Thursday, October 4, 2012

Presidential Debate Uno-What Did they really say about health care?

A few months ago I wrote an article entitled Why We Don’t Want to Get Rid of Medicare, Our Best Tool For Health Care Reform which alluded to Republican attempts to “block grant” both Medicare and Medicaid programs and Mitt Romney, Republican Presidential Candidate stated as much in his debate with Presidential Obama last night. To the one person who questioned the validity of my previous article, please feel free to eat crow now. This piece reviews the 2010 health care reforms that Mr. Romney would eradicate, based on his debate comments.

Romney indicated there is broad based support to have the federal government just give state governments money to administer their own Medicaid programs for low income residents, without government mandates. Sure, who wouldn’t want more money to meet a social need, without strings attached? The problem with this is the federal government is funded by all states and all residents and not merely a few, though as Mr. Romney has suggested 47% of us are just free loaders, enjoying life on the dole. To be fair, funding Medicaid benefits is a challenge for all states because the federal government does not pay anywhere near the cost of the program. Some states, like Oregon have used this challenge to come up with a creative health care plan which assigns values to health services and targets public dollars to those which do the most good for its Medicaid population. Actually the Oregon approach is also used in Scandinavia and Europe, where programs funded by the government must meet certain criteria for health effectiveness.  This is incidentally, what the Accountable Care Act and the Center for Medicare and Medicaid (CMS) programs seek to accomplish.
 Having completed many fifty-state analysis of Medicaid and other health programs, there is currently sufficient variety in state Medicaid programs. Some of the variables include; at which level of poverty must one bear in order to become eligible for state medical assistance, variations in plan benefits, and levels of cost sharing. As a tax payer we have to ask ourselves if it is prudent to merely give money to another agency without some performance expectations and program measurement criteria. States who wish to modify their Medicaid plans may currently do so under Section 1115 Waver Plans, which has been around for over a decade. Nearly half of the states already have 1115 Waivers.

Mr. Romney indicated he wouldn’t change Medicare for those who are retired or near retirement, whatever that means (needs their votes), but his plan is to have eligible residents under age 55 subject to block granting for a health care budget. What this means is a fixed allowance would be given to each eligible person to purchase insurance and then get rid of the most popular social program today, Medicare. I wonder what would happen to the “hold harmless” clause that prevents health care providers from charging patients more than what they receive in reimbursement without Medicare setting the standard.  Block granting is a means to affix a budget for a health care spend, similar to what many employers do for their health care programs. This is a way to increase cost sharing among program recipients and to fix costs for the plan sponsor. The problem with this approach is two-fold; you are ultimately passing on a greater burden of health care expenses to those who are least able to pay for it. Let’s face it many seniors have to choose between dinner and their medications, especially since the U.S. government chooses not to bargain with the pharmaceutical companies. Secondly, eliminating the largest stakeholder would remove much of the systemic power for change in health care processes. The arc of Medicare is sufficiently large that as a nation we are able to conduct low-cost demonstration projects to find out which is the best way to align physician compensation with improved clinical results for patients. And changes made by Medicare or CMS do impact the entire health care delivery system in the United States. No other element of the health care system has this much influence.
In order for the country to effectively lower the cost of health care proportionally, we must create a better model of delivery and block granting Medicare by allowing private sector insurance companies to do this is not the answer. What you may ask is wrong with this, well for one thing, private sector insurance companies charge three times as much as Medicare for plan administration and this does not include the margin for profits. As an expert in the health insurance industry and someone who used to negotiate employer plans, I understand all too well the various loads and expense factors which the private sector includes in administration. So, the smart health care consumer will want to spend less for the administrative load, just as the smart investor does for mutual funds. But the Romney health care answer would simply foist the health care purchaser into the already more expensive private sector marketplace. Additionally, the private sector has long had the reputation for “cherry picking” risks and avoiding those folks who are more likely to need health care services. In fact, this is the main reason we have Medicare today, because the private sector insurance companies did not want to serve the elderly, much less the low-income elderly. In conclusion, if you want to have less of your insurance premium dollars paying for your actual health care, have difficulty finding an insurance company that will accept you, and be responsible for a much greater portion of your health care expenses, then by all means, the Romney Plan is for you.

Health Care Expenditure Oversight by A Panel of Experts-Yeah or Ney
Another one of the health care reforms Mr. Romney would obliterate is the Independent Payment Advisory Board which is an appointed commission of health care experts, which would have the authority to rein in Medicare spending. Romney used the scare tactic harking back to the anti-Clinton-health-plan era, which is that this panel would tell you what medical treatments you could have. This is not true, as the advisory panel would examine treatments for targeted diseases and view the most effective outcomes and recommend practices which would save the nation money in the Medicare program without harming the patient. By the way, this is also a process I was involved in while working as an internal consultant for a large hospital group.  The government wouldn’t be telling you what procedure you can have but rather what it is willing to pay for. This is exactly what we need a speed checking device on the gas pedal, as Medicare spending is a huge concern and our elected officials have conflicts of interest from drug company, medical supplier, and big hospital corporations who contribute to their election campaigns.  Do you want someone who is beholden to a private company with a financial interest in the outcome deciding what your health benefits will cost? Why wouldn’t you want an informed unbiased group of experts who use data driven consensus based process making this national policy decision?  Mr. Romney said that private sector always hasbetter solutions than government and solutions to health care spending should be left to the private sector. Well, if that is the case, then why is health care so expensive when we already have private sector individual and employer-based insurance? The answer is none of those stakeholders can change the health care delivery system on their own and we need to work together as a nation to accomplish this gargantuan task.

Hopefully this will clear the fog on the fifteen minutes of the debate which was devoted to health care.

This article was written by Roberta E. Winter, MHA, MPA, and may be reprinted with her permission or better yet, just share it on the paperless wings of the world.