Thursday, June 25, 2009
# Last event of day was spirited discussion w/ staffer of Rep Crowley.3:30 PM
# Now at Doc/Nurse town hall hosted by Dr. Howard Dean. 1st up, Rep Jan Jakowski.11:15 AM
# Rep Jan Jakowski talks about how we need better nurse-patient ratios & more primary care docs (beef up loan forgiveness programs).10:59 AM
# Sen Lautenberg (D-NJ).10:17 AM
# Now NY-NJ-MD Town Hall. Rep Rangel speaking.10:07 AM
# Surprise guest Senator Gillibrand (D-NY).10:03 AM
# Dr. Howard Dean speaking now.9:49 AM
# Dr. Val Arkoosh speaking now. AMA does not represent majority of docs. NPA wants quality, affordable health care for all.9:39 AM
# Just snapped a photo w/ Dr. Howard Dean & Prez-Elect of NPA Dr. Val Arkoosh.9:24 AM
# Now at HCAN rally with thousands across from Capitol. Saw Schumer & Edie Falco speak.9:23 AM
# Met with staffers of Reps Wiener and Engel this morning.9:21 AM
# NPA going strong in DC today.9:19 AM
Tuesday, June 23, 2009
Prognosis: Debt; Treatment: Public Health Insurance Option + Investment in a Public Health Infrastructure
He writes that President Obama (and others) have defined the major problem with our health care system as being unsustainable growth in costs, while congressional Democrats have primarily focused on expanding coverage to the uninsured:
congressional Democrats and the most involved interest groups behind them are far more passionate about universal coverage than about controlling costs. Thus Obama's political calculation: Push for health-care reform that delivers universal coverage -- and insist on as many levers to control costs going forward as possible.
He explains that this disconnect between the problem and proposed solution comes from the fact that it's easy to expand coverage but hard to control costs. He states that proposed cost saving measures, such as focusing on prevention, shifting from specialist care to primary care, and changing provider payments from fee for service, all are unproven, and he implies that expanding coverage to include all Americans would inevitably lead to more debt. He gives several suggestions to the President on how to ensure that whatever "new burden" we take on with health care reform "is really paid for".
As a physician, I do think universal coverage and equitability in our health care system is a "moral imperative" - I see patients without health insurance or with inadequate health insurance who have put off necessary care due to costs and suffered the consequences - but for the sake of argument, let us just talk about costs.
If we expand health insurance coverage without controlling costs, as outlined by Mr. Hiatt, we would have the equivalent of the Massachusetts plan. Their health exchange ("Commonwealth Connector Authority") and individual mandate to purchase insurance (with subsidies for lower income individuals and families), along with Medicaid expansion and other measures, has achieved more than 97% health insurance coverage. This initially improved access to care (more individuals had a usual source of care besides the ER and a preventive care visit in the preceding 12 months), and decreased the financial burden of health care costs on some families (with fewer people spending more than 10% of their income on out of pocket costs). However, without a mechanism to control costs, there have been challenges in limiting increases in premiums and some of the gains in affordability have been lost.
This is where the public health insurance option comes in. Massachusetts does not have a true public health insurance option. The Congressional Budget Office's $1.6 trillion estimate on the 10 year costs of the Senate Health, Education, Labor, and Pension committee's health reform bill did not include evaluation of the public health insurance option. A proposal by the Commonwealth Fund for comprehensive health system reform including a public health insurance option, provider payment reform, and investment in public health infrastructure was estimated to have a net impact over ten years of $3 trillion in savings. While the upfront costs in expanding insurance coverage may appear daunting, as long as it is coupled with a mechanism to control costs, it will be a wise investment that improves access, quality, and slows growth in health expenditures.
And the cost savings are not just wishful thinking - lower administrative costs and the ability to negotiate lower rates from providers and pharmaceutical companies would allow a public plan to offer premiums at least 20% less than those of comparable plans in private individual or group markets. This expansion of coverage would not reduce overall health care costs, but these savings are not included in the 1.6 trillion dollar price tag for the HELP committee's proposal. If employers or individuals previously with commercial insurance chose to buy into the public plan and its less expensive premiums, there could be significant savings overall.
A public health insurance plan would also likely reduce the costs of premiums of private health insurance through competition. 94% of health insurance markets are "highly concentrated" by FTC standards and most metro areas only have one or two options for consumers. This near monopoly is not good for costs or quality.
The effects of payment reform may be more difficult for the CBO to estimate, but a public plan would have a clear advantage over private insurers in shifting incentives toward prevention, care coordination, and evidence based medicine. Managed care was supposed achieve these goals in the private sector, but it has failed to control costs or improve quality. Medicare has begun to align payment with outcomes through pay for performance and nonpayment of care for preventable complications instead of simply reimbursing for the volume of care provided. A public plan would have the national scope to influence practice patterns across the country; a public plan would offer transparency and could be held accountable if cost or quality measures were not being reached; and a public plan would have the mission of disseminating effective payment innovations to other payers as a public good.
There are many other reasons why we need fundamental health care reform - most pressingly because it is unconscionable to deny sick patients necessary care because of inability to afford health care costs - but the realities of increasing health care expenditures do require a discussion of costs. While it is unfortunate that a misleading CBO estimate on the costs of one version of the health care bill have decreased momentum for reform, drawing on the lessons from Massachusetts, we can still use this information to promote meaningful change. Relying on the private health insurance industry to control costs would be a mistake. However, adding a public health insurance option is extremely popular, with 72% of Americans supporting a public plan in the most recent poll, and would provide several mechanisms to control costs. The American people are correct on this one, and our elected representatives better be listening.
Aaron Fox, MD
National Physicians Alliance
New York City - Local Action Network
Saturday, June 20, 2009
Today, in salon.com article, Robert Reich gave some advice to President Obama on how to achieve universal health care despite the cost concerns that came up this week: make health reform a priority, utilize your popular support and don't compromise! He identifies allies (the 76% of Americans who support a public health insurance option) and opponents (Republicans, the medical-industrial complex, the AMA). And while I certainly support the approach of protecting your allies with a strong plan instead of watering things down to appease opponents, here is my advice to President Obama: you could find much more support for what you do want to do among physicians, if you were to look beyond the AMA.
The AMA does not speak for all physicians. As a medical student, I was active in the AMA but became frustrated with the disconnect between their mission ("to promote the art and science of medicine and the betterment of public health") and what I perceived to be their primary lobbying objective (advocating for higher reimbursement rates for physicians).
The membership in the AMA is declining, and now includes no more than 25% of physicians. In the current debate about the government’s role in health reform, the AMA has opposed a public health insurance option, but again, the organization does not represent my opinion, and likely does not represent the majority of physicians.
A study by Aaron Carroll and Ronald Ackerman, published in the Annals of Internal Medicine in April 2008, demonstrated strong support for universal health care among a random sample of over 2000 physicians (including all specialties). When asked the question, "In principle, do you support or oppose government legislation to establish national health insurance?" 59% of physicians responded that they supported national health insurance while only 32% opposed. This was a 10% increase from a similar survey conducted 5 years earlier. Now, two years later (the survey was conducted in 2007), I am certain the support has increased further. Physicians are not afraid of government involvement in health care financing.
In the past week, attention has turned to the health reform bills coming out of Congress, and the National Physicians Alliance, the American Academy of Family Physicians, and a coalition representing over 215,000 physicians and medical students released a public statement in support of the President and in support of a strong public health insurance option.
“As doctors who work on the front lines of our fractured healthcare system, we are convinced by firsthand experience that our patients desperately need health care reform that protects them from falling through the cracks. This means reform that creates the freedom of choice to keep their current plan, choose another private plan, or have the choice of a carefully designed quality, affordable public health insurance plan.”
While the AMA differs in their approach to health care reform, President Obama has much support within the physician community. As a doctor, it is troubling to me that I take care of extremely sick patients in the hospital but do not know where they will get their follow up care, or how they will pay for their medications, if they are uninsured or underinsured. As a medical educator, it is frustrating to me to waste time teaching medical residents how to fill out paper work and interact with insurance companies when we should be discussing clinical decision making and evidence based medicine. As an American, it angers me that so many other countries have similar (or better) medical care without the hassle or expense of our system. There are thousands of doctors like me who want to provide all of their patients with high quality care regardless of insurance status but just can't do so in the current system.
So, President Obama, be bold and demand universal coverage, including a public health insurance option. There are plenty of doctors who have your back.
Aaron Fox, MD
National Physicians Alliance
Friday, June 19, 2009
Thursday, June 18, 2009
Tuesday, June 16, 2009
The truth is that many people have their health care rationed by private health insurance companies. No one who has Medicare complains that government bureaucrats are getting in the way of the doctor-patient relationship. It is private health insurance bureacrats who are standing between people and their physicians.
Most Americans currently don't have a choice when it comes to health insurance. Republicans who are in favor of the free market should be in favor of real competition between public and private health insurance options that would keep everyone honest and prices competitive.
As a physician and member of the National Physicians Alliance (npalliance.org), I believe strongly that we need health reform now, and that it must include a public health insurance option. If we can spend $1 trillion on a war of uncertain merit, we can certainly spend that much to ensure the good health of all our citizens.
William Jordan, MD, MPH
Development Director, New York Local Action Network
National Physicians Alliance
Thursday, June 11, 2009
Tuesday, June 9, 2009
Monday, June 8, 2009
Thursday, June 4, 2009
The author visits regions of the country where healthcare is very expensive, and places where it's very cheap. He finds doctors who are thinking mostly about profit, versus doctors thinking about what's best for their patients. He concludes that all the insurance reforms and public plans will not solve our healthcare problems. Only when medicine returns to a patient-centered focus will we be able to control costs. Changing the culture of the medical profession is not just a lofty goal, it's an economic necessity.
To me, there is no more powerful argument than this for why the NPA exists and must continue to grow. Gawande connects something that even the most hardened conservative cares about --- the growth of healthcare costs --- to something that we all believe, the need to rebuild the covenant between patients and doctors.
I would urge everyone to read this article, or at least the conclusion. His way of framing the subject is the perfect tool to recruit supporters to our cause in general and our organization in particular.
Wednesday, June 3, 2009
Thought I would share a few articles full I've been responding to today. These are both highly conservative (but widely read) publications.
From 'The American Spectator': Obama Poised to Flip-Flop on Health Insurance Mandate
From 'The Washington Times':
Obama 'Strongly Backs' Public Health Option
I forgot to add a link to our website...oops. Next time.