The Users' Guide to the Health Reform Galaxy

Robert Otto Valdez makes Christmas appeal to the U.S. Senate

Robert Otto Valdez, PhD, executive director of the Robert Wood Johnson Foundation Center for Health Policy at the University of New Mexico, channels FDR and Jimmy Stewart to make the case for expanding Medicare to achieve universal health coverage.

I was reminded the other day watching “Mr. Smith Goes To Washington” that
sometimes you just need to say what needs to be said until the Senate hears what is
right. This is right: We all have a right to life and liberty. These are founding principles
of our nation; they define our social contract to one another. And one cannot have life
and liberty without good health. ALL those living and working in the USA must have
access to quality health care and healthy communities, lest we break the social
contract itself. The Senate’s debates on health insurance reform must restore our
nation’s social contract in accord with these principles.

President Franklin Delano Roosevelt commented that “the test of our progress is not
whether we add more to the abundance of those who have much; it is whether we
provide enough for those who have too little.” The Senate would be wise to heed
these words as they debate health insurance options for our nation. History shows
that private enterprise and the profit motive do not ensure the well-being of every
individual - public commitment is essential to achieve our ideals as a society.

We would do well to recognize our own history with the Social Security program,
the cornerstone of our nation’s economic security. At first, coverage was
limited to only a few. Only gradually, over several decades, was the program
expanded to its present nearly universal form. Today, it is recognized as our nation’s
most important anti-poverty program, the major or only source of income for many
seniors.

I'm dreaming of a white paper ...

David C. Colby, vice president of research and evaluation at the Robert Wood Johnson Foundation, shares his favorite health reform policy papers in the spirit of regifting.

While many of you might already have visions of sugar plums dancing through your heads, I (not surprisingly) have health reform on my mind.  That doesn’t mean I am not in the holiday spirit. In fact, I propose a “white elephant” holiday gift exchange here at the foundation. ‘Tis the season of regifting.  The best part of the gift exchange is how it highlights that value is truly in the eye of the beholder.  Many recycled gifts are still perfect gifts.

In that spirit, I want to regift to you some of this year’s health reform policy papers that are as good as stocking stuffers today as when they were released last February, April, June or October. I started with 12 gifts of policy analysis, but with Hanukkah wrapping up tomorrow, feel free to pick your favorite eight…

America’s Uninsured Crisis
Released in February by the Institute of Medicine (IOM), this report addresses three key questions: (1) What are the dynamics driving downward trends in health insurance coverage? (2) Is being uninsured harmful to the health of children and adults? (3) Are insured people affected by high rates of uninsurance in their communities?

Crossing Our Lines: Working Together to Reform the U.S. Health System
In June, three wise men, former Senate Majority Leaders Howard Baker, Tom Daschle and Bob Dole completed The Leaders’ Project on the State of American Health Care, a two-year consensus-building process resulting in a plan for reforming America’s health care system.  This report outlines their key recommendations.

How Do We Pay For Health Reform?
Conducted by Urban Institute researchers and released in July, this analysis reports that savings from many popular health reform ideas would finance the lion’s share of the cost of comprehensive health care reform. The authors also conclude that a combination of revenue options would provide more than enough money to fill the gap between the cost of reform and the savings resulting from it.

How Does the Quality of U.S. Health Care Compare Internationally?
This analysis from the Urban Institute, which we released in August, looks at the evidence on how quality of care in the United States compares to that in other countries and highlights the implications for health reform.

How Will the Uninsured Be Affected by Health Reform?
In this four-part series, released in August by RWJF and the Kaiser Commission on Medicaid and the Uninsured, the Urban Institute’s Lisa Dubay and Allison Cook calculate how many uninsured people could gain coverage through a health reform scenario that draws on proposals being discussed on Capitol Hill.

Bending the Curve
Released in September, this report is not about making candy canes. Compiled by the Engelberg Center for Health Care Reform at the Brookings Institution, the paper proposes that health care reform should include comprehensive efforts to achieve higher-value care. The report was co-signed by a distinguished group of scholars and policymakers: Joseph Antos, Ph.D., (American Enterprise Institute for Public Policy Research); John Bertko (Brookings Institution); Michael Chernew, Ph.D., (Harvard Medical School); David Cutler, Ph.D., (Harvard University); Dana Goldman, Ph.D., (RAND Corporation); Mark McClellan, M.D., Ph.D., (The Brookings Institution); Elizabeth McGlynn, Ph.D., (RAND Corporation); Mark Pauly, Ph.D., ( University of Pennsylvania); Leonard Schaeffer (University of Southern California); and Stephen Shortell, Ph.D., (University of California, Berkeley).

Is Massachusetts Reform Working for Doctors?
This study, published in the Oct. 21 issue of the New England Journal of Medicine, finds that 70% of practicing physicians in Massachusetts support health reform three years after its passage in 2006. We partnered with Blue Cross Blue Shield of Massachusetts Foundation to fund the research, which was designed and conducted by researchers at the Harvard School of Public Health.

Trust for America’s Health Prevention Poll
The poll, conducted for RWJF and Trust for America’s Health by Greenberg Quinlan Rosner Research and Public Opinion Strategies, indicates the majority of Americans support disease prevention investments as a part of national health reform. Poll findings were released in November.

A State Policymaker's Guide to Federal Health Reform
These three documents released by the National Academy for State Health Policy (NASHP) last month identify the most challenging health policy issues that states are addressing; describe the tools they have at their disposal and how federal health reform may affect those tools. It also describes the support they would need to implement federal health reform legislation.

County and City Health Departments: The Need for Sustainable Funding and the Potential Effect of Health Care Reform on their Operations
This report, released earlier this month by Health Management Associates, analyzes the effects that substantial funding cutbacks from local, state, and federal sources have had on already-strapped local health departments.

Leveling the Field - Ensuring Equity Through National Health Care Reform
Bruce Siegel, M.D., and Lea Nolan, M.A., from the Center for Health Care Quality, The George Washington University School of Public Health and Health Services, published this piece in the Dec 3 edition of the New England Journal of Medicine. The paper discusses how health reform legislation would reduce racial and ethnic disparities by extending coverage to disadvantaged groups.

The Cost of Failure to Enact Health Reform: Implications for States
Released at the end of September, researchers from the Urban Institute used their Health Insurance Policy Simulation Model to estimate how coverage and cost trends would change in every state between now and 2019 if the health system is not reformed.

Wishing you a happy and healthy holiday season. May all your policy papers be white!

Pushing ahead with malpractice reform - with or without Congress

Philip K. Howard, founder and chairman of Common Good, writes about establishing special health courts as a way to reform the medical liability system.

 

Health care reform gives the sense of a ship tossed about in stormy seas, with political decisions to steer here or there in reaction to the uncertain winds of public opinion and a gale of special interests.  The fact of a partisan mutiny makes the destination very uncertain.  Will reform capsize altogether, will it wash us onto the shoals of unaffordability, or will it lead us towards a new social contract?  

 

The area in which I’ve been most involved is trying to improve our system of medical justice.  The basic goal is to create a reliable system of justice that will provide the transparency and openness needed to improve patient safety, the trust in justice needed to reduce defensive medicine, and a reduction in adversarial process needed for quick and fair compensation for injured patients. 

 

It’s hard to find anyone in health care who doesn’t support some version of this change—patient safety experts, consumer groups, providers, as well as editorial boards and the public at large, all overwhelmingly support trying to create a reliable foundation of justice.  (See here, here, and here.) 

What H1N1 taught us about public health preparedness

Richard Hamburg, deputy director of Trust for America's Health, writes about the H1N1 flu outbreak as a test of the nation's public health system with important lessons for emergency preparedness and health reform.

The H1N1 flu outbreak has been a real-world test of the nation’s public health system, and the results are mixed at best.  The good news is that earlier investments in emergency preparedness created a larger stockpile of antiviral medications. But the outbreak also revealed serious, underlying gaps, including a lack of real-time disease surveillance and laboratory testing, outdated vaccine production capabilities, limited hospital surge capacity and a shrinking public health workforce.

The seventh annual edition of  Ready or Not? Protecting the Public’s Health from Diseases, Disasters and Bioterrorism  shows that a band-aid approach to public health is inadequate.  The report found that 20 states scored six or less out of 10 key indicators of public health preparedness. Montana had the lowest score of all with three out of 10.

Variation in preparedness means that where people live can determine how well they are protected from health threats.  In the case of a pandemic or infectious disease outbreak, one weak link in the public health chain – including providers’  reluctance to treat those who are uninsured or underinsured - could result in disaster for everyone.

Finding the sweet spot between affordability and access in health reform

Bowen Garrett, a senior research associate at the Urban Institute, writes about finding the sweet spot between making health care more affordable for low- and middle-income families while limiting overall costs.

As legislators continue to hammer out details on key provisions of health reform legislation, they face a difficult balancing act. To craft a successful health reform bill, they must limit the overall cost of the reform package, while at the same time, making health insurance affordable for low- and middle-income families. That’s no small feat for even the most nimble-footed of policymakers. 

A key component in finding the right balance is where to set levels of premium and cost-sharing subsidies.  These subsidy levels will go a long way toward determining how affordable insurance coverage and access to medical care would be for families under reform.  If the levels are wrong, the cost burden will be too high for low- to moderate-income families driving down compliance with an individual mandate. The resulting lack of widespread compliance would ultimately make it very difficult to maintain insurance reforms on the table because at their core, they depend on broad risk pools.

In case you feel like singing about health reform

This is the time of year when certain songs get stuck in my brain and between that and editing this health reform blog...well, you can see the results, below.  For the record, I really wanted to make this a more diverse offering, but the only Chanukah song I know is the Dreidel song, and I couldn't quite get there with the lyrics, so I invite all of you to try where I failed in the comments.

ONE  (sung to the tune of "Santa Claus is coming to town")

We're waiting to shout,
We're waiting to cry,
Wanna find out Who's covered or dies.
Health reform is coming to town.

We're making our lists,
We're checking it twice
Wanna see if politicians make nice.
Health reform is coming to town.

We need a better system.
We know we need it now.
We need to do a better job
and we need to figure how.

Oh....

We're waiting to shout,
We're hoping for change,
Gonna find out
if Congress eases our pain
Health reform is coming to town.

TWO (sung to the tune of "O little town of Bethlehem)

O leaders in our capital,
how much we need you now.
Beyond thy frequent many rifts
health care needs your know-how.

Yet in thy chambers rumbles
the ghosts of reform past.

The hopes and fears of all the years
could you all meet, at last?

THREE  (sung to the tune of...oh geez, it should be pretty obvious.)

Joy to the world
Reform at last!
Our health and health care dreams!
Let every one
get care they need!
And cover everyone....
And cover everyone....
And decrease costs through qua-li-ty.

FOUR (Sung to the tune of "Here comes Santa Claus")

Here comes health reform
Here comes health reform
Right down Washington Lane,
Reid and Pelosi...and Snowe and Baucus
are pulling on the rein,
Docs are talking, insurers balking,
but a bill is still in sight,
Hang your stockings and say your prayers, so health reform happens tonight.

Here comes health reform
Here comes health reform
Right down Washington Lane
Americans need this
More than ever
We can't fail again!
Hear those interests
Wrangle, jostle
Sometimes prospects look grim
Maybe we'll see a bill by Christmas
So all of us start to win!

This and that on health reform

The December edition of the Health Wonk Review is available at Workers’ Comp Insider. Check it out for a well seasoned collection of thoughts on health policy and reform, including two of our posts about a holiday gift that should be on everyone’s wish list and resolutions for the New Year to put the gift to use.
 
I also like pointing to blog posts that give us a fresh take (rather than the standard commentary fare) on what's going on in health reform, so take a look at the New Health Dialogue blog. Joanne Kenen shares a chart illustrating a common disease trajectory, where a patient suffers from a near-death crisis and rebounds (but not completely), and then suffers another crisis, which may be his final one. She turns this chart upside-down, and uses it to depict the anatomy of a Senate deal:
 
“There's a deal. Then it falls apart (the near death crisis -- only instead of the ER everybody rushes to Harry Reid's office). Then there's another deal (remember the chart is moving in a positive direction, so each successive peak means it's closer to success). And crisis. Etc. Finally, the chart peaks. There's a deal. There's a bill. There's health reform. It also helps if it's almost Christmas.” 

As the year wraps up, please also take a moment to visit our annual list of research articles, and let us know which pieces you find most influential.

Health reform could hurt minority groups if not done right

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, writes that equity should be an important component of health reform.

Health care reform could actually hurt minority groups unless Congress makes some fixes. Without an explicit focus on equity, reform could leave millions of these Americans behind.

The goal of the reform bills in the House and Senate is to dramatically expand access to coverage, including for minority groups, which are traditionally under-insured. But the bills also envision measuring doctors’ and hospitals’ results and paying them based on how well they perform. And while that is a laudable goal, it could also hurt minority groups if not done right. If, for instance, we start measuring and penalizing hospitals depending on how many patients need to be admitted again, hospitals could have incentives to turn away the poorest and sickest patients; who tend to also be people of color. And safety net hospitals that underperform, already overburdened and underfunded, would be further deprived of resources.

The issue looms large given that racial and ethnic minority groups will be in the majority in the U.S by 2050. They already account for half the uninsured, are poorer in health, suffer more disease and are more likely to get inferior care. There are also equity implications in the transformation taking place in provider reimbursement as the notion gains ground that we need to systematically and rigorously examine how well our doctors and hospitals perform and pay them accordingly.  Especially important, in the interest of attaining quality care for all patients, is measuring how well the system treats minority groups.

The poll is open for the Year in Research

Every year, RWJF sponsors a contest so that you can help us choose and promote what, out of all the research efforts RWJF funds, really pushed your buttons.  And this year, our research releases and publications placed a particular emphasis on topics and questions that we thought were particularly relevant for the health reform debate.  So, take a look at the overall list, and then vote.  Voting closes on Dec. 23.  

Making health care quality information easier for patients to grasp

Chris Queram, president and CEO of the Wisconsin Collaborative for Healthcare Quality, describes an "all-or-none" measure for reporting on the quality of diabetes care. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

Last year alone, the number of people with diabetes in Wisconsin jumped by a quarter, to more than 400,000. The Wisconsin Collaborative for Healthcare Quality, where I work, is taking a new approach to fighting this epidemic.

Managing a chronic disease like diabetes can be tough for patients — besides taking steps to live a healthy lifestyle, there are the regular medical tests for blood sugar and cholesterol, not to mention feet exams and other important checkups.

The Collaborative, which the Robert Wood Johnson Foundation supports as part of its Aligning Forces for Quality initiative, decided to simplify matters by developing an “all-or-none” measure for diabetes. This method has been catching on as reporting on quality has become more extensive and more complicated.

Consider the Joint Commission, which accredits and certifies more than 17,000 hospitals and other health care organizations:  It measures care for acute heart-attack patients nine ways. It has five measures for pneumonia.

Measurement experts started asking whether it wouldn’t be far better to simply tell patients if a clinic or hospital meets a specific set of quality measures rather than making the patient sort through a long list of measures, some of which their doctor or clinic may meet and some of which they may not.  Hence the “all-or-none” name for this innovative and patient-centered approach.

Performance Measurement and Public Reporting Are Driving Tangible Quality Improvements in Minnesota

Jim Chase, president of MN Community Measurement, argues that results from six years of measurement and public reporting in Minnesota and other regions have boosted quality, with clear implications for national health care reform. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

Last year, doctors at the HealthEast Care System in St. Paul noticed something interesting: After starting to meet monthly to focus on the dozen health care quality measures that MN Community Measurement reports publicly each year, they found they were among only a handful of Minnesota medical groups to get above-average grades on at least half the measures.

The annual measurement report “demonstrated that we could achieve better outcomes for our patients -- because others were doing it,” said Linda Walling, medical director for clinical informatics at the 14 HealthEast clinics. “Our clinicians want the best for their patients and this appealed to their competitive nature.”

That first step, it's a doozy

It’s tough times for those of us in the blogosphere who are focused on health reform.  After all the frenzied activity this year so far, we’re now in the position of wondering what deals are being cut behind closed doors as the Senate debates its version of a bill.  Oh, you still hear the occasional hand-wringing about whether [INSERT PREFERRED VERSION OF BILL] will cover enough people, do enough to control health care spending, or, if you want to believe the extremists, end up funding amoral behaviors, but for the most part, we’re all waiting to see if a signed bill will be in our stockings, or not. 

I have two innate characteristics that tend to war with each other over things like health reform legislation—one, I’m a rules-driven person, and I believe in process to the extent that it allows for fairness and for a range of perspectives to inform the debate, but two, I’m also naturally impatient, and I hate process when it is subject to numerous wrangling and gaming attempts until it no longer looks like a process anymore, it just looks like...a bureaucracy.  So part of me wants to find value in this hurry-up-and-wait period that Congress and the Administration have been engaged in all year, with respect to health reform legislation, but part of me wants to say, let’s just get this part over with, already, and move on to the next part.

Some of my impatience, I think, comes from what I learned in law school (on top of learning that I didn’t, actually, want to practice law), and it’s this:  the law, or rather, the compilation of statutes and legislative acts and regulations that we understand to be the law, is a really blunt instrument for change.  No matter how many pages of legislation you pass, legislation alone will not change the behaviors and practices that have led us to our current health care woes.

Health reform: A holiday gift for every consumer?

Steven Findlay, senior health policy analyst with Consumers Union, explains why health reform would benefit everyone, even if it is initially disorienting.

The great health reform debate of 2009 has moved into a new phase this month with the full Senate now debating the legislation. I can’t imagine a more profound Christmas, Hanukkah, and Kwanzaa present for the nation than a Senate bill by December 24. The redeemed Scrooge himself would be proud.

Though initial Senate passage won’t seal the deal, it would create momentum that could be tough to stop.

Misinformation about how this legislation will affect consumers has abounded amid the hyper-partisan debate and the complexity of the bills. So let’s be very clear on this critical point: This legislation will benefit every American in the long run. Every single one of us. And we are not talking about some vague social good, or an indirect trickle-down effect. The legislation will directly impact our lives for the better by expanding health insurance coverage and making it more secure, by making the health system fairer and more consumer-friendly, by taking solid steps to improve the quality and safety of care, and, over time, by constraining health care costs and premiums.

To be sure, if it becomes law, the legislation will also create anxiety and confusion. Change always does. New choices and new rules would bring initial stresses. And, of course, the legislation creates a new and far-reaching demand — the requirement to have health insurance. There’s no way around it: That requirement will trigger some tough moments for millions of currently uninsured families. They will have to choose whether to adjust their budgets and obtain coverage or pay a tax penalty (and remain uninsured) because they decide they simply can’t afford the coverage even with the government subsidies that will be available.

Imagining the pain of such decisions already makes us sad. But we at Consumers Union believe that the “individual mandate” or “shared responsibility” requirement will provide people with something of significant value. First and foremost, it could spare your family from severe financial strain or even bankruptcy if serious illness strikes or an accident occurs. Health insurance also lowers the barrier to ongoing care with coverage of routine doctor visits and preventive health services.