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Here We Go Again

by Emily Friedman

First published in Hospitals & Health Networks OnLine, October 7, 2008

It's election time, and although experts had predicted that health policy would be front and center during the campaign, other issues have risen to the forefront of public attention: the economy, fuel prices and the usual array of character issues regarding the candidates. But the stakes for health care couldn't be higher, and if the health care community is going to be heard, its members need to know the key issues.

Emily Friedman
Emily Friedman

Ah, yes; our great exercise in self-government, the national general election. Our proof to the world that its oldest democracy still functions. Of course, that proof might get a bit lost in the coming month amidst all the mud-slinging, irrelevant side issues, uninformed press coverage, spinning, blogging and other attendant antics that this quadrennial event engenders.

Also, this particular election offers the health care community some major challenges. A Kaiser Family Foundation poll in August 2007 indicated that health care was the second overall public concern after the Iraq war (27 percent overall, with Democrats rating it as important as the war and Republicans ranking it second). But an August 2008 Kaiser Foundation survey found that only 16 percent of the public cited health care as the top concern, ranking it fourth; for Democrats, it was third, and for Republicans, it was fifth.

Keeping the Focus

So if health policy is going to stay on the table as a priority in this election, it will be necessary for health care professionals to press for its inclusion, despite the higher profile of inflation, fuel, unemployment and all the entertaining but unimportant topics that surface during any election campaign. Here are 10 health care issues that should be part of the election debate, no matter whom you are supporting.

The Issues

Medicare. This program, which covers many of the health care costs of over 44 million people, is facing a serious meltdown in that its own trustees predict it will go broke in 2018 or 2019. It will start paying out more than it takes in several years before that, just as the baby boomers are flooding into the program.

Legislation passed this year will lower the (some say, excessive) payments that private Medicare health plans have been receiving for years, beginning in 2010. These savings are to be used to prevent a 15 percent cut in Medicare physician payments, in an environment in which many physicians are already requiring Medicare beneficiaries to pay extra "fees" of $1,500 or more just to be allowed into their practices. Meanwhile, the Medicare health plans are fighting to keep the money. Who is going to get what part of the Medicare pie, and how much access beneficiaries will have, are key issues.

Long-term care. More than 9,000 baby boomers are turning 50 every day, and many of them are facing the unpleasant fact that their parents cannot live on their own, but have no long-term care insurance (and most of those policies are fairly useless, anyway). In many cases, these boomer families are also trying to pay for their kids' college education. Nursing homes are appropriate only for the sickest of the sick, and assisted living is expensive, to say the least.

This country has no public policy regarding financing of long-term care for the frail elderly other than to allow those who have exhausted their resources (and often, they haven't, but have hidden them pretty cleverly) to qualify for Medicaid; this group represents the largest portion of Medicaid spending, even though they are a minority of all beneficiaries. (Don't get me started on how these greedy old people are stealing health care out of the mouths of low-income children; you can't equate a healthy child with a demented 90-year-old in terms of how much it costs to provide care.) The fact is that terrible bargains are made every day in terms of how frail elderly people are cared for, ranging from warehousing in substandard conditions to bankruptcy to suicide, and I don't hear anybody on the campaign trail even mentioning the issue.

Medicaid. One of the best-kept secrets in American health policy is that this is the largest insurance program in the country -- larger than Medicare -- covering 48 million people. Its beneficiaries are a heterogeneous group, including low-income children and (usually female) parents, some pregnant women, persons with AIDS, some disabled people, low-income nursing home residents, low-income chronically ill in the community, Medicare beneficiaries who are too poor to pay their premiums and co-payments (by the way, there are 6 million of those folks -- not a minor population) and other groups.

Diane Rowland of the Kaiser Commission on Medicaid and the Uninsured has described Medicaid as "a Christmas tree," and she's right; it is responsible for covering all kinds of people, with this or that ornament dotting this or that part of the tree. The problem is that states pay a portion of the freight, sometimes as much as half, and when the economy goes soft, states have a tendency -- perhaps I should say a predisposition -- to cut the program. These cuts tend to take three forms: lower provider payments, restricted benefits and, if necessary, tossing people off the program. But even if a person can stay eligible, the fact is that in most states, Medicaid pays less than hospital costs, which doesn't exactly make its beneficiaries the most popular patients in town. Many physicians -- in some cases, most physicians, depending on the state -- won't accept Medicaid patients, and the situation with dentistry is worse, which led to a Medicaid-eligible 12-year-old in Maryland dying of an abscessed tooth that led to a fatal brain infection. No dentist would see him.

Given that most of these people are the poorest of the poor, they don't have anywhere else to go. State and federal cuts in Medicaid have at least one inevitable result: more uninsured Americans.

State Children's Health Insurance Program (SCHIP). Most readers of this column are familiar with the SCHIP situation, given that I wrote about it earlier this year. The program was up for reauthorization, because it had only a 10-year run unless Congress renewed it. The Democratic Congress wanted to expand it; President Bush wanted to restrict it. Congress passed two bills expanding it; the president vetoed both. The vetoes were upheld. The program technically went out of business last September, but is limping along with emergency congressional funding at 2007 levels; that will expire in June 2009. SCHIP provides coverage to 6 million kids; if it goes away, the disenfranchised, uninsured population will increase by more than 10 percent -- and they will be children, who have no say in the matter.

Insurance generally. There's been a lot of talk lately -- one might say a number of exposés -- about the behavior of private insurers, especially in the small-group and individual market. To sum up a rather nasty business -- and the severity of the problems depends on the state -- commercial insurers (and some nonprofits) vigorously avoid those who are sick or disabled or might become so. Some insurers in California (and probably other states) sold individual policies to unsophisticated individuals and then denied payment if the policyholders filed claims, asserting fraud.

The insurers have been handed their lunch by regulators, and policyholders have been offered some restitution and even restoration of policies (I'm not sure I'd want one), but that does little good for the people who were bankrupted or whose care was terminated in mid-stream because their claims were retroactively denied; one of these policyholders was a woman being treated for aggressive breast cancer.

If we wish to have a pluralistic public-private market, policymakers must take a long, hard look at private insurance practices, and whether we want to continue to allow insurers to avoid the sick, injured and disabled. I would add that with genetic testing becoming more common, the future looks even more glum, unless policymakers intervene.

The health care workforce. This is a difficult issue; I must say, I do wonder, when the average medical school graduate leaves school carrying $140,000 or more in debt, where all the federal funding for medical education goes. I also wonder why nursing school faculty are so underpaid that few want the job, while qualified applicants for these schools are turned away for lack of teachers -- in a nation where the health care profession that faces the greatest future shortage is nursing.

To what use, exactly, is all the federal and state funding being put as it disappears into the giant maw of health professions education? Nonetheless, if we want young people to choose nursing and primary care (and the most recent survey found that only 2 percent of medical students want to go into primary care), then students (and in some cases, faculty) should be getting financial support before they all head for cosmetic surgery and dermatology.

E-health. Needless to say, this topic is a whole article -- if not a book -- in itself, but I'll just hit the high (or low) points. Health care is moving toward (we hope) an interoperable system of electronic data collection, storage and sharing. Already, we have electronic health records, personal health records, community health information data banks, e-prescribing and more. Will this make health care easier and more efficient? For payers and providers, of course, yes. For patients? Well, maybe. But along with this revolution (and it is one) come some serious concerns, among which are: What about privacy of personal medical information in a basically unregulated private insurance market? How will we lace together all the different systems that are up and running? What about competing and conflicting standards? How are small medical practices and clinics and rural hospitals and distressed safety-net providers supposed to pay for all this? And what will be done about those providers who won't get with the program, and those insurers and employers who "mine" these databases to weed out bad risks? Who's in charge here? No one seems to be minding the store.

Market issues. These aren't new, but that doesn't mean they aren't vexing. To what degree should unbounded competition control health care? What about corruption and profiteering in both the for-profit and nonprofit sectors? Why are the penalties for those who violate the few existing rules so minor? Should insurance executives be able to personally earn hundreds of millions of dollars simply by selling policies in a country where nearly 50 million people lack coverage? What about waste? What about fraud? What is the proper role of the market in this sector?

Nonprofit tax status. For nearly five years now, nonprofit hospitals have been under the gun from a variety of critics over a very simple issue: How should low-income uninsured patients be treated? Should they be forced to pay billed charges? Should their homes and farms be forfeit? How much interest should they be charged? What should a hospital or health system be required to do to retain nonprofit status? Should the amount of free care provided to truly poor uninsured people be the standard, as it once was? Many people thought, when Iowa Republican Sen. Charles Grassley, who has vigorously pursued this issue for years, lost chairmanship of the Senate Finance Committee to Democrat Max Baucus of Montana, that the discussion would end. Guess again. And remember that in this weak economy, states and localities are casting about for new sources of taxation.

State and local issues. Most news media focus on the national election picture, and even local media are more interested in congressional and municipal elections than in health care issues on the local level. But the fact is that many of the issues I have discussed here do come down to the state and local level, from efforts to broaden coverage to providers' tax status to whether such-and-such a provider is going to get an easement to whether a safety-net hospital or clinic is going to be allowed to go up the flume. It is much more difficult to get information on these more localized issues than on the vague generalities of national health policy platforms, but in the end, they may affect you more than who gains the White House or control of Congress.

The future of American health care is riding on this election, even if the candidates are busy talking about less difficult things. It is our job to get them to talk about what will happen to our system and its patients, whether they want to or not. The issues are complex and not easily explained; the special interests are many; the stakes are incredibly high. But if our concerns are not part of the debate because we did not see to it that they were, then we have no one to blame but ourselves.

And by the way, if you don't vote, you have no right -- no right -- to complain about what happens.

I have compiled this list of Web sites for those of you who seek further information on health care election issues. Do understand that some of these sites are maintained by special-interest organizations and that the information contained therein may not be impartial. There are also many coalition Web sites offering information on various health care issues. Nonetheless, it's a start. Your state and, where applicable, local hospital association sites are also likely to be helpful.

Informative Web sites (in alphabetical order)

The American Association of Homes and Services for the Aging (long-term care providers)

The American Health Care Association (long-term care providers)

The American Hospital Association

The American Medical Association

The Commonwealth Fund

Divided We Fail

Families USA (also sponsors

The Henry J. Kaiser Family Foundation

Political Web sites (in strict alphabetical order)

The Democratic National Committee

John McCain Web site

Barack Obama Web site

Politico (nonpartisan political analysis and commentary)

The Republican National Committee

First published in Hospitals & Health Networks OnLine, October 7, 2008

© Emily Friedman 2008

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