Monthly Archives: December 2012

Health Wonk Review-The Holiday Edition

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On this last holiday week-end, I hope many of you will have the time to read  the  newest edition of Health Wonk Review, a round-up of some of the best health care posts of the past two weeks.

This time Lynch Ryan hosts HWR on  Worker’s Comp Insider. . The posts raise provocative  questions:

Did the LA Times Sensationalize Blue Cross of California’s rate increases?

Why doesn’t President Obama require that CMS negotiate for drug discounts –a move that would take us $200 billion closer to a cliff-avoiding deal?

[My guess is that this will happen sometime this year. Back in April of 2011 Naomi published a HealthBeat post suggesting that Obama had put the idea of letting Medicare negotiate prices back on the table].

How do commercial insurers evaluate physician quality?

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Pelosi Says “There’s Still a Chance”

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Last night House Majority Leader John Boehner withdrew his “Plan B” proposal for the budget. He had no choice:  conservative Republicans in the House made it clear that would not vote for a plan that raises taxes for ANYONE—even millionaires.

Many in Washington believe this makes a bungee-jump over the “fiscal cliff” inevitable. As I have explained, that is not as scary as it sounds. The precipice is an imaginary line drawn in the sand and dated “January 1.”  Any damage done if we miss the deadline can easily be reversed.  Early in January Congress would, no doubt, extend tax cuts for 98% of all Americans while voting down Draconian across- the- board spending cuts scheduled to kick in the first of the year.

But today, House Minority Leader Nancy Pelosi said “there is still a chance for a deal” before year-end. In fact, Pelosi probably knows that House Democrats and Republicans have more than enough votes  to extend tax cuts for the 98% now. The Senate has already passed a bill that would do just that. And in the House few  Republicans are eager to stand up and vote to hike taxes  for the vast majority of Americans. Conservatives just want to give the same break to the wealthiest 2%. But by now, most Republicans recognize that some tax increases are inevitable.

Pelosi’s optimism makes me hopeful. She’s a superb vote-counter, and she knows what’s happening on the other side of the aisle.

                    CEOs Urge Republicans to Compromise 

As Bloomberg reported yesterday, corporate chieftains have begun to lobby Republicans to give way on tax increases: CEOs such as Lloyd Blankfein of Goldman Sachs Group Inc., Robert Iger of Walt Disney Co. and Randall Stephenson of AT&T Inc. have been meeting with White House officials and their “support for Obama’s tax stance has split the Republican business alliance, driving a wedge between CEOs urging compromise and the nation’s most prominent small-business group.

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Gun Control: No Room For Compromise

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When it comes to guns, the United States is exceptional. We have the highest civilian gun ownership rate in the world, with 89 guns per 100 people, according to the Geneva-based Small Arms Survey. 

The U.S. gun lobby sometimes cites Switzerland as an example of a country that has many privately owned guns and little violent crime. (Their  argument seems to be guns don’t kill people; only lunatic Americans kill people.)

In fact, ammunition kills people. It is true that  Switzerland, like the United States, has a strong gun culture with many shooting clubs — but it also has a mass citizen militia. Members of the part-time militia, in which most men serve, are allowed to keep their weapons at home, and the country of less than 8 million people owns at least 2.3 million weapons, many stashed under beds and in cupboards. But while Swiss homes contain guns, ammunition is largely kept under lock and key at local military depots.

                                       American “Exceptionalism”

 Someone once described Canada as “a country in North America where everyone has health insurance.” The same pundit defined the U.S. as “a country in North America where everyone has a gun.”

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The Empowered Patient

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When you or a loved one enters a hospital, it is easy to feel powerless. The hospital has its own protocols and procedures. It is a “system” and now you find yourself part of that system.

The people around you want to help, but they are busy—extraordinarily busy. Nurses are multi-tasking. Residents are doing their best to learn on the job. Doctors are trying to supervise residents, care for patients, follow up on lab results, enter notes in patients’ medical records and consult with a dozen other doctors.

Whether you are the patient or a patient advocate trying to help a loved one through the process, you are likely to feel intimated—and scared.

Hospitals can be dangerous places, in part because doctors and  nurses are fallible human beings, but largely because the “systems” in our hospitals just aren’t very efficient.  In the vast majority of this nation’s  hospitals, a hectic workplace undermines the productivity of  nurses and doctors who dearlly want to provide coordinated patient-centered care.

At this point, many hospitals understand  that they must streamline and redesign how care is delivered and how information is shared so that doctors and nurses can work together as teams. But this  will take time. In the meantime, patients and their advocates can help improve patient safety.

Julia Hallisy’s Story

Julia Hallisy learned about patient safety the hard way. Hallisy’s daughter, Kate, was diagnosed with an aggressive eye cancer when she was five months old. Over the next decade, she went through radiation, chemo, reconstructive surgery, an operation to remove her right eye, a hospital-acquired infection that led to toxic-shock syndrome and an above-the-knee amputation.

“My husband and I spent years of our lives in hospital hallways, waiting rooms, and emergency rooms,” Hallisy recalls. “We became savvier and more educated the longer my daughter’s illness went on. . . .

“We slowly came to realize that the quality of healthcare she was receiving, as mediocre as it sometimes was, was actually far superior to the care other families around us in the hospital were receiving. They began to notice this discrepancy as well, and they wanted to know how we knew the things we did and who had given us such valuable ‘inside’ information. We had to explain to them that we had come across everything we knew . . . by watching our daughter suffer through medical errors, misdiagnoses and inexperienced medical providers, and investigating the mistakes and taking steps to make sure they didn’t occur again.”

Kate was treated at some of the finest hospitals in the San Francisco area.

She died in 2000. Kate was eleven years old

                             Empowering a Patient,  an Advocate, or a  Survivor

How could a mother handle such unspeakable grief? Hallisy decided to write a book that might help others. In 2008,  I reviewed it on HealthBeat.

At the time I wrote: “Remarkably, The Empowered Patient is not an angry book. It is not maudlin. To her great credit, Hallisy manages to keep her tone matter-of-fact as she tells her reader what every patient and every patient’s advocate needs to know about how to stay safe in a hospital.”

Recently, Hallisy emailed to tell me know that the book has now become a non-profit foundation: The Empowered Patient Coalition.

Go to their website and you will find fact sheets, checklists, and publications including, A Hospital Guide for Patients and Families that you can download at no charge. I found the Hospital Guide eye-opening. I have read and written a fair amount about patient safety in hospitals, but it told me many things that I did not  know.

For instance, did you realize that it is perfectly appropriate to ask your surgeon how many times he has performed this particular operation?

Are you aware that you (or your advocate) can—and should—read your medical records while you are in the hospital? (This may be the only way you will find out that your doctors disagree with each other about your treatment.)

Do you know what to do if you if you request a consultation with a more experienced physician because you have serious questions about the decisions made by residents –and hospital staff don’t agree that you need to talk to someone higher up on the ladder?

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U.S. Media Loves “Fiscal Cliff” Metaphor; The Economist Recognizes that It’s An Imaginary Line in the Sand

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In the U.S., pundits cannot resist the fiscal cliff metaphor: it’s colorful, punchy and easy to understand. It’s just two words long. What’s not to like?

It’s not true.

The metaphor assumes that if Republicans and Democrats fail to reach an agreement on the budget by the end of the year, the U.S. economy falls over a cliff,  crashes, and burns.  The “cliff “metaphor complements the equally imaginative “iceberg metaphor” that some fear-mongers use to portray the deficit. (Think Titanic) 

It’s all a bit more complicated than the metaphors suggest.

What few conservatives mention is that the deficit has already begun to dissolve:  since 2009 the deficit has fallen from 10% of GDP to 7% in the fiscal year that ended on September 30th.  By historic standards this is still enormous, and must be addressed. But  the numbers demonstrate that, over time, we can reduce the deficit without renting the nation’s safety nets.

As for the cliff, there is no precipice—just an imaginary line, drawn in the sand, as Republicans and Democrats play “chicken.”

The Economist understands all of this. The lead story in the most recent issue focuses on the “cliff” and points out that “worries” about what will happen if we go over that precipice are “understandable”  but “overblown.” The “risk of economic catastrophe is minimal.” Any damage would be short-term. 

I don’t always agree with the Economist: the UK publication has its own sometimes eccentric slant on things. But on the whole, it is a thoughtful publication—well-researched and fact-checked.  Moreover, in this case, distance may give the Economist a perspective on the problem that some in the U.S. lack.

                                   Exaggerating the Threat to the Middle-Class      

Yesterday’s New York Times suggests that if we cross that line in the sand, an already beleaguered the middle-class will suffer great hardship, and this “Complicates Democrats’ Stance in Talks.” 

The analysis suggests that Democrats don’t dare just stand back and let Bush’s tax cuts expire– as they will if party leaders don’t reach a settlement by year-end: “Only a small handful of policy voices on the left are making the case for the tax cuts to fully expire. In part, that is because the economy is still growing slowly, and tax increases have the potential to weaken it.” But it is also because “If the two parties fail to come to a deal by Jan. 1, taxes on the average middle-income family would rise about $2,000 over the next year. That would follow a 12-year period in which median inflation-adjusted income dropped 8.9 percent, from $54,932 in 1999 to $50,054 in 2011.”

This assumes that once we miss the January 1 deadline, tax hikes for the middle-class would become permanent—which, of course, is not true. Talk about how much more a family would pay over the course of 2013 falls somewhere between hyperbole and hysteria, ignoring what everyone knows:

“If the Bush tax cuts expire, Democrats will presumably simply propose to restore them in January for those [families] earning less than $250,000,” the Economist observes, “daring Republicans to block them.” 
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Subsidies: Will You Receive a Tax Credit to Help You Buy Insurance in 2014? How Much?

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Beginning in 2014, millions of Americans will discover that they qualify for subsidies designed to help them purchase their own health insurance. The aid will come in the form of tax credits, and many will be surprised by how generous they are.

Not only low-income, but moderate-income families earning up to 400 percent of the federal poverty level (FPL) – currently $44,680 for a single person and $92,200 for a family of four – will make the cut.

Yesterday, I posted about subsidies on null.com. The post includes a calculator which tells you whether you would be eligible, and how much you would receive. Even if your employer offers health benefits, you might qualify for a tax credit  if the plan too expensive, or too skimpy. (I explain how the government defines those terms.) I also explain how the government calculates subsidies, and what happens if you live a place where healthcare is particularly expensive.

Click here for the full post   If you like, come back here to comment.

“Fiscal Cliff” Talks: An Update

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Today, for the first time since the election, President Obama and House Speaker John Boehner met alone, face-to-face, at the White House to discuss ongoing negotions over the budget.   (I can’t help but see the photo, which shows Obama with a hand on Boehnr’s shoulder, as a reference to the “Saturday Night Live” skit that appeared last night.  

I’m more and more hopeful about the budget negotiations. Recentlly, I wrote that Obama had “won round one,” explaining that I believed CNN’s report that  the Republicans and Democrats have reached a deal on taxes. “Both sides agree the wealthy will pay more, so now fiscal cliff talks come down to how much Republicans can wring out of the White House in return for giving in on taxes.”  Based on everything I know about the economics and the politics of the situation, this makes sense. /

Since then Boehner has said:  “No progress has been made.”

This does not change the story:  If, as CNN’s sources say, (and I believe) Republicans have conceded that taxes cuts for the top 2% must expire Janauary 1, while cuts for the remaining 98% will continue, that doesn’t mean they are ready to make the agreement public.

Understandably, Republicans are not willing to acknowledge that they lost round one of negotiations until they can also announce that they won something in round two.  Nor does  President Obama want to blind-side Boehner by letting it leak that a tax deal is in place. That would be counter-productive.

                          The Inside Story and the Outside Story

Recentlly, the Washington Post’s Ezra Klein reported:  “Right now, the fiscal cliff negotiations are proceeding on two tracks.

“One track includes the press releases, public statements and legislative tactics the two parties are deploying to prove the purity of their faith and their commitment to beating the other side to a bloody pulp. Watch these closely and it’s easy to get depressed.  . . ‘There isn’t a progress report;’ Republican House Speaker John Boehner sighed Friday, ‘because there’s no progress to report.’

“The other track includes the offers, counteroffers and red lines proposed by Boehner and President Obama. If you look at these closely, a deal is taking shape.”

 I agree with Ezra about the “two tracks”. But I don’t agree regarding the “shape” of the deal that is emerging.

First, I agree that  the majority of Republicans in Congress have accepted the fact that the Bush-era tax breaks for folks earning over $200,000 (and couples earning over $250,000) will have to expire. I won’t try to guess when politicians will complete the two stages of bargaining and be ready to announce a deal. We may go right up to the January 1 deadline.

Moreover, it is  possible that when it comes to cutting government spending, too many Republicans will remain stubbornly, and foolishly, intransigent — insisting on concessions that would inflict pain on the middle-class.

If that happens, I predict that President Obama will let us sail over the so-called “fiscal cliff.”  He knows this wouldn’t do any permanent damage to the economy.  As Rutgers reported today, even Wall Street does not seem panicked by the prospect: “Investors have peered over the cliff and realized they are looking at a gentle slope . . . . some investors say lawmakers still have time in early 2013 to strike a deficit-reduction deal without imperiling the economy. A survey of 62 Wall Street money managers released on December 5 showed market losses would be manageable if the U.S. goes over the fiscal cliff, even though worries still run deep.

Many on Wall Street understand that, early in the spring, the administration could undo Draconian spending cuts, while lowering tax rates for the 98%. Public pressure will ensure that happens. (In the meantime, the Treasury Secretary could lower withholding rates so that middle-class Americans didn’t suddenly see their paychecks trimmed.)

But taking a ride down that slope would do lasting damage to the GOP.  Polls show that voters would blame Republicans. This is why I think that, in the end, Republican leadership in Congress will do whatever it must to make a deal before January.  As I indicate in the post below. Tea Party extremists in the Republican party are being side-lined.

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Obama Wins Round One of Budget Negotiations

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CNN is reporting that the “Fiscal cliff deal is down to wrangling over the details.” While others in the media continue to say that talks are stalled, everything I know about both the economics and the politics of the situation tells me that CNN is right.

At 4:30 this afternoon, CNN updated its story: “Both sides agree the wealthy will pay more, so now fiscal cliff  talks come down to how much Republicans can wring out of the White House in return for giving in on taxes.

“To President Barack Obama, it’s all about first locking in additional revenue from raising taxes on high-income owners, an outcome the GOP has long rejected.”

President Obama had made it clear that negotiations over government spending on safety nets such as Medicare wouldn’t begin until Republicans accepted a higher marginal tax rate for individuals earning over $200,000 and couples earning over $250,000.

The president dug in, and, according to CNN, he has won round one.

“Retiring Republican Rep. Steve LaTourette of Ohio told CNN on Thursday that he sensed a shift in the House GOP approach during a conference meeting the day before.

“A GOP source told CNN that talks between staff members on both sides resumed Thursday for the first time this week, after Obama and Boehner spoke by phone the day before.”

A Two-Step Approach

It is not clear whether negotiations over so-called “entitlements” will be concluded before the end of the year. But CNN, reports

“All signs point toward a two-step approach sought by newly re-elected Obama — an initial agreement that would extend lower tax rates for income up to $250,000 for families, while letting rates return to higher levels from the Clinton era on income above that threshold.”  That agreement on taxes will be signed and sealed before the end of the year.

“Even conservatives such as Oklahoma Sen. Tom Coburn and Louisiana Gov. Bobby Jindal acknowledge the obvious — taxes on the wealthy are going up despite opposition by Republicans.

“‘Whatever deal is reached is going to contain elements that are detrimental to our economy,’ Jindal wrote Thursday in an opinion piece published by Politico. ‘Elections have consequences, and the country is going to feel those consequences soon.’”

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How Much Will We Save If We Raise the Age When Seniors Can Apply for Medicare to 67? Less than Zero

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The budget deadlock continues.

President Obama is clear: if we want to strengthen the economy, we can no longer afford President Bush’s tax cuts for the wealthiest 2% of all Americans. At the same time,  he is equally firm that he will continue tax relief for the other 98%.

House Speaker John Boehner has responded by characterizing Obama’s proposal as coming from “La-la land.”  Once again, Boehner has insisted that his party will not agree to let marginal tax rates for Americans earning over $200,000 ($250,000 for couples ) rise back to where they were in the 1990s.

Instead, Boehner proposes slicing social safety net programs. As part of the package, he continues to insist that we raise the age when Americans can apply for Medicare from 65 to 67. If we did this, the Congressional Budget  Office says, Medicare spending would decline by about 5 percent. 

                                     “We Are Not Living Longer”

On the face of it, lifting the eligibility age for Medicare might sound like a reasonable idea. After all, longevity has increased. Can’t we wait a couple of years before we ask the government to cover our health benefits?

First, “We” are not living longer. “Some of us” are living longer. But low-income and median-income Americans (who most need these benefits) die sooner than the  politicians who propose that we raise the age requirement for Medicare.

Research from the Social Security administration shows that increases in life expectancy have not been shared.  In 1977, life expectancy at age 65 for a man who was in the bottom half of earners during his peak earning years was 79.8 years; a 65 year-old male who was in the top half of earners at the same point in his career, could assume that he would live roughly 10 years longer,  to 80.5

Over the past 30 years, the gap has widened, During those three decades life expectancy  grew dramatically for the top half of earners, while remaining nearly flat for the bottom half. 

Education serves as another marker for life expectancy: According to the Center of Disease Control (CDC) between 1996-2006, the difference in life expectancy at age 25 between those with less than a high school education and those with a bachelor’s degree or higher increased by 1.9 years for men and 2.8 years for women.  On average in 2006, 25-year-old men without a high school diploma had a life expectancy 9.3 years less than those with a Bachelor’s degree or higher.  Women without a high school diploma had a life expectancy 8.6 years less than those with a bachelor’s degree or higher.

Race also plays a role. For example, a white male born in 2009 can expect to live to be 76.3 while an African-American male born that year is likely to  die shortly after he turns 70.  Lift the age when he becomes eligible for Medicare to 67, and he may be  be suffering though the final stage of a chronic disease before he qualifies. Yet, he, like every other working American, will have contributed to Medicare for decades.

Finally, occupation helps determine how long you live. Low-income workers are more likely to be engaged in work that is physically grueling. By age 65, the body is wearing out. At that point, a person needs Medicare.

As David A. Smith, Director, Public Policy Department, American Federation of Labor and Congress of Industrial Organizations (AFL–CIO) testified at a 1998 hearing on the Future of Social Security before the House Ways and Means Sub Committee on Social Security:  “It is clear that people who spend their work lives scrubbing floors in a nursing home, moving 5 liter engine blocks around a factory floor, pouring steel into a Bessemer mill, or hauling bricks around a construction site can count on a shorter life span and a shorter work life. They are more likely to experience work place injuries and to lack the continued physical endurance necessary to perform their jobs very far into their 60’s.”

As a simple matter of fairness, asking those who have worked harder to wait another  two years before receiving Medicare seems cruel.

                                       The Bogus Financial Argument 

Admittedly Republicans might not acknowledge the “fairness” argument. If you believe that a person’s health is a matter of “personal responsibility,” you might say that if the poor are aging faster than the rest of us, it is because they smoke, eat too many carbs, and generally “don’t take care of themselves.”                                           

But, fairness aside, when you look at the numbers, it turns out that the claim that we can save billions by requiring that everyone wait until 67 before applying for Medicare is bogus.
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As We Approach the Fiscal Cliff: What is the GOP’s Primary Goal?

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In theory, the GOP’s main concern is the deficit. We must reduce it they say—and we must do it now–or face a financial Armageddon. But somehow or other, “cutting the deficit” always turns out to mean “reducing entitlement programs.”

Let me suggest that cutting those entitlements programs is the GOP’s primary goal.

Why would I say this?

Earlier this week , wh en Republican House speaker John Boehner presented his party’s counter-proposal for solving the budget deadlock, he once again put lifting the eligibility age for Medicare from 65 to 67 near the top of his list. Yet, it you take a hard look at the numbers, it becomes clear that this proposal would not save money–or strengthen the economy. Moreover, entitlement programs did not create the current deficit.

Begin with forcing seniors to wait until they are 67 before they can apply for Medicare. As I explain in the post above, this proposal simply shifts costs to employers, the states, everyone buying insurance in the Exchanges, other Medicare beneficiaries, and 65 and 66-year-olds themselves. It does not lower the nation’s total healthcare bill. Indeed, the GOP’s remedy would wind up costing us twice as much as we now spend providing Medicare benefits for people who are 65 and 66. (See graph in the post above).

I am not  the first person to make this argument. The Kaiser Family Foundation and the Center for Budget Policy and Priorities  offer  eye-opening numbers that prove the point.  One would think that, if the GOP’s main goal were to save the economy, Republicans would be interested in these numbers.

One would be wrong.  They ignore them (and seem to have persuaded the mainstream media to follow suit.) Why would conservatives close their eyes to the financial facts? The GOP has an agenda, and it’s not about the deficit. The party’s main fear is “creeping socialism.”

Conservatives use the deficit as an excuse for slicing benefits that they acknowledge will inflict pain on the people who most depend on Medicare, Medicaid and Social Security—the elderly and the poor.

 

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