Today the EMBRACE healthcare plan turns 6 years old. It was published in the April 7th 2009 issue of the Annals of Internal Medicine. It may have missed the debate that finally resulted in the Affordable Care Act, but now that the ACA has been established it is time to go to the next step. It is time to resurrect this blog and start to promote EMBRACE!
No matter what we may think about the Affordable Care Act (ACA), it is clear that it was only a Band-Aid to a very broken system. In the next few weeks I will post various articles and links that explain some of the inherent flaws of the current system and the ACA’s unsuccessful attempt to fix it- and how EMBRACE will solve it.
As those who know the EMBRACE plan understand that, unlike the ACA or any of the so-called healthcare reform proposals around, EMBRACE was developed by healthcare professionals to fix the real problems of our healthcare system. The plan was developed with the understanding that fixing our current system cannot be accomplished by reforming insurance or increasing coverage alone.
A recent post on TPM explains one of the subtle issues that affect clinicians and their patients that was brought about because the ACA did not address the issue of the quality of insurance that it offers. It is no use to increase the number of people covered if those people cannot find a doctor or facility that accepts their insurance.
This issue is a predictable deficiency of the ACA that does not only involve Medicaid, but also the private insurance plans that are available on the Federal and state run exchanges.
With EMBRACE, everyone has the same coverage for Tier 1 (basic) services; a coverage that pays the same to providers no matter the patient (and there are no ‘networks’ of doctors that you have to belong to) . Private Tier 2 insurance (for non essential services) also provide more uniform and transparent coverage.
Well its looking pretty ugly (and depressing) down there in the Senate these days (the NY Times has a good description of the shenanigans), but what seems most distressing to me is that for the rest of us there is a kind of ambivalence and even apathy in the air; like what comes from overwhelming exasperation and helplessness at what is happening.
I am not really sure what is going to emerge from all this, but I hope it will be something that will at least help cover most of the population. Its clear that it isnâ€™t going to be much more than that.
In the mean time, I think we need to continue to push for EMBRACE. I have taken a bit of time in the last two weekends to update the website even more. Please take a look: www.hpfhr.org. You will see that I have added several new web pages (see the side bar on the Home Page) that show the advantages of EMBRACE from different points of view, including patients, physicians, politicians and businesses. I am working to complete the Business and the Insurance pages and would be glad for any suggestions on these or any part of the site. I am hoping that these pages will help more people to understand the advantages of EMBRACE.
So, if you know anyone or meet anyone who you think might be interested (especially patients and politicians) please direct them to the web site. Also: to make it easier to remember I obtained a new web address: www.TheEmbracePlan.org. It will direct everyone to www.hpfhr.org!
As healthcare providers who have taken keen interest in reforming our current healthcare system to benefit our patients, we can only give qualified support to the insurance reform plan now being considered in Congress. We say “qualified” because we cannot be sure exactly what form it will take or how it will affect our patients. What many once thought would be meaningful healthcare system reform, even President Obama now understands, will be nothing more than health insurance reform. But as Voltaire said, the best is the enemy of the good; and in this case health insurance reform may still be a good step forward in healthcare reform; if it is done right.
By expanding access to the right type of healthcare services, even health insurance reform could improve healthcare for the entire population, without increasing (and maybe even decreasing) cost.
What are the right types of healthcare services that could achieve these goals? Well the most important ones are for diagnosis and treatment of chronic conditions (such as diabetes and high blood pressure) that can lead to more severe -and costly- conditions later on. Emphasis on these “preventative” services as well as science driven treatment of life threatening illnesses would not only make our healthcare system more effective, it will also make it more affordable.
The problem is that not all healthcare insurance gives the same access to these services. Currently, patients with Medicaid find that most private practice physicians will not accept their insurance, and end up relying on public clinics (which are often staffed by doctors-in-training), the emergency room or going without regular care. The end result is that many of these patients tend to put off medical care until their illness is more advanced and the work-up and treatment more complex; and significantly more expensive.
The key is that Medicaid reimburses doctors very poorly, significantly below many practice’s break-even point. This is particularly true for office-based outpatient visits, so private practices cannot afford to extend their services to these patients.
Our concern is that all five of the current proposals in Congress largely rely on Medicaid to extend coverage; a strategy that looks good on paper, but does little to improve the efficiency or effectiveness of the healthcare system. As can be seen in the Massachusetts experience, where they claim more than 97% of the population is covered, many of the newly insured complain that they cannot find a practice that accepts their insurance!
Another proposal is the so-called “Public Option” plan (POP) designed to offer Medicare-like services to the entire population and compete with private insurance plans, with the hope of making them more efficient and affordable. Medicare, unlike Medicaid, offers more realistic reimbursements for providers. Although these reimbursements are somewhat lower than from the average negotiated private insurance plans, many providers find them acceptable since classic Medicare (before private insurance companies began to manage some plans through “Managed Medicare”) does not require as much overhead as when dealing with private insurance. It is this edge, in fact, that Congress and the Obama administration hope will make the POP competitive with private insurance.
Our concern with the POP is that its success will largely depend on how many and which providers will accept it and how Congress will encourage participation by providers. A case in point is Connecticut’s Charter Oak Health Plan. Like the POP Charter Oak was established to help the uninsured who did not qualify for Medicaid or Medicare to purchase low cost insurance. To date, it is reported that over 2000 patients had signed up for the coverage through the plan but it is unclear how many physicians had signed up. Our informal poll of a large physician group found only one private internist accepting the plan. In fact, Charter Oak patients have reported to us that the only internists they could find were the ones working in “Medicaid Clinics”.
Unfortunate we see a potential parallel between Charter Oak and the POP. To help keep costs low, the POP will likely lower reimbursements to doctors and hospitals. As long as these are similar to or more than Medicare, it is likely that most providers will accept the plan. If, however, the reimbursement is low or there is a lot of overhead, many physicians will opt out and this will make the POP less competitive with the private plans and therefore would fail. If on the other hand, Congress links Medicare with the POP (that is forcing the doctors to take either both or neither) then the U.S. may get two sets of doctors and hospitals: the “Private Providers” for the more privileged who can afford private insurance and the “Public Providers” for the rest.
We need and want meaningful healthcare reform and we would even settle for health-insurance reform, but Congress needs to choose carefully; because with healthcare, it is a fine line between reform and deform.
There is a very good analiysis in Talking Points Memo of the Public Option initiative in the Senate. I am copying it here for convenience:
As Senate leaders begin work on a Democrat-only health care bill, they’re finding themselves confronted with an unexpected irony: Though the caucus has reached an uneasy consensus around a public option that’s modeled in many ways after a private insurer, it may be necessary to make the public option more liberal, and thus, more politically radioactive, if it’s to overcome a number of unique procedural hurdles.
This is the needle Democrats may have to thread if they want a public option, and at the same time, want to bypass a Republican filibuster. And the key for them will be keeping conservative Democrats on board.
“A very robust public option that scores significant savings would presumably be easy to justify doing through reconciliation,” says a Senate Democratic aide. “But it is still being studied whether other, more moderate versions of a public option could pass parliamentary muster.”
According to Martin Paone, a legislative expert who’s helping Democrats map out legislative strategy, a more robust public option–one that sets low prices, and provides cheap, subsidized insurance to low- and middle-class consumers–would have an easier time surviving the procedural demands of the so-called reconciliation process. However, he cautions that the cost of subsidies “will have to be offset and if [the health care plan] loses money beyond 2014…it will have to be sunsetted.”
And there the irony continues: Some experts, including on Capitol Hill, believe that a more robust public option will generate crucial savings needed to keep health care reform in the black–and thus prevent it from expiring. But though that may solve the procedural problems, conservative Democrats have balked at the idea creating such a momentous government program, and if they defected in great numbers, they could imperil the entire reform package
It’s a very technical conundrum with huge policy ramifications. So it’s not surprising that Republicans are on to it, and preparing for war.
Sen. Judd Gregg (R-NH)–ranking member on the Budget Committee–says the only way for the public option to survive the process is for it to be “very aggressive in setting rates, price controls and rationing,” a fact which may cost Democrats a number of conservative votes within their own party. However, if it’s too weak, and doesn’t meet the procedural demands of the reconciliation process, Gregg says the Republicans are preparing myriad objections to it and other aspects of the Democrats’ reform plan.
Each year, Congress passes a budget, but sometimes it has to enact a separate bill to raise or reroute funds in order to meet the budget’s demands. That’s the reconciliation bill–and it’s so important that Senate rules exempt it from a filibuster. But they also prevent it from being a vessel for any old provision that the majority party wants enacted. The specifics of these limits (enshrined in the so-called Byrd rule) are complex, but the overarching rule of thumb is that provisions passed through this process must have a significant budgetary component (i.e. involve the moving around of federal money) and that the legislation should not, in the long run, increase the federal deficit. (A recent historical example: the 2001 Bush tax cuts were passed via the reconciliation process. They survived the Byrd rule because they had a huge budgetary impact, but since they vastly increased the federal deficit, they sunsetted, and had to be renewed after five years.)
As Gregg and Paone and the Democratic source indicate, a more liberal public option might be easier to push past these procedural hurdles than the public option that’s currently on the table. But That doesn’t mean some of the less robust options are completely off the table. According to Paone, “sufficient funds would probably be needed from the general revenue to subsidize the public option or to provide “seed” money for a coop plan,” if either of them were to survive, indicating that creating private co-operative in lieu of a public option may still be feasible under the reconciliation process.
But that doesn’t change the underlying dilemma. The path of least political resistance is beset by procedural obstacles; and the path of least procedural resistance is beset by political ones.
The link below should direct you to a detailed side-by-side summary comparing the major reform bills in the House and Senate. As we all know, the three committees of jurisdiction over health care in the House have all reported a bill. House leaders are expected to bring that legislation to the floor in the fall. In the Senate, one of two committees with jurisdiction have reported legislation (Committee on Health, Education, Labor and Pensions). The other panel, Committee on Finance, has yet to finalize its proposal.
If you are like me, you are probably shaking your head in disgust at the current level of “discussions” taking place regarding healthcare reform. It’s not just the tone and rancor of the conversations or even the incredible amount of misinformation and fear mongering that appalls me; it’s the fact that all this energy and political capital is being exerted for what amounts to HEALTH-INSURANCE reform that would probably not really address some of the more important issues in HEALTHCARE reform.
Finally, (and also germane to the above discussion) I noticed a story today on the front page of the Connecticut Post (but only available in the Greenwich Time web site) entitled “Activists taking aim at Himes”. I am copying it below for those who are interested in reading it in its entirety. Personally, I know that Jim is a great listener and is very open to suggestions about healthcare reform. After reading this article I feel that we (members of HPfHR and all who are interested in real healthcare reform-and therefore promoting a reasonable discussion about it) need to go out and support Jim (or Congressmen in your district if you are not in Fairfield County) at these town hall meetings.
Football teams aren’t the only ones with a playbook.
Audience members at a series of recent town hall meetings hosted by U.S. Rep. Jim Himes, D-Conn., have developed their own, scripting up a series of offensive plays designed to get the freshman congressman back on his heels on topics such as government spending and his support of a public option for health care reform.
Greenwich Time obtained a copy of the playbook, a political action memo recently disseminated to members of Right Principles, a Fairfield-based political action committee that characterizes itself as “Unapologetically American” on its Web site.
“The objective is to put the rep on the defensive with your questions and follow-up. The rep should be made to feel that a majority, and if not, a significant portion of at least the audience, opposes the socialist agenda of Washington,” the memo said.
The four-page memo instructs readers on everything from the phrasing of questions and need to follow up, to where to stand during the meetings and directions for checking the congressman’s voting record.
Bob MacGuffie, the group’s co-founder and the memo’s author, said he was merely trying to help individual constituents concerned about Himes’ positions and is not part of some larger effort to discredit congressional Democrats.
“People are on their own. This is organic. This is grassroots. It’s going on all over the country,” said MacGuffie, a Fairfield resident who described
himself as a Libertarian.
About 1,000 people are on the group’s mailing list, according to MacGuffie, who engaged Himes himself during a May town hall meeting at the Pequot Library in Southport on government spending, which he said has spiraled out of control since Himes arrived in Washington, D.C., in January.
Though he could not recall the specific exchange, which was posted on the video archive Web site YouTube.com, Himes said he has been confronted by constituents on numerous occasions who don’t share his views on health care and other topics.
“These folks, they kind of get in your face,” Himes said. “Listening to passionate and even angry people is part of my job.”
An unequivocal supporter of a public option for health care, Himes said in an Aug. 6 Greenwich Time opinion piece that the proposed government insurance program would provide much-needed competition and help bring down costs nationally, given that 90 percent of Americans live in markets dominated by one or two insurers. No one would be forced to participate, he has said.
Himes was familiar with the group’s memo, which he said he read on some political blogs.
“There’s clearly sort of a movement nationally to be very aggressive in meetings with congressmen,” Himes said. “At points, it’s spilled over to something a little ominous.”
MacGuffie accused Himes in Tuesday’s interview of changing the times of his town hall meetings, as well as their subject matter, and being less than forthright in his answers to questions from audiences.
“You try to get candor, and you just don’t get candor,” said MacGuffie, who cut the interview off after a few questions.
Himes denied MacGuffie’s claim that he is trying to keep critics at bay.
“His notion is absurd,” Himes said. “We publicize very clearly time, location and subject of every meeting we have.”
Himes said he has gone out of his way to seek input from constituents about key issues such as health care reform.
“I was one of the members of Congress to push hard to ensure that we had an opportunity during the (August) recess to go back and discuss health care reform with our constituents,” said Himes, whose congressional Web site has a map showing all of his public events.
After an Aug. 6 public forum hosted by his office in Stamford on the Federal Aviation Administration’s controversial airspace redesign in the Northeast, Himes said he carved out an extra hour to talk with constituents about health care reform.
Health care threatened to steal the show again on Monday during a series of debriefings Himes held at local synagogues on his trip last week to Israel and the West Bank. People showed up at the meetings trying to talk about health care, according to Himes’ aides.
They will get their chance. Himes’ office has scheduled a public forum to discuss health care for 6:30 p.m. Sept. 2. The venue has been changed to Norwalk City Hall from Norwalk Hospital because of concerns about crowd control, those familiar with the event said.
Elizabeth Kerr, Himes’ communications director, acknowledged that the rash of confrontations between members of Congress and their constituents over health care reform has scared off some groups from hosting such forums.
“At a number of local venues where we have previously held public events, we have explicitly been told that, given the current climate, they would be uncomfortable hosting a public event on health care,” Kerr said.
Public dissent at town hall meetings is hardly a new phenomenon.
In 2005, when President Bush was floating the idea of allowing workers to open up private investment accounts to supplement their Social Security, then-U.S. Rep. Christopher Shays, R-Conn., who Himes defeated last November, faced a barrage of criticism from constituents on the proposal at a town hall meeting in Darien.
Among those groups that mobilized its members to attend such events was Democracy for America, the liberal grassroots organization founded by former Vermont Gov. and Democratic Party Chairman Howard Dean.
Dean’s brother, Jim Dean, a Fairfield resident like MacGuffie, is the current chairman of the Burlington, Vt.-based organization, a strong supporter of the public health care option.
“We alerted people to that. We didn’t give them talking points or anything. We didn’t have to,” Dean said of the town hall meetings on Social Security.
When it comes to health care reform, Dean said many agitators across the nation are spreading myths about how government insurance will lower the quality of medicine.
“This discussion about death panels and the public option is ridiculous,” Dean said.
On the second page of MacGuffie’s memo, readers are instructed to be bold.
“You need to rock the boat early in the rep’s presentation,” the memo said. “Watch for an opportunity to yell out and challenge the rep’s statements early.”
Himes said such overtures can backfire, however.
“People who stand up and act rudely and obnoxious do delegitimize themselves and the cause they’re advocating, Himes said.
Once again there has been a long hiatus between entries on the blog. This is part because of my schedule and part because of the resignation that there is not much we can now do to influence what Congress is developing as its health-insurance reform legislation.
I cannot say that I am happy with what is immerging as the working proposal, but I did find one interesting detail in the “Public Plan” as can be seen in this graphic in the NY Times today : both the Senate and the House seem to have adopted the concept of “tiering” levels of coverage. In the Senate version this is discussed as the Public Plan covering only “essential health benefits”, while the House version has 3 tiers: basic, enhanced and premium. Now, although this may indicate someone has read EMBRACE (but I cannot say that EMBRACE is the only one to propose 3-tiered coverage and a concept of ‘basic’ coverage), it is a long way from what EMBRACE would offer.
The three tiered concept in EMBRACE is meant to SEPARATE private insurance from the publicly financed plan in an effort to AVOID competition between the public and private coverage. The Public Plan, on the other hand, is designed to enhance competition and, it is hoped, force the private plans to become more affordable and more efficient. However, it is hard for me to see how this is going to work. In the Senate plan, the lack of more robust offering will effectively relegate it to a second rate policy that would really not be able to compete with the “full service” private plans”. The House version has more of a chance to work, but as Jacob Hacker, one of the developers of the Public Option concept, once stated in one of his earlier works, there are inherent problems when any public plan has to compete with private plans.
Without going into details, the concept goes like this: If left to the natural competitive forces (i.e. without government regulation), the private insurance companies have significant advantages in head to head competition. By picking only the lowest risk clients (young, affluent, Caucasians with no pre-existing disease) they get a huge return for their investment AND they leave the higher risk to the government to cover. This, in a way, is what is happening now with Medicaid. To make the Public Plan or any other government plan work, private insurance must be regulated and in addition some advantages may need to be given to the Public Plan.
This latter scenario (of protective legislation) is what is being done with both Senate and House versions. This may not be a bad thing, especially if you want to even the playing field, but if done too much may actually hurt the delivery of healthcare.
Here are two of the scenarios I am afraid of:
1) If the Public Plan is not attractive enough to consumers (because it does not offer enough coverage or it is too expensive), it will not be able to compete with the private insurance plans. If nobody buys them it will not be able to force down costs for private insurance. This would then be used as a case study of why healthcare reform can NEVER work and there will not be another push for a long time.
2) To make the Public Plan more competitive, CMS will likely dictate reimbursements to providers (as opposed to the negotiated reimbursement rates with private insurance companies). These, like standard Medicare, would likely be non-negotiable and would only offer take-it-or-leave-it terms. This in turn can lead two scenarios: a) providers would not take patients with the Public Plan, which would lead to a similar failure as discussed above, or b) CMS would tie the Public Plan to standard Medicare. In this latter scenario CMS would tell providers (who have to sign a pledge that they would take all Medicare patients and not charge them more than what CMS pays) that if they want standard Medicare patients they must also take Public Plan patients. This would force doctors and other providers to choose between private and public plans and would in essence create two types of doctors: government and private. This would be a complete disaster to our healthcare delivery system.
Really the ONLY way to make our healthcare system work is to separate private from public insurance. With the single payer model, this is done by banning private insurance, but since you cannot outlaw them they will still continue to exist as they do in other countries with single payer systems. EMBRACE is the only plan that allows private and public plans to operate freely, but separately.
Please spread the word to your colleagues and to your Congressmen.
I found this piece by Robert Reich that I think really puts the politics of the current healthcare debate in perspective.
How Pharma and Insurance Intend to Kill the Public Option, And What Obama and the Rest of Us Must DoJune 5, 2009, 10:19PM
I’ved poked around Washington today, talking with friends on the Hill who confirm the worst: Big Pharma and Big Insurance are gaining ground in their campaign to kill the public option in the emerging health care bill.
You know why, of course. They don’t want a public option that would compete with private insurers and use its bargaining power to negotiate better rates with drug companies. They argue that would be unfair. Unfair? Unfair to give more people better health care at lower cost? To Pharma and Insurance, “unfair” is anything that undermines their profits.
So they’re pulling out all the stops — pushing Democrats and a handful of so-called “moderate” Republicans who say they’re in favor of a public option to support legislation that would include it in name only. One of their proposals is to break up the public option into small pieces under multiple regional third-party administrators that would have little or no bargaining leverage. A second is to give the public option to the states where Big Pharma and Big Insurance can easily buy off legislators and officials, as they’ve been doing for years. A third is bind the public plan to the same rules private insurers have already wangled, thereby making it impossible for the public plan to put competitive pressure on the insurers.
Max Baucus, Chair of Senate Finance (now exactly why does the Senate Finance Committee have so much say over health care?) hasn’t shown his cards but staffers tell me he’s more than happy to sign on to any one of these. But Baucus is waiting for more support from his colleagues, and none of the three proposals has emerged as the leading candidate for those who want to kill the public option without showing they’re killing it. Meanwhile, Ted Kennedy and his staff are still pushing for a full public option, but with Kennedy ailing, he might not be able to round up the votes. (Kennedy’s health committee released a draft of a bill today, which contains the full public option.)
Enter Olympia Snowe. Her move is important, not because she’s Republican (the Senate needs only 51 votes to pass this) but because she’s well-respected and considered non-partisan, and therefore offers some cover to Democrats who may need it. Last night Snowe hosted a private meeting between members and staffers about a new proposal Pharma and Insurance are floating, and apparently she’s already gained the tentative support of several Democrats (including Ron Wyden and Thomas Carper). Under Snowe’s proposal, the public option would kick in years from now, but it would be triggered only if insurance companies fail to bring down healthcare costs and expand coverage in he meantime.
What’s the catch? First, these conditions are likely to be achieved by other pieces of the emerging legislation; for example, computerized records will bring down costs a tad, and a mandate requiring everyone to have coverage will automatically expand coverage. If it ever comes to it, Pharma and Insurance can argue that their mere participation fulfills their part of the bargain, so no public option will need to be triggered. Second, as Pharma and Insurance well know, “years from now” in legislative terms means never. There will never be a better time than now to enact a public option. If it’s not included, in a few years the public’s attention will be elsewhere.
Much the same dynamic is occurring in the House. Two members who had originally supported single payer told me that Pharma and Insurance have launched the same strategy there, and many House members are looking to see what happens in the Senate. Snowe’s “trigger” is already buzzing among members.
All this will be decided within days or weeks. And once those who want to kill the public option without their fingerprints on the murder weapon begin to agree on a proposal — Snowe’s “trigger” or any other — the public option will be very hard to revive. The White House must now insist on a genuine public option. And you, dear reader, must insist as well.
This is it, folks. The concrete is being mixed and about to be poured. And after it’s poured and hardens, universal health care will be with us for years to come in whatever form it now takes. Let your representative and senators know you want a public option without conditions or triggers — one that gives the public insurer bargaining leverage over drug companies, and pushes insurers to do what they’ve promised to do. Don’t wait until the concrete hardens and we’ve lost this battle.