National Institute of Health Policy - Advancing health policy dialogue

Commentary from Dave Durenberger
Monday, October 7, 2013


October 1 was the beginning of an exciting new journey for health policy reformers.  To create a uniquely American health system.  We can hardly expect most Americans to understand that they too have been enlisted on such a noble journey.  Given the partisan nature of the attacks on both the passage and the implementation of the new law.

The rebuilding of health care in America did not start with the "glitchy" insurance exchanges.  It began in communities across this country years ago. It began with the consolidation and integration of physicians, physician groups, and hospitals in places like Minneapolis-St. Paul and with the "disruptive technology" of retail clinics, urgent centers, and health information apps.

The PPACA aka OBAMACARE provides the financial rewards of informed consumer choices and reformed public and private financing of health and value-based healthcare.  It lacks a common vision of the destination: A uniquely American health system.  It should acknowledge that there are many places in America you can go today and meet leaders who can see that future. It does not yet have genuinely conservative Republican authors who believe there is a way that plays to our strengths as a nation, not to our weaknesses.


The PPACA adds a unique dimension to U.S. health policy.  Something that is common to every developed nation's policy.  National goals for health policy.  The goals reflect public opinion regarding the most appropriate way to a healthier America and more affordable, accessible, high quality health care.  They reflect "reformer" activity in many communities across the country. Goals are a means to bring elected policy makers from all parts of the country and both political parties closer to comparing inter-governmental approaches to:  Healthy people, healthy communities, and a value-based health insurance and care provider system.

To achieve these goals, the law committed us to change the financial incentives provided by the third party public and private payers on whom we depend. It established new rules to enhance both collaboration and competition in healthcare markets.  These "markets" as we call them number somewhere between the 302 hospital referral regions in the Dartmouth Atlas and the 380 metropolitan statistical regions (MSA) identified by demographers.  Obamacare may be a new national policy, but its implementation depends on the willingness of Americans and their elected representatives at the local and state level to do better at what they already do best.


Some say this makes it more difficult to gauge the new law's success.  I say it's a marker for real success when responsible leadership in all these "laboratories" of government's role in reform can look to folks in situations just like theirs for ways to improve what they are trying to do.  That's exactly what's going to happen starting Oct 1, 2013.  All of us Republicans and Democrats and Independents will be the better for it.

Republican Governors like John Kasich of Ohio and Democratic Governors like John Kitzhaber of Oregon will be comparing notes on what to tell HHS/CMS and their Washington elected reps can be done to improve Obamacare. Like maybe get rid of the name and even Republicans might get to like it.

Kasich, a former House Budget chair, is famous for telling an Ohio GOP legislator, "At heaven's door St. Peter is probably not going to ask you much about what you did about keeping government small. But he is going to ask you what you did for the poor."

Arkansas Democratic Governor Mike Beebe received an okay from HHS to initiate a federally-funded "premium support" for private Medicaid Insurance.  This could be the reform Medicaid has been needing.  Republicans should applaud the Governor.


Congressional Democrats demonstrated in PPACA their willingness to sacrifice European single payer, government controlled systems, for an American system.  Instead of working with them, the national Republican establishment dedicated itself to defeating President Obama.  By, among other tactics, refusing to participate in the passage of health reform.  Reform which, in a March 4, 2009 meeting in the White House, 150 leaders of the U.S. Health care industry agreed to help Congress design and pass.

A year later, the law passed both houses of the Congress without any Republican support, and was signed by President Obama. At that point, the Republican establishment declared it unconstitutional, and every elected Republican vowed to stop its implementation in every state they controlled. The Republicans in Congress vowed to Repeal and Replace it, but could not agree on a replacement. The U. S. Supreme Court found it constitutional.  On a parallel track Congressional Republicans worked to Defund and Delay its implementation.


Which brings us to the sorry state of current affairs.  The national party of "conservatives" claimed Obamacare violates their "conservative" principles. They have managed to convince many Americans that the new law, not the extraordinary cost of our health care (twice the OECD average for less health), is the biggest spending problem they face.  Elected Republicans at the state level have done everything they can to throw sand in the gears of Medicaid expansion and the tax subsidies that come with the introduction of consumer choice health insurance exchanges; so they can point to the "glitches" in launching an electronic market place as, what Speaker Boehner calls, "an unmitigated disaster".

A national disaster which justifies shutting down the national government.  As we have recently discovered,  see the NYT article here, this was a plot hatched shortly after the 2012 elections by, among others, my old friend, Reagan Attorney General Ed Meese, and his buddies, the billionaire Koch brothers. With the help of all the usual suspects from former Sen. Jim DeMint and Heritage Foundation to former Republican leader Dick Armey and Freedom Works.  This campaign is now in the "blame the shutdown on the President who refuses to negotiate with us" phase.


Consider the fact that Republicans on the many committees of health policy jurisdiction in Congress have never been willing to negotiate improvements.  Their best known "improvement" is a $30 billion tax cut over ten years for one industry.  Medical devices. They cannot come up with off-setting savings without shifting the $30 billion to the rest of the health system including health care patients. The device industry resists any alternative, like public financing of value-based medical devices.

It would be a serious mistake for the President to negotiate a delay of or changes in the law under the national economic crisis conditions Republicans have created.  There are reasonable Republicans in the Senate and in the House and among the Republican Governors with whom the White House has already engaged and will continue to engage on this subject.  It is up to Speaker Boehner and his leadership team to do what Mitch McConnell and the majority of Republicans in the Senate did last week. Provide some realistic leadership.

Cut a deal on the FY 2014 budget and the debt ceiling in exchange for the President's commitment to engage over the next eight months on entitlement, tax, and health policy reform. We all know it's an election year and Republicans in the House have pinned their re-election plans on defeating Obamacare.  In the current partisan political environment, and with public confidence in Congress at historic lows, it looks impossible.

BUT Republicans need to start winning in Red non-Tea Party states and districts if they want to take the White House in 2016. They need to get beyond Tea Party Americans like South Dakota State Rep. Stace Nelson who wants to run for the U.S. Senate. "I am a Christian, a conservative, and a Republican, in that order," says he.  Focus on a broader conservative "changing the role of government" agenda.  God knows there are unlimited possibilities, starting with improving health and disability financing policy, and education and housing . . . . . .


I mean the non-Tea Party Republicans like John Kline and Eric Paulsen of Minnesota's 2nd and 3rd congressional districts. Minnesota healthcare leaders want to implement health reform, get the politics out of it asap, and they want Republicans in Congress to work with Democrats to improve the law not kill it. Kline and Paulsen supposedly represent about 75% of the House Republicans while Michele Bachmann represents the 25%. They know they can't successfully repeal Obamacare while Obama is President.  They hope it fails in the implementation because with it goes the taxes that help support it like the medical device tax and the Cadillac insurance benefits tax. They like to blame all the problems that have beset Washington since 2009 on an intransigent President who they say has plenty of time for golf but not for them.


House Agriculture Committee Chair Frank Lucas (R-OK) is a veteran house member and a more than capable chair of his committee where he works with former Democratic Chair Colin Peterson of Minnesota's 7th Congressional District.  Like John Boehner and other veteran Republicans, he has borne the brunt of the Tea Party attack on federal spending.  In this case, on the Agriculture Re-Authorization Act from which his colleagues already stripped all funding for nutrition programs (food stamps). House Republicans say this will "make sure that the unemployed become self-sufficient."  Frank Lucas says, "I've gotten to the point where I can no longer gauge the House."


Nope.  Since the President and others start calling them out on this issue, some congressmen, mainly the doctors turned politicians, have come up with proposals.  Now the conservative think tanks are chipping in.  None will expand coverage. None go to fundamentals of systemic change except for the publicly-funded, high-deductible insurance system. Cong. Paul Ryan's reforms of Medicare and Medicaid have been pushed into a corner while he reestablishes his creds with Tea Party colleagues.


Of course.  Any genuine dialogue over the future of federal and state spending on income security policy can get you there.  In congressional parlance that's entitlement reform and tax reform.  Both are about "spending." Either through programs like Medicare, Medicaid, VA Health or TriCare.  Or through tax-preferred expenditures for private health insurance, health care, services, and corporate tax preference including taxation of not-for-profit corporations.

Privatization of public insurance programs like Medicare and Medicaid has already been tried. It works. Individuals and associations that benefit from the existing programs or tax policy will object.  That's why bi-partisan is the only way to go.


Because MN health care leaders support reform and the Democratic leaders of our state decided early on to implement the national health reform law, the state's health insurance industry and health care delivery system has had time to prepare for the new involvement of thousands in this new consumer choice health care marketplace.

Interestingly MN insurance plans have priced the Minneapolis-St. Paul marketplace as the lowest cost in the state.  And the southeastern MN marketplace served largely by the Mayo Clinic as the highest.  These factoids and many other interesting results of greater consumer involvement in much more transparent health care market places will begin the learning curve on which real value-based reform will take place here. And across the country.


The easily neglected step-child of health care reform - long-term care financing - has been once again given short shrift.  A Commission was appointed and an experienced Executive Director employed.  But it was given just a few months to come up with a solution that many of us have studied, debated, resolved to change, and failed for now about 30 years. This Commission failed by a 9-6 vote. Click here for the full report, and here for the alternate report.

We Americans are aging into our predictable disabilities at record speed.  Geriatricians and others who care deeply about us are trying to get the health system’s attention for just a few hours to demonstrate how much we could "bend the cost curve" if we simply tried one or more of the great solutions that have been kicked around for decades.


Reformers know that 75% of health care costs are in labor, not technology.  They know that the recent discovery of the information revolution and of performance data and improvement measures has finally reached the health care systems of this country.  So the old guild system of health and medical professions must change - fast. How?  What needs to change?  Professional standards?  Education?  Scope of practice laws? What?

The authors of Obamacare wisely provided for a national commission to go deep in these up-to-now controversial areas and make recommendations for policy change.  Dr. Peter Beurhaus of Vanderbilt University Medical Center, who just happens to be a doctoral graduate of the Minnesota State University, Mankato, School of Nursing, was named chair of the commission. And then the commission was defunded.


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