Innovation in the PPACA

Via Kevin Drum, a serious effort to incentivize efficiency in Medicare:

Under the new health law, Medicare will reduce payments to hospitals if too many patients are readmitted after treatment for heart attacks, heart failure or pneumonia. In addition, Medicare will cut payments to hospitals if they do not replace paper files with electronic health records, and it will further reduce payments to hospitals with high rates of preventable errors, injuries and infections.

This sounds like a great idea, so long as we can keep it going the route No Child Left Behind tended to force poor schools to take:

Administration officials said they were aware of concerns that some hospitals might try to increase their performance scores by avoiding high-risk patients. The officials said they would watch closely for signs of such a problem.

I'm not 100% positive that I'm on board with this plan, but it's certainly a step in the right direction.


Also, via Drum, more doctors prefer a national single-payer system:

Remember this was support for federal legislation to establish National Health Insurance. That’s far more radical than the PPACA. And 59 percent of physicians supported it. That was an increase of 10 percent from what we found five years earlier, and it was statistically significant. More than half the respondents from every medical specialty supported it, with the exception of surgical subspecialties, anesthesiologists and radiologists. That means support included a majority of general surgeons, medical subspecialists and obstetricians/gynecologists. 

Most significantly, in pretty much every specialty we measured in both years, support went up from 2002 to 2007.

If doctors aren't the leaders of the resistance to national health insurance, who is left?  Hospital administrators? 

Ryan v. Klein

Took me more than a day.  I'd suggest reading Ezra's response in full, 'cause it's not that long and he really eviscerates Ryan for his dodginess.  But here's my critiques of Ryan's response:

First line:

Experience and economics support the view that the best way to control costs without sacrificing quality is to give consumers more power to act as a check on erratic pricing, deteriorating quality and excess care. 

This is a bold statement, and one that doesn't have any real grounding in reality.  Unless you live in a major urban area, you probably don't have many choices of hospital-level providers (about 3 out of 5 of my clients are hospitals that are the only ones in their immediate area, i.e. within about an hour's drive).  Further, as I constantly lament, it is rare that a consumer of health care services gets full, complete information on pricing prior to receiving care.  That's slowly changing in some areas, and non-essential things like elective cosmetic procedures and Lasik have had it for years, but for most medical services there just is no option to see what something's going to cost you ahead of time.

Some have argued that we can somehow fix this by removing elected officials from the process of managing Medicare. That we should instead empower unelected bureaucrats to achieve the results our political system has been unable to produce. Even accepting the dubious proposition that we could separate these bureaucrats from the influence of politics, or that such a thing would be consistent with our principles as a nation ruled by a constitutional, limited, and democratic government, I do not share your faith in the ability of small groups of experts to make wise decisions about treatment options on behalf of tens of millions of seniors. (bold mine- JG)

 This is a swipe at the IPAB, Medicare's medical procedure review committee that steers Medicare dollars toward the most cost-effective treatment.  What Ryan is saying here is that costs will be lower and health care outcomes will be better if we just take the doctors out of the equation.  This seems, to me, a bit silly on its face- if consumers could make healthcare decisions better than doctors, why have doctors at all?


What Ryan is really saying here is the dodge libertarian-conservatives tend resort in discussions about effective policy, namely resorting to a pure values argument.  It sidesteps the policy issue entirely and reframes the question as a moral issue, which would be fine if we were having a debate over the morality of universal health care, but we're not!  Ryan's plan concedes the moral case for providing healthcare for all (at least, all seniors) before he even sets out explaining how he's going to make it happen- but when a tough policy decision rears its head, he ducks back behind a moral argument that leaves no room for policy options.


 It's also a pretty transparent exploitation of  political buzz-words. "Unelected bureaucrats" sounds bad, but what he could also call them is "doctors and medical professionals".  I'd be willing to bet that most people don't want a "government bureaucrat" advising them on healthcare decisions, but would gladly welcome the advice of a doctor.  Does a doctor's advice become invalid because he draws a paycheck from HHS?  And if so, why is it less valid than advice from the doctor who gets paid by a hospital or HMO, which benefits financially if costly and unnecessary tests are run?

And it forces 20 million additional Americans into a broken Medicaid system that is already failing the Americans it serves. Our budget moves health-care policy in the opposite direction — away from government-centered health care and toward patient-centered health care that promotes competition and consumer choice.

This line strains my ability to be non-partisan.  Broadly speaking, Medicaid is a broken system because it is always first on the chopping block whenever budget cuts are an issue (which they almost always are).  Conservatives have been trying to starve Medicaid to death for years, and have largely succeeded.  


That said, speaking as someone who would have killed for Medicaid coverage for my loved ones in the last few years, I would certainly have welcomed being "forced" into such a system.  My only "choice" was to take out loans to pay for student insurance plans in school and then find a job that provided health insurance.  Both plans covered a majority of the cost of our care, but even the leftover costs were still ruinous.  My cousin, by comparison, has been on disability Medicaid for cancer for years and gets essentially free coverage, including testing and prescription drugs.  She remains poor, but only because it is difficult for her to find work due to her chronic illness, not because she accrues health care debt in excess of 50% of her yearly gross income like yours truly.

However, if we reform Medicare so that it looks more like the system that members of Congress enjoy — in which federal employees choose from a list of competing plans and get the coverage that delivers the best value to them

Members of Congress enjoy access to competing plans that have offer lower out-of-pocket costs because of the enormous risk pool that the federal government brings to the table.  Most employer-provided insurance is not nearly this generous, and those that are represent companies with thousands of employees.  This is important, because only with a large risk pool can an insurance company afford to insure everyone cheaply- they need several relatively healthy people paying regular premiums to make up for the cost of just one chronically ill person.  Now, it is possible to have everyone purchase individual health insurance, essentially making every citizen a member of an enormous risk pool- but costs will only remain under control if you ensure that all the healthy people pay into the system to support the sick ones.  In other words, you need an individual mandate.


The rest of Ryan's responses fall into the same general categories: Medicaid is failing, choice will mean lower costs,  government is bad, inefficient, etc.  He also points out that some foreign country's plans have problems (using some remarkably cherry-picked data without any relevant comparison to how much worse our healthcare system is doing).


All this said, I think Ryan's responses are some of the most cogent and thoughtful of any Republican or conservative politician on the issue of the rising cost health care.  It would be nice if Rep. Ryan could give us a fully policy-oriented response without resorting to conservative shibboleths (government bad!) or ducking behind moral arguments (also, government bad!).  This is especially ironic considering that what became PPACA started out as the conservative response to single-payer.  The right won that argument, but here we are with the right-wing bloc in Congress arguing that what was the conservative pole of the issue a decade ago is now an indefensibly liberal position.


I wonder where we will be in another ten years.