Health Politics

HEALTH REFORM: Polls Holding Steady Into Thanksgiving Break

Meredith Hughes — Tue, 24 Nov 2009 18:10:00 -0500

The latest Kaiser Health Tracking Poll is in, and the health care reform approval numbers are holding pretty steady. Slightly more people than last month, 54 percent, believe the country will be better off if health reform passes. And 42 percent -- an improvement from earlier this year -- believe that health reform will personally benefit them or their families.

The number who believe health reform will hurt them (24 percent) or the country (27 percent) is down slightly from last month. Roughly the same one-in-four don't think health reform will affect them. Democrats and Independents are more likely than Republicans to view health reform as positive. However, when asked about specific provisions in the health care bills, a majority ranked as "extremely" or "very" important these components of reform: affordable, available health insurance, coverage for people with pre-existing conditions, providing subsidies to help the uninsured purchase coverage, requiring all Americans to have health insurance, filling the Medicare donut hole, and not adding to the U.S. budget deficit.

The Robert Wood Johnson Foundation Health Care Consumer Confidence Index (RWJF Index) found that Americans' confidence in their health insurance coverage and access to care increased in October, from 96.6 in September to 104.4 points.

The Kaiser tracking poll also asked Americans about health reform financing options, including a tax on high income earners, or a "Cadillac tax" on high value health plans. A near majority of Americans, 47 percent, strongly favor the tax increase for high income individuals and families (like the one found in the House bill), while 29 percent strongly support the Cadillac tax.

The poll also revealed the ongoing problems Americans face in accessing affordable care during economic hard times. In the past year, a majority of Americans (53 percent) reported putting off care because of cost. According to the RWJF index, 20.6 percent of Americans reported difficulty in paying their health care bills.

For more detailed analysis of what polling data means for health reform, check out our earlier posts.

HEALTH POLITICS: Senate Dems Not Giving Up On A Bipartisan Bill

Meredith Hughes — Mon, 23 Nov 2009 20:33:00 -0500

Maine's Republican Senators Susan Collins and Olympia Snowe both voted with fellow Republicans Saturday against the Democratic bid to bring health reform legislation to the Senate floor. Yet both are moderates who have broken with their party in the past, and both have signaled they would consider voting for the health bill -- if Democrats change it enough, reports The New York Times. Collins told the Times,

I have ruled out voting for this bill, but I still very much want to vote for a bill and that is why I am continuing to have discussions. I still cling to the belief that it is possible for a group of us to come together and rewrite the bill in a way that would cause it to have greater support.

Everyone was pretty excited when Senator Snowe decided to vote for Senate Finance chairman Max Baucus's version of a health care reform bill. Yet at the time, Senator Snowe warned her colleagues loudly and clearly that her vote to get that bill out of committee didn't assure her vote on final passage.

Since then, several moderate Senators expressed similar sentiments -- Ben Nelson (D-NE), Mary Landrieu (D-LA), Blanche Lincoln (D-AR), and Joe Lieberman (I-CT) voted to move ahead with debate but have made it quite clear they aren't entirely happy with the bill. Like Lieberman, Snowe is concerned about including the much debated public option. Collins worries the Senate bill does not go far enough in lowering health care costs and providing coverage.

In their remarks on the Senate floor this past weekend, neither Snowe nor Collins endorsed the bill, but they did not engage in the same line of anti-health reform attacks as other Republicans. According to the Times,

Both senators have talked privately with Democrats and independents about devising joint amendments on areas like cost control, and both said they would keep seeking compromises. Ms. Snowe said that would "be a true test of whether there is a will to improve this legislation in a non-ideological, bipartisan manner.

In the race to get to 60 votes on the Senate floor, every vote counts. With just a few moderate Democrats (and Independents) on the fence about health reform legislation, Senate Majority Leader Harry Reid might really need the support of moderate Republicans like Snowe and Collins to get final bill passed. Reid told the Times he isn't giving up on a bipartisan bill,

We reach out to our Republican colleagues, and we would like to work with them. But everyone should understand we're going to do a bill. We hope that we don't have to do it with Democrats, but if we have to, we will.

HEALTH POLITICS: Money, Money, Money, Money

Joanne Kenen — Mon, 23 Nov 2009 18:31:00 -0500

The Washington Post ran an interesting chart about how senators voted on Saturday. It included the uninsurance rate back home, and the health industry contributions they have received (although it wasn't clear either there, or on OpenSecrets.org exactly how this particular chart defines the health industry -- and of course some sectors of the health industry favor reform). But no matter how you look at the relationships between the votes and those numbers, it did come down -- no surprise, unfortunately -- to a party line vote.

USA Today also has a piece on the massive amount of lobbying money being spent on the health care battle. It seems that just about everybody has hired a lobbyist, and the total cost exceeded $422 million during the first nine months of 2009. The paper also has a useful run down of what four provider groups (doctors, hospitals, drug companies and insurers) and four health insurance purchasers or consumers (employers, the insured, seniors, and the uninsured) stand to win and lose under current versions of the legislation.

HEALTH REFORM: One Hurdle Down, Many More To Go

Joanne Kenen — Mon, 23 Nov 2009 13:48:00 -0500

"A Motion to Invoke Cloture on the Motion to Proceed" seems like a pretty obscure way to start the Thanksgiving holiday festivities, but we'll take our victories where we can get them.

We all know the obstacles remaining -- from a (abortion) to z ( we couldn't think of a really great Z on Monday morning -- Xanax only sounds like a Z. For now we'll settle for Zocor as a placeholder for more fights on pharmaceutical pricing). But a supermajority of the United States Senate has agreed to begin the historic debate on health care reform after the holidays. And that's an achievement which gets us closer to another achievement.

We're not going to rehash everything in the weekend papers, because we expect that a ridiculous proportion of our readers were either watching the vote on C-Span or at least tracking it on their Blackberries. But a few good links to point you to:

At the Treatment, Harold Pollack writes on the absurdity of listening to Republicans complain that the Democratic health care bill is too skimpy in its help for the poor.

One says that the program is too stingy. He recounts a heartrending tale of seriously-ill Texas children going without needed care because pediatric specialists would not take low Medicaid reimbursement rates. Another notes disparities in neonatal mortality between Medicaid and private insurance patients. "Care delayed is care denied," he intoned to great effect. A third laments that poor people will be consigned to the "medical Gulag" of Medicaid. A fourth suggests that the only reason poor people are made eligible for Medicaid rather than for private coverage is to make the CBO numbers look better.

Maybe not quite Dada-esque, and unfortunately the bottom line is too serious for Monty Python.

At the Boston Globe, Lisa Wangsness has a reasonably upbeat assessment of the changes of compromise on the public option. It's obviously still a big hurdle, but as Ohio Democrat Sherrod Brown noted, there is a lot of support in the Democratic party -- and in the country as a whole -- for inclusion of some form of a public option.

At the Health Affairs blog, law professor Tim Jost has several posts giving a good strong summary of what the Senate bill does and doesn't do.

A lot of ink over the weekend on Blanche Lincoln. This piece from the LA Times offers a good look at what Lincoln is facing back home a year before she faces the voters for re-election. The Washington Post's Dana Milbank also weighed in, noting that the Senate debate had a bit of Southern Gothic/Tennessee Williams flavor to it... down to a leading role played by a Southern woman named Blanche...

HEALTH POLITICS: Everybody's Working For The Weekend

Meredith Hughes — Fri, 20 Nov 2009 18:28:00 -0500

Or, at least, the Senate will be working this weekend. The Senate plans a rare Saturday night vote on a motion to proceed with Senate Majority Leader Harry Reid's $848 billion health care reform bill, released earlier this week. The pressure is on for Senate Democrats, who need 60 votes to ensure the bill makes it to the floor to begin debate.

Reid melded the Senate Finance and HELP committee's reform bills, but his "deep personal involvement in assembling the overhaul of the health care system," makes it "Reid's bill," writes Carl Hulse in The New York Times. If Reid successfully guides the health care reform bill through the Senate, it could be the biggest victory his career, and a huge boon for Obama and the Democratic Party, writes Hulse, but if he fails, it could mean disaster for the Democrats and an even tougher re-election battle for Reid in his home state of Nevada. Many Democrats expressed faith in Reid's skills as a legislator and a tactician, according to the Times,

Colleagues say Mr. Reid's extensive knowledge of Senate tactics and well-honed understanding of what drives and divides his Democratic colleagues leave him well positioned to pull off a legislative coup that has eluded seasoned and determined lawmakers for decades.

"I don't think there are many people in the whole world other than Harry Reid who could do this," said Senator Mary L. Landrieu, Democrat of Louisiana.

Landrieu however is one of three Democratic centrists who Reid is still wooing, along with Ben Nelson (D-NE) and Blanche Lincoln (D-AR). Moderates cite concerns about the cost to states and the abortion language. Nelson has now said he will vote with Reid on the first procedural motion. Lincoln told Reid her plans, but hasn't made them public. But as CongressDaily noted,

...the fact that Democrats aren't backing away from the weekend vote suggests that Lincoln has accepted the argument from leaders that Democrats should vote to move the bill, even if they oppose it and might vote against it in the end.

As we've mentioned before, Senator Joe Lieberman (I-CT) has threatened to block the final bill if it contains a public health insurance option. But for now he's agreed to vote with Democrats to get the debate started.

Reid even struck up a compromise of sorts with Republican opponents. According to Politico, Republicans agreed not to read the 2,074 page health reform bill out loud in its entirety. Instead, Reid offered them a full day of debate on Saturday before the evening vote. That means that everyone (even us!) gets a chance to head home for Thanksgiving.

Earlier this week, top Democratic strategists, such as pollsters Mark Mellman and Geoff Garin, White House communications director Dan Pfeiffer and White House deputy chief of staff Jim Messina, met with Senate Democrats to discuss the importance of health reform, reports TIME. Mellman urged senators to remember they are all in this together. A victory on health reform is important to the American people who are struggling with health care cost and coverage. But it's also important to the president's agenda and the Democratic Party's success in the upcoming midterm elections, said Mellman. Health reform wasn't the only element in the deep and wide Democratic losses following President Clinton's failure to pass health reform in 1994, but it was a big factor.

The battle could get uglier as the health reform bill moves through the Senate, but for now it looks like the Democrats are ready to get started on this debate. Time to make history. Time to make progress.

HEALTH POLITICS: A Fresh Look at Malpractice

Joanne Kenen — Fri, 20 Nov 2009 16:46:00 -0500

Over the past year or so, we began detecting some subtle changes in how Democrats were talking about malpractice. They weren't embracing the Republican tort reform agenda, weren't about to start limiting damages and saying "Sorry Charlie" to people who had suffered heartbreaking harm. But they weren't just changing the subject either. They were recognizing a problem, and considering solutions. Liability problems as well as larger obstacles to addressing serious patient safety problems.

We posted about it a few times (here and here). I started reading more about it, and I started talking (and listening) to what doctors had to say. Not just lobbyists for doctors, but doctors. Including some progressive docs in primary care who favor health reform or a single payer system. I have a piece online in American Prospect today, outlining some alternatives to traditional malpractice lawsuits that are worth trying. (Not to replace the current court system, but to test alternatives. And while we test alternative dispute resolution or other approaches, it should be voluntary.) One of my conclusions was that malpractice is getting in the way of all sorts of other things we need to do to fix our system. Getting in the way politically and economically. And getting in the way of some of the changes we need to make to create a system that is safer, evidence-based, and less wasteful. Some doctors will resist changes to the system -- because change is hard, or change is something that they don't think applies to them, or, for some doctors in some settings, change can sock them in the wallet. Getting the malpractice piece out of the way, or at least minimizing it a bit, may remove the legal smokescreens and let us get to the heart of the change resistance.

The CBO recently did its first estimate on the price of defensive medicine. I left out that figure from this article because it was based quite specifically on potential savings from Republican legislation ($11 billion a year). I don't think there is an agreed upon overall estimate that defensive medicine in the current system costs -- to federal health programs, the privately-insured, the doctors. But for readers who want a summary of some of the recent literature on this, Factcheck.org has a good wrap.

The approaches I mentioned -- health courts, "disclose and apologize" and certificates of merit -- aren't the only ideas floating around. As we do more comparative effectiveness research, and learn more about what doctors should be doing and why or why not, we may be able to weave more "safe harbors" into the legal system. Right now, as all the current confusion about prostate screenings and mammograms illustrates, we still have a lot of trouble agreeing on and comprehending best practices.

In the near future, we're going to post a bit more on patient safety (which we wrote about the other day) and have a bit more to say on the AMA's evolving views on malpractice and health reform. For now, we're going back to watching the Senate....

QUALITY: Dying Well Beats Dying Badly. And Expensively

Joanne Kenen — Fri, 20 Nov 2009 14:01:00 -0500

As we've written a lot on end of life care, we notice when others do the same. NPR's Joseph Shapiro this week reported on La Crosse, WI where 96 percent of the adults who die have an advanced directive. That extraordinarily high figure arises from the innovations and commitment from Gundersen Lutheran hospital. Careful, sensitive discussions by trained doctors and nurses -- they use a 12 page guide -- is time consuming. Medicare doesn't reimburse them for that time, A provision in the House health care bill would change that -- the provision that was caricaturized as a "death panel." The Senate bill doesn't contain it.

Shapiro's thoughtful piece shows many aspects of end of life decision-making, but one element we liked in particular was that it shows these decisions are not static. People can reflect, and can change. That's the beauty of advanced directives or advanced care planning. Joe Hauser, one of the patients profiled in the NPR piece, initially declined dialysis for his failing kidneys. His wife Janice begged him to reconsider. So he gathered more information and spoke to a nurse. He and his wife were trying to decide whether to visit a dialysis center, and a support group. He learned that if he tried dialysis, he would always have the option of stopping. When Shapiro last spoke to him, Hauser was still leaning against dialysis. But he wasn't sure:

There's a surprise. He extends his left arm across the kitchen table. He wants to show what he calls his "buzzer." It's a spot at his wrist where you can feel the vibration from an artery and a vein that a surgeon has joined together.

It turns out that Joe Hauser's decided to be ready, if he changes his mind. And if he decides he wants dialysis, then the needle of the dialysis machine can slip right in to that spot -- the fistula -- that the surgeon has prepared at his wrist.

We should point out that the Washington Post.'s Alec MacGillis also had a fine story about LaCrosse earlier this fall. Don't think we linked to it at the time. MacGillis looked at both the economics of end of life care, and some of the local cultural traits of La Crosse. The population is full of people of German or Scandinavian descent who seem to have a pretty pragmatic view of aging and dying. And the local doctors and nurses have a culture, too, that values communicating with patients, and respecting their wishes. People in LaCrosse spend far fewer days in the hospital in their final weeks and months of life than people elsewhere in the country. Not because the Wisconsin community doesn't want to spend the money, but because that's what the people who live there, and die there, choose.

This coming Sunday (Nov 22) 60 Minutes will do a piece on end of life, featuring our occasional guest blogger Dr. Ira Byock (read his posts here and here). The short preview on the CBS website focuses a lot on costs; we suspect the televised segment will tell a moving story about quality of care, and patient choice. Because we too have accompanied Dr. Byock in that ICU, and sat in on his team meetings, and we know that quality -- and care -- is what motivates them.

One last relevant link -- Oregon Democrat Rep. Earl Blumenauer, who authored the House provision on end of life conversations, wrote an op-ed in the New York Times this week, describing how a measure that had long and deep bipartisan roots turned into political poison: "The battle lines were being drawn. Little did I know how deep the trenches would be dug, nor how truth would be one of the first, and most obvious, casualties." Live and learn.

COST: The Price is Right for Health Reform

Paul Testa — Thu, 19 Nov 2009 18:50:00 -0500

After weeks of anticipation and speculation, Senate Majority Leader Harry Reid has unveiled the legislation that will bring health reform to the Senate floor in the coming weeks.

While waiting for the details of the bill to come out Wednesday, we created a little office pool, called the Price is Right for Health Reform. In an office-wide email, we asked our peers to guess the CBO's estimates of the gross costs of the bill. Showcase Showdown rules (closest without going over) applied. We were intentionally vague in our question because estimating the true costs of the bill is inherently a difficult process.

The number we were looking for was $848 billion. The CBO's estimate of the gross cost of the bill is essentially the total cost of coverage provisions over the next 10-years. This is the number most frequently reported in the media as the "cost" of the various health reform bills being discussed. But is this really the best indicator of the true costs of health reform? Maybe not. First, timing matters: $848 billion over ten years is a lot different than a $787 stimulus bill where 90 percent of the money is spent within the first 3 years. So do deficits. How much does a bill cost if it's fully paid for and in fact reduces the deficit as is the case for both the House ($109 billion) and Senate ($130 billion) bills?

We received plenty of calls from our co-workers asking just these questions. We tried to stay quiet, because we were interested in what the educated, non-health policy wonks think about the cost of reform. True to our think tank's "post-partisan roots" we got a range of answers from "too little" to "$600 trillion, Obama lies." We got a couple of "$1" which we assume was a reference to the bill's deficit neutrality, and $90 billion which seems like a reasonable estimate of yearly costs. But the majority of the answers clustered within the $800-$900 billion range, surprisingly close to the final answer. Few people seemed willing to go above $900 billion, suggesting the power of the official price tag President Obama put on reform during his September address to a Joint Session of Congress. So who won? The answer after this non-commercial break:

Marc Goldwein, the Policy Director, Committee for a Responsible Federal Budget and Policy, took home the prize for his guess of $845 billion. Lisa Guernsey, the Director, Early Education Initiative, came agonizingly close with pick of $850 billion. New America's President Steve Coll, was the next closest with a prediction of $837 billion.

Marc's prize potentially includes a Dodge Neon from 1996, a natural wood-like dinette set from 1982, or more likely a beer and some wings from the re-opened Black Rooster Pub (take that Peace Corps!). We suspect he'll also want us to plug the excellent work he and his colleagues do on all things budget. Congratulations Marc. Help control the pet population. Have your pets spayed or neutered.

As a side bet, we also asked contestants to name which current Senator looks most like Bob Barker. What do you think?

HEALTH POLITICS: Steady as She Polls

Paul Testa — Wed, 18 Nov 2009 14:13:00 -0500

If polling on health reform were a band, we'd call it The Hold Steady.

Several new surveys out this week show the public remains as conflicted as ever on health reform -- convinced of the need for change, but worried about the impact on their lives and the lives of their family.

A Washington Post-ABC News poll released Tuesday shows 48 percent of those surveyed supported the proposed reforms; 49 percent opposed them. An AP poll released Monday found a similar split, with 41 percent in favor; 43 percent opposed and 15 percent undecided.

These even divides are consistent with past polls, suggesting that the uproar in August was more of a bump in the road than turning point. However beneath the topline questions are some interesting trends.

First, as the Washington Post points out, while public approval of President Obama's handling of health reform has declined he still holds a double digit lead over Republicans. Possibly more importantly, support for reform among seniors -- the group most critical of current proposals -- is up 13 percent from September, suggesting that some of most offensive scare tactics directed at seniors, such as death panels and socialized medicine, may be losing their edge.

As we've noted before, support for the major policies of health reform legislation remain generally strong. But the answers to these questions often depend on how the question is framed. In the AP poll 67 percent favor requiring all Americans to have some form of insurance, but 64 percent opposed a law that "would require every person to have health insurance and pay money to the government as a penalty if they did not, unless the person is very poor." The fluidity of such answers reinforces the points made by Robert Blendon in a recent column for Kaiser Health News:

[P]olls show countervailing concerns about the congressional plans. These involve the potential impact of the bills on Americans' health costs and affordability, their taxes, the extent of government interference in their health care decisions, and worries that health care for those receiving Medicare will deteriorate. Regardless of public enthusiasm for health reform as a principle, and support for many policy elements in the House bill itself, most Americans do not see their healthcare situation as getting better if this legislation is signed into law, and some see their situation as getting worse.

In the weeks ahead, Americans are unlikely to read the 2000-page House bill. Rather, they will form their judgment about the final legislation based on others' assessments. They will rely on those whom they trust as intermediaries to clarify its impact on them.

That impact is unclear as the Senate stages a sort of modern adaption of Samuel Beckett's classic work, with it's current production of "Waiting for CBO." The release of a bill and CBO cost estimate, which could come later Wednesday, should help lessen our existential unease, but the real challenge for proponents of reform will be explaining the bill in a way that makes its benefits clear and its costs worthwhile. The jury of public opinion is still out, but its verdict may come quickly.

HEALTH REFORM: Monday Morning Quarterback

Paul Testa — Mon, 16 Nov 2009 15:44:00 -0500

It's Monday, the day after Sunday, which in America means a surprisingly large number of Americans are talking trash about their fantasy football teams. (Good hustle Ben, but the Cleveland Steamers are on a roll.) So forgive us for the gridiron gab, as we reset the play clock on health reform.

As you know, the passage of H.R. 3962 in the House two Saturdays ago pushed health reform into the red zone and brought us closer to the goal line than we've ever been before. The problem, as the Senate prepares to take the field, is that the goal posts keep getting pushed back. A slow handoff between Senate Majority Leader Harry Reid (D-NV) and the CBO has delayed the bill's release, but Reid seems determined to keep the ball moving. Roll Call's Emily Pierce lays out the potential Democratic gameplan going forward:

The key vote, which Reid plans to call after he receives the CBO score, would be on a motion to limit debate -- or invoke cloture -- on a motion to proceed to the bill. The leadership aide said Reid is working under the presumption that he will have a CBO score "sooner rather than later" this week and that the Senate will be in a position to kick off debate before Members go home for Thanksgiving.

Reid wants to get the cloture vote on the motion to proceed over with before the holiday because he would like to spend all three weeks before Christmas amending and debating the health care bill. If he has to wait until after Thanksgiving to take the vote, the time-consuming procedural hoops he has to jump through could delay the start of the amendment process until the second week of December.

It's an ambitious schedule, one that will require the Nevada-native to channel another Rocky Mountain icon to engineer the final drive on health reform (a drive we're confident the people of Cleveland will actually like). Even without a shortened clock, these kind of things are never easy.

The Reid-option for a state opt-out on the public health insurance plan has some moderates worried, and the Democrats will have trouble keeping all of their members onside when tackling issues of abortion and immigration. Finally, Senate Minority Leader Mitch McConnell (R-KY) has been calling for a delay of game.

Like most armchair announcers, we're not a big fan of this kind of prevent defense, because the only thing it's intended to do is prevent Democrats from winning. But this game is about more than politics, and health reform is one issue our leaders can no longer afford to punt on. There may be a lot of close downs in the coming weeks, but we stand by our predictions: come Super Bowl XLIV, the Chamber of Commerce will have to look for something else to spend its money on.