The Year of Reform

BRIAN KLEPPER

Originally published 12/23/10 on iPractice.

“The search for static security — in the law and elsewhere — is misguided. The fact is security can only be achieved through constant change, adapting old ideas that have outlived their usefulness to current facts.”

William Osler, MD, 1849-1919

Even as the healthcare reform process hit snags, it had a sense of inevitability. For decades, anyone with even a modest understanding of how the current system worked could only conclude that it was too costly, delivered too little value, was fragmented in ways that often thwart quality and safety, and was an inordinate burden on the rest of the economy. It was, in a word, unsustainable.

So the question was not whether change would come or not, but what forms it would take. And, of course, against this backdrop was the nagging worry, at least for doctors, that it would mean a further erosion of position: more intrusion and less say.

Perhaps it isn’t the practice of medicine, per se, that has become so challenging, but the environment of practice. The system can be complex, adversarial, and bureaucratic, wringing away the pleasure of caring well for patients.

A Special Issue of Health Wonk Review - American Health Care Reform: Voices of Health Care Analysts

Here we are, with the first edition of Health Wonk Review (HWR) in a new decade. It is a pregnant moment, as reconciliation begins between the House and Senate health care reform bills, when the best health wonks are weighing in on how we arrived here and what it will probably mean to have a few key successes and some very significant failures at a time when most everyone in the country who doesn’t have power yearns for real solutions. 

Will Republicans Be Spoilers or Problem-Solvers on Health Care Reform

BRIAN KLEPPER and DAVID C. KIBBE

In theory Congress' return from recess next week could offer a new beginning to the health care reform process, giving everyone a chance to take a deep breath and recalibrate the components of change.

Nine months into the wrangling around a new Administration, the talk-show right has seemingly hijacked the discussion on health care, Democrats' signature issue, with the standard tools that demagogues have always used: leveraging popular prejudices with oversimplification, hyperbole, and distortion. The die-hard GOP faithful's leaders - Gingrich, Palin and others (see this off-the-deep-end speech by Rep. Mike Rogers (R-Mich)) - are of course playing spoilers, independent of the cost. They hope to goad centrist voters into abandoning the Democrats so they can retake power. Witness South Carolina Republican Jim DeMint's comment, "If we're able to defeat Obama on this, it will be his Waterloo. It will break him."

Families USA Health Action 2008: An Alternative Plan

Families USA is an impressive organization that has built a formidable platform over the year through its base, consumers. But to achieve the reforms it advocates for, it must leverage that platform with the one group that has enough strength and motive to bring meaningful reforms to fruition: large employers.

A wonderful meeting (Full disclosure: They brought me in to blog my impressions.), The Families USA conference that ended Saturday brought together some impressive Congressional politicians - Nancy Pelosi, Tom Daschle, Ken Salazar, Blanche Lincoln - and true health care experts - Don Berwick, Tony Fauci - with "consumer advocates" from around the country.

I thoroughly enjoyed the people at the conference. They were, for the most part, knowledgeable about health care and committed to driving a better system. (My favorites were a group of California Gray Panthers, all of whom were VERY up on the issues). There were also bright young people relatively early in their careers, and representatives from community health advocacy organizations around the country, all fervently dedicated to a better, more equitable health system.

My concern was that I believe this group under-appreciates the influence of health care lobbies over Congress and the policy process. They WANT things to change for the better, and they advocate for approaches they KNOW are more logical and reasonable than the way health care is currently done. So why WOULDN'T we do it that way?

The answer, of course, is because it would damage Congress' largest contributors. Almost every politician I heard speak patronized this crowd, making a point to tell them that their input was vital. Would that it were so. If it were, Congress wouldn't take the money it does from health care interests throughout the continuum, and shape policy for their benefit rather than ours. And, please note, the lobbying rules didn't change substantially when the Democrats retook control.

Families USA's leader is a warm, brilliant, articulate guy (and great dancer!) named Ron Pollack, who has guided this organization for years and made it into the health care consumer advocacy powerhouse it is today. He has a clear, unifying, noble vision for how American health care ought to be delivered and financed, evidenced by the caliber of speakers who agreed to talk at this conference.

Unfortunately I don't believe we can get there by relying on consumer advocates. Ardent and well-intentioned as they may be, they lack a power base, and simply cannot compete with large corporations for the attentions of Congress. I hope I'm wrong about this, but this is why I doubt that meaningful reform will take place after the elections. Even if we get a President who is disposed to real change, getting there will require that Congress go along, and they're beholden to the health care industry.

Families USA has built a formidable platform. There's no reason why, quietly, discretely, this group couldn't reach out to certain non-health care business leaders and groups, explain how their interests align with those of non-HC business - we all seek a more stable and sustainable health system that allows the nation to be healthier and more economically competitive - and facilitate a new coalition that could overwhelm the power wielded by the health care sector. After all, they're 1/7th of the economy. Non-Health Care business is 6/7ths.

They're just looking for someone with a compelling reason and a plan to come together, and help us all resolve this issue so we can get on with other equally pressing matters that face the nation.

Families USA Health Action 2008: Tom Daschle on Reform

Former Senator and Majority/Minority Leader Daschle gave the opening address on the 2nd day of the Families USA Health Action conference. Mr. Daschle has a new book coming out in March on America's health system and our past efforts to fix it.


I was honestly impressed with Mr. Daschle's grasp of the sweep of health care problems and how they play out. Mostly importantly, he was clearly aware of the deep challenges associated with getting meaningful change, given the industry's control of Congress and the policy-making process.

"One of the biggest tactical mistakes we've made, the opponents of health reform have defined the debate. As a result, we've lived under a number of myths. Perhaps the biggest myth of all is that the US has the best health system in the world. So before the debate can begin, we need to all understand the same basic facts. We need to understand how we got here and where we need to go."

"Incremental change in our system is no longer a viable option. Instead we need comprehensive reform. In growing numbers the American people are demanding that we do something. Our goal should be to build what current and retired members of Congress have today, and make that available for all Americans."

Here are some elements of his platform.

- Establish an autonomous oversight body for health care comparable to the Federal Reserve for our monetary sector. We need to give this group the ability to control costs, starting with chronic disease, which represents the largest block of costs to the system.

- Investments in information technology would result in quantum leaps in efficiencies and quality improvements.

- Pooling would aggregate the risks/costs for small business and individuals.
- Negotiate drug pricing. Build on and leverage the purchasing volumes that government already  is responsible for.

- Prevention. Wellness, easy access and early intervention clearly saves enormous dollars.

- Comparative Effectiveness. As the Congressional Budget Office and Institute of Medicine have recently pointed out, an autonomous national institute that could use large data sets to identify the approaches that work best would clarify and unify clinical practice throughout America, and would have significant impact on both quality and cost.
- Transparency. We cannot fix our problems until we can see them more clearly.

- Medical Malpractice. Make it easier for physicians to make the best decisions, and protect them from frivolous legal actions.

- Patient-provider interactions. Take advantage of technology to smooth the flow of communications between patients and the health system.

- Universal Coverage. Increase access through health vouchers and coverage.

This is a much more thorough list than Ms. Pelosi offered, and Mr. Daschle seemed more aware of, sensitive to and committed to the political challenges represented by the relationship between Congress and health care special interests. While none of his recommendations are novel or particularly surprising, there is no question that Mr. Daschle's experience, access to governmental and business power, and clarity about what needs to be done represent important potential in the ongoing effort to actually get real change accomplished

Families USA Health Action 2008: Nancy Pelosi's Opening Address

The featured highlight address at the opening session of the Families USA conference is by Nancy Pelosi, Congress' first woman Speaker. In person, Speaker Pelosi clearly comes across as a brilliant and warm woman, a friend of Families USA, and she was introduced as a champion of social justice and equality in the 110th (2007) Congress, passing the first minimum wage increase in a decade and making college more affordable for working families. While I'm not certain this is true, I heard comments beforehand that this speech was slated as a major health care policy statement by the Speaker.

On Practical Reforms

Now that health care reform is once again an active, visible issue in state governments and the presidential campaigns, the ideas are flying fast and furious. Predictably, some ideas are better than others.