Sunday, February 28, 2010

The States' Role in Health Reform

Interested in the States' role in health reform, the Disease Management Care Blog cracked open the latest New England Journal of Medicine on its way to the Disease Management Colloquium. Maybe it's because the DMCB is developing hyperolympicosis and is about to go on a marchmadness bender, but it concluded this article had many parallels to the biased TV announcer favoritism that too often transforms a perfectly fine sports broadcast into a migraine. Too bad the Journal doesn't have a 'mute' button that otherwise helps its readers get past the authors' unwarranted framing to, like, maybe learning about the underlying issues.

The DMCB says check this article out for yourself, but here's a minimalist summary with some other things to think about.

The reason States can't reform health care is because:

Insurance is profoundly expensive: The logic here is that States simply cannot afford to make a 'real investment in the population.' Accordingly, the only entity that come up with the money to pay for expanded Medicaid, preserve Medicare and provide premium subsidies for everyone else is the Federal government.

Think about: States have to make the tough trade-offs between affordability and health care gains. The fact that Massachusetts came up with its own reform suggests it's within reach, but that there are lessons to be learned about combining a relatively rich benefit with optimistic assumptions. That being said, what is the evidence that Washington DC can do that better or cheaper? Where is that remote.....

Practicality: This says the States are unable to stand up to health insurers' ‘price gouging and exclusion(s)’ and, what’s more, insurers will simply exit any State with an 'unappealing 'business climate.

Think about: According to this link, some State Insurance Commissioners have been doing their job with these insurers quite nicely thank you. Many not-for-profit health insurers are State-based or regional and have no where to go. Now, where's that mute button.....

The Law: ERISA shields employer-based and self-funded insurance plans from the States' reach. They are outside the States' purview, which means the Feds need to step in.

Thnk about: The DMCB recalls that ERISA was enacted in the first place because State insurance commissioners were too effective in regulating plans that extended across State borders and a law was needed to restrain the States. Need to aim carefullly.....

Reality: Last but not least, it’s argued that patients and their insurance move across State lines, resulting in adjacent States having insurance programs that “are far less generous” than their neighbors. This creates disparities, which begs the involvement of Washington DC to assure fairness.

The DMCB doesn’t understand why this is necessarily a problem when the elected representatives of a State do what they think is best for their constituents, unless the idea of a national program is to mandate a one size fits all single benefit structure for everyone everywhere.


The DMCB recognizes that this really comes down to subjective policy preferences, not the faux hard science being portrayed in the Journal. The arguments in favor of greater Federal involvement come down to its ability to control costs once it begins to effectively regulate insurance, that the markets that exist today are neither fish (heavily regulated) nor fowl (free and transparent) and need to be fixed in one direction or another, and that an enlightened legal and regulatory environment courtesy of Wasthington DC could bring the insurers and providers to heel.

Think that makes sense? You be the judge, but don't take this article's word for it.

No comments: