IP-2-2012 (March 2012)
Author: Linda Gorman
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Governments at all levels are facing severe fiscal stress, and Medicaid is the largest and fastest growing publicly-funded health program in the United States. State and federal authorities have had little success in controlling Medicaid expenditures with conventional reforms, and changing it from an entitlement program to a block grant program is now under discussion.
This Issue Paper explores how transforming Medicaid into a block grant program offers the promise of improving patient care and restraining the growth in program costs.
NCPA 2009 (February 2009)
Author: Linda Gorman
To our knowledge, the Oregon Health Plan is the first government health care program anywhere in the world that has drawn up a formal procedure for rationing. After comment from interested parties, this state health program for low-income people ranks treatment for various diseases and conditions, currently from 1 to 680, in order of priority. The health care dollars available determine which priorities are met. As program costs have grown, the list of covered procedures has become shorter.
In 2099, the state will pay only for the first 503 procedures. It won’t pay to remove ear wax, treat vocal cord paralysis, or repair deformities of one’s upper body and limbs. It will fund therapy for conduct disorder (age 18 and under), selective mutism in childhood (a prolonged refusal to talk in social situations where talking is normal), pathological gambling, and mild depression and other mood disorders.
Reordering Priorities. Surprisingly, between 2002 and 2009 there was a fairly radical reordering of the plain language priorities. A great many life-saving procedures that ranked high in 2002 have been relegated to a much lower position in 2009, while procedures that are only tangentially related to life and death have climbed to the top. (While extensive code lists define actual treatment, most people must rely on the plain language to judge list adequacy.)
For example, medical treatment for Type I diabetes, which ranked second in 2002, was demoted to 10th place in 2009. Oddly, given that not providing treatment for Type I diabetes is a death sentence, it has been placed behind spending on smoking cessation, sterilization and drug abuse treatment. And this is not an isolated case.
Routine and Preventive Care First. As of 2009, the rapid and complete treatment of medically correct-able problems and diseases has taken a back seat to routine and preventive care. For instance:
Bariatric surgery for people with Type II diabetes and a 35 or greater Body Mass Index (BMI) number is ranked 33rd.
This means that the rationing board thinks that stomach surgery to control obesity is more important than surgery to repair injured internal organs (88), a closed hip fracture (89), or a hernia showing symptoms of obstruction or strangulation (176).
Abortions rank 41st, indicating that the state considers using public money for abortions more important than treating an ectopic pregnancy (43), gonococcal infections and other sexually transmitted diseases (56), or an infection or hemorrhage resulting from a miscarriage (68).
In 2002, when treatments through 566 were funded, there was far more emphasis on actual medical care and measurable interventions that save lives and improve individual functioning. Various interest groups have spent the last seven years reordering the political priorities embodied in the list.
The Ethics of Rationing Are Not so NICE. The Oregon Health Services Commission Web site explains that the 2009 list emphasizes preventive care and chronic disease management because these services are less expensive and often more effective than treatment later in the course of a disease. However, there is no evidence that preventive care will reduce expenditures for the general population. Good evidence for the cost-effectiveness of disease management programs…
Minority-Report (January 2008)
Author: Linda Gorman & R. Allan Jensen
SECTION 1: Introduction
This document offers an alternative to the recommendations approved by the Colorado Blue Ribbon Commission for Health Care Reform (the 208 Commission or Commission) at its meeting on November 19, 2007. Its authors are among the Commissioners who voted against that set of recommendations. On November 7, 2007, the Commission passed a rule requiring any commissioner who wished to submit a minority report to vote against the entire package of recommendations. Although the authors voted against the entire package, they do agree with some of the recommendations contained in the set.
In general, the authors believe that the Commission recommendations view the private sector as the source of U.S. health care woes and an expansion of government control as the solution. The authors of this report have an opposite view. They believe that ill designed government interference has done positive harm to the development of the U.S. health care system over the last 80 years. As government programs have grown, they have begun to stress U.S. health care to the breaking point.
In short, government is the problem, not the solution. Significant health care reform requires a transformation of government policy, with the goal of lowering costs through deregulation and of aligning incentives by ensuring, to the largest extent possible, that individuals buying health care are not spending someone elses money.
One of the biggest problems in health care reform is that parties with different viewpoints do not agree on basic facts. Simple logic dictates that it is nearly impossible to agree upon a reform plan without agreement on what needs to be reformed, and a basic weakness in the overall 208 Commission process was the failure to establish an agreed upon body of basic facts. Without this factual basis, the Commission members often could not even agree upon the problems that needed to be addressed let alone on sensible solutions to them.
There are three main areas in which the Commission recommendations fall short. The first is that a vibrant free market for private health care and health insurance, one that offers responsible people a wide choice of health plans, physicians, and treatments, with a variety of ways to pay for each, should be the central part of any serious health care reform plan. Though some Commission recommendations mention consumer choice and market reform, other recommendations make such reforms impossible, too many of its recommendations would destroy or severely damage private health plans, private health insurance, and private medical care.
An unacceptable number of Commission recommendations simply mimic the salient control points in the 2006 Massachusetts health care reform legislation, along with the disastrous Massachusetts decision imposing guaranteed issue and community rating on the individual insurance market in the early 1990s. Those regulations destroyed the Massachusetts individual insurance market and ultimately led to the adoption of the 2006 statute. Similar regulations had similar effects in other states, effectively destroying the individual insurance markets in New Jersey, Maine, Tennessee, Kentucky, New York, and Vermont. Their imposition in Colorado will cripple its individual market, increase health insurance costs for large numbers of people, expand dependence on government programs, and retard innovation in health care delivery and coverage.
The second major area of disagreement is the Commissions neglect of promising developments in account-based consumer-directed health care initiatives and the decision to instead favor various mandated insurance programs directed or controlled by government. While there is considerable evidence that account-based consumer-directed programs reduce costs, there is no evidence that the Commission recommendations for government expansion programs decrease costs. There is, in fact, some evidence that such programs actually increase them.
The third area of disagreement is that the Commission recommendations substantially extend government control of medical practice without addressing compelling evidence that this has the potential to degrade care and increase costs. Though the Commission frequently asserts that its recommendations will lower costs, improve care, extend medical care to more people, or foster useful innovation, it does not provide adequate evidence to support its case. Cost estimates for the reform plans are likely understated because the model used to estimate costs was subject to a number of known problems. They are discussed further in Section 4.
It is the authors view that any successful health care reform policy needs to address: 1) substantive reform of government programs, 2) incentives to reduce waste, and 3) the reduction of costly and unneeded administrative and regulatory burdens. These are the foci of the largest cost problems in the current health care delivery system. When the cost of health care drops, health insurance premiums drop and paying cash for care becomes possible. Paying cash further reduces costs by reducing third party payer overhead, with the result that more people can receive better health care for the same money.
The authors also believe that the organizational processes adopted by the Commission likely caused its decision making to suffer from moderate to severe anchoring, framing, and availability biases. The lack of structured fact finding, discussed in detail in Section 5.4, was an important contributor to these problems.
Author: Health Care Policy Center
Preventive care tips from the American Academy of Pediatrics:
Parents need to be advised that rigid, motorized pool covers are not a substitute for 4-sided fencing, because pool covers are not likely to be used appropriately and consistently.
Pediatricians should alert parents to the dangers that standing water presents to children. Parents need to be advised that they should learn CPR; and they should keep a telephone and equipment approved by the US Coast Guard (eg, life preservers, life jackets, shepherd’s crook) at poolside.
When people talk about more money for preventive care and health education, this is what they have in mind. These tips are two of the 190+ verbal advice directives that the American Academy of Pediatrics (AAP) thinks that physicians should verbally deliver to their patients in the name of preventive care. The Academy also recommends various health screening questions, most of which make nosy neighbors look as inquisitive as big box store clerks. They begin with do you ride in airplanes, continue with things like “Do you have a swimming pool or spa at your home,” and progress to the utterly outrageous “Do you have firearms at home,” and “Does your child have ‘toy’ firearms at home.”
Note the scare quotes around toy. To the AAP, there is no such thing as a toy firearm.