacare passed even at the cost of trillions and trillions of dollars, even if it hits the economy like a million ton of bricks and drives UNEMPLOYMENT to 20%, even if cancer patients and the Elderly all have to be refused treatment. Because he's a true believer in Obamacare and Obama!!!

Posted by: valwayne | November 19, 2009 7:39 PM | Report abuse

Here's the Grand Bargain: You give the government all your money and all your freedom, and they give you some nice black chains to wear forever.

Posted by: doctorfixit | November 19, 2009 8:16 PM | Report abuse

Not a grand bargain... a corrupt bargain.

Posted by: clankie | November 19, 2009 9:47 PM | Report abuse

The numbers only look good for the first ten years because there are ten years of taxes and six years of spending. In the second decade, the non indexing of the tax increases raises billions by increasing taxes on middle class taxpyers. What do you think 20 years of compounding is for? The dems think we're fools. It's not the insurance, it's giving up all our individual power to the dems and the SEIU..

Posted by: hdc77494 | November 19, 2009 10:00 PM | Report abuse

The "grand bargain" is unfortunately one made with the devil, in this case. And the costs are greatly underreported. Take the costs to the states, for instance, of the increased eligibility for Medicaid. States are facing crushing budget shortfalls already because of the prolonged recession. They will be forced to increase taxes--probably real estate taxes--to cover their share of these new federal mandates. How will that affect the housing market, as more people can't afford the increased cost? Are we looking at yet more defaults? Hard to say. But it is certain that the costs are far larger than we are being told. And the "grand bargain" will be irreversible.

Posted by: Toosoonoldtoolatesmart | November 19, 2009 10:54 PM | Report abuse

Ezra, I'd love to hear your take on the recent mammogram dispute. I think it's a great example of why cost control is so damn hard. Here's a science-based guideline that will cut costs and save people from inappropriately early treatment. Seems easy. But it's being met with HOWLS from radiologists and labs, who are using their privileged position to scare women into sticking with unnecessary treatment.

The problem with cutting waste out of our system is that almost every penny of waste out there has a constituency benefiting from it. And these constituencies can almost always say "if you don't pay us exactly what we want, this group of patients will SUFFER." How do the Senate cost-cutting provisions deal with that?

Posted by: NS12345 | November 19, 2009 10:57 PM | Report abuse

Although at the same time, it has been pretty amazing to see the GOP getting all incensed over MEDICARE and SCREENING of all things. I would be excited if I thought it would last beyond election day 2010.

Posted by: NS12345 | November 19, 2009 11:01 PM | Report abuse

Let me just tell one of the commenters above that I did practice medicine for a while. It was hard work but it was rewarding and I would have gladly worked for 1/3rd or less of what I was making. Early on, I threw an office party at a beach house which I thought was pretty posh but later I was embarrassed when I found out the luxuries some of my colleagues enjoy on a daily basis--it was really kind of slumming it for them. I personally know about 10 docs who make more than $1 million from patient care alone, and dozens who make more than $500,000. One of them lives in a $10 million home. Another one flies first class to his European chateau every other weekend. You mentioned business income, and I also know several docs who own hospitals or surgi-centers. I know one who owns about 200 Subway restaurants. Several have income from "medical devices" which they use on their patients. One plastic surgeon bragged to me he made $5 million in a year. As far as I know, none of these people were independently wealthy before they got into medicine. All of them got considerable taxpayer support for their education. Now it's true that some docs provide fair value for services rendered but I only knew one who I would say was underpaid. She had a mostly Medicaid practice in a rural area. Bottom line: Doctors should not be getting rich off their patients, and they are, and that has to change.

Posted by: bmull | November 20, 2009 6:35 AM | Report abuse

Jodigirl,

don't feel bad. I talk to many CEO's who are genuises in their businesses and very successful and for some reason can't get their heads around it too. HSA's are plans that instead of having a copay apply for services have everything (except for preventative care) be subject to a deductible (say $2000 or $2500 and twice that for family's). There are many ways to do it and some include prescription integration (allowing people to get prescriptions for copays) but the theory is that if people are more accountable for their costs then they won't spend as much and the studies show that. HSA plans go up a good amount less annually than standard health benefit plans. In fact I met with a CEO where his employee's entire POTENTIAL outlay of cost is less than the premium differential and he still didn't do it. Very very frustrating.

Posted by: visionbrkr | November 20, 2009 7:41 AM | Report abuse

bmull:

First - I have been in health care for over a decade myself, and have NEVER seen a physician become a millionaire seeing patients. I have worked in private practice, at a private hospital and two universities (U of Michigan, Rush Univ. in Chicago).

Second - If you were a doctor then you must know hundreds of doctors, yet only 10 reached a million dollar income level. Moreover, it is not possible that they earned that from just seeing patients (it's NOT mathematically possible, or perhaps you have been out of medicine too long to know that).

Third - The physicians that you mentioned who were millionaires, I am guessing are also the ones inventing devices, investing in other businesses like Subways, and investing in surgi-centers? They are NOT millionaires from seeing patients, they are millionaires from other investments. Why shouldn't ANYBODY be allowed to invest in 200 Subways and make a lot of money at it?

Fourth - There is NO REASON a hard working physician should not be allowed to earn a half million dollar a year income!! IF ANY CAREER CHOICE SHOULD BE ALLOWED TO REACH THE STATUS OF WEALTHY IN THIS COUNTRY, IT'S DOCTORS!! How else do we encourage the brightest and best of our youth to choose the incredibly IMPORTANT career path? This is America. We are the wealthiest nation in the world. Yet we are going to tell people whose career choices REQUIRE more expensive and the longest education/training process that culminates into a high risk, stressful, very demanding field that THEY cannot achieve the American dream of wealth, but others with less education, less risks, less demands, etc., that they CAN?

The physicians I know DO NOT NEED to be millionaires. They're not asking to be. But they should be allowed to attain wealth because of what they do. When you have so many lawyers living in a million dollar home, yet your doctors can't afford that, who went to school nearly double the length of a lawyer, carries risk, etc., something is wrong.

I am curious, why did you leave medicine?

Posted by: Jodigirl | November 20, 2009 1:35 PM | Report abuse

There are already many great comments and truths about health care in the posts here -- which is why, despite the time it takes, I continue to look past frustratingly fatuous and obtuse original articles like Klein's here.

As many have pointed out, this bill looks *nothing* like true reform in any respect, but rather more like the heavy hand of liberalism/progressivism and disingenuous Democrat policy grandstanding run amok in the healthcare sector. Choking regulations; billions in new taxes that will never be realized at the levels expected; cuts that will be reversed every time some voting bloc screams "Not *my* benefits!"; dozens of new bureaucracies; the unelected Sec'y of HHS anointed as super-arbiter of health insurance and delivery structure, cost, etc.; porky "demonstration" projects for care delivery methods that have already been run ad nauseam.

I have no doubt Ezra Klein is intelligent and has studied the issue. His simmering glee here reflects his bias toward the Democrats' dishonest plan. "It is, at its base, a grand bargain: The coverage expansion gets liberals to agree to, and even advocate for, cost controls they would never otherwise consider."

Well, the House voted *this week* to override the SGR reductions in doctor fees (so both the House and Senate bills just got a few hundred billion more expensive). So much cost controls they normally wouldn't consider. Considered and rejected.

No. It is, at its base, a grand deception. Massive cost increases in taxes and cost-shifting to the private sector in the form of higher premiums, which the CBO doesn't need to include in its cost estimate. And a big lie about Medicare cuts that will never happen.

Posted by: Imperfections | November 20, 2009 3:48 PM | Report abuse

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