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Opinion: Back to the Obamacare Future
Natural experiments are rare in politics, but few are as instructive as the prototype for ObamaCare that Massachusetts set in motion in 2006. The bills for "universal coverage" are now coming due, and it appears the state political class is prepared to do lasting damage to one of America's top-flight health-care systems. read more
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Integrity Necessary Ingredient in Health Care
I never agree with any politician 100% of the time. However, I am in 100% agreement with Attorney General Troy King’s decision to hold the pharmaceutical industry accountable for overcharging Alabama’ s Medicaid Department. I have heard a lot of people describe King’s actions as bold and courageous. That may be accurate, but in my opinion, he is simply upholding the oath of office he took when he swore to protect the citizens of the State of Alabama.
In 2005, King authorized the State to file suit against over 70 pharmaceutical companies. The State alleged that the defendants systematically overcharged the Medicaid Department by manipulating the prices of its prescription medication. Since that time, four of the cases have gone to trial and Alabama jurors have awarded the State over $350,000,000. Additionally, 16 other pharmaceutical companies have settled their cases with the State for over $120,000,000. That is a lot of money that was stolen by these companies. Fortunately, through Mr. King’s efforts, some of the stolen proceeds have been recovered by the State. The bulk of these settlements have been paid into the State’s General Budget Fund, which in turn finances Medicaid.
There have been a few people, mainly the pharmaceutical industry and their talking heads (their lobbyists), that have been critical of Troy King for recovering these funds. However, Mr. King really had no other logical choice. These companies stole money from the State and its Medicaid Department, an agency whose sole purpose is to assist the less fortunate. These companies, in effect, stole from poor people. The facts were just too compelling for anyone, much less the State’s Chief Legal Officer, to sit idly by and do nothing. His efforts to recover the stolen money should be applauded.
Mr. King’s critics are trying to paint him as a rogue Attorney General for his actions in these cases. Nothing could be further from the truth. There are 27 other Attorneys General in the United States seeking to hold these same companies accountable to the citizens of those States for the same conduct. That is over half of all the States in this great country. Just as here, juries in those other states have rendered substantial verdicts because, again, they determined that those defendants had stolen money from their states, too. Additionally, at least one of the pharmaceutical companies pled guilty to criminal acts for this wrongdoing. Did you catch that? That’s right- the company pled guilty to CRIMINAL acts for the same type of wrongdoing going on in Alabama.
The four jury verdicts rendered in Alabama are now on appeal with the Alabama Supreme Court. It is interesting to note that the Alabama chapter of AARP, with over 500,000 members, filed a brief in support of the State’s position in these cases. The taxpayers of Alabama will just have to wait and see how our Supreme Court rules. Hopefully, our Court will uphold the verdicts, just as a recent United States Circuit Court of Appeals did.
As a physician and health care consultant, I don’t routinely support legal action against those involved in providing health care. However, the fact that pharmaceutical companies were found guilty of overcharging Medicaid contributes to the overall costs of health care, at the same time physician fees are continually being cut. We must have integrity and credibility if our health care system remains economically viable. Physicians, pharmaceutical companies, hospitals and other health care providers must work together along with insurers to make sure that all services are appropriately compensated, but not enriched to the point that exceeds reason.
If these trends continue, we will be relegated to a government run health care system. We, as physicians and activists, must embrace morality in the delivery of health care, starting with the pharmaceutical industry
It is our hope that the Alabama Supreme Court will exercise the same common sense that Troy King did in deciding to pursue these claims for the State, that four juries used in unanimously finding in favor of the State and that 500,000 members of AARP used in endorsing the State’s position.
Randy Brinson, MD
Chair, Christian Coalition of Alabama
http://voices.washingtonpost.com/ezra-klein/2009/09/medical_mapractice_costs.html
Sept 23, 2009 Washington Post
Medical Malpractice Costs
David Leonhardt’s column today is a smart take on medical malpractice costs:
The direct costs of malpractice lawsuits — jury awards, settlements and the like — are such a minuscule part of health spending that they barely merit discussion, economists say. But that doesn’t mean the malpractice system is working.
The fear of lawsuits among doctors does seem to lead to a noticeable amount of wasteful treatment. Amitabh Chandra — a Harvard economist whose research is cited by both the American Medical Association and the trial lawyers’ association — says $60 billion a year, or about 3 percent of overall medical spending, is a reasonable upper-end estimate. If a new policy could eliminate close to that much waste without causing other problems, it would be a no-brainer.
At the same time, though, the current system appears to treat actual malpractice too lightly. Trials may get a lot of attention, but they are the exception. Far more common are errors that never lead to any action.
After reviewing thousands of patient records, medical researchers have estimated that only 2 to 3 percent of cases of medical negligence lead to a malpractice claim. For every notorious error — the teenager who died in North Carolina after being given the wrong blood type, the 39-year-old Massachusetts mother killed by a chemotherapy overdose, the newborn twins (children of the actor Dennis Quaid) given too much blood thinner — there are dozens more. You never hear about these other cases.
So we have a malpractice system that, while not as bad as some critics suggest, is expensive in all the wrong ways.
Kevin Drum has further thoughts:
Here's a little-known fact that helps to make this clearer. If you're injured in a hospital, how do you know if you're the victim of malpractice? After all, not every surgery has a positive outcome. If yours didn't work out, that doesn't mean the doctor was negligent.
The answer is: You don't. Unless you sue. Most hospitals refuse to release their internal records unless you sue them and force disclosure via discovery or a subpoena. This means two things. First, lots of suits that look frivolous (because they're dropped quickly) aren't. They were merely attempts to see the actual records of a case. If there were an easier way to do that, the suit would never have been filed in the first place.
Second, despite our famously litigious nature, suing is a lot of work. Most people don't want to do it just on the chance that there might have been some malpractice. And most people don't. Which means that lots of cases of malpractice are never discovered.
We could fix this pretty easily by making it much easier for patients to see the records of their own cases. If we did, that would cut down on "frivolous" lawsuits and it would increase the number of justified lawsuits. That would be fairer for everyone, but it probably wouldn't cut medical malpractice costs. It would increase them. That's why the medmal warriors never talk about this. They like the idea of cutting back on frivolous suits, but they're much less keen on admitting that there's also a lot of genuine malpractice that goes completely unnoticed.
Even if we eliminated medmal suits entirely, the cost savings would be pretty modest. Genuine reform, on the other hand, would likely cost us money. That's why you never hear much about it.
The sad irony of the malpractice system is that it has led doctors and hospitals to be much less transparent with their data, which has made it harder to find out when things go wrong, which has made it harder to put in place systems that keep things from going wrong. But the best way to reduce malpractice costs would be to reduce malpractice.
The problem isn't in courtrooms so much as on the operating table. But because it's doctors who are angry about malpractice suits, most of the fixes are from their perspective. What we need is malpractice reform from the patient's perspective. That wouldn't be the system we have now, or mere caps on damages: It would be serious work and investment in better practices.
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Rep. John Carter: Examining the Evidence on Health Care Reform
There was an old country judge that had the highest criminal conviction rate in the state. When a reporter from the state capital came down to investigate this judicial phenomenon, the judge explained that he simply instructed the jury to listen very carefully to what the prosecutor had to say, then make their decision. The reporter cried indignantly, "Don't you also tell them to listen to the defense?" The judge replied, "Well, I used to, but it just confused ‘em."
20 years as a Texas judge taught me a few things about listening to both sides of an argument. In most cases, both sides truly think they're right. Then they start presenting arguments and evidence to try to prove their case. Naturally, neither side will present anything remotely supportive of their opponent, even if they know it's true. So as a judge, you sit there and weigh the evidence presented by all with a grain of salt, knowing that either side is capable of stretching the limits of veracity and withholding relevant information if not in their favor.
That's precisely the kind of case that all Americans are having to judge right now concerning the healthcare reform proposals being pushed by Democrats in Washington.
We hear it everyday in the press - the President says anybody who likes their current health insurance will get to keep it, while opponents say all private health insurance will be gone by 2013. Democrats in the House say their plans will control rising healthcare costs, while opponents say it will drive costs even higher. Opponents say the new system will eventually start denying care to elderly, and encourage euthanasia, while supporters say it won't.
Who's right? With our very lives at stake, along with 19% of our gross domestic product, being wrong could be deadly for us personally as well as our free market economy.
Let's examine the evidence together. In looking at the both sides of this case, let's leave out the emotion and political rhetoric, and try to look at just the facts on each major point.
To begin, we can only examine the bill passed by Democrats in the House Energy and Commerce Committee in late August, HR 3200. That will not be the final bill, if there is a final bill. The current House version would first be voted on by the entire House, where changes would be made, then reconciled with whatever the Senate passes, changed again, then brought to a final vote in both Chambers. But this Committee version is all we have in writing, so that's what we must judge.
1. Can You Keep Your Current Health Plan?
The bill contains no provision that would specifically abolish any health plan. But it would require all individuals and employers to purchase health plans approved by a new federal agency starting in 4 years, or pay a heavy tax penalty. It is not enough to require a health plan be purchased - it must be a federally approved plan to avoid paying an 8% payroll penalty by employers or a 2% income tax penalty by individuals. The bill allows the new federal agency to set any requirements they like on what constitutes an "approved" plan. Whether a current individual plan could survive and be approved by this new bureaucracy is suspect, as is whether an employer will continue to offer any current plan under these circumstances.
Verdict: PROBABLY Not
2. Will This Help Control Health Care Costs?
This issue is one of the most clear. After extensive research, the non-partisan Congressional Budget Office (CBO), which is currently overseen by the Democrat majority, officially reported to Congress that not only would it not hold down health costs, it would push them even higher than doing nothing. The number one problem with American health care is high cost, and this bill would make it worse.
Verdict: No
3. Does The Bill Encourage Denial of Care and Euthanasia for the Elderly?
There is no language specifically calling for denial of care or euthanasia. But language was added requiring Medicare to pay for "end of life counseling" that will include educating senior citizens on the option of pre-authorizing the cessation of life-sustaining care, and in states which allow physician-assisted suicide, education on that option as well. President Obama has made repeated references to avoiding costly treatments for elderly patients, and other nations that have adopted this same style health system do in fact limit medical treatments and encourage euthanasia for elderly patients. These facts, coupled with the creation of a new federal agency that will unilaterally determine what benefits are included in "approved" health plans AFTER the bill passes, is heavy evidence that the bill may encourage denial of care and euthanasia. But in this issue there is even more - a proverbial "smoking gun." The very advocacy groups like the now-defunct Hemlock Society that have historically lobbied for legalized suicide were instrumental in adding the "end-of-life" counseling section to the legislation.
Verdict: Yes
4. Does the Bill Use Federal Funds to Pay for Abortions?
There is nothing specific in the bill to fund abortions. However, the yet unspecified new rules for all "approved" health plans - rules that will be written by Obama Administration appointees AFTER the bill passes - could include abortion coverage. Over concerns on this issue, an amendment prohibiting abortion funding was submitted in the House, and subsequently voted down by Democrat members of the Committee. This provides substantial evidence that the new federal health plan rules could require abortion coverage by all health plans in the country, while the final decision remains unknown.
Verdict: Likely
5. Is This the Beginning of Single-Payer Healthcare?
Like most issues concerning this bill, there is no specific provision that would mandate single-payer socialized medicine and the shutdown of private sector healthcare. But as early as 2003 then-Senator Barack Obama was advocating single-payer healthcare publicly, and has recently stated along with key House Democrats that this bill would lead eventually to single-payer healthcare, over a period of 10-20 years. All of these comments are on tape and available to the public.
Verdict: Likely Over Time
6. Will the Bill Increase the Federal Deficit and Federal Taxes?
No argument here from either side. The bill will cost $1.28 trillion in the first 10 years according to CBO, and raise taxes $818 billion on those who cannot afford to buy insurance, not counting surcharges on small business income.
Verdict: Yes
7. Will the Bill Cost American Jobs?
No argument here either. The Obama Administration's own White House Council of Economic Advisors has estimated 4.7 million Americans will lose their jobs if the bill passes, as employers who cannot afford health insurance or the 8% payroll tax penalty will have to fire their employees, move overseas, or go out of business.
Verdict: Yes
There are many more issues to this bill than seven, but in my opinion the answers to just these are enough to reach a final judgment on HR 3200: NO.
HR 3200 is fatally flawed, does not provide the health reforms we truly do need in this country, and should be buried. It is one of the worst pieces of legislation I have examined since being elected to the House. It would destroy the finest quality health care system in the world, undermine the free market, throw Americans out of work, and violate the moral principles of the majority of this country in the process.
Examining all the evidence is not just important in determining action on legislation, but in writing that legislation to begin with. Like the story of the old judge who only listened to one side of a case, this bill was written without any consideration of opinions from anyone other than the liberal Democrat faithful, with a resulting faulty outcome.
We can do better. We don't need the federal government to take over the healthcare industry, we just need some commonsense bipartisan reforms.
First, we are already in bipartisan agreement to make affordable health insurance available to folks with pre-existing health conditions who are presently barred from buying a health plan.
We can let small businesses and organizations join together to purchase group insurance at the same affordable rates as big business, allowing more small employers to offer coverage.
We can remove restrictions on buying health insurance across state lines, letting families in prohibitively high-cost states purchase affordable plans in other states.
To pass these reforms will require a simple concession from the Democrat majority. That is to agree to work with Republicans in a bipartisan effort, and listen to both sides of the case before reaching a verdict.
Congressman John R. Carter represents the 31st Congressional District of Texas.
Alabama’s Health Care Crisis Becomes Alabama’s Health Care Implosion
Almost 10 years have passed since there has been any serious consideration of the need for major health care reform here in the State of Alabama. Back in late spring 1998, Michael Ciamarra, then domestic policy advisor for Governor James, and later myself, serving as health care advisor to the governor, developed a series of initiatives to head off an impeding crisis in the state’s health care obligations ranging from Medicaid reform to indigent care. After Governor James lost his bid for reelection, myself and others made several vain attempts to get the Governor’s office attention to the need for controlling and improving the delivery of health care to the citizens of Alabama.
Today, in Montgomery, we have one of our major health care institutions, Baptist Medical Center South, reeling in losses from unreimbursed care leading to a mass exodus of physicians from its staff and others looking to reduce their own exposure to an ever growing contingent of uninsured indigent patients. To understand the problem, I can only personally relate my experience on city wide call for gastrointestinal emergencies last weekend. Patients with gastrointestinal bleeding, diverticulitis, liver cirrhosis, and diabetic complications were consulted at Baptist South, most without insurance and many from outside our own county, yet treated by the medical staff in Montgomery. Because of staff shortages, hours passed until these patients could be adequately seen along with late nights and long hours caring for those with no means of reimbursement. The same can be said of trauma services, general surgery, and orthopedic emergencies, whose injuries are frequently associated with substance abuse, alcohol, or gun violence; in which most are unemployed or poorly educated.
A similar problem has arisen in San Diego County, California where 3 county hospitals are sinking in red ink, with losses exceeding 3 million dollars annually. Some are at risk of being taken over by the federal government where others are closing their doors and moving their beds to surrounding suburbs to escape the burgeoning illegal alien population that is seeking health care, obviously without the means to pay for the care.
To make matters worse, the state’s own health care obligations for state employees, the state prison population, Medicaid, retirees, and teacher health benefits continue to skyrocket, reaching close to $1.5 billion in the next fiscal year. Health benefits, if continuing at the present rate, will soon outstrip the ability of the legislature to appropriate funds, risking cuts to other essential services.
The question arises, what can be done ? The answer is not simple. It will require the will and the intellect of the new governor and the legislature to have the political will to make the sacrificial changes in the way health care is delivered to cope with this growing problem. The Governor’s office must take leadership in this area and not totally neglect this crisis.
The recommendations from 1998 are still viable today in 2006. These recommendations take into consideration the needs of all citizens combined with the moral obligations that health care institutions rightfully are entrusted to deliver and the obligations of the state to its citizens and the health care providers of our state.
1.Enact a tax credit of up to $10,000 for each physician in the state for unreimbursed care delivered to citizens of the state. The amount would be pegged at the rate of reimbursement by Medicare or Medicaid, whichever is higher which would be filed on the health providers state income tax return. Each claim would be subject to an audit by the Examiners of Accounts and the Department of Revenue to ensure accuracy.
This would increase the availability of physicians to care for those who have no means or are ineligible for health care insurance.
2.Require minimal catastrophic health care coverage all individuals at 500% of the
Poverty level ($49,000 a year for single, $100,000 for family of four) and scaled down from that level with a state insurance purchasing pool to provide a number of insurance plans for those under this income threshold to be provided by employers.
This plan has been advocated by the American Medical Association and is in force in the State of Massachusetts.
3.Creation of 9 Regional Health Care Centers of Excellence to provide health care
For indigents and uninsured in their metropolitan areas and the surrounding service areas and counties to be determined by existing referral patterns, in Birmingham, Montgomery, Huntsville, Tuscaloosa, Mobile, Dothan, Florence/Decatur, Auburn, and Anniston/Gadsen areas. Those centers would bid on the health care contract from the state of Alabama with state tax resources from the regional counties paying for the service. In return, the health care facilities would have preference on certificate of need and receive the point of service contracts for private insurance plans funded by the state, with preventive health and global cost containment contracts to be monitored by the state to ensure that these plans are fiscally sound for those served by the state plans.
4.Creation of Blue Ribbon Health Care Advisory Board with a Cabinet Level
Position to Serve as a Liasion between the Medical Association, the Legislature, and the Congressional Delegation to examine waivers to improve and protect the federal programs such as Medicaid, and increase the availability of these programs.
These are not easy plans to implement and would likely affect the reimbursement certain health care entities receive. Our flagship health care training programs would likely be called upon to provide technical and specific specialty needs to make this plan workable.
However, it can be done and we can dramatically improve health care availability and the financing of its implementation. Yesterday, the Democratic Leadership Council of Alabama and the Baxley campaign made health care an important issue in their platform. I implore both gubernatorial candidates to make this an issue in this election. The people of Alabama and the health care providers of this state and its health care facilities and medical centers deserve it.
Randy Brinson, MD, is a gastroenterologist here in Montgomery, and previously served as health care advisor to Governor James.
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