Former Health and Human Services secretary Tommy Thomposon (HHS.gov)
Health Care Reform Waits
Lawmakers Dabble at The Edges
By Mike Lillis
05/09/2008
| 7 Comments
In 2004, Tommy Thompson, then-Health and Human Services secretary, approached his boss with a request. Observing that the nation's doctors and hospitals operate a tangled web of incompatible forms and technologies, Thompson asked President George W. Bush to create a universal system of electronic medical records that would follow patients around the country, eliminate redundant treatments and, according to some estimates, trim billions of dollars from the nation's annual health care tab. Thompson wanted the president to establish the system within 18 months.
"He came out for 10 years," Thompson said this week, "and as a result, we haven't been able to get there."
The anecdote, which Thompson told the Senate Finance Committee Tuesday, offers a glimpse of the obstacles facing health-reform advocates. With medical costs skyrocketing, employers increasingly dropping or trimming coverage, Medicare projected to go belly-up in a decade and the number of uninsured Americans tickling the 50 million mark, most observers contend the health-care system needs a complete overhaul. But such shakeups are rare in Washington, where special interests spend millions to keep things as they are, and the political will to confront industry is all but absent. Instead, lawmakers tend to dabble at the edges of problems until sweeping change becomes unavoidable. The health reform debate now seems to revolve around when that time will arrive.
Thompson said that 2009 brings a great opportunity to overhaul the system. He argued that, politically, big reform will be feasible with the arrival of a new administration, while, fiscally, it will be necessary because of Medicare's looming bankruptcy.
"It's the perfect storm," he said.
On Thompson's side, there is near-unanimous agreement that the health-care system is broken. Patient advocates, for example, decry the millions of uninsured; employers want a coverage model that won't nip their competitive edge over foreign companies, and doctors and hospitals want to spend less time wrangling with insurers over payments. Taken together, the troubles reveal a system in need of transformation. "One piece is not going to do it," Thompson said. "It is too broken."
Congressional lawmakers acknowledge as much. But identifying the problem is different than agreeing on the solution. Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee, which oversees Medicare and tax policy, conceded the "many difficult decisions" lawmakers face.
For that reason alone, few observers agree with Thompson that the reforms will arrive next year. David Walker, former head of the Government Accountability Office, argued that health care costs threaten to bankrupt the country if Congress fails to act, but an overhaul won't -- and shouldn't -- come overnight.
"It is possible to achieve some incremental reforms next year," said Walker, now president of the Peter G. Peterson Foundation, which aims to promote solutions to America's budget challenges, "but comprehensive reform will have to be done in stages over a number of years."
The health care debate arrives during an election year when polls reveal that the struggling economy and the war in Iraq are foremost on voters' minds. Donna Shalala, secretary of Health and Human Services under President Bill Clinton, however, called those polls "misleading."
"It seems very clear that when Americans talk about their economic concerns," she told Senate lawmakers, "they're talking about health care."
The three current presidential hopefuls have each unveiled ambitious health reform plans, though in each case, the details -- like how to pay for universal coverage -- have been kept purposefully vague to avoid criticism. Experts point to popular bipartisan proposals, like renewing the State Children's Health Insurance Program, as probable successes in 2009. But change on the scale that many say is needed to fix the entire system remains an idea for the more distant future.
"Taking something as big as health care, you're just asking for trouble if you try to do it in one fell swoop," said David Merritt, project director at the Center for Health Transformation, a right-leaning Washington-based policy organization. "Hillary Clinton can testify to that."
Merritt's reference was to the health care overhaul proposed in the first years of the Clinton administration. Facing well-heeled opposition from the insurance industry, among others, the plan went down in flames. Its failure was seen as a turning point for the administration, and is often cited as a central contributor to the Republican takeover of Congress in 1994.
In a 1995 issue of Health Affairs magazine, several architects of the Clinton proposal weighed in on the reasons for the plan's failure, and offered some advice to future administrations.
"We have seen that although the 'window of opportunity' might exist for major government action to address a particular policy issue, the tendency is for experts to overestimate the willingness of middle-class Americans to sacrifice and risk the uncertain consequences of major changes in their lives," wrote Robert J. Blendon, Mollyann Brodie, and John Benson, who had all worked on the Clinton plan.
"Thus, if substantial reform is to be achieved during these windows of opportunity, the legislation must be more modest in its reach than many reformers may see as desirable."
Reached by phone this week, Blendon said, "I haven't changed my mind a bit."
Blendon, a professor of health policy at Harvard University, pointed out an irony underlying the health-reform debate: While many Americans express dissatisfaction with the current system, many also harbor a fear of change. "Some of these reforms, while they might make great policy sense, won't have any legs when brought to the public," he said. "They are risk averse to a lot of changes in the health-care sector."
Instead, Blendon said, reform advocates in and out of Congress will probably have to wait a few more years until the crisis becomes the subject of more dinner-table conversations.
"Governments solve things when they perceive a crisis facing the middle class that they can't escape from," he said. "And then everyone says we should have done it 10 years ago. But it needs to be perceived as a real crisis and it needs to be on the front pages every day. Then you can really do big things."
Yet, all sides of the debate agree that the current system is a train-wreck -- and they have the statistics to back it up. In 2006, Americans spent roughly $2.1 trillion on health care, according to the Centers for Medicare and Medicaid Services -- roughly 16 percent of the nation's gross domestic product, or $7,000 for every man, woman and child in the country. Meanwhile, medical inflation (at 6.7 percent) is about twice that of overall inflation. Without legislative changes, the Congressional Budget Office projects that total health care spending will jump to 25 percent of GDP in 2025 and 37 percent in 2050.
Despite all the spending, 47 million Americans are uninsured.
"The problems are greater than the incremental solutions that Congress has tried to date," Baucus said in a statement.
Baucus faces a difficult task. From the left, liberal Democrats and patient advocates are pushing to increase the government's role in covering the uninsured while improving care for millions more. From the right, conservative Republicans and the numerous medical industries are urging more patient responsibility and privatization of care. The ultimate strategy will inevitably involve some compromise on everyone's part -- and a tangible crisis to bring it about.
As Peter Orszag, head of the Congressional Budget Office, told reporters last November: "The political system is not very good at dealing with gradual problems. It's good at dealing with crises."
The question remains when America's health-care system will be perceived as such.
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© 2007 The Washington Independent
Comments:
Posted 05/09/2008 10:44am with
I nominate Steve Kagan to take charge of Health Care reform in the House. He’s obviously very principled and committed to the issue:
“One of the first things U.S. Rep. Steve Kagen (D–Wisc.) did when he took office last year was to nix his congressional health care coverage. The move stunned a human resources staffer, who, the lawmaker says, looked at him as though he were insane.
“I’ll respectfully decline until you can make that same offer for all of my constituents,” he says he told her, explaining his decision to turn down what many say is the Cadillac of U.S. health plans.”
Full story: http://www.sciam.com/article.cfm?id=an-uninsured-doctor-i…
Posted 05/09/2008 12:46pm with
The almost 3 million registered nurses provide about 95% of all reimbursed health care services (given the nature of the majority of nursing care which is a 24/7 endeavor versus the episodic appointment based care provided by physicians, therapists and other licensed providers). Yet nurses are not represented at all in any healthcare reportage, they don’t have a seat at the policy table, nor are nursing experts and nursing research cited when addressing health system reform and patient quality.
Until this huge missing component is included and addressed throughout all of healthcare system design, delivery and reimbursement issues and policy, a fundamental change will not occur with enough breadth and depth to change the outcome.
I blog about professional nursing, patient advocacy/safety and healthcare at Universalhealth and at Home of the Brave. I’ll be happy to serve as a resource for nursing issues and to provide contacts to expert nurses and nursing researchers across clinical specialties.
Posted 05/09/2008 01:42pm with
Annie: Point well taken. While health information technology, comparative effectiveness, chronic disease management and preventive care tend to monopolize the health reform debate, nurses will play a central role in any solution and shouldn’t be overlooked. The good news is that experts seem to recognize this. In testimony Tuesday, both Thompson and Shalala were quick to point out the importance of nursing, and both called for improvements in training and education programs. (Shalala pushed loan forgiveness, for example, while Thompson promoted greater incentives for nurses to get PhDs so they can turn around and teach new folks.) Whether these items will be prioritized above the others could be an issue, but they do seem to have an audience among policymakers.
Posted 05/09/2008 04:28pm with
Except that salaries for nursing faculty run BELOW what novice two-year associate degree graduate nurses earn in their first clinical jobs! Prospective faculty can expect to earn between 1/3 and 1/2 less than their counterparts employed in service settings.
BTW – nurses are educated and are not trained. Training apprentice-like programs went out in the 1950s.
Shalala is probably one of the most informed influentials about nursing – as she exhibited during her time on the Dole/Shalala commission which investigated the military healthcare system failures uncovered by the Priest/Hull reportage at Walter Reed. But even then, the crux of the problem wasn’t ever reported: the failure was that inpatient and intensive rehabilitation NURSING is not an offered service by the military healthcare system. The affected patients had been held by the military instead of being medically discharged and transferred to VA or civilian inpatient rehab settings. It was the absence of NURSING and nursing case management of patients was – and still is – at the root of the problem.
But who knew? No one was ever interested in looking at the missing pieces. And because you and your healthcare reporter colleagues don’t know a great deal about nursing and how it’s practiced, you never saw the gaping holes in the picture.
Thanks for your response and interest – it’s appreciated (in spite of my crankiness and complaints otherwise).
Posted 05/09/2008 06:10pm with
The only solution to the health care crisis is the creation of a single-payer, universal health care system in this country. It is the only way to tackle such a huge issue. If Congress tries to do it piecemeal, it will never get done. The California Nurse’s Association are exactly right, and I am a fan of Obama, but I think he should rethink his position. Taiwan recently went to a universal health care system and saved money in the process. As an incentive to get Republicans on board, we should also overhaul Medicare and Medicaid and fold these programs into an American Universal Healthcare System to try to achieve savings there as well.
Posted 06/22/2008 10:01pm with
To institute a single pay system means bucking some massive powers that be with enormous vested interests. Examples: the medical insurance industry, the pharmaceutical industry, not to mention the hospitals and doctors. Just what initial steps does Congress etc. need to take to effect change in this medical system which is controlled by the aforementioned groups? We need a think tank of top people, movers and shakers, to brainstorm this whole issue and come up with and implement solutions and action steps. How could we get such a group established? How could it be funded? Maybe John Edwards could spearhead such a movement. Let’s get it going!
Posted 06/30/2008 12:42am with
HEALTH CARE THROUGH YOUR OWN JOB IS A MUST. or better yet, stop doing drugs, overeating and drinking booze.. You’ll feel better you hypocondraic!
JOHN McCAIN’S 3R ECONOMIC PLAN 2008
Abbreviated version
Progressive Republican Candidate John McCain comes through for America with his 3R economic plan. In the persona of Theodore Roosevelt, McCain’s plan just makes sense.
NUTS AND BOLTS of the plan are simple.
The US needs a separate tax revenue source before it can move away from fossil energy fuels which supply hundreds of billions of dollars in taxes for state and federal agencies.
Here is the John McCain 3R solution.
McCain’s 3R is about technical, closely monitored and rapid hands on training from pros to create new pros. Thousands of currently-job-displaced “once leaders in the manufacturing arena” will be asked to train and play instructor rolls in the 3R plan.
Paid, of course, as these new leaders will help create a whole new style of prosperous America. A massive restructure providing thousands of new American MFG companies means millions of new jobs for infrastructure alone.
1. RETHINK: America must see globally on what America is capable of in our current state of technology, engineering and meet the demands that face the world.
“RE-Think” the basic job goals involve the dwindling retirement, health care and social security plans that are failing Americans. With a strong base and a higher Gross Domestic Product (GDP) America has a new bargaining chip in the way we live and the ways we retire.
Private Sector framework is in place and current laws allow the 3R to happen. The Progressive attitude of John McCain to get things done by crossing party lines will resurrect America.
2. REFORM: The American people must demand higher quality products and less restricted trade routes for Made in USA components. We will lead the way of MFG again!
The USA will reform its dead manufacturing base to create the most innovative and green-engineered products possible. We will compete in a world market along with other high quality products. Our Private Sector teams are making this reality now.
3. REINVENT: America and Americans must reinvent themselves to reach and maintain these standards and by sheer American ingenuity, control the world’s marketplace in the competitive manner, as the USA has always been proud to be #1.
Americans are going back to McCain’s 3R-schooling program where they are paid to reinvent their skills and learn new skills to design and lead their personal LLC, Corporation or joint venture company. That’s easy enough to comprehend and just as easy to implement.
The 3R plan is designed as a six-month rapid advancement system. Graduates may return for additional skill enhancements from time to time, or step up after new advanced training in executive management.
While manufacturing is a very important part of this plan, thousands of other new businesses must to be created to meet the new surge of 3R manufacturing industries to create a new era of prosperous Americans.
Initial estimates of 1 in 5 students will begin his or her own company and drive even more Americans into a viable lifestyle with real jobs, real benefits and a retirement to look forward to.
This 3R plan will be done without costing taxpayers (or the government) additional funds. America has the means to follow through with John McCain’s 3R plan, ready and in place across the USA. The buildings we need sit vacant for the most part. By assuming leases on abandoned stores and factories across America with MC-3R schools and mini-manufacturing training centers, the USA made products can be sold and support the stores. Building owners write off the loss in taxes over a few years if they donate the space!
This is the new place for financial speculators to invest!
The speculators who first drove the economy with mortgage investments and most recently with crude oil investments have a better arena for their investments. America as nation of industrious individuals who want to work and want to succeed will make them huge profits. The supply of eager Americans with ideas and dreams to prosper is limitless.
Although the thousands of new businesses manufacturing USA Made products is exciting enough, the real excitement comes from the massive amount of additional jobs that will be created to provide the new housing, new buildings, new parks, shopping, grocery stores, schools, government outlets and so much more.
McCain’s Progressive nature embodies Theodore Roosevelt more than any US presidential candidate in history since the original Rough Rider blazed the greatest era of growth in America.
We need John McCain to lead our nation with the same type of change.