REPUBLICAN HEALTHCARE PLAN – THE CARE ACT
Wednesday, April 2nd, 2014
Republicans do have a replacement healthcare plan! Nancy
www.johnlocke.org/newsletters/research/2014-03-14-sou22itrbc15vag53vam9mk413-health-update.html
Republicans do have a replacement healthcare plan! Nancy
EXCERPT FROM THIS ARTICLE: The benefits of the digital revolution are large. But we’ll also have to deal with problems and unanticipated consequences, mostly related to privacy, the possibility of misuse, and the concern that patients might be overwhelmed with so much information. The government via the FDA will need to play a role to ameliorate all three of these potential issues. Regardless, digital medicine is coming over the next few years with the force of a hurricane whether we doctors—and we patients—are ready or not.
A sweeping transformation of medicine has begun that will rival in importance the introduction of anesthesia or the discovery of the germ basis of infectious disease. It will change how patients and physicians interact. It will change medical research and therapy. “Sick care”—the current model of waiting for you to get sick and then trying to alleviate symptoms and make you well—will become true “health care,” where prevention is the mantra and driving force. Welcome to the world of digital medicine.
First and foremost, the digitalization of medicine will personalize health care: Treatment will be tailored to each person as a unique individual suffering a unique illness according to his or her genetic makeup. Currently, therapy is based on population statistics. Patients are separated into groups defined in various ways but usually by similar symptoms or by the results of basic lab tests (like cholesterol levels). These groups are then treated with drugs that may help many people, but not all of them, and often only a fraction of them. By incorporating information from an individual’s DNA, the data made available through digitalization will enable clinicians to match individuals with treatments. Only patients who will benefit will get a particular drug.
This is huge. Giving drugs to patients who are not helped has been enormously expensive and often perverse. Particularly with anticancer drugs, it often condemns such patients to horrendous side effects for no benefit.
Second, digitalization will democratize medicine: You will own or control the data about your own medical condition, and you will be able to analyze it instantly by your connectivity to the Web. In many ways, the profession of medicine today is where Christianity was when the Gutenberg Bible put scriptures into the hands of the laity. But the profession is going to change, subtly and not so subtly shifting power away from the medical-industrial complex: doctors, health insurers, hospitals, medical labs and Big Pharma. (more…)
Perhaps the most unpleasant aspect of my otherwise quite enjoyable job as a college professor has been the requirement to assign grades to students. Given that we’re now about halfway through implementation of the Affordable Care Act—which even President Obama is happy to call “Obamacare”—it seems appropriate to assign midterm grades. These are not intended as a forecast of the final grade; moreover, implementation of Obamacare is the responsibility of many thousands of individuals, not just one. Nevertheless, as President Truman’s legendary Oval Office desk sign reminds us, “The buck stops here” when it comes to presidential leadership. So whether President Obama likes it or not, the public and historians are likely to base their assessment of his performance on how well his “signature piece of domestic legislation” is implemented.
First Grading Standard:
Promises vs. Performance
Both as a candidate and as president, Barack Obama has made at least 80 promises related to health care. For purposes of grading, I have focused on the 8 most consequential.
Promise #1: Universal Coverage. Candidate Obama promised on June 23, 2007: “I will sign a universal health care bill into law by the end of my first term as president that will cover every American.” The latest CBO projections last May show that as of the end of 2013, Obamacare will have reduced the number of nonelderly uninsured by less than 4 percent. This figure excludes 11 million unauthorized immigrants (51 percent of whom are uninsured). Even when Obamacare is fully implemented in 2017, it will cover only 92 percent of the nonelderly population who are not unauthorized immigrants (nearly everyone age 65 and above is already covered by Medicare), and 84.7 percent of that group already had coverage in March 2009, a full year before Obamacare was signed into law. Even if we concede that other countries relying on an individual mandate have failed to drive their uninsured rates below 1 percent (Switzerland) or 1.5 percent (Netherlands), Obamacare will close only 53 percent of the gap that existed when President Obama was sworn into office. Grade: F.
Promise #2: No New Taxes on the Middle Class. Candidate Obama promised on September 12, 2008: “I can make a firm pledge under my plan, no family making less than $250,000 a year will see any form of tax increase. Not your income tax, not your payroll tax, not your capital gains taxes, not any of your taxes.” Using official estimates from the Congressional Budget Office and the Joint Committee on Taxation, the House Ways and Means Committee projects that Obamacare will increase federal revenues by $1.058 trillion between 2013 and 2022. Only 30 percent of this total will be raised from taxes that exclusively target taxpayers earning over $200,000 (singles) or $250,000 (married). The remaining 70 percent will be borne by households at all other income levels. Tax Policy Center figures show that such households do not account for more than half of all federal taxes. So even if we generously assume such households will bear a similar share of the myriad levies to be imposed on health insurers, medical device manufacturers, and drug manufacturers—levies which will be passed onto consumers—that still leaves at least 35 percent to be borne by families at or below middle-class incomes.
And these figures do not include the hundreds of billions of dollars in new revenue that will have to be collected by states to pay for their share of Obamacare-induced growth in Medicaid. Nor do they include the impact of “taxation by regulation”—i.e., the tens of billions of dollars in higher premiums that young Americans are being forced to pay under Obamacare’s modified community rating rules in order to subsidize predominantly higher-income people who happen to be older. In short, President Obama’s promise at best was 65 percent true and more likely 50 percent or less true. Grade: F. (more…)
Something strange is happening in Washington. We are slowly dismantling the federal government, even as its spending is growing larger. The paradox is that governmental competence is being systematically degraded while the government’s size, as measured by its budget, is increasing. We are spending more and getting less, and — unless present trends are reversed — this will continue for years. It threatens the end of government as we know it.
The cause is no mystery. An aging population and higher health spending automatically increase budget outlays, which induce the president and Congress to curb spending on almost everything else, from defense to food stamps. Over the next decade, all the government’s projected program growth stems from Social Security and health care, including the Affordable Care Act. By 2024, everything else will represent only 7.4 percent of national income (gross domestic product), the lowest share since at least 1940, says Douglas Elmendorf, head of the Congressional Budget Office.
This is the central budget story, and it’s largely missed — or ignored — by political leaders, the media, political scientists and the public. The welfare state is taking over government. It’s strangling government’s ability to respond to other national problems and priorities, because the constituencies for welfare benefits, led by Social Security’s 57 million, are more numerous and powerful than their competitors for federal support. Politicians of both parties are loath to challenge these large, expectant and generally sympathetic groups.
The United States, of course, is not the only advanced society grappling with aging, but it is extreme in its stubborn denial of the obvious. The Pew Research Center recently polled people in 21 countries about whether aging is a problem. The United States ranked 19th in its unconcern, ahead of only Indonesia and Egypt, whose populations are young. Only 26 percent of Americans thought aging was a problem. The share was 87 percent in Japan, 55 percent in Germany and 45 percent in France. (more…)
The Wall Street Journal is making it more difficult to copy their articles so I am now just providing the links to the articles below. Nancy:online.wsj.com/news/articles/SB10001424052702304337404579211742820387758?mod=ITP_opinion_0 – AN ALLY FRETS ABOUT AMERICAN RETREAT – An influential Saudi royal prince talks about the U.S. debacle in Syria, the Iranian threat, and ‘this perception that America is going down.’online.wsj.com/news/articles/SB10001424052702303789604579195592650374168?mod=ITP_opinion_0 – WHY IT TAKES SO LONG TO BUILD A BRIDGE IN AMERICA – There’s plenty of money. The problem is interminable environmental review.online.wsj.com/news/articles/SB10001424052702304527504579172201270531632?mod=ITP_opinion_0 -Our students can no longer write cursiveonline.wsj.com/news/articles/SB10001424052702303653004579210172838389630?mod=ITP_opinion_0 – WORSE THAN OBAMACARE – Obama’s biggest failure is that he hobbled the U.S. economy by Daniel Henninger
online.wsj.com/news/articles/SB10001424052702303531204579207724152219590?mod=ITP_opinion_0 – OBAMACARE FORCED MOM INTO MEDICAID – The authors’s mother preferred to pay for her own health care rather than be on the government dole. Now she has no choice
online.wsj.com/news/articles/SB10001424052702304527504579171710423780446?mod=ITP_opinion_0. – YOU ALSO CAN’T KEEP YOUR DOCTOR – The author had great cancer care and health insurance. Her plan was canceled and now she worries how long she’ll live.
online.wsj.com/news/articles/SB10001424127887324432404579051123500813210?mod=ITP_opinion_0 – GREEN ENERGY IS THE REAL SUBSIDY HOG – Renewables receive three times as much money per energy unit as fossil fuels.
by Becki Gray, Carolina Journal, October 3, 2013.
Before Obamacare, before individual mandates, before exchanges, there was Medicaid. Started in 1965 under President Johnson as part of his War on Poverty, Medicaid extended health insurance coverage to low-income Americans.
Today, Medicaid is the largest publicly funded insurance program in the country. It serves low-income families, the elderly, and disabled. One In five Americans is on Medicaid, more than one-third of the births in the United States are covered by Medicaid, and one-fourth of U.S. children get health care through Medicaid.
Medicaid covers one in nine North Carolinians — 1.6 million of us — and 51 percent of births are covered by Medicaid, the sixth-highest rate in the nation.
Medicaid is funded jointly by the state and federal governments. North Carolina’s share of the program is about $3 billion, while total Medicaid spending in N.C. is closer to $14 billion.
Medicaid spending has grown 90 percent over the last decade and is the fastest-growing part of our state budget, with spending rising by 15 percent in 2011-12; 16.8 percent in
2012-13; and a projected 17.2 percent in 2014-15.
North Carolina’s Medicaid costs are the highest in the South and among the highest in the nation. We have more people enrolled and spend more per patient than neighboring states. Twenty-five percent of the state’s primary care physicians aren’t accepting new Medicaid patients, limiting access, reducing health outcomes for patients, and driving up costs.
Uncontrolled expenses result in consistent budget overruns. Just this year, legislators faced a $400 million shortfall. Since Medicaid is a federal entitlement program, it has to be funded before anything else. Medicaid is the biggest driver of state budget decisions, crowding out other priorities. (more…)
What the GOP’s Defund-ObamaCare Caucus is failing to see is that ObamaCare is no longer just ObamaCare. It is about something that is beyond the reach of a congressional vote.
As its Oct. 1 implementation date arrives, ObamaCare is the biggest bet that American liberalism has made in 80 years on its foundational beliefs. This thing called “ObamaCare” carries on its back all the justifications, hopes and dreams of the entitlement state. The chance is at hand to let its political underpinnings collapse, perhaps permanently.
If ObamaCare fails, or seriously falters, the entitlement state will suffer a historic loss of credibility with the American people. It will finally be vulnerable to challenge and fundamental change. But no mere congressional vote can achieve that. Only the American people can kill ObamaCare.
No matter what Sen. Ted Cruz and his allies do, ObamaCare won’t die. It would return another day in some other incarnation. The Democrats would argue, rightly, that the ideas inside ObamaCare weren’t defeated. What the Democrats would lose is a vote in Congress, nothing more.
A political idea, once it becomes a national program, achieves legitimacy with the public. Over time, that legitimacy deepens. So it has been with the idea of national social insurance.
German Chancellor Otto von Bismark’s creation of a social insurance system in the 19th century spread through Europe. After the devastation of World War I, few questioned its need. In the U.S., Franklin Roosevelt’s Social Security system was seen as an antidote to the Depression. The public’s three-decade support for the idea allowed Lyndon Johnson to pass the Medicare and Medicaid entitlements even in the absence of an economic crisis.
Going back at least to the Breaux-Thomas Medicare Commission in 1999, endless learned bodies have warned that the U.S. entitlement scheme of Social Security, Medicare and Medicaid is financially unsupportable. Of Medicare, Rep. Bill Thomas said at the time, “One of the biggest problems is that the government tries to administer 10,000 prices in 3,000 counties, and it gets it wrong most of the time.” But change never comes.
Back when the mess that is Obamacare was working its way through the legislative sausage factory, warnings about “death panels” almost derailed the entire enterprise. There were two, somewhat related, areas of concern: (1) that Obamacare’s many cost/benefit bureaucratic boards would lead to explicit health care rationing; and (2) that doctors paid to “counsel” elderly and dying patients about end-of-life treatment would actually pressure them to refuse expensive treatments. Owing to the lack of popular trust, the end-of-life counseling provision was dropped to grease the way for Obamacare’s final passage.
Now, the proposal is back in both the House and Senate, with bipartisan support. The Care Planning Act of 2013 is the most far-reaching of the bills. Supported by the AARP and sponsored by Senators Mark Warner (D-Va.) and Johnny Isakson (R-Ga.), the bill ostensibly aims to compensate medical providers who accept Medicare and Medicaid for participating in end-of-life treatment discussions with patients. But that’s just the tip of the proverbial iceberg.
No one is against doctors discussing end-of-life treatment options with patients. That’s part of good medical practice. But once the federal government sets the pay, it will make the rules. It won’t be enough for doctors to talk to their patients about tube feeding, cardiopulmonary resuscitation, and the like. If they want to be reimbursed, doctors will have to structure the conversations in the way the government instructs.
Ever wonder why the health care bureaucracy is becoming so byzantine and sclerotic? This bill—meant to encourage conversations—is 46 pages long. It would create a Care Planning Advisory Board, an “expert” panel of 15 members, three appointed by the president and the remainder by the four partisan leaders of the House and Senate (three apiece). Imagine the patronage opportunities! (more…)
EXCERPT FROM THIS ARTICLE:Under 340B, eligible hospitals are allowed to buy drugs from drug companies at forced discounts of 25% to 50%. The hospitals can then bill government and private insurers for the full cost of the drugs, pocketing the spread. The arrangement gives 340B-qualified hospitals a big incentive to search for patients and prescribe lots of drugs. The costlier the drugs, the bigger the spread. So expensive cancer drugs are especially appealing.
The original legislation creating 340B envisioned that only about 90 hospitals that care for a “disproportionate share” of indigent patients would qualify. But remember, this is a well-intentioned government program handing out money, with the usual result: By 2011, 1,675 hospitals, or a third of all hospitals in the country, were 340B-qualified.
Even flourishing hospitals like the Hospital of the University of Pennsylvania and Duke University Health System feed off the subsidies. In 2011, Duke bought $54.8 million in drugs from the discount program and sold them to patients for $131.8 million, for a profit of $76.9 million—a substantial portion of the health system’s 2011 operating profit of $190 million. Only one in 20 patients served by Duke’s 340B pharmacy is uninsured. The rest have their prescription costs covered by Medicare, Medicaid or commercial insurers.
President Obama promised to mend the failings in the American health-care system, and yet for cancer treatment, ObamaCare is taking a rotten feature of the old system and making it worse.
The Affordable Care Act expands a program called 340B, which siphons money from drug makers and insurers to subsidize certain hospitals. The program has been expanded as a way to offset some of the cuts that the law imposes on hospitals. One significant side effect: 340B is increasing the cost of cancer care—and harming its quality.
When the program began in 1992, its aim was to support hospitals that cared for many uninsured, indigent patients. Over the years, the program was radically broadened, gradually morphing into a government cash cow that hospitals of every description have learned to exploit. (more…)
Marnie Baker, a pediatrician at California’s MemorialCare Health System, has an easy manner and ready smile. Now, though, her job is to be the bearer of a serious and, for some of her colleagues, unwelcome message.
She’s the voice of a program that digitally tracks their performance, informs them when they don’t measure up—and cajoles them to improve.
MemorialCare is part of a movement by hospitals around the U.S. to change how doctors practice by monitoring their progress toward goals, such as giving recommended mammograms. It isn’t always an easy sell. At one clinic earlier this year, physicians grilled Dr. Baker, who is director of performance improvement at a MemorialCare-affiliated physician group.
Cardiologist Venkat Warren said he worried that “some bean-counter will decide what performance is.” He wondered whether doctors would be pushed to avoid older and sicker patients who might drag down their numbers.
“If it isn’t cost-cutting, what is it?” Dr. Warren asked.
“It’s providing better value,” Dr. Baker responded.
Encounters like these are one result of the changes sweeping American health care. Technology is making it easier to monitor doctors’ work as patients’ details are compiled electronically instead of on paper charts. Software makers are selling new tools to crunch the data. Software called Crimson offered by the Advisory Board Co. ABCO -1.54%now includes information on more than a half-million doctors, up from fewer than 50,000 in 2009.
At the same time, more physicians are going to work for hospital systems, which are under pressure to hit quality goals and cut costs. Many are striking deals with insurers that pull them away from traditional “fee-for-service” reimbursement, which pays for medical procedures individually.
Insurers—which themselves increasingly track physician results—are moving toward providing a set payment for the overall care of a patient. This system means that doctors who provide costlier-than-average care could break the budget.
The federal health law is speeding these trends. Under the law, hospital payments and penalties from the federal Medicare program will be linked to their performance on quality gauges, particularly rehospitalizations, which are costly. The law also created a new Medicare initiative for “accountable care organizations,” providers that get extra rewards for efficiency and quality performance.
To succeed under the new health-care economics, hospital executives say, they must lean on doctors, who make nearly all the key decisions on what treatments, tests and drugs patients get. “The last frontier is the physicians,” says Thomas Heleotis, vice president of clinical effectiveness at Monmouth Medical Center, part of New Jersey’s seven-hospital Barnabas Health system. (more…)