The Users' Guide to the Health Reform Galaxy

Thinking comprehensively about the role of the consumer in health reform

(In this post, Elliott Fisher, director of the Center for Health Policy Research at the Dartmouth Medical School, and Mark McClellan, director of the Engelberg Center for Health Care Reform at the Brookings Institute, give an overview of the Accountable Care Model approach to delivering care and also address questions raised by Francois DeBrantes about ACOs in a recent post on this blog.)

A recent post by Francois DeBrantes lamented the lack of attention in policy discussions to the potentially important role of the informed consumer.    We completely agree with DeBrantes that consumer engagement can make a critical difference in how health care is delivered, and supporting more effective consumer engagement is an essential element of efforts to reform our health care system.  We need to do a much better job of supporting both consumers and providers in delivering better care at a lower cost.

How the Dartmouth Atlas data continues to make the case for change

(Today we welcome our first post from Risa Lavizzo-Mourey, M.D., M.B.A., RWJF’s President and CEO.)

The Robert Wood Johnson Foundation gave Jack Wennberg and his then-small band of researchers their first RWJF grant in 1993.  I have colleagues here (I won’t say how old they are) who remember learning about Dartmouth research in their graduate school educations, at the very beginnings of their health policy careers.  And over time, the analysis produced by the Dartmouth Atlas Project has only gotten richer.  It began with Jack asking the question about why rates of tonsillectomies in the state of Vermont were staggeringly different from community to community—and now we hear Dartmouth Atlas data being cited by Peter Orszag and Mark McClellan and numerous members of Congress as they wrestle with health reform and how to achieve better quality and rein in health care spending. 

What can we take from the increasingly fervent attention that people are paying to this decades-long research effort?  Why does this data get more salient, rather than less? 

Medicaid in 2009: Time to be at the front of health reform

(Today’s post comes from Stephen Somers, PhD, president and chief executive officer of the Center for Health Care Strategies, a nonprofit health policy resource center located in Hamilton, New Jersey.)

As President Obama has said, now is the time to get serious about health care reform. Medicaid, however, has been largely absent from national reform headlines -- in part because almost everyone inside the Beltway probably assumes that it will remain a pillar of the system and also because the running of Medicaid is left largely to the states. We do not know what exactly will emerge from the deliberations in Washington, but we are certain that state Medicaid programs will have multiple opportunities to take the lead in implementing health care reform.

Much of the focus—properly so—will be on expanding coverage, for instance, for low-income childless adults and low-wage working parents, either through pure extensions of Medicaid/CHIP-based public insurance or various public/private partnership arrangements. These policy reforms will create the first major set of opportunities for state leadership on outreach and enrollment simplification. In the next several years, it is not hard to imagine that Medicaid/CHIP enrollment could go from 60 million to as many as 75 million Americans. While this enrollment leap has obvious dollars-and-cents implications, a behind-the-scenes consequence is the need for Medicaid agencies to step up with increased capacity and leadership to coordinate this increasing patient load.

What health insurance exchanges could mean for families and their health care

(We welcome today another post from Sara Rosenbaum, who wrote before on considering the safety net as a part of health reform.)

During the 2008 campaign, voters could see a clear choice between the health reform visions laid out by the two candidates: Senator McCain proposed to replace the current employment based system with a single, individual insurance market covering everyone, while then-Senator Obama proposed to allow persons with employment insurance to keep what they had and to create a new health insurance system for persons without access to employer coverage, Medicare, or Medicaid.

Now the national health reform debate is in full swing and, as would be expected, it is the Obama approach going forward. End of story? Hardly. 

In health reform, where is the consumer?

(Today, Francois DeBrantes gives us another post on payment reform, this one specifically focusing on the role of the consumer--or absence of--in the current discussions about health reform and ideas for how patients and consumers can help achieve higher-quality, more efficient care.)

What I’ve noticed increasingly in the health care reform debate is that there is little said, if anything, about the role of the consumer as an important market-maker.  Maybe it’s not a popular concept in a policy world dominated by the “top-downers.”  I don’t mean that to sound unnecessarily pejorative—I have no doubt that the policy-makers that are grappling with health reform right now are doing so with the best intentions of ultimately helping many more people get better care—but if that’s the case, why aren’t they talking more about whether the people themselves can actually help drive care to get better and less costly?

Doing nothing could cost a lot.

(Today we have two posts as a follow-up to the release of a report last week that estimates the costs of health care should reform efforts completely fail. Karen Ignagni of America's Health Insurance Plans and Len Nichols of the New America Foundation offer us some more commentary on this report, to follow on last week's post from John Holohan on the day of the release.  For video commentary from Karen Ignagni and Len Nichols on this topic, you can access the webcast of the briefing here.)

Karen Ignagni:  An Urgent National Priority

The new Urban Institute report offers a strong economic argument for why we need health care reformand reminds us how important it is that we act now to achieve it.

The most expensive thing we can do is nothing at all. Rising health care costs are choking businesses, burdening working families and straining state budgets. The Medicare trust fund is running out of money sooner than anticipated and, as we see in the new report, the costs of providing uncompensated care could more than double over the next ten years.

If we don’t bend the cost curve, even more of our country’s GDP will go to health care costs and other issues, like energy and education, will suffer. We can’t afford for that to happen.

A look at the world from a health perspective

By Abbey Cofsky

As policy-makers continue their discussions about health reform, the topics that are getting out to the public usually have to do with health care financing and delivery options.  However, let me direct your attentio to an Op-Ed in the San Francisco Chronicle last week about the H1N1 epidemic -- which was not about critiquing or praising the global response or advocating for a vaccine, but more about making the case for paid sick days.  The issue has surfaced again due to the implications of policies and recommendations that encourage or require those with flu-like symptoms to stay home from work in order to prevent the spread of the virus.  The Op-Ed, authored by Ellen Wu, the executive director of the California Pan-Ethnic Health Network, and Dr. Rajiv Bhatia, co-author of a 2008 health impact assessment (HIA) of California's proposed Paid Sick Days law, makes the case that paid sick days reduce the spread of flu and protect the public from communicable diseases by allowing infected workers to stay home, reducing health costs and saving lives.   

My point here is not to support or challenge the case made in the op-ed. Rather, it is to highlight the methodology -- the health impact assessment -- used to evaluate the health implications of a paid sick day policy and provide a health-based perspective to the policy-making process.  Health impact assessments, according to the definition used by the CDC, are “a combination of procedures, methods, and tools by which a policy, program, or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population.”

Let's take that out of public health speak and put it into plain English.

Health reform: What is the cost of failure?

(Today's blog post comes to us from John Holahan, Ph.D., director of the Health Policy Research Center at the Urban Institute, in conjunction with the release of a new report from the Urban Institute and RWJF on this topic.)

Health reform is now a major issue before the nation. The failure to enact reform in 1993-1994 has been followed by several years of increasing costs and growing numbers of uninsured.  There is even some consensus about how to do it, through Medicaid expansions, local or regional exchanges, income related subsidies, and an individual mandate.  There are also many difficult issues to be resolved. But we are also engaging in this debate in a time of a serious turndown in the U.S. economy.  As desirable as it may be to reform the healthcare system, many are asking the question about whether we can afford to enact a health plan at this time that includes substantial subsidies for low and moderate income Americans. 

To others of us the question is whether we can afford failure, that is what is the cost to business, the federal government, and American families – if we fail? 

Health reform--we need to widen the lens.

(This post comes to us from Dr. Paula Braveman, director of research, and Dr. Susan Egerter, co-director of research, for the Robert Wood Johnson Foundation's Commission to Build a Healthier America.  See the RWJF web site and the Commission web site for a wide range of materials on how to shape policies to make Americans healthier where they live, work, learn, and play.) 

We need health reform in the United States, and we need it quickly.  We spend more than any other industrialized country on health care, yet consistently rank at or near the bottom of affluent nations on key indicators of health.  There is wide consensus about the need for change, but are we likely to achieve a healthier America solely through the approaches to health reform now on the table?

It will be over when it's, well, over

This blog went a little quiet towards the end of last week, although other health and health care blogs certainly made up for our silence, given the buzz about some ruffled feathers following the White House meeting with health care industry stakeholders. Meanwhile, I was at a meeting for Aligning Forces for Quality (AF4Q), which is RWJF's big effort to help regions across the country achieve better health care, with or without help from the feds (although sound health reform policies would be much appreciated, thank you very much in advance).  The Dartmouth Atlas Project and other research can lead one to the conclusion that regional variations in health care spending are wildly irrational and that considerable health care savings are there to be found; the data can also lead you to the conclusion that health care is national and local, and that communities might be able to find some local solutions to their local health and health care woes, and that's one of the reasons AF4Q came to exist.

Anyway, the meeting with the teams representing the 15 Aligning Forces regions--teams comprised of those who give care, get care, and pay for it--covered an awful lot of ground, and health reform was THE hot topic of the meeting, and the Aligning Forces folks got several good briefings on the politics and mechanics of the health reform legislation currently being debated in DC.  To some extent, the briefings were gravy--after all, these are health care leaders who are living and breathing some of the policies being debated in DC, like measuring and publicly reporting on health care quality, and getting physicians and consumers to engage--but on another level, the briefings engendered a little bit of anxiety amongst the AF4Q grantees, especially when someone told them that health reform will be "finished" by this fall.  They had that feeling, you know, of "are we being left out of the party?  Will health reform be over by the time we get to show off our results?"

More is not always better.

(Today's post comes to us from Dr. David C. Goodman, professor of pediatrics and of community and family medicine at Dartmouth Medical School. He is also the director of the Center for Health Policy Research and co-principal investigator of the Dartmouth Atlas Project.)

Do we need more doctors?  The question is being asked with increasing frequency in the context of health reform.

How much disruption do we need in health reform?

Last week, Clayton Christensen came to RWJF and gave a talk on disruptive innovations and health care, and "disruptive innovations" is one of those memorable concepts, kind of like the tipping point, that feels immediately applicable to almost everything anyone's working on, especially if what you're working on has to do with fixing huge delivery and payment systems issues that are bedeviling an entire industry (e.g., health care). 

Of course, his talk made a bunch of us think about the concept of disruptive innovations as it applies to health reform, since we're all trying to read the tea leaves that emerge from the White House summits and the Senate Finance roundtables and figure out how much change we're potentially looking at with this year's reform efforts.  The change we're after has to be pretty big--it has to be measured in dollars and cents, which is why the $2 trillion figure for health care cost savings, proposed by insurers and pharma and other industry reps made things seem a lot more real, all of a sudden, but it also has to be meaningful, meaning, the change has to translate into better results for the people who give care and get care and pay for it. 

The language of health reform and the politics of fear

The blog Politico.com released a memo on May 5 from Dr. Frank Luntz, advising the GOP on “the language of healthcare 2009."  The memo contained detailed advice to Republicans about how to communicate about health reform, and, you know, no one really likes to have the sausage-making that goes into memorable messaging exposed like that, so the discussion in the blogosphere following the release of the memo has been rich, to say the least.  Some of the reactions have been tinged with a tiny bit of glee, a tone of, “Look, it’s the not-so-secret playbook!”  And some of the reactions have been a bit worried, a sort of, “Gird your loins—people are getting ready to bring down health reform in 2009.” 

Health care that's affordable, too

(This post comes to us from Reverend Cory Sparks, the pastor of the Faith United Methodist Church in Youngsville, Louisiana.  Rev. Sparks is a member of the PICO National Clergy Caucus.  The PICO National Network helps faith-based organizations engage in community organizing around issues of critical importance to urban and rural communities, and has worked with the RWJF's Coverage team as part of a recent solicitation for ideas from the field.)

As the pastor of a church in Louisiana, I often receive phone calls from church members who are in the hospital. When the mother of Connie, one of our members, went in for knee replacement surgery, I wasn’t surprised when she called me up. But I was surprised when Connie said she wasn’t calling to ask for prayers for her mom. Connie started to cry as she asked me to pray for another member of our church. The woman had been sick for months and lacked health insurance. Connie, who suffers from similar illnesses, was crying because she worried about the family and their finances. Even with health insurance, Connie and her family struggle to pay their out-of-pocket costs for medication. Connie couldn’t imagine how the other family could afford a diagnosis, much less treatment.

Connecting value to coverage: a first glimpse

by Mike Painter

Would you take a virtual walk with me across the Dartmouth Atlas map on RWJF's web site?  Just follow the link.  Now, move your cursor first over, say, anywhere in Minnesota.  There, you'll see that 2006 Medicare reimbursements were roughly $6,700 per beneficiary.  Now, move your cursor across the country, way over to Massachusetts--specifically, Boston, for instance.  There, 2006 Medicare reimbursements were almost a whopping $3,000 per beneficiary higher.  You'd sure think that the quality of care in Massachusetts must be extraordinarily better for that extra $3,000 per person--but, guess what?  It's not--it's roughly the same--maybe even worse in some cases.  Plus, Massachusetts has embarked on its own universal coverage experiment.  First in its class, Massachusetts is providing the rest of us with a real-world unfolding example demonstrating how health care cost, quality, value, and coverage intersect.  If Massachusetts could figure out how to pay for high-quality care at the level of, say, Minnesota, their coverage experiment might just get exponentially easier.

If we build it, they will come--but will we be ready?

By Susan Hassmiller

Let's assume, for argument's sake, that policymakers will be successful and will pass some kind of health reform legislation this year.  And let's go further and say that this legislation will extend some kind of health coverage to the nearly 47 million uninsured Americans. 

What then?  If more people get the coverage they need, who will provide the needed care?  Will our current primary care workforce--the people who provide the care that addresses our most essential and basic needs--have the capacity to handle such an increase in demand?

To reconcile or not to reconcile: that is the question

Anyone who's been following the doings in DC on health reform knows that "budget reconciliation" has been discussed a lot, namely, whether we will see major health reform action through the budget reconciliation process, or through some other means.  And the people who say things like, "It's looking likely that health reform will happen through budget reconciliation," usually say it with the air of someone who knows exactly what that means, and expects that everyone who hears them say it also knows that that means.

I think I know what I know and also what I don't know, and while I can infer what people mean when they talk about budget reconciliation in such portentous tones, I wanted to confirm that it means what I thought they meant--especially since Congress has just passed a budget plan for 2010 that allows for budget reconciliation to be used after October 15 if health reform legislation has stalled.  So I went and looked up exactly what the heck people do mean when they keep on invoking budget reconciliation, in other words, I wanted to discern exactly why using this process is significant.