Today begins a four day online debate between five Albuquerqueans with widely varying beliefs on the best way to reform the nation's health care system.
Perhaps I shouldn't call this a debate, but rather a discussion. From today through Friday, each participant will have the opportunity to discuss what they believe is the best way to reform the health care system. Today they answered my questions, but the remainder of the week's agenda will be determined by each other and by the commenters.
I strongly encourage you to voice your beliefs in the comments below - particularly insightful posts or those deserving response will be brought up into the discussion.
Here is the introduction and my questions to the participants:
The Congressional Budget Office, the important agency charged with providing non-partisan economic analysis to Congress, writes, "The federal budget is on an unsustainable path, primarily because of the rising cost of health care." Medicare and Medicaid costs are predicted to explode over the next fifty years and experts and politicians alike agree that substantial reform of the health care system is necessary. The public agrees as well. In a recent Pew poll, 71% of those polled said that the health care system needs to be either completely rebuilt or fundamentally changed.
That same Pew poll also shows that 75% favor "changing the system so that all Americans have health insurance that covers all medically necessary care." Republicans, Democrats, and Independents all showed a majority in favor.
The debate burning in Congress right now centers on the best way to expand coverage while cutting costs. Some argue that a "public option," a government-run insurance plan that would compete with private insurers, is the best way to achieve those goals. Others disagree and argue that the market can right itself and lower costs through health insurance exchanges. Others want to eliminate the employer-based system altogether, favoring a single-payer system run entirely by the government or a competitive free market system with exchanges.
So here are my questions: What is the ideal way to expand coverage and cut costs in our health care system? Does the current focus on costs undermine the importance of quality of care, as discussed in Win Quigley's article on Sunday? How can we change the incentive structure that leads to the use of expensive procedures that may not lead to optimal health outcomes? And, finally, what proposals or ideas in Congress strike you as smart and feasible?
Answer one or all.
 Brian S. Colón is Chairman of the Democratic Party of New Mexico. Mr. Colón was raised in Valencia County. He received his Bachelor's Degree from New Mexico State University in 1998 and graduated from the University of New Mexico School of Law in 2001. In 2004, Mr. Colón was named Outstanding Young Lawyer of the Year by the New Mexico State Bar Association and one of New Mexico's Forty Under 40 Power Brokers by the New Mexico Business Weekly. He was elected to his first two year term as Chairman of the Democratic Party of New Mexico in April of 2007. He was re-elected without opposition to a second two year term in April 2009.
Our health care system is broken. Forty-five million Americans don’t have insurance, either because they can’t afford the high premiums or they were denied coverage because of pre-existing conditions—including 23 percent of people in New Mexico. Many families are losing their choice of doctors due to insurance cutbacks -- some are losing the choice to even visit a doctor when they’re sick. Elderly couples across New Mexico are being forced to choose between buying groceries or the medications they need.
Without reform, health insurance premiums will hit the stratosphere and will continue to erode American workers’ and families’ benefits—and even more Americans will be without coverage. But despite these grave realities, for years Washington has been beholden to special interests – politicians failing to make the tough choices, imperiling our economy, our security and the health of our fellow citizens in the process.
We’ve all heard stories from friends and families who have been affected by the high costs of health care. The Democratic Party of New Mexico has received dozens of stories from individuals telling about why they need health care reform.
Stories like Gregory Johnson of Albuquerque, a father of three children who works 80 hours a week to provide for his family. His employer offers health insurance but his portion of the premium is too expensive. He has made the difficult decision to not purchase the insurance so that he can put food on the table and a roof over his family’s heads.
Politicians from all sides of the aisle agree that the system isn’t working. So now it’s time to move from talk to action, and that’s why President Obama has committed to swiftly enacting substantial reform that’s based on three principals -- reducing the costs of care for families, businesses and government, guaranteeing Americans can keep their choice of doctor and coverage, and ensuring that all Americans have access to quality, affordable health insurance.
Reforming the system will undoubtedly be a huge undertaking. Health care is an issue that affects every American and the only way we can successfully change the system is by bringing all voices to the table. However, the Democratic Party of New Mexico strongly believes that any comprehensive reform must include a public option to increase competition and drive down health care costs.
We must move beyond the divisive arguments that have plagued past attempts at reform. Americans can no longer bear the burden of a broken health care system. We must act now to enact reform that works for families, local governments, and businesses alike.
To do this, President Obama has promised to work in an open, inclusive, and transparent manner where all ideas are encouraged regardless of political stripes. Working with Members of Congress, hospitals, doctors, businesses and unions, the President is committed to making sure we finally enact comprehensive health care reform. Working together, we can reduce long-term growth of health insurance costs, guarantee choice of doctors, invest in prevention and wellness, end barriers to coverage for people with pre-existing medical conditions, and ensure every American receives the health care they need and deserve.
This is more than just a social issue, it’s an economic issue as well—and over the long term, reforming our health care system will lead to faster economic growth, higher take-home pay for workers, greater employment opportunities, a more level playing field between small and large businesses, and deficit control.
Make no mistake - achieving comprehensive health care reform will not be easy. Controlling cost growth cannot just be a lofty goal, it must become a reality. We need reforms that reward prevention and wellness, that emphasize quality over quantity, and encourage patient involvement. These reforms are vital to our nation and New Mexico economic stability.
This is truly a historic moment in our nation’s history. I, like many New Mexicans, am excited for the opportunity before us to enact real and substantive change. Together, we must look beyond the critics and supporters of the status quo to the brighter future that lies ahead. We can act. We must act. The future of our nation and our people depends on it.
 Todd Sandman serves as director of public and government relations for Presbyterian Healthcare Services, a New Mexico, not-for-profit healthcare system of hospitals, physicians and a health plan.
We have two challenges in federal health care reform that we are trying to solve at the same time. First, 400,000 New Mexicans and 45 million Americans do not have health insurance and this makes them less healthy and more vulnerable. Second, many of us with insurance struggle to afford what we have today. We also know that the individuals, employers and governments who purchase insurance will not be able to afford what healthcare is expected to cost in the years to come.
At Presbyterian Healthcare Services, we are confronted with these issues everyday. Our emergency department caregivers across New Mexico can speak to providing care for thousands of patients for whom we will never be paid. At the same time, our health plan employees know all too well the small businesses and employers who struggle with huge increases in their premiums.
I am hopeful that the President and Congress will seize this opportunity to ensure that every American has health insurance. Yet, we know that it is price that precludes many individuals from purchasing insurance and scarce dollars that cause state governments to make decisions to expand or restrict coverage. So, ultimately, our nation's ability to insure everyone and keep everyone insured is a cost issue.
So how will we lower the cost of healthcare? Thus far, the reform debate tends to focus on how much the government will pay for certain budget items - cutting money from hospitals ($200 billion) or private Medicare plans ($176 billion). But budget reductions are not reform. If we want to create a high-quality, affordable system for years to come, our policy-makers should focus not on how much, but how we pay for care.
This is important because the federal government is the single largest purchaser of healthcare and its payment decisions set a course that states and private insurers follow. For decades, payers have reimbursed doctors and hospitals for the services and procedures they render for patients. This fee-for-service model then places all the incentives in our system for treating sick patients. If we want to make healthcare more affordable for the long-term, we need to move away from a strict fee-for-service model and into one that rewards health. To explain, I'll steal two critically important insights from Clayton Christensen's recent book "The Innovator's Prescription":
"Chronic disorders account for three-quarters of direct medical care costs in the United States. And of the myriad chronic diseases, five of them - diabetes, congestive heart failure, coronary artery disease, asthma and depression - account for most of these costs."
and
"There are more than 9,000 billing codes for individual procedures and units of care. But there is not a single billing code for patient adherence or improvement, or for helping patients stay well."
Three-quarters of direct medical care costs are spent on chronic disorders and we have no current payment incentives in the system for doctors to help patients stay healthy and manage their conditions. I know others in the reform debate like to focus on insurance company profits, how much doctors make, or other perceived cost drivers, but the most important thing we could do in reform is tackle the 75 cents of every medical dollar that is going toward chronic disease. As purchasers of insurance, the government, employers and individuals need to design ways to pay for health and healthy outcomes instead of simply service.
As for the much-discussed public option, advocates like to describe that it would make private plans "more competitive." How would it do this? By paying doctors and hospitals much less for their work. The House of Representatives released a draft of their healthcare bill in June that called for a public plan that would pay providers at Medicare rates. It would probably surprise most people to learn that, in 2008, Medicare reimbursed Presbyterian's hospitals and medical clinics across New Mexico less than the cost of delivering care to Medicare patients. We lost money for every Medicare patient treated. Such a public plan might lower costs, but I worry about the implications for doctors and hospitals in our state.
Vicki L. Perrigo, M.D., MACP, FAAD, recieved her bachelor's degree in Biology from the University of Southern California in 1972 and her M.D. from UC Davis in 1976. Ms. Perrigo did her Internal Medicine residency at UCI/Long Beach VA from 1976-1979 and her Dermatology residency at the University of New Mexico from 1980-1983. She is licensed to practice medicine in California and New Mexico.
What is increasing the cost of health care is the defensive medicine that physicians must practice during these litigious times. As an Internist/Dermatologist I know first hand how many tests are ordered in order to protect myself from lawsuits. What will solve this problem includes rebuilding the relationship of trust between physicians and their patients, educating patients as to the imperfection of medical care, (e.g. if you are treated for being sick/broken, you cannot expect to be returned to a perfect healed state 100% of the time), and putting a cap on awards from malpractice claims.
Additionally, the practice of medicine has changed from a doctor-patient interaction, to a patient-insurance-doctor interaction. We need to cut down on the number of middlemen who get in the way between patients and doctors. Also, it would help to have more options for health care insurance. Now there are limited choices for the patient and virtually no competition between insurers for patients. Most of the money for insurance premiums is kept by the insurance company and not spent on patient care. Their profits margins are astronomical.
Eventually we will need to face difficult decisions regarding the rationing of healthcare. Who should be saved? Who should receive high-tech treatment? How much can we, as a society, support the critically ill?
There is nothing in the Bill of Rights that guarantees Americans health care. Nevertheless, we want health care, and we want perfect all-inclusive health-care for everyone. There is a moral level below which people should not drop, and all Americans should have coverage for medically necessary care. Again, though, how high tech do we need to be with every patient? We can use our heads and ‘practice' medicine if we are freed up from the fear of being attacked if the results are not perfect.
No system will work if physicians are afraid of being sued. We will continue to order tests ‘just in case', instead of just treating people based on their history, physical exam, and basic lab tests. Yes, occasionally, we will miss something but no one is perfect and we should not be expecting perfection from what is still imperfect science. When a doctor errs, let him be disciplined by his peers, and let there be a limit as to what can be paid out to the injured party and his attorneys. Then we can all go back to work for the improved health of our patients' bodies, instead of their wallets.
 Barbara Wold has been providing news and opinion on local and national politics on the Democracy for New Mexico blog since 2004. She was the Democratic National Committee's official state blogger from New Mexico during the 2008 Convention in Denver, and is involved in Democratic Party politics and progressive grassroots activism.
The ideal way to reform health care would be to implement a single-payer system similar to that used in a number of European countries and many other places. Single payer eliminates the high costs for administration and profits common to private insurance companies, and has the government handle primary administrative tasks. Single-payer is the cheapest way to provide universal care. Virtually every advanced country provides universal coverage for much less than the U.S. spends on health care using some version of single payer. For example, France provides what is almost universally seen as top notch care for about half of what we currently spend on a system that leaves 45 million without coverage.
Although President Barack Obama agrees that single payer would be the best way to proceed, he has explained that we can't pursue it because it would be too disruptive to our present system, which is characterized by employer-provided care and private insurance companies. Instead, the President has recommended a mixed system, still mostly employer-based, but where patients can choose their coverage from an array of private insurance plans, as well as a so-called public option managed by the government.
If the public option is robust, national in scope, affordable and available to all on day one, it can compete with private insurers on cost and other factors and thus provide an effective tool to hold down prices in the private sector and generally. Without a public option, we can expect health care costs to continue to skyrocket. There is little real competition among health plans in many areas of the country, where it's common to have only one or two insurance companies offering coverage. Private plans can pretty much charge whatever they want without consequences in numerous areas of the country, especially in small towns or cities and rural areas where virtual monopolies constitute the markets.
A national public option can also provide a proving ground for discovering and implementing "best practices" that provide quality care without utilizing unnecessary or ineffective treatments and tests that can drive up costs without significantly improving outcomes. A recent article in The New Yorker examines how unnecessary procedures and tests can drive up costs without improving outcomes.
There are many versions of health care reform currently being considered in Congress. The Senate Health, Education, Labor and Pensions (HELP) Committee proposal is considered one of the best (that we know about) in terms of affordability, guaranteeing access and providing quality care. Nobel prize-winning economist Paul Krugman is a fan of this plan and his recent column lays out the reasons why. According to Krugman,
The HELP plan achieves near-universal coverage through a combination of regulation and subsidies. Insurance companies would be required to offer the same coverage to everyone, regardless of medical history; on the other side, everyone except the poor and near-poor would be obliged to buy insurance, with the aid of subsidies that would limit premiums as a share of income.
Employers would also have to chip in, with all firms employing more than 25 people required to offer their workers insurance or pay a penalty. By the way, the absence of such an "employer mandate" was the big problem with the earlier, incomplete version of the plan.
And those who prefer not to buy insurance from the private sector would be able to choose a public plan instead.
According to the Congressional Budget Office (pdf), this plan would cost about $597 billion over the next ten years. If Medicaid coverage for the poor and near-poor is added in, the total rises to about $1 trillion. According to Krugman, this figure amounts to about 4 percent of the $33 trillion we would spend on health care over the next decade without reform -- and without universal coverage. Cost-saving measures like ending Medicare overpayments to private insurers and decreasing spending on procedures with no demonstrated health benefits will cut the increase dramatically.
We can thus attain universal coverage and provide high-quality care for a relatively small increase in spending, with prospects for more savings as we go along. If we don't adopt such a reform plan, it's a good bet that we'll be spending as much or more in the next ten years as costs continue to rise at a rate much higher than inflation, growing millions of our citizens still have no coverage and our businesses remain at a distinct disadvantage in trying to compete with companies in nations that provide universal coverage. Now is the time.
 Paul Gessing became the first full-time President of the Rio Grande Foundation in March of 2006. Since joining the Foundation, Gessing has been a prominent voice for limited government and individual liberties in policy areas including: taxes, health care, education, and transportation.
Prior to joining the Foundation, Gessing headed up the lobbying efforts of the National Taxpayers Union (NTU) a respected taxpayer-advocacy organization in Washington, DC.
Paul graduated from Bowling Green State University in Ohio with a degree in Political Science in 1997 and he received his Masters in Business Administration from the University of Maryland in 2005. Paul is originally from Cincinnati, Ohio, but he has several family members in New Mexico and has spent a great deal of time in the state over the years.
Paul and his wife Krista were married in October 2007 in Algodones, NM. In his spare time, Paul enjoys playing basketball, golf, playing with the family dogs, and traveling.
What is the ideal way to expand coverage and cut costs in our health care system?
There is no "silver bullet" when it comes to reforming health care, but certainly the marketplace, ie. patients and their doctors, should be empowered to solve the problems. Government is simply not equipped, nor does it have the adequate information on the health care needs of 300 million Americans to come up with a one-size-fits all solution.
A few health care reforms that Congress should be considering are: Offer the same tax benefits for individuals that are now offered to employers for the purchase of health care; Allow individuals to purchase health insurance policies regulated in other states, thus circumventing costly mandates and other regulations; block grant the costly Medicaid program and means test Medicare, both of which result in cost-shifting where doctors must shift costs to insurance companies and individuals because government reimbursement rates do not cover the actual cost of services.
Does the current focus on costs undermine the importance of quality of care, as discussed in Win Quigley's article on Sunday?
In an ideal world, we'd all have unlimited access to high quality health care. In the real world, a world of limited goods where real tradeoffs are essential, cost must be a central focus of the health care debate. The problem is that advocates of additional government intervention, "universal" coverage, and single-payer systems avoid the issue. They'd rather focus on health care as a "right" and divert attention to some of the all-too-real flaws with the current system.
The truth is that cost is central to the debate. "Medicare for Everyone" as many on the left advocate is simply not viable because the existing Medicare system is broken. Adding the rest of us into Medicare would only hasten the program's demise or result in huge tax hikes that would only further dampen economic growth. Rather than acting as if government has some magical powers to cut costs and improve allocation of services, Congress needs to closely examine the impact specific policy decisions will have on the price and affordability of health care.
How can we change the incentive structure that leads to the use of expensive procedures that may not lead to optimal health outcomes?
This question really gets to the heart of the ongoing health care debate. The single greatest flaw in our current health care system is the outsized role of the third-party payer. The genesis of this policy, as President Obama has rightly pointed out, was during WWII when health care became a commonly-offered fringe benefit. This eventually led the federal government to offer massive tax incentives to employers for the purchase of health care for their employees.
The long-term result of this system has been an over-reliance on insurance companies with health care consumers having little in the way of cost information to prioritize their health care decisions. This has led to spiraling costs as certain groups whether they be geographically or demographically determined have been particularly prone to over-using the health care system, thus driving up costs, forcing companies to scale back and pushing more people to go without or rely on publicly-funded plans.
Returning a bulk of health care decisions and day-to-day costs to consumers - as opposed to employers and insurance companies - is the single best way to improve care while also reducing the cost of health care.
The second round of the debate is now posted. Leave any comments or responses there.
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