Health Reform Roadblocks

By Andy Miller
WebMD Guest Blogger

Eighty percent done.

That's what White House spokesman Robert Gibbs said last weekend about progress on legislation to revamp the nation's health care system. "We've got about 80% agreement," Gibbs said on Fox News Sunday. "We're still working on that last 20%."

That last 20% will be a hard slog. It's where the horse trading will be done and details sweated out. Where a deal may crumble -- or be watered down enough to be meaningless. Meanwhile, the political conflicts will percolate when Congress enters its August recess.

The broad agreement on reform includes requiring individuals to purchase health insurance and providing subsidies for lower-income people so they can afford it. And there's agreement on barring insurers from rejecting people with pre-existing medical conditions and not allowing them to charge higher premiums due to a person's health status.

Changing those insurance practices alone is a very important step, says Stuart Altman, a health policy expert at Brandeis University.

Show Me the Money
The hard part -- the final 20% -- breaks down this way:

Extending insurance coverage for up to 45 million uninsured won't come cheap – or easy.

Lawmakers have proposed a mix of ideas on how to pay the $1 trillion reform cost, and each, in turn, has drawn opposition. The House legislation introduced a surtax on the wealthiest Americans. Another proposal aims to end or cap the tax exemption on workers' health benefits paid by employers. More recently, a tax on insurers for more expensive -- sometimes referred to as "Cadillac'' or "gold-plated" -- benefit plans has surfaced.

A levy on sugary beverages, meanwhile, has gone nowhere. "That affects everybody – it ticks off too many people,'' says Dean Smith, a health care expert at the University of Michigan.

Much of the money is needed to subsidize coverage for the uninsured. But the more people who get subsidies, the greater the price tag. Will subsidies be available to people up to 300% of the poverty level ($66,150 for a family of four), or 400% ($88,200 for a family of four)? The influential, fiscally conservative Blue Dog Democrats have worked to lower the subsidy ceiling.

And a requirement that large employers provide insurance or pay a penalty -- fiercely opposed by business groups -- may not make the final cut. The Senate Finance Committee is working on an alternative to that mandate.

"It's impossible to do health reform without taxing someone,'' says Bill Custer, a health insurance expert at Georgia State University. A sunset provision on a new tax, he adds, could provide some political cover.

Overall, the money problem is the biggest potential deal-breaker for reform, Michigan's Smith says.

Get a Grip on Health Costs
U.S. health care spending rose 6.1% in 2007, a rate much higher than general inflation. And that increase was actually less than previous years.

There's consensus on trying to "bend the cost curve,'' but not how to accomplish it, says Stan Dorn, a senior research associate with the Urban Institute.

President Obama has pushed for an independent Medicare commission that would set payment policies for the huge government program. The panel could make politically unpopular decisions to control spending. "Medicare is going to go broke,'' says Altman. "What's bugging Obama is this Medicare problem.''

One line of attack is to transform the way that doctors are paid. Physicians typically get fees for each service they give to patients. That can lead to unnecessary tests and procedures – and higher costs. Reformers have pushed "bundled payments'' to doctors and hospitals, where, in Obama's words, ''you aren't paid for every single treatment ... but instead are paid for how you treat the overall disease."

Already, Dorn says, "there are islands of success, like the Mayo Clinic,'' where doctors are paid by salary. Reform legislation could test these ideas in pilot projects, then extend them more broadly, he says.

There's also a push to compare the effectiveness of medical treatments, medications, and devices to save money and improve quality of care.

None of these ideas, though, will deliver substantial savings in the short term.

How Does Government Fit In?
Much of the partisan wrangling centers on having a Medicare-like public insurance option to compete with health insurance companies. Obama himself has pushed a public plan to ''keep insurance companies honest.''

Republicans see it as a red-meat issue. They have argued a public option would run private insurance companies out of business and lead to a government-run health system. "The health insurance industry is one of the most regulated industries in America," said Sen. Jon Kyl (R-Ariz.) this week. "They don't need to be 'kept honest' by the government."

Some liberal Democrats say they would rebel at legislation that didn't include a public option. "Our votes won't be there if there isn't a public option," said Rep. Jerrold Nadler (D-N.Y.)

Altman of Brandeis says the public plan issue "has been a lightning rod,'' but also a distraction.

Meanwhile, a bipartisan group on the Senate Finance Committee is leaning toward a compromise: creating nonprofit health cooperatives that could compete locally with insurers for business.

Politics and Compromise
Obama and Democrats want a bipartisan bill, but Mitch McConnell (R-Ky.), the Senate minority leader, so far is skeptical. "The only thing bipartisan about the measure so far is the opposition to it," said McConnell.

The Senate Finance Committee is likely to produce a bill with the best hope for some GOP support.

A final bill -- if it gets that far -- may be a compendium of compromises to achieve support from some Republicans and the Blue Dog Democrats, though the result may fall quite short of universal health insurance coverage, Michigan's Smith says.

Still, there is widespread recognition that the health care system needs change, says Marilyn Moon, director of the health program at the American Institutes for Research. "There is an understanding that this problem will not fix itself.''


Sources: Fox News, "Transcript: Robert Gibbs on 'FNS'"; The New York Times, "Reach of Subsidies Is Critical Issue for Health Plan", "Hospital Savings: Salaries for Doctors, Not Fees"; The Associated Press, "Deal With 'Blue Dogs' Sets Up Health Care Vote", "Democrat Says Health Overhaul Needs GOP to Pass"; The Wall Street Journal, "Liberals Fear Losing Public-Plan Option"; Kaiser Health News, "Big Employers Could End Up Paying 'Cadillac' Tax", "Senate Committee's Reform Bill Could Cover 95% of Uninsured"; Health Affairs, "National Health Spending in 2007: Slower Drug Spending Contributes to Lowest Rate of Overall Growth Since 1998"; Stuart Altman, Sol C. Chaikin professor of national health policy, Brandeis University; Marilyn Moon, vice president and director of the health program at the American Institutes for Research; Dean Smith, professor and senior associate dean for administration of the University of Michigan School of Public Health; Stan Dorn, senior research associate, the Urban Institute; Bill Custer, associate professor, Institute of Health Administration, Georgia State University.

Health Care Reform: Now or Never?

By Andy Miller
WebMD Guest Blogger


Midnight, New Year's Eve, 2009.

Conventional wisdom says that if major health care reform hasn't passed Congress by then, it may not be revived for years, if at all.

Why is it now or (maybe) never?

This year offers an unusual alignment of stars that makes health reform's chances better than at any time since 1993, when Bill and Hillary Clinton launched an overhaul plan that later fizzled in Congress.

The confluence of favorable 2009 factors starts with political realities.

President Obama, a popular leader in his first year in office, has robust Democratic majorities in both houses of Congress. He clearly upped the stakes in recent days, and again in a televised news conference Wednesday night, on the importance of getting health reform done now.

But if major legislation isn't approved this year, Congress enters an election year in 2010, when it typically avoids the big-idea bills. The next year begins a presidential election cycle, notes Julius Hobson, senior adviser on health care for Bryan Cave, a law firm. "It's now or never -- that's why the president is pressing Congress,'' Hobson says.

Secondly, unlike during the Clintons' flameout, major medical stakeholders have stepped up to support reform efforts.

That includes the health insurance industry. Insurers have agreed to not reject applicants due to pre-existing medical conditions, as long as everyone is required to have coverage. The industry behind the potent anti-reform "Harry and Louise'' ads in the '90s is now on board, albeit with an asterisk: Health insurers fiercely oppose a public insurance option run by the government.

The American Medical Association has thrown its support to the House Democrats' plan, though not all physicians would agree. Hospitals have agreed to some concessions to help pay for health reform, as has the pharmaceutical industry.

And retail giant Wal-Mart, whose health benefits plans have drawn strong criticism in the past, has endorsed a requirement that employers provide insurance to workers.

"There is tremendous momentum,'' says Ken Thorpe, an Emory University health policy expert. "The stage is set.''

While this coalition has given reform a big boost, the interest groups also have objected to certain proposals. "Everybody wants reform,'' Hobson says. "Everybody has something they like, but everybody has something they dislike, too.''

Reform opponents, meanwhile, appear to be gathering strength. Bradley Blakeman, a Republican strategist, said in response to Obama's news conference, "The president is selling a product that no one wants. He is desperate and refuses to pull the plug on health care legislation that even Democrats concede is DOA.''

Conservative "Blue Dog" Democrats are balking at proposed new taxes and inadequate health cost containment in various reform plans.

And polls show that public confidence on health reform is slipping. CNN released a poll of polls Wednesday that found less than half the country approves of how Obama is handling the issue.

Obama targeted those public perceptions Wednesday night -- and the issue of how it affects the average taxpayer: the ''What's in this for me?'' question.

"This is not just about the 47 million Americans who don't have any health insurance at all,'' he said. "Reform is about every American who has ever feared that they may lose their coverage if they become too sick, or lose their job, or change their job. It's about every small business that has been forced to lay off employees or cut back on their coverage because it became too expensive … If we do not control these costs, we will not be able to control our deficit. If we do not reform health care, your premiums and out-of-pocket costs will continue to skyrocket. If we don't act, 14,000 Americans will continue to lose their health insurance every single day.''

He returned later to that pocketbook problem. "Premiums for families that have health insurance have doubled over the last 10 years,'' he said. "They've gone up three times faster than wages … Employers are going to put more and more costs on employees or they're just going to stop providing health care altogether."

Other health care statistics are worsening, too. A Gallup poll released Wednesday found 16% of American adults -- one in six -- are uninsured. That's up from an average of 14.8% among those interviewed in 2008.

The U.S. spends much more on health care than other countries, yet the medical results are worse than many nations, Obama also noted.

His push on health reform undoubtedly will continue through the summer and into the fall, to get a bill this year. "Everyone recognizes that inaction will make all the problems infinitely worse,'' Hobson says.

Still, E. Richard Brown, director of the UCLA Center for Health Policy Research and an expert on health reform, says 2009 is not the last chance for reform.

It could come together again in 2011, if defeated this year, Brown says. "If we don't get it done now, the same pressures will be there in two years.''

Yet Brown also sees 2009 as a prime opportunity. "It's an opportunity we cannot afford to pass up. I do think this moment is a rare moment, an alignment of different interest groups. ''

SOURCES: Julius Hobson, senior policy adviser, Bryan Cave LLP; Ken Thorpe, professor, Rollins School of Public Health, Emory University; E. Richard Brown, director, UCLA Center for Health Policy Research; New York Times web site; CNN web site; Politico, The Arena; American Medical Association; California Healthline web site; Gallup Poll.

Growing Girth: Obesity in America

There's no sign of a slowdown in obesity, with about 26% of U.S. adults being obese in 2008, according to the CDC's latest obesity statistics, which were released today.

But if you take a close look at that figure, you might see a little wiggle room.

The CDC calculated adult obesity rates based on phone interviews with more than 400,000 U.S. adults who gave their height and weight as part of a national health survey in 2008.

Be honest -- if you were called for that survey, how accurate would you be in reporting your stats? Would you fudge it a smidge -- and when was the last time you got on a scale to check?

Even if you know your numbers to the ounce and inch, there's a chance that BMI (body mass index), which relates height to weight, doesn't do you justice.

For instance, BMI doesn't show how much of your weight is muscle, how much is fat, and where that fat is distributed. Having a large waist (over 40 inches for men; over 35 inches for women) may put you at higher risk of type 2 diabetes, high blood pressure, high cholesterol, and heart disease. That's why some health experts like checking waist measurement or waist-to-hip ratio, instead of relying on BMI.

Plus, there is debate about whether weight is really what matters, or whether fitness -- regardless of size -- is more important.

In August 2008, researchers reported that nearly a third of obese people aren't at high risk of diabetes or heart disease. That same study showed that being skinny doesn't mean you're a low risk of those conditions. And in 2007, Italian researchers coined the term "normal-weight obese" to describe people who weren't overweight but had a high percentage of body fat.

But in April 2008, other researchers reported that being physically active doesn't totally make up for being overweight.

Stigma about obesity is also important. Too often, weight gets cast in "good" or "bad" terms, though it's a lot more complex than just personal choices, as experts from Mississippi -- the nation's fattest state -- recently told WebMD.

The CDC's new report isn't about all that. It's a statistical snapshot, the latest in a long line of similar reports.

What do you think it will take for the U.S. to start to curb obesity? How does the term "obesity" make you feel -- especially if you're one of the millions of Americans in that category -- and are your biggest weight challenges about your personal choices, your environment (like whether you can afford healthy food), or how people treat you?

Diprivan in Michael Jackson's Medicine Cabinet?

While it may be of no surprise to find out that another fallen star has a wide array of drugs in his medicine cabinet, I was still quite shocked about the reports of Diprivan found in Michael Jackson's home.

If true, I can't think of one reason to have Diprivan -- also called propofol -- in your home.

Diprivan is an injectable drug used to either put someone to sleep before surgery or sedate and keep someone calm on a breathing machine in the hospital.

It's an extremely strong sedative and one that causes unconsciousness and often stops breathing -- that's why it's only given to people on a ventilator breathing machine.

Reports have suggested that Jackson suffered from insomnia but Diprivan is not used (or at least certainly shouldn't be used) to treat insomnia -- or any other medical condition.

Diprivan acts very quickly in the body and also leaves the body very quickly. Someone would lose consciousness within seconds and wake up within 10 to 15 minutes after receiving a shot of Diprivan. In the hospital, a continuous infusion is usually given in the vein and it may take the person an hour or so to awaken.

There have been reports of other drugs in the Jackson home as well, including Demerol and Oxycontin. Both of these are narcotic painkillers and are used to treat severe forms of pain.

Oxycontin has received quite a bit of attention in recent years due to the high rate of reported abuse. More than 12% of 18- to 25- year olds reported using the drug for nonmedical reasons in 2006, according to federal figures.

The particularly troubling thing about all of these drugs in the Michael Jackson case is that they all can slow -- and even stop -- breathing if too much is taken.

It's not known at this point if Diprivan -- or any other drug -- contributed to Jackson's death. However, reports were that he was found not breathing but had a slight pulse. All these drugs could have slowed and potentially stopped breathing, which would have eventually -- within a few minutes -- stopped the heart.

And then if you combine 2 or more of these drugs, the risk of an overdose and death goes exponentially higher. The much awaited toxicology results should be ready in a few weeks and hopefully that will solve the mystery of Jackson's death.