Wednesday, September 24, 2008

The Big Bailout, Obamaite David Cutler vs. McCainiac Gail Wilensky and the New England Journal of Medicine Roundtable on Health Care Reform

Take a diazepam, don your dark sunglasses, apply those ear plugs, don’t look at your 401K and disregard the Feds’ looming commitment of $2300 dollars per person to The Big Bailout. Imagine the US Congress will not be distracted by the wars in Afghanistan and Iraq, the growing militancy of Iran or the volatility of energy prices. You’re now ready to view the remarkably civil and educational 56 minute on-line video that pits the earnest optimist Obamaite David Cutler against the experienced technocrat McCainiac Gail Wilensky in an “Election 2008” roundtable on health care reform. Q&A were from Karen Davis of the Commonwealth Fund, Jon Kingsdale of the Massachusett's Health Insurance Connector Authority and Thomas Lee of Partners HealthCare.

No time? No problem. The Disease Management Care Blog had a glass of Sauvignon Blanc (the best is still Cloudy Bay 2005), donned the high mag spectacles, turned the volume up, accepted its financial advisor’s advice to not cash out (now is the buying opportunity!) and wrote up this summary for your reading pleasure.

David Cutler of Harvard says Obama has 3 goals:

1) Access to quality and affordable care. This should “not very hard” if waste and redundancy are reduced and if we have the will to spend money in the short term. Spending can be partially funded by rolling back the Bush tax breaks and using that to fund tax credits. Lower prices plus insurance reforms that encourage more participation in risk pools will lead to even lower costs.

2) Modernizing the costly wasteful and doctor-unfriendly system. This will happen thanks to “investment” in state-of-the-art prevention, comparative effective analyses, quality measurement and reporting, electronic records, paying for quality and achieving tort reform by preventing errors with health information technology HIT and settling disputes outside of courts.

3) mainstreaming non-politicized public health principles to address tobacco, obesity global epidemics and other issues. Emphasis on non-politicized.

The DMCB take away: even with the fiscal room to maneuver, it was unlikely that Congress would go along with “short term” spending increases. In the Q&A, Dr. Wilensky correctly pointed out that true “waste” is rare. What is far more common is health care that is high cost, low value and high demand. There is little proof that the modernization items listed above will reduce cost individually or in combination. And while the present administration elevated this to an art form, when hasn’t public health been vulnerable to political interference?

Gail Wilensky of Project Hope reports McCains’s emphasis is on controlling costs. To do that, he proposes harnessing the purchasing power of an increasingly mobile job-changing workforce. Giving these individuals tax credits for insurance purchases and letting insurers openly and transparently compete across State lines will not only reduce the number of uninsured in the short term but force the market to control costs over the long term.

Yes, there are predictably high spenders who will be unable to buy insurance at any price. For those who can’t access employer-based coverage under COBRA, the Feds can kick in new dollars for “high risk” insurance pools.

There was little disagreement over the need for the modernization ideas listed above.

Dr. Wilensky reminded the audience that the admittedly imperfect Medicare Modernization Act taught us that passage of a health care bill is possible when Congress’ preeminent role is respected and Presidential leadership is deployed to achieve the best compromise. Contrast that with the Clinton reform debacle. Ms. Wilensky asked which candidate has the best track record of working with a Senate in which 60 votes are never a sure thing.

The DMCB take away: Dr. Wilensky believes individuals spending their own cash can deputize health insurers to do something about runaway cost inflation. Health insurers are already doing their darndest to do that within State lines, so it’s hard to see how that will happen in a cross state market unless they’re willing to risk another backlash. The more likely result is that persons will buy inadequate coverage. McCain is also counting on a precarious pre-bail-out pot of money. Finally the MMA was an example of what happens when a single political party uncompromisingly dominates the national discourse.

Is the DMCB being a morose, cynical nattering nabob of negativity? While both sets of proposals have their problems, they offer a real contrast between government involvement in a failing market versus using government to rehabilitate that market. In the end, however, their reliance on new spending, other national security distractions, recent news that the number of unsinsured dropped and the willingness of States to promote their own reforms makes the DMCB believe that the likelihood that either candidate’s proposals will succeed in the next year or two is very unlikely. Anything meaningful happening after the Big Bailout will require a miracle.

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