Lessons of 93

HEALTH POLITICS: Bob Dole: Better Late Than Never Brigade In the Nick of Time

Joanne Kenen — Thu, 08 Oct 2009 20:52:00 -0400

In 1993-94, then Senate Minority Leader Bob Dole, a Kansas Republican who had presidential ambitions and a hankering to regain his position as Senate Majority Leader, helped kill President Bill Clinton's health reform initiative.

Fifteen years leader, he regrets letting politics trump policy, and he is urging fellow Republicans not to repeat his mistake.

"I want this to pass," he said. "I don't agree with everything Obama is presenting, but we've got to do something." He added that he expected to see a Rose Garden signing ceremony within months.

Dole joins a lengthening parade of prominent Republicans, including Bill Frist, in endorsing health reform. (They may not change many minds in a polarized Congress, but might be a help to centrists in both parties. Having Frist and Dole on board would make it easier for someone like Republican Olympia Snowe to vote yes... and harder for a moderate Democrat like Ben Nelson to vote no.)

Looking back at 1993-94, Dole blamed himself, Hillary Clinton and politics for the failure.

"Politics took over," he said. "And you (the public) lost."

There's also been a bit of back and forth in the press with Dole saying that the current Senate Minority Leader Mitch McConnell told him not to publicly support health reform. A McConnell spokesman denied it.

Dole has been working on bipartisan health reform with other former Senate leaders. He and Tom Daschle released a statement this week acknowledging that the various reform bills in Congress are flawed but "provide some basis on which Congress can move forward."

"The American people have waited decades and if this moment passes us by, it may be decades more before there is another opportunity," they said.

HEALTH POLITICS: Harry and Louise Are Back (Again)!

Meredith Hughes — Thu, 16 Jul 2009 21:42:00 -0400

Harry and Louise are back! And, as we've mentioned before, they're pro-reform this time.

Families USA and PhRMA recently announced a team up for a $4 million ad buy, so prepare for Harry and Louise to come back on the air in a big way.

As you may recall, Harry and Louise were the face of the anti-reform movement when Bill Clinton attempted to reform the health care system in the early nineties. During their time in the national spotlight in 1994, they were a focal point for the public fear that health reform would hurt, rather than help, the American people. The original Harry and Louise ads featured a middle class couple sitting at their kitchen table, discussing their fears that "Sometime In The Future," faceless government bureaucrats were going to take away their health care choices. "Having choices we don't like is not choice at all," Louise lamented.

In February of this year, before health reform lit up the national agenda, Kaiser Health Tracking Polls show that Americans had the same worries -- health care reform will help others, but it probably won't help me. With more and more policy specifics for health reform legislation coming out everyday, President Obama has promised the American people that there are benefits in there for them. Successful health care reform will help everyone, by guaranteeing lower costs, higher quality, and better access to care.

In 2008, they returned during the presidential election, this time lamenting the high costs of health care and the problems with consistency of health coverage for all Americans. They sent the message that health care reform is an urgent necessity, rather than a danger. Louise advised the candidates, "whoever the president is, health care should be at the top of his agenda. Bring everyone to the table, and make it happen."

This statement has proven oddly prophetic. Right now, health care is President Obama's top legislative priority, and he certainly has brought a lot of people to the table -- including, most recently, the AMA. They endorsed the House's health care bill earlier this week.

And now they're back again, this time calling for quality, affordable health care coverage that won't be denied to those with pre-existing conditions or disappear when Americans change or lose their jobs. You can view the ad here or below (or on your TV Sometime In The Future).

The original Harry and Louise ads set up an unhappy choice for the American people -- keep the coverage you have now, or face the unknown (and by implication awful) consequences of health care reform. But now we know the consequences of not reforming the health care system are far worse than any "unknown." And we do know what reform means, because we've seen it in action in high-performing health systems all across the United States. It means lower costs for everyone, and better quality care.

Harry and Louise have proven to be a surprisingly good barometer for the state of health care reform in the U.S., so it's nice to hear Harry say "this time, we might finally get health care reform."

We're right there with you, Harry.

COVERAGE: A Context for the New Uninsured Estimates

Joanne Kenen — Wed, 20 Aug 2008 12:55:00 -0400

Next week the U.S. Census Bureau will release its updated estimate of the number of uninsured people—now officially at 47 million. David Colby at the Robert Wood Johnson Foundation helpfully assembled some accessible foundation-backed papers and issue briefs on who the uninsured are, what being uninsured means, what the federal environment for change looks like now, and how the states have or have not stepped up. Here's the link to the series "The State of Research on the Uninsured: Putting Census Estimates in Perspective" and we're providing a few of the summaries and abstracts below. We'll post a similar brief guide to some of our own issue briefs and papers on the uninsured before the Census numbers come out.

I personally found the ER paper particularly informative when it came out a few months ago, and my colleague Dr. Guy Clifton has blogged about this topic several times (and explained to me aspects of the ER crisis that I had not previously understood). It's not just the uninsured crowding our ERs, it's everybody. Patients who can't get timely access to primary care, patients who cant' get after-hours routine care if they get sick (or if their physician didn't make time for them during the regular work day), patients whose chronic diseases are not properly controlled so they end up in crisis, or whose pain is not treated well—the list goes on and on. The uninsured, of course, are a big chunk of it, probably about 15 percent of ER visits, and of course as the overall number of uninsured people grows, that means more volume in the ER. The ER is one way of measuring the distress of our health care system, and it's definitely in distress.

Defining the Problem and Potential Solutions

Falling Behind: Americans' Access to Medical Care Deteriorates, 2003-2007
Between 2003 and 2007, the number and proportion of Americans reporting going without or delaying needed medical care increased sharply, according to findings from the Center for Studying Health System Change's nationally representative 2007 Health Tracking Household Survey. People reporting access problems increasingly cited cost as an obstacle to needed care, along with rising rates of health plan and health system barriers.

Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States?
The authors analyzed emergency department (ED) visits in the United States to learn whether the rise in ED use could be attributed to uninsured individuals. They conclude that the documented rise in ED visits between 1996 and 2004 cannot be primarily attributed to the uninsured. Instead, major contributors to the rise in number of visits are increased visits by non-poor people and people with other regular sources of care.

Health Insurance Coverage of Young Adults
This Urban Institute analysis looks at why young adults are disproportionately uninsured and what policies could address their coverage gaps. While conventional wisdom suggests that these largely healthy young adults reject coverage because of their youth and vitality, the facts tell a more complicated tale. Large numbers of young adults do not work full time and are not full-time students, leaving them without their own employer-sponsored insurance—or their parents'—and without the income to afford private market coverage.

Knowing What Works in Health Care
Despite unprecedented advances in biomedical knowledge and the highest per capita health care expenditures in the world, the quality and outcomes of health care for Americans vary dramatically across the country. Improved knowledge about which treatments and procedures are effective could lead to less regional differences, stronger consensus on standards and guidelines, and lower costs.

To this end, the Robert Wood Johnson Foundation asked the Institute of Medicine to convene a committee to recommend methods to better identify the most effective health care services. This resultant report provides a blueprint for a national clinical effective assessment program. One of the committee's key recommendations is that the U.S. Department of Health and Human Services create a single entity (the Program) with the authority, resources and capacity to: (1) set priorities for evidence assessment; (2) assess evidence (systematic review); and (3) develop or endorse standards for evidence-based clinical practice guidelines.

The central premise underlying the report is that decisions about the care of individual patients should be based on the current best evidence available, and that having a single body charged with evaluating and sorting information will help to clarify for physicians, health care providers, and patients which evidence is valid.

Igniting Health Care Payment Reform
Health care costs, which are driven by payments to hospitals, physicians and other health care providers, have been steadily increasing across time. The PROMETHEUS Payment® approach is an attempt to address the rise in health care costs while maintaining high quality patient-centered care by developing a new approach to pay for health care services.

PROMETHEUS aims to promote value and quality in health care, decrease the administrative work of providers, and offer reasonable compensation to providers given scientifically—determined treatment for patients with specific conditions.

How Far Can States Take Health Reform?
Expectations for state leadership in health reform have never been higher. States are thought to function as "laboratories of democracy," but they do not fulfill this role effectively because insufficient attention is paid to experimentation and knowledge translation. Congressional proposals to encourage state action cover too narrow a span of state health policy, do not provide states with sufficient authority to tackle major health policy challenges, and supply insufficient funding. This paper concludes with a description of a more robust state-federal partnership that would be more likely to yield substantial health reform.

State Health Access Profile: A Chartbook of Health Care Access Indicators for States
Who is insured? What percentage of employers in a state offer health insurance? Who could get medical care if they needed it? The State Health Access Profile answers those questions, and many more, on a state-by-state basis. The chartbook is published annually by the University of Minnesota's State Health Access Data Assistance Center (SHADAC), with support from RWJF.

POLITICS: Sometimes Health Reform Bills Do Pass...

Joanne Kenen — Tue, 13 May 2008 13:51:00 -0400

We've all done a lot of looking back to the lessons of 1993-94, and the long list of reasons the highly complex, ill-timed and politically-polarizing Clinton health care plan failed. But today the journal Health Affairs published an essay looking back not just at the failures of the Clinton plan but at the successful passage of two major health reform initiatives--the truly bipartisan State Children's Health Insurance Program (SCHIP) and the Medicare Modernization Act, which added prescription drug coverage for seniors.

The article, written by New America's Len Nichols, and Hill veterans Elizabeth Fowler and Christine Ferguson, acknowledges that the drug law remains controversial--a lot of Democrats don't like the basic structure of the drug benefit, and parties are still fighting about payments and changes the law makes to the overall Medicare program. But enough Democrats did back the legislation to see it enacted (barely), and some of them today acknowledge that even if it isn't the bill they would have written, even if they want to change some of it, it is helping seniors get their medication. The authors cite several reasons for its passage. Among them: President Bush took a hands-off approach to the details, letting Congress do its job of legislating. Republican Congressional leaders enforced party discipline so they held together to pass legislation that would help them politically. And, in the several years that lawmakers worked on the issue the two parties' models for delivering the drug benefit evolved to have at least some common ground.

The children's health program has been widely perceived as a bipartisan success from the outset. Clinton backed it, but Congress led the initiatve from the start. "The episode illustrates exemplary congressional leadership, a lack of partisanship, and a president leaving details to Congress while championing the basic goal and message of expanding coverage for low-income children."

Not so, however, for the second chapter of SCHIP, last year's reauthorization battle and Bush's veto. In that case, Bush rejected a bipartisan Congressional initiative and Republicans split among themselves, with the more conservative ones winning the day.

The authors conclude with three lessons (or wishes?) for next year.

Make health reform the top priority.
Be leaders, not partisans.
Develop a broad consensus, but leave the details to Congress.

Hope the folks on both ends of Pennsylvania Avenue next year, whoever they may be, are listening.

POLITICS: But Will Voters Still Love Health Policy Reform in the Morning?

Joanne Kenen — Mon, 12 May 2008 19:24:00 -0400

We hear lots of talk about health care reform and the presidential campaign, and certainly it registers in the polls. But is it resonating enough to make a difference in November—and will the next president, whoever that is, put the issue front and center if voters don't demand it?

As John Whitesides of Reuters wrote the other day:

"The sharply contrasting health care visions of Republican John McCain and his Democratic presidential rivals offer the promise of a grand campaign debate—if the candidates find room on a crowded agenda.

While health care reform ranks as the second-biggest domestic issue after the economy in most national opinion polls, it will compete with the Iraq war, taxes, high gas prices, and other topics for a prime-time spot in the campaign."

The history of public opinion and health care reform is worth recalling. It's only a slight oversimplification to say that "the public" identifies problems in the health system and demands change in the abstract. But then after hearing politicians argue about reform proposals for months, and being bombarded with critiques from interest groups, the public can end up quite change-averse. That support for abstract ideas about change becomes fear or opposition to concrete proposals. And the public tends to worry more about what health insurance means to them—can they afford it, can they count on it—than what it means to society as a whole and the uninsured. As Mollyann Brodie, the Kaiser Family Foundation's public opinion expert, told a gathering of health policy veterans recently (a few slides from her presentation below):

Goals are easy to agree upon
Solutions are hard
Change is scary

Health care is further complicated because people hold rather contradictory views—they don't trust government meddling in their heath care, but they want government to fix it. With a free lunch on the side. As Larry Jacobsen, a political scientist who studies health politics at the University of Minnesota and its Humphrey Institute of Public Affairs wrote recently in the New England Journal of Medicine:

"Health care reform efforts have been undermined not only by Americans' ambivalence toward government but also by the split between public dissatisfaction with the overall system's performance and patients' satisfaction with personal health care. Whereas more than 70% of Americans are quite negative about the country's coverage and costs, less than 40% are disappointed with their own circumstances. A mere 15% complain about the quality of care they receive."

All this suggests that public is more likely to follow if leaders have some kind of consensus among themselves on where to lead. Heated, divisive, partisan debates about complex topics tend to push voters back into a cocoon of the status quo. Only the status quo doesn't really exist anymore. Our system is hurt, and inaction will only make it worse.

Of course heated presidential campaigns aren't the best venue for working out consensus on complex social and economic policy. But on the morning after November 4th, we'd like to see the next president, whover that may be, articulating a vision and starting to build the coalitions that will give Americans the health care they need and deserve.

POLITICS: Daschle Promotes "Health Board" for Saner System

Joanne Kenen — Wed, 05 Mar 2008 19:40:00 -0500

We caught Tom Daschle, the former Senate Majority Leader and newly-minted health wonk, discussing his new book "Critical" today. We were delighted to hear him take issue with the too-common refrain that "America has the best health care in the world." Politicians in both parties say that, and it was an effective slogan against the Clinton health care reform in the early 1990s. It drives us nuts. Yes, we have great doctors and great research and great medical schools and great technology but no, we don't have the best health care in the world available on a consistent basis to all Americans. Daschle's phrase was that we have "islands of excellence in a sea of mediocrity." Like Daschle, we believe that any initiative to expand coverage also requires us to acknowledge our quality gaps and address spending that doesn't buy value.

Daschle, as you may have heard, favors creation of a Federal Health Board, which is loosely to the medical world what the Federal Reserve Board is to the monetary world. It would not "ration" care but it would make rational decisions about care. Daschle recalled that when he was in the Senate, he would get lobbied about things like the cost of oxygen tanks or reimbursement rates for various medical procedures. He concluded that Congress should set overall health policy but not make those technical decisions, which don't belong in the political realm. "Congress doesn't have the institutional capacity" to make those decisions, he told a jam-packed audience at the Center for American Progress. His ideas have been attacked by some on the right already as a Big Brotherly bureaucracy, but Daschle said a "Fed Health" could provide some rational framework for what we should cover and how we pay for it -- even in a McCainiac market-oriented health policy.

Daschle, who is close to the Obama campaign, didn't utter the "M" word (mandates). Obama of course opposes the individual mandate; Clinton endorses it (as do some Republicans). We worry that the mandate fight can be unnecessarily divisive. Daschle's book doesn't dwell extensively on mandates but he doesn't mince words either: Page 166: "The only way we can achieve universal coverage is to require everybody to either purchase private insurance or enroll in a public program. As long as we can make health insurance affordable and accessible for everyone, this is a reasonable requirement."

Like everyone else who survived the health care wars of the early 90s, Daschle came away with a hefty list of Things Not to Do Again Next Time. Being more inclusive, more open to "a vital center" was part of his message. Trying not to squeeze thousands of complex, technical decisions in draft legislation is another. Maybe a Federal Health Board could let Congress hash out a national health policy, without having to worry so much about doctor's fee scales or the how the cost of oxygen will play in Peoria.