Insuring Resources Commentary:
As President Obama has reiterated throughout this process, ad nauseum at times, the insurance companies no longer have a free ride. Or at least in paraphrasing-- he has used language like that. And perhaps its true, not in Wisconsin, but perhaps for most of the country. In Wisconsin, I'd bet that little will change comparatively. Through our insurers and our Medicaid program we'll still cover more residents than almost every other state and we'll still regulate insurers like its a matter of life and death, because here it always has been serious business. In Wisconsin we'll continue to have insurers and providers push the envelope toward better quality and efficient care, because, that's what we do.
So bring on the scrutiny, Wisconsin will continue to excel and we'll continue to light the way for states like Alabama, Louisiana, and Georgia. Regulators, the state Medicaid programs, and domiciled insurers alike are scared stiff in the South, and they should be. Ever wonder why they are screaming and suing the federal gov't saying this federal health reform and the individual mandate are unconstitutional? Because down there insurance regulations and Medicaid coverage are virtually non-existent. The PPACA ends that and starts an era of accountability.
But yes, I agree with Milliman and their analysis that follows below. Scrutiny is going to be intense and is yet another reason I'm upset with Wisconsin's Congressional delegation. Now, Rep. Ron Kind (D-LaCrosse) and Sen. Herb Kohl have tried to add a Wisconsin flavor to health care reform. For the most part, I believe, they tried diligently but failed to convince their colleagues. Congress had a chance to expand our quality and efficient care processes nationwide, but didn't.
Sen. Feingold, Rep's. Baldwin, Obey, Petri, Sensenbrenner, Kagen and Moore were virtually non-existent in the debate and ideas process. Rep. Ryan in contrast has plenty of ideas and has provided a thoughtful counter proposal to the process. Although I disagree with most of Ryan's HSA and tax credit ideas I applaud his effort.
As for the Milliman analysis below I've highlighted in bold the portions I want you to pay the most attention to...... but again we're way ahead of the game.
-------------- --------- --------
Milliman: Expect The PPACA Package To Lead To Intense Regulatory Scrutiny
The health insurance industry will face intense regulatory scrutiny due to the new Patient Protection and Affordable Care Act and its companion, the Health Care and Education Reconciliation Act of 2010, according to Milliman Inc.
PPACA was created by H.R. 3590 and HCERA, which was signed into law today, was created by H.R. 4872.
“While new regulation does not necessarily go into effect immediately, it is clear that health insurers now face increased scrutiny and a new layer of regulatory complexity,” researchers at Milliman, Seattle, write in an analysis of the new laws. “Health plans will have to focus on minimum loss ratios and administrative efficiency and will have to balance challenging cost dynamics against the need for affordable policies.”
PPACA would create a new system of health insurance exchanges that would help individuals and small businesses buy subsidized, standardized packages of health benefits. The new exchanges will change the level competition, the researchers say. The effects will be different in each state, and they may include reduction of distribution costs and potentially tempering of rate increases in the individual and small group insurance markets, the researchers add.
Also, due to an influx of an estimated 30 plus million new people into the insurance and Medicaid markets, “insurers will face unique pricing and risk-mix challenges,” the researchers write.
Some of the other considerations the researchers have identified:
- Cost effectiveness will be central, as in provider risk-sharing methods and evidence-based medicine. However, the researchers also note that “a new emphasis on prevention has uncertain cost implications.”
- New requirements—such as minimum loss ratios for insurers and the new tax on health insurers that sell relatively expensive "Cadillac plans," which is set to take effect in 2018--will affect plan design.
- Medicare Advantage plans will become less attractive to consumers and carriers, and the plans will face difficult questions about efficiency and benefits mix.
- Enterprise risk management will become essential.
- Strategic considerations will be influenced by local dynamics, including geographic cost variation and the existing regulatory environment in each state.
Tuesday, March 30, 2010
Friday, March 26, 2010
Wisconsin Physicians Weigh in on the PPACA
Insuring Resources Commentary:
So what do Wisconsin physicians think of the newly enacted health insurance reform law of the land- the Patient Protection Affordable Care Act (PPACA)? Well, for the most part they like it, but they too, would like to see more emphasis on quality and efficiency. That speaks volumes doesn't it? Please see the statement below from the Wisconsin Medical Society.
I hope readers don't see this is as self-serving when I post opinions that agree with my take on this legislation. If you look back at the beginning of this blog in August 2009 you'll see that I have been a consistent advocate for payment reform and for Wisconsin's quality and efficient care.
As I've noted all along Wisconsin is in a pretty good place overall when it comes to our health care and health insurance systems.
1) We have numerous health plans that focus on quality and efficiency that are seen as national models.
2) We have a very low number of uninsured persons due to Wisconsin's BadgerCare program which provides greater Medicaid access to low-income individuals than the PPACA.
3) We have perhaps the strongest set of proactive insurance regulations in the nation.
4) We possess additional safety net programs like our Health Insurance Risk Sharing Program (www.hirsp.org) and Medicaid Purchase Plan (http://dhs.wi.gov/medicaid/Publications/p-10071.pdf) that together cover more than 30,000 Wisconsinites.
Wisconsin is a national model for how reform should be done. Its a pity our Congressional leaders couldn't expand Wisconsin's models nationwide.
********** ********** ***********
Reaction to health care reform legislation mixed
Madison (March 22, 2010)—“Members of the Wisconsin Medical Society have advocated for access to high quality health care for all patients in Wisconsin since the organization’s inception in 1841. Yesterday’s passage of health system reform (Patient Protection Affordable Care Act) by the U.S. House of Representatives extends coverage to millions of Americans who are currently uninsured, eliminates both lifetime caps on coverage and insurers’ ability to deny coverage for children because of pre-existing conditions. These are definitely steps in the right direction.
“At the same time, many issues remain unresolved, such as national lawsuit reform and the permanent fix of Medicare’s flawed payment formula, which penalizes cost-efficient states such as Wisconsin and threatens access to care for our seniors.
“Wisconsin physicians have been recognized nationally for providing the highest quality care at a low cost, and we support payment efforts such as those championed by Rep. Ron Kind that focus on value, not volume. Because Wisconsin’s health care safety net is already severely stressed, we are concerned about how this legislation and the subsequent reconciliation bill will impact the delivery of care in our state.”
Statement attributable to Robert Jaeger, MD, President, Wisconsin Medical Society.
So what do Wisconsin physicians think of the newly enacted health insurance reform law of the land- the Patient Protection Affordable Care Act (PPACA)? Well, for the most part they like it, but they too, would like to see more emphasis on quality and efficiency. That speaks volumes doesn't it? Please see the statement below from the Wisconsin Medical Society.
I hope readers don't see this is as self-serving when I post opinions that agree with my take on this legislation. If you look back at the beginning of this blog in August 2009 you'll see that I have been a consistent advocate for payment reform and for Wisconsin's quality and efficient care.
As I've noted all along Wisconsin is in a pretty good place overall when it comes to our health care and health insurance systems.
1) We have numerous health plans that focus on quality and efficiency that are seen as national models.
2) We have a very low number of uninsured persons due to Wisconsin's BadgerCare program which provides greater Medicaid access to low-income individuals than the PPACA.
3) We have perhaps the strongest set of proactive insurance regulations in the nation.
4) We possess additional safety net programs like our Health Insurance Risk Sharing Program (www.hirsp.org) and Medicaid Purchase Plan (http://dhs.wi.gov/medicaid/Publications/p-10071.pdf) that together cover more than 30,000 Wisconsinites.
Wisconsin is a national model for how reform should be done. Its a pity our Congressional leaders couldn't expand Wisconsin's models nationwide.
********** ********** ***********
Reaction to health care reform legislation mixed
Madison (March 22, 2010)—“Members of the Wisconsin Medical Society have advocated for access to high quality health care for all patients in Wisconsin since the organization’s inception in 1841. Yesterday’s passage of health system reform (Patient Protection Affordable Care Act) by the U.S. House of Representatives extends coverage to millions of Americans who are currently uninsured, eliminates both lifetime caps on coverage and insurers’ ability to deny coverage for children because of pre-existing conditions. These are definitely steps in the right direction.
“At the same time, many issues remain unresolved, such as national lawsuit reform and the permanent fix of Medicare’s flawed payment formula, which penalizes cost-efficient states such as Wisconsin and threatens access to care for our seniors.
“Wisconsin physicians have been recognized nationally for providing the highest quality care at a low cost, and we support payment efforts such as those championed by Rep. Ron Kind that focus on value, not volume. Because Wisconsin’s health care safety net is already severely stressed, we are concerned about how this legislation and the subsequent reconciliation bill will impact the delivery of care in our state.”
Statement attributable to Robert Jaeger, MD, President, Wisconsin Medical Society.
Thursday, March 25, 2010
Health care costs out of control - a cartoon
Insuring Resources Commentary:
I like to post viepoints from others, particularly when they agree with mine.
* * * * * * * * * * * * *
Health care ambulance is out of (cost) control
From The Capital Times, Madison WI
Cartoon and opnion by Phil Hands
Wednesday, March 24, 2010 10:33 pm |
I don’t usually draw cartoons on national issues, but I thought this cartoon did a pretty good job of summing up my feelings on our new health care bill.
Don't get me wrong, I'm glad the Democrats passed a health care reform bill.
It's good that insurance company's can no longer cry "pre-existing condition” and drop paying customers as soon as they get sick. I'm glad kids won't be denied insurance on the basis of pre-existing conditions anymore, and it's good that millions more Americans will have access to health insurance.
But for as massive as this bill is, there is very little in it that will actually make health care cost less and that is the crisis we are facing. Health care is too darn expensive, whether or not you have insurance to pay for it.
This bill needed to include serious tort reform and incentives to end the obscene practice of paying doctors by the amount of tests they order and not by the health of their patients. If you could somehow add provisions like these the bill, it would have been a lot better.
Wednesday, March 24, 2010
Lean Process in Practice
Insuring Resources Commentary:
I found the article included below on GE Healthcare's website. It details how Brigham and Women's Hospital in Boston, MA, implemented Lean tools in their clinical laboratory. These processes streamlined their laboratory operations and reduced wait times for lab tests.
The article states:
"The effort brought about rapid and significant improvements in key measures of quality and consistency. For example, in just six months, average wait times in phlebotomy decreased from 14-17 minutes to 4-5 minutes. In addition processing in the laboratory for specific tests (see table) now meets cycle time goals more than 90percent of the time."
This was accomplished by "Eliminating non-value-added tasks, such as duplicative sample container labeling, and "Reconfiguring one station that had been reserved for patients susceptible to fainting by installing a chair that can be used for all patients."
There's no information in the article about cost savings, but reduced wait times and elimination of non-value added tasks must achive some savings.
----- ------ ------ ------
LEAN TOOLS IN THE CLINICAL LABORATORY
Rapid-improvement events enhance laboratory performance
As plans advanced to automate the Clinical Laboratories, Brigham and Women’s Hospital faced growing specimen volumes in constrained space amid concerns about technician retention and recruitment.
The hospital staff worked with the Performance Solutions consulting group of GE Healthcare and the hospitals’ Center for Clinical Excellence as a part of a Lean Skills Transfer engagement to assess laboratory performance and design process improvements at all key steps in the value stream, from the time the patient arrives to provide a specimen until the lab report is complete.
The effort brought about rapid and significant improvements in key measures of quality and consistency. For example, in just six months, average wait times in phlebotomy decreased from 14-17 minutes to 4-5 minutes. In addition processing in the laboratory for specific tests (see table) now meets cycle time goals more than 90percent of the time.
“While our volumes were growing, we were also planning for laboratory automation,” says Dr. Milenko Tanasijevic, the Director of Clinical Laboratories. “We wanted to optimize workflow first, rather than automate suboptimal processes. Lean offered a unique set of tools that allowed our staff to break processes down into discrete steps to discern between non-value-added and critical, value-added steps.
“We achieved significant improvements in patient satisfaction, reduced wait times in
phlebotomy, streamlined processes and shortened laboratory turnaround time.”
Streamlining phlebotomy
A team made up of Clinical Excellence process improvement leaders, laboratory staff, and GE lean experts conducted a value stream mapping session in November 2007. Then they performed five kaizen rapid-improvement events over the next six months, each focusing on specific process areas.
One kaizen addressed wait times in the outpatient phlebotomy clinic, a small space with five drawing stations. Patients arrive without appointments and are seen on a first-come, first-served basis. Wait times were inconsistent: some patients were seen almost on arrival, but others waited 30 to 40 minutes, or longer.
The analysis found an imbalance between demand and staffing, especially early in the day. Patients arriving before the actual opening time caused a backlog that had a ripple effect lasting into the morning. To address that, the team decided to open the center 30 minutes earlier and increase staffing during the morning hours.
The kaizen also identified ways to manage patients’ expectations and improve patient flow. A “take a number” system allowed patients to anticipate their wait time. Those patients needing urine testing had their specimens collected in the interval between arrival and blood draws.
The team also introduced a flow coordinator role, responsible for escorting patients from the waiting area to the drawing stations, instead of having the phlebotomists walk to the waiting area and call for patients. The team also took several steps to make the phlebotomists’ work more efficient. These included:
> Eliminating non-value-added tasks, such as
duplicative sample container labeling.
> Reconfiguring one station that had been reserved
for patients susceptible to fainting by installing a
chair that can be used for all patients.
Improving laboratory workflow Four kaizens addressed various aspects of laboratory sample handling and processing workflow. The critical metrics included cycle time from logging of the specimen to entry of the result to the Laboratory Information System, measured for average time and percent compliance with cycle time goals.
The team made a variety of changes in staffing and procedures to eliminate issues that caused processing bottlenecks. Data gathered during the process made it possible to optimize staff levels to meet demand.
In addition, instead of having individual technicians perform all specimen processing steps, the Lean participants devised a team-based approach, reducing technician travel distance significantly. The group also reconfigured workspace layouts and co-located equipment for efficiency.
Sustaining momentum
Using lean tools to make processes more visible to staff and patients was a key tenet in working across the value stream. Surveys showed that phlebetomy patient satisfaction increased by more than 20 percentage points after the kaizen improvements.
The benefits of Lean and the kaizen have lasted well beyond the original engagement. For example, after the first 5S project, the hospital staff undertook two more such activities in other areas of the chemistry laboratory.
“Lean and the kaizens have enabled us to brainstorm solutions and actually go out and test them in a real-time mode,” says Tanasijevic. “It shortened the interval from issue identification and idea generation to trying out proposed changes in the laboratory.”
Dorothy Goulart, MS, RN, Director of Performance Improvement with the Center for Clinical Excellence, observes, “We have had success with facilitating design sessions
and involving staff and managers in problem solving, but we were challenged to consistently implement and sustain changes. By combining change acceleration, Lean and kaizen event approaches, we have been able to strengthen our institution’s ability to achieve tangible results while building new capabilities and knowledge.”
I found the article included below on GE Healthcare's website. It details how Brigham and Women's Hospital in Boston, MA, implemented Lean tools in their clinical laboratory. These processes streamlined their laboratory operations and reduced wait times for lab tests.
The article states:
"The effort brought about rapid and significant improvements in key measures of quality and consistency. For example, in just six months, average wait times in phlebotomy decreased from 14-17 minutes to 4-5 minutes. In addition processing in the laboratory for specific tests (see table) now meets cycle time goals more than 90percent of the time."
This was accomplished by "Eliminating non-value-added tasks, such as duplicative sample container labeling, and "Reconfiguring one station that had been reserved for patients susceptible to fainting by installing a chair that can be used for all patients."
There's no information in the article about cost savings, but reduced wait times and elimination of non-value added tasks must achive some savings.
----- ------ ------ ------
LEAN TOOLS IN THE CLINICAL LABORATORY
Rapid-improvement events enhance laboratory performance
As plans advanced to automate the Clinical Laboratories, Brigham and Women’s Hospital faced growing specimen volumes in constrained space amid concerns about technician retention and recruitment.
The hospital staff worked with the Performance Solutions consulting group of GE Healthcare and the hospitals’ Center for Clinical Excellence as a part of a Lean Skills Transfer engagement to assess laboratory performance and design process improvements at all key steps in the value stream, from the time the patient arrives to provide a specimen until the lab report is complete.
The effort brought about rapid and significant improvements in key measures of quality and consistency. For example, in just six months, average wait times in phlebotomy decreased from 14-17 minutes to 4-5 minutes. In addition processing in the laboratory for specific tests (see table) now meets cycle time goals more than 90percent of the time.
“While our volumes were growing, we were also planning for laboratory automation,” says Dr. Milenko Tanasijevic, the Director of Clinical Laboratories. “We wanted to optimize workflow first, rather than automate suboptimal processes. Lean offered a unique set of tools that allowed our staff to break processes down into discrete steps to discern between non-value-added and critical, value-added steps.
“We achieved significant improvements in patient satisfaction, reduced wait times in
phlebotomy, streamlined processes and shortened laboratory turnaround time.”
Streamlining phlebotomy
A team made up of Clinical Excellence process improvement leaders, laboratory staff, and GE lean experts conducted a value stream mapping session in November 2007. Then they performed five kaizen rapid-improvement events over the next six months, each focusing on specific process areas.
One kaizen addressed wait times in the outpatient phlebotomy clinic, a small space with five drawing stations. Patients arrive without appointments and are seen on a first-come, first-served basis. Wait times were inconsistent: some patients were seen almost on arrival, but others waited 30 to 40 minutes, or longer.
The analysis found an imbalance between demand and staffing, especially early in the day. Patients arriving before the actual opening time caused a backlog that had a ripple effect lasting into the morning. To address that, the team decided to open the center 30 minutes earlier and increase staffing during the morning hours.
The kaizen also identified ways to manage patients’ expectations and improve patient flow. A “take a number” system allowed patients to anticipate their wait time. Those patients needing urine testing had their specimens collected in the interval between arrival and blood draws.
The team also introduced a flow coordinator role, responsible for escorting patients from the waiting area to the drawing stations, instead of having the phlebotomists walk to the waiting area and call for patients. The team also took several steps to make the phlebotomists’ work more efficient. These included:
> Eliminating non-value-added tasks, such as
duplicative sample container labeling.
> Reconfiguring one station that had been reserved
for patients susceptible to fainting by installing a
chair that can be used for all patients.
Improving laboratory workflow Four kaizens addressed various aspects of laboratory sample handling and processing workflow. The critical metrics included cycle time from logging of the specimen to entry of the result to the Laboratory Information System, measured for average time and percent compliance with cycle time goals.
The team made a variety of changes in staffing and procedures to eliminate issues that caused processing bottlenecks. Data gathered during the process made it possible to optimize staff levels to meet demand.
In addition, instead of having individual technicians perform all specimen processing steps, the Lean participants devised a team-based approach, reducing technician travel distance significantly. The group also reconfigured workspace layouts and co-located equipment for efficiency.
Sustaining momentum
Using lean tools to make processes more visible to staff and patients was a key tenet in working across the value stream. Surveys showed that phlebetomy patient satisfaction increased by more than 20 percentage points after the kaizen improvements.
The benefits of Lean and the kaizen have lasted well beyond the original engagement. For example, after the first 5S project, the hospital staff undertook two more such activities in other areas of the chemistry laboratory.
“Lean and the kaizens have enabled us to brainstorm solutions and actually go out and test them in a real-time mode,” says Tanasijevic. “It shortened the interval from issue identification and idea generation to trying out proposed changes in the laboratory.”
Dorothy Goulart, MS, RN, Director of Performance Improvement with the Center for Clinical Excellence, observes, “We have had success with facilitating design sessions
and involving staff and managers in problem solving, but we were challenged to consistently implement and sustain changes. By combining change acceleration, Lean and kaizen event approaches, we have been able to strengthen our institution’s ability to achieve tangible results while building new capabilities and knowledge.”
Monday, March 22, 2010
More Details on Final Health Insurance Reform Bill
Insuring Resources Commentary:
I will now refrain from calling this a health care reform bill. This is health insurance reform and therefore is an ugly stepsister of true reform. This reform does not provide the incentives we need for quality and efficiency. Therefore, I do not believe it will rein in health care costs. Opportunity Lost.
The insurance reforms listed below are essential, there is no question about that. But the opportunity to make health care and health insurance affordable has been botched. The efficiency and quality incentives apply only to Medicare, which covers about 15% of Americans.
------------------
This list was posted by CBS News
Cost: $940 billion over ten years.
Deficit:
Would reduce the deficit by $143 billion over the first ten years. That is an updated CBO estimate. Their first preliminary estimate said it would reduce the deficit by $130 billion over ten years. Would reduce the deficit by $1.2 billion dollars in the second ten years.
Coverage:
Would expand coverage to 32 million Americans who are currently uninsured.
Health Insurance Exchanges:
The uninsured and self-employed would be able to purchase insurance through state-based exchanges with subsidies available to individuals and families with income between the 133 percent and 400 percent of poverty level.
Separate exchanges would be created for small businesses to purchase coverage -- effective 2014.
Funding available to states to establish exchanges within one year of enactment and until January 1, 2015.
Subsidies:
Individuals and families who make between 100 percent - 400 percent of the Federal Poverty Level (FPL) and want to purchase their own health insurance on an exchange are eligible for subsidies. They cannot be eligible for Medicare, Medicaid and cannot be covered by an employer. Eligible buyers receive premium credits and there is a cap for how much they have to contribute to their premiums on a sliding scale.
Federal Poverty Level for family of four is $22,050
Paying for the Plan:
Medicare Payroll tax on investment income -- Starting in 2012, the Medicare Payroll Tax will be expanded to include unearned income. That will be a 3.8 percent tax on investment income for families making more than $250,000 per year ($200,000 for individuals).
Excise Tax -- Beginning in 2018, insurance companies will pay a 40 percent excise tax on so-called "Cadillac" high-end insurance plans worth over $27,500 for families ($10,200 for individuals). Dental and vision plans are exempt and will not be counted in the total cost of a family's plan.
Tanning Tax -- 10 percent excise tax on indoor tanning services.
Medicare:
Closes the Medicare prescription drug "donut hole" by 2020. Seniors who hit the donut hole by 2010 will receive a $250 rebate.
Beginning in 2011, seniors in the gap will receive a 50 percent discount on brand name drugs. The bill also includes $500 billion in Medicare cuts over the next decade.
Medicaid:
Expands Medicaid to include 133 percent of federal poverty level which is $29,327 for a family of four.
Requires states to expand Medicaid to include childless adults starting in 2014.
Federal Government pays 100 percent of costs for covering newly eligible individuals through 2016.
Illegal immigrants are not eligible for Medicaid.
Insurance Reforms:
Six months after enactment, insurance companies could no longer deny children coverage based on a preexisting condition.
Starting in 2014, insurance companies cannot deny coverage to anyone with preexisting conditions.
Insurance companies must allow children to stay on their parent's insurance plans through age 26.
Abortion:
The bill segregates private insurance premium funds from taxpayer funds. Individuals would have to pay for abortion coverage by making two separate payments, private funds would have to be kept in a separate account from federal and taxpayer funds.
No health care plan would be required to offer abortion coverage. States could pass legislation choosing to opt out of offering abortion coverage through the exchange.
**Separately, anti-abortion Democrats worked out language with the White House on an executive order that would state that no federal funds can be used to pay for abortions except in the case of rape, incest or health of the mother. (Read more here)
Individual Mandate:
In 2014, everyone must purchase health insurance or face a $695 annual fine. There are some exceptions for low-income people.
Employer Mandate:
Technically, there is no employer mandate. Employers with more than 50 employees must provide health insurance or pay a fine of $2000 per worker each year if any worker receives federal subsidies to purchase health insurance. Fines applied to entire number of employees minus some allowances.
Immigration:
Illegal immigrants will not be allowed to buy health insurance in the exchanges -- even if they pay completely with their own money.
I will now refrain from calling this a health care reform bill. This is health insurance reform and therefore is an ugly stepsister of true reform. This reform does not provide the incentives we need for quality and efficiency. Therefore, I do not believe it will rein in health care costs. Opportunity Lost.
The insurance reforms listed below are essential, there is no question about that. But the opportunity to make health care and health insurance affordable has been botched. The efficiency and quality incentives apply only to Medicare, which covers about 15% of Americans.
------------------
This list was posted by CBS News
Cost: $940 billion over ten years.
Deficit:
Would reduce the deficit by $143 billion over the first ten years. That is an updated CBO estimate. Their first preliminary estimate said it would reduce the deficit by $130 billion over ten years. Would reduce the deficit by $1.2 billion dollars in the second ten years.
Coverage:
Would expand coverage to 32 million Americans who are currently uninsured.
Health Insurance Exchanges:
The uninsured and self-employed would be able to purchase insurance through state-based exchanges with subsidies available to individuals and families with income between the 133 percent and 400 percent of poverty level.
Separate exchanges would be created for small businesses to purchase coverage -- effective 2014.
Funding available to states to establish exchanges within one year of enactment and until January 1, 2015.
Subsidies:
Individuals and families who make between 100 percent - 400 percent of the Federal Poverty Level (FPL) and want to purchase their own health insurance on an exchange are eligible for subsidies. They cannot be eligible for Medicare, Medicaid and cannot be covered by an employer. Eligible buyers receive premium credits and there is a cap for how much they have to contribute to their premiums on a sliding scale.
Federal Poverty Level for family of four is $22,050
Paying for the Plan:
Medicare Payroll tax on investment income -- Starting in 2012, the Medicare Payroll Tax will be expanded to include unearned income. That will be a 3.8 percent tax on investment income for families making more than $250,000 per year ($200,000 for individuals).
Excise Tax -- Beginning in 2018, insurance companies will pay a 40 percent excise tax on so-called "Cadillac" high-end insurance plans worth over $27,500 for families ($10,200 for individuals). Dental and vision plans are exempt and will not be counted in the total cost of a family's plan.
Tanning Tax -- 10 percent excise tax on indoor tanning services.
Medicare:
Closes the Medicare prescription drug "donut hole" by 2020. Seniors who hit the donut hole by 2010 will receive a $250 rebate.
Beginning in 2011, seniors in the gap will receive a 50 percent discount on brand name drugs. The bill also includes $500 billion in Medicare cuts over the next decade.
Medicaid:
Expands Medicaid to include 133 percent of federal poverty level which is $29,327 for a family of four.
Requires states to expand Medicaid to include childless adults starting in 2014.
Federal Government pays 100 percent of costs for covering newly eligible individuals through 2016.
Illegal immigrants are not eligible for Medicaid.
Insurance Reforms:
Six months after enactment, insurance companies could no longer deny children coverage based on a preexisting condition.
Starting in 2014, insurance companies cannot deny coverage to anyone with preexisting conditions.
Insurance companies must allow children to stay on their parent's insurance plans through age 26.
Abortion:
The bill segregates private insurance premium funds from taxpayer funds. Individuals would have to pay for abortion coverage by making two separate payments, private funds would have to be kept in a separate account from federal and taxpayer funds.
No health care plan would be required to offer abortion coverage. States could pass legislation choosing to opt out of offering abortion coverage through the exchange.
**Separately, anti-abortion Democrats worked out language with the White House on an executive order that would state that no federal funds can be used to pay for abortions except in the case of rape, incest or health of the mother. (Read more here)
Individual Mandate:
In 2014, everyone must purchase health insurance or face a $695 annual fine. There are some exceptions for low-income people.
Employer Mandate:
Technically, there is no employer mandate. Employers with more than 50 employees must provide health insurance or pay a fine of $2000 per worker each year if any worker receives federal subsidies to purchase health insurance. Fines applied to entire number of employees minus some allowances.
Immigration:
Illegal immigrants will not be allowed to buy health insurance in the exchanges -- even if they pay completely with their own money.
House approves Health Insurance Reform- a timeline of how it will roll-out
Insuring Resources Commentary:
Health Insurance Reform is almost a reality. Sorry, we didn't get health CARE reform. The Senate must now pass by a simple majority the changes the house made to the original Senate bill. Then the President must sign it and that's it.
But what happens, when? See below courtesy of the Wall Street Journal.
--------------------------------
WSJ- 3/22/10
What happens in 2010
Subsidies begin for small businesses to provide coverage to employees.
Insurance companies barred from denying coverage to children with pre-existing illness.
Children permitted to stay on their parents' insurance policies until their 26th birthday.
What happens in 2011
Set up long-term care program under which people pay premiums into system for at least five years and become eligible for support payments if they need assistance in daily living.
Taxes and fees
Drug makers face annual fee of $2.5 billion (rises in subsequent years).
What Happens in 2013
Taxes and fees
New Medicare taxes on individuals earning more than $200,000 a year and couples filing jointly earning more than $250,000 a year.
Tax on wages rises to 2.35% from 1.45%.
New 3.8% tax on unearned income such as dividends and interest.
Excise tax of 2.9% imposed on sale of medical devices.
Cost control
Medicare pilot program begins to test bundled payments for care, in a bid to pay for quality rather than quantity of services.
What Happens in 2014
Create exchanges where people without employer coverage, as well as small businesses, can shop for health coverage. Insurance companies barred from denying coverage to anyone with pre-existing illness.
Requirement begins for most people to have health insurance. Subsidies begin for lower and middle-income people. People at 133% of federal poverty level pay maximum of 3% of income for coverage. People at 400% of poverty level pay up to 9.5% of income. (Poverty level currently is about $22,000 for a family of four.)
Medicaid, the federal-state program for the poor, expands to all Americans with income up to 133% of federal poverty level.
Subsidies for small businesses to provide coverage increase. Businesses with 10 or fewer employees and average annual wages of less than $25,000 receive tax credit of up to 50% of employer's contribution. Tax credits phase out for larger businesses.
Taxes and fees
Employers with more than 50 employees that don't provide affordable coverage must pay a fine if employees receive tax credits to buy insurance. Fine is up to $3,000 per employee, excluding first 30 employees.
Insurance industry must pay annual fee of $8 billion (rises in subsequent years).
Cost control
Independent Medicare board must begin to submit recommendations to curb Medicare spending, if costs are rising faster than inflation.
What Happens in 2016
Taxes and fees
Penalty for those who don't carry coverage rises to 2.5% of taxable income or $695, whichever is greater.
2017
Coverage
Businesses with more than 100 employees can buy coverage on insurance exchanges, if state permits it.
What Happens in 2018
Taxes and fees
Excise tax of 40% imposed on health plans valued at more than $10,200 for individual coverage and $27,500 for family coverage.
Health Insurance Reform is almost a reality. Sorry, we didn't get health CARE reform. The Senate must now pass by a simple majority the changes the house made to the original Senate bill. Then the President must sign it and that's it.
But what happens, when? See below courtesy of the Wall Street Journal.
--------------------------------
WSJ- 3/22/10
What happens in 2010
Subsidies begin for small businesses to provide coverage to employees.
Insurance companies barred from denying coverage to children with pre-existing illness.
Children permitted to stay on their parents' insurance policies until their 26th birthday.
What happens in 2011
Set up long-term care program under which people pay premiums into system for at least five years and become eligible for support payments if they need assistance in daily living.
Taxes and fees
Drug makers face annual fee of $2.5 billion (rises in subsequent years).
What Happens in 2013
Taxes and fees
New Medicare taxes on individuals earning more than $200,000 a year and couples filing jointly earning more than $250,000 a year.
Tax on wages rises to 2.35% from 1.45%.
New 3.8% tax on unearned income such as dividends and interest.
Excise tax of 2.9% imposed on sale of medical devices.
Cost control
Medicare pilot program begins to test bundled payments for care, in a bid to pay for quality rather than quantity of services.
What Happens in 2014
Create exchanges where people without employer coverage, as well as small businesses, can shop for health coverage. Insurance companies barred from denying coverage to anyone with pre-existing illness.
Requirement begins for most people to have health insurance. Subsidies begin for lower and middle-income people. People at 133% of federal poverty level pay maximum of 3% of income for coverage. People at 400% of poverty level pay up to 9.5% of income. (Poverty level currently is about $22,000 for a family of four.)
Medicaid, the federal-state program for the poor, expands to all Americans with income up to 133% of federal poverty level.
Subsidies for small businesses to provide coverage increase. Businesses with 10 or fewer employees and average annual wages of less than $25,000 receive tax credit of up to 50% of employer's contribution. Tax credits phase out for larger businesses.
Taxes and fees
Employers with more than 50 employees that don't provide affordable coverage must pay a fine if employees receive tax credits to buy insurance. Fine is up to $3,000 per employee, excluding first 30 employees.
Insurance industry must pay annual fee of $8 billion (rises in subsequent years).
Cost control
Independent Medicare board must begin to submit recommendations to curb Medicare spending, if costs are rising faster than inflation.
What Happens in 2016
Taxes and fees
Penalty for those who don't carry coverage rises to 2.5% of taxable income or $695, whichever is greater.
2017
Coverage
Businesses with more than 100 employees can buy coverage on insurance exchanges, if state permits it.
What Happens in 2018
Taxes and fees
Excise tax of 40% imposed on health plans valued at more than $10,200 for individual coverage and $27,500 for family coverage.
Thursday, March 18, 2010
Final Health Care Reform Vote May Occur Sunday
Insuring Resources Commentary:Health care reform passage is inching closer to passage.
But the cost efficiency and quality initiatives STILL only pertain to Medicare. Dems are still not opening their eyes to the bi-partisan possibilities that lean and efficent health care payment reforms would foster. I firmly believe if the package included a timeline for real payment reforms based on efficiency some Republicans would vote for it. Or at the very least some of the conservative public would view them very negatively for not voting for reforms that tackle cost across the board.
Both sides apparently agree this is needed, I've cited several quotes from Senators and Representatives from both sides (Waxman, Grassley, Harkin, Kohl, Hatch and others) on this blog since I started in August. Why is it not in the bill? I'll let you the reader speculate on that one.
As you'll see from the article below, the actual details have changed very, very little.
--------------------------- -----------------------
Source: Associated Press (March 18, 2010)
House Dems on track for vote on $940B health bill
WASHINGTON – House Democrats are pushing to the brink of passage a landmark, $940 billion health care overhaul bill that would simultaneously deliver on President Barack Obama's promise to expand coverage while slashing the deficit, a strategy aimed at attracting support from the party's fiscal conservatives.
The 10-year plan would provide coverage to more than 30 million people now uninsured through a combination of tax credits for middle class households and an expansion of the Medicaid program for low income people. Release of the legislation later Thursday sets the stage for a House vote on Sunday.
It would restructure one-sixth of the U.S. economy in the biggest expansion of the social safety net since Medicare was created in 1965. It would also impose new obligations on individuals and businesses, requiring for the first time that most Americans carry health insurance and penalizing medium-sized and large companies that don't provide coverage for their workers.
Hospitals and doctors, drug companies and insurers would gain millions of new paying customers, but they would also have to adjust to major changes. Medicare cuts would force hospitals to operate more efficiently or risk going out of business. Insurance companies would face unprecendented federal regulation. Health care industries would be hit with new federal taxes. Upper-income households would face a new tax on investment earnings.
Rep. Steny Hoyer of Maryland, the Number 2 House Democrat, said the economy would be stronger in the long run. The bill is estimated to reduce federal deficit by more than $130 billion over its first 10 years — and $1.2 trillion in the second decade, he said. Hoyer called it the biggest deficit reduction bill since the 1990s, when President Bill Clinton put the federal budget on a path to surplus.
Authoritative numbers from the Congressional Budget Office were expected later Thursday, but Speaker Nancy Pelosi, D-Calif., was already pleased. "We loved their number," said Pelosi, who is privy to the estimates.
"I think the momentum is growing for this bill," said Hoyer. "The more and more people have looked at this bill...a greater number of people are becoming more comfortable."
The Democrats' drive took on a growing sense of inevitability, picking up endorsements Wednesday from a longtime liberal holdout and from a retired Roman Catholic bishop and nuns who broke with church leaders over the bill's abortion provisions.
"This is a magnificent bill for the American people," said the Democrat's top vote-counter, Rep. Jim Clyburn, D-S.C. Leaders appeared increasingly confident of getting the 216 votes they need to pass the bill.
But House Republican Leader John Boehner of Ohio said his party's lawmakers will "do everything that we can do to make sure this bill never, ever, ever passes."
The legislation would be vulnerable to attack after it passes, since the biggest changes would be phased in slowly. The major expansion of coverage would not come until 2014, when new health insurance marketplaces open for business.
In the meantime, the legislation calls for a series of new consumer benefits. Starting this year, insurers could not deny coverage to children because of an pre-existing health problem, nor could they place lifetime dollar caps on the amount of coverage. A nhigh-risk health insurance pool would provide coverage to uninsured people who can't get private coverage because of health problems.
Democrats are following a complicated two-track legislative strategy for passing the bill. First, the House will have to approve a Senate bill that many of its Democratic members object to. Then both chambers will quickly pass a package of fixes agreed to in negotiations with the White House.
Since the House will vote first, Hoyer said lawmakers are seeking assurances from their Senate counterparts that they have enough votes to pass the follow-up measure as well.
Democrats are promising 72 hours for lawmakers and the public to review the legislation once it's released, so that would push a House vote on the bill until Sunday at the earliest — "during daylight hours," said Rep. Henry Waxman, D-Calif.
Sunday is also the day Obama plans to leave for an overseas trip. Obama already has delayed the trip once so he can be present for the vote and help with the 11th-hour arm-twisting that inevitably will precede it.
Hoyer said Obama's travel plans would not interfere with Democrats' ability to pass the bill. "I think the president's presence helps, but is it needed?" said Hoyer. "You can dial a cell phone anywhere in the world."
Obama expressed optimism in an interview Wednesday with Fox News Channel. "I'm confident it will pass," he said. "And the reason I'm confident that it's going to pass is because it's the right thing to do."
In a last minute flurry Wednesday, Democrats were revisiting details of a planned tax on high-cost insurance plans that's been a sticking point for organized labor. Richard Trumka, head of the AFL-CIO, met with Obama at the White House on Wednesday, and officials said the labor leader raised concerns. Obama has proposed significantly softening the tax in keeping with an earlier deal with organized labor, and labor leaders want to preserve that accord, at a minimum.
Trumka was to brief members of the AFL-CIO's executive council on Thursday, and the federation was expected to announce whether it would support the legislation.
The long-anticipated measure is actually the second of two bills that Obama hopes lawmakers will send him in coming days, more than a year after he urged Congress to remake the U.S. health care system. The first cleared the Senate late last year but went no further because House Democrats demanded significant changes — the very types of revisions now being packaged into the second bill.
After heavy lobbying from Obama, liberal Rep. Dennis Kucinich, D-Ohio, announced his support Wednesday, becoming the first Democrat to declare he would vote in favor of the legislation after opposing an earlier version. Shortly after Kucinich's announcement, a letter was released from 60 leaders of religious orders urging lawmakers to vote for the legislation.
The endorsement reflected a division within the Catholic Church. The U.S. Conference of Catholic Bishops opposes the Senate-passed legislation, contending it would permit the use of federal funds for elective abortions.
Late Wednesday, however, retired Bishop John E. McCarthy of Austin, Texas, told The Associated Press he was urging approval of the legislation.
Reflecting growing opposition among states to the health care bill, Idaho Gov. C.L. "Butch" Otter, a Republican, signed a measure Wednesday requiring the state attorney general to sue the federal government if residents are forced to buy health insurance. Similar legislation is pending in 37 other states.
But the cost efficiency and quality initiatives STILL only pertain to Medicare. Dems are still not opening their eyes to the bi-partisan possibilities that lean and efficent health care payment reforms would foster. I firmly believe if the package included a timeline for real payment reforms based on efficiency some Republicans would vote for it. Or at the very least some of the conservative public would view them very negatively for not voting for reforms that tackle cost across the board.
Both sides apparently agree this is needed, I've cited several quotes from Senators and Representatives from both sides (Waxman, Grassley, Harkin, Kohl, Hatch and others) on this blog since I started in August. Why is it not in the bill? I'll let you the reader speculate on that one.
As you'll see from the article below, the actual details have changed very, very little.
--------------------------- -----------------------
Source: Associated Press (March 18, 2010)
House Dems on track for vote on $940B health bill
WASHINGTON – House Democrats are pushing to the brink of passage a landmark, $940 billion health care overhaul bill that would simultaneously deliver on President Barack Obama's promise to expand coverage while slashing the deficit, a strategy aimed at attracting support from the party's fiscal conservatives.
The 10-year plan would provide coverage to more than 30 million people now uninsured through a combination of tax credits for middle class households and an expansion of the Medicaid program for low income people. Release of the legislation later Thursday sets the stage for a House vote on Sunday.
It would restructure one-sixth of the U.S. economy in the biggest expansion of the social safety net since Medicare was created in 1965. It would also impose new obligations on individuals and businesses, requiring for the first time that most Americans carry health insurance and penalizing medium-sized and large companies that don't provide coverage for their workers.
Hospitals and doctors, drug companies and insurers would gain millions of new paying customers, but they would also have to adjust to major changes. Medicare cuts would force hospitals to operate more efficiently or risk going out of business. Insurance companies would face unprecendented federal regulation. Health care industries would be hit with new federal taxes. Upper-income households would face a new tax on investment earnings.
Rep. Steny Hoyer of Maryland, the Number 2 House Democrat, said the economy would be stronger in the long run. The bill is estimated to reduce federal deficit by more than $130 billion over its first 10 years — and $1.2 trillion in the second decade, he said. Hoyer called it the biggest deficit reduction bill since the 1990s, when President Bill Clinton put the federal budget on a path to surplus.
Authoritative numbers from the Congressional Budget Office were expected later Thursday, but Speaker Nancy Pelosi, D-Calif., was already pleased. "We loved their number," said Pelosi, who is privy to the estimates.
"I think the momentum is growing for this bill," said Hoyer. "The more and more people have looked at this bill...a greater number of people are becoming more comfortable."
The Democrats' drive took on a growing sense of inevitability, picking up endorsements Wednesday from a longtime liberal holdout and from a retired Roman Catholic bishop and nuns who broke with church leaders over the bill's abortion provisions.
"This is a magnificent bill for the American people," said the Democrat's top vote-counter, Rep. Jim Clyburn, D-S.C. Leaders appeared increasingly confident of getting the 216 votes they need to pass the bill.
But House Republican Leader John Boehner of Ohio said his party's lawmakers will "do everything that we can do to make sure this bill never, ever, ever passes."
The legislation would be vulnerable to attack after it passes, since the biggest changes would be phased in slowly. The major expansion of coverage would not come until 2014, when new health insurance marketplaces open for business.
In the meantime, the legislation calls for a series of new consumer benefits. Starting this year, insurers could not deny coverage to children because of an pre-existing health problem, nor could they place lifetime dollar caps on the amount of coverage. A nhigh-risk health insurance pool would provide coverage to uninsured people who can't get private coverage because of health problems.
Democrats are following a complicated two-track legislative strategy for passing the bill. First, the House will have to approve a Senate bill that many of its Democratic members object to. Then both chambers will quickly pass a package of fixes agreed to in negotiations with the White House.
Since the House will vote first, Hoyer said lawmakers are seeking assurances from their Senate counterparts that they have enough votes to pass the follow-up measure as well.
Democrats are promising 72 hours for lawmakers and the public to review the legislation once it's released, so that would push a House vote on the bill until Sunday at the earliest — "during daylight hours," said Rep. Henry Waxman, D-Calif.
Sunday is also the day Obama plans to leave for an overseas trip. Obama already has delayed the trip once so he can be present for the vote and help with the 11th-hour arm-twisting that inevitably will precede it.
Hoyer said Obama's travel plans would not interfere with Democrats' ability to pass the bill. "I think the president's presence helps, but is it needed?" said Hoyer. "You can dial a cell phone anywhere in the world."
Obama expressed optimism in an interview Wednesday with Fox News Channel. "I'm confident it will pass," he said. "And the reason I'm confident that it's going to pass is because it's the right thing to do."
In a last minute flurry Wednesday, Democrats were revisiting details of a planned tax on high-cost insurance plans that's been a sticking point for organized labor. Richard Trumka, head of the AFL-CIO, met with Obama at the White House on Wednesday, and officials said the labor leader raised concerns. Obama has proposed significantly softening the tax in keeping with an earlier deal with organized labor, and labor leaders want to preserve that accord, at a minimum.
Trumka was to brief members of the AFL-CIO's executive council on Thursday, and the federation was expected to announce whether it would support the legislation.
The long-anticipated measure is actually the second of two bills that Obama hopes lawmakers will send him in coming days, more than a year after he urged Congress to remake the U.S. health care system. The first cleared the Senate late last year but went no further because House Democrats demanded significant changes — the very types of revisions now being packaged into the second bill.
After heavy lobbying from Obama, liberal Rep. Dennis Kucinich, D-Ohio, announced his support Wednesday, becoming the first Democrat to declare he would vote in favor of the legislation after opposing an earlier version. Shortly after Kucinich's announcement, a letter was released from 60 leaders of religious orders urging lawmakers to vote for the legislation.
The endorsement reflected a division within the Catholic Church. The U.S. Conference of Catholic Bishops opposes the Senate-passed legislation, contending it would permit the use of federal funds for elective abortions.
Late Wednesday, however, retired Bishop John E. McCarthy of Austin, Texas, told The Associated Press he was urging approval of the legislation.
Reflecting growing opposition among states to the health care bill, Idaho Gov. C.L. "Butch" Otter, a Republican, signed a measure Wednesday requiring the state attorney general to sue the federal government if residents are forced to buy health insurance. Similar legislation is pending in 37 other states.
Thursday, March 11, 2010
Insurance Industry Offers Data on Means to Reduce Skyrocketing Health Care Costs
Insuring Resources Commentary:
Now we're getting somewhere!
If this data allows some alteration in the p[ending reform bills this could be the catalyst to lead to a bipartisan solution on health care reform. This is very encouraging, but we'll see...
****Full disclosure: I write and edit health insurance continuing education textbooks and study guides for AHIP****
---------------------------------
WASHINGTON BUREAU -- The health insurance industry has agreed to give the Obama administration detailed data on what a health reform bill must do to reduce the skyrocketing cost of health care.
The data will be available “very shortly,” a spokesman for America’s Health Insurance Plans, Washington, said today.
AHIP President Karen Ignagni promised to provide the data Wednesday during AHIP’s annual National Policy Forum.
She made her comments after Health and Human Services Secretary Kathleen Sebelius told health insurers that continued health insurance industry opposition to health reform and continued escalation of premiums will ultimately hurt the industry.
In response, Ignagni said she hoped that providing the data and Sebelius’s appearance will mark the “beginning of a change” in the tone of the health reform debate.
In comments at the conference Tuesday, Ignagni had decried the “vilification rather than problem solving” that now marks the debate over health reform legislation.
In her comments, Sebelius said that opposition to the Democratic legislation “won’t work in the long run for the American people or our healthcare system.”
Her concern, she said, is that if insurers continued to oppose Democrats’ health legislation, premium increases would continue and more small businesses would drop health coverage for their employees.
“You can continue your opposition to reform,” Sebelius said. “If you do, and reform goes down to defeat, we know what will happen.”
In response, Ignagni said after Sebelius’ comments that “insurers have been concerned that the current legislation will make the current system more expensive and not more affordable.”
Her specific concern is that health coverage mandates in the current versions of health reform legislation do not provide enough incentives to buy health insurance are not strong enough.
If enough young, healthy individuals choose not to buy insurance, “the people in the pool will be the oldest ones and the ones with the highest health problems,” Ignagni said.
At the same time, the White House issued a memorandum to all government departments calling for them to use “payment recapture audits” designed to curb waste and fraud, presumably primarily in the Medicare and Medicaid system.
This would give incentives to private auditors to examine government payments and report fraud to the agencies.
This was designed to adopt a key Republican proposal on health reform, curbing fraud and abuse in government programs.
Now we're getting somewhere!
If this data allows some alteration in the p[ending reform bills this could be the catalyst to lead to a bipartisan solution on health care reform. This is very encouraging, but we'll see...
****Full disclosure: I write and edit health insurance continuing education textbooks and study guides for AHIP****
---------------------------------
WASHINGTON BUREAU -- The health insurance industry has agreed to give the Obama administration detailed data on what a health reform bill must do to reduce the skyrocketing cost of health care.
The data will be available “very shortly,” a spokesman for America’s Health Insurance Plans, Washington, said today.
AHIP President Karen Ignagni promised to provide the data Wednesday during AHIP’s annual National Policy Forum.
She made her comments after Health and Human Services Secretary Kathleen Sebelius told health insurers that continued health insurance industry opposition to health reform and continued escalation of premiums will ultimately hurt the industry.
In response, Ignagni said she hoped that providing the data and Sebelius’s appearance will mark the “beginning of a change” in the tone of the health reform debate.
In comments at the conference Tuesday, Ignagni had decried the “vilification rather than problem solving” that now marks the debate over health reform legislation.
In her comments, Sebelius said that opposition to the Democratic legislation “won’t work in the long run for the American people or our healthcare system.”
Her concern, she said, is that if insurers continued to oppose Democrats’ health legislation, premium increases would continue and more small businesses would drop health coverage for their employees.
“You can continue your opposition to reform,” Sebelius said. “If you do, and reform goes down to defeat, we know what will happen.”
In response, Ignagni said after Sebelius’ comments that “insurers have been concerned that the current legislation will make the current system more expensive and not more affordable.”
Her specific concern is that health coverage mandates in the current versions of health reform legislation do not provide enough incentives to buy health insurance are not strong enough.
If enough young, healthy individuals choose not to buy insurance, “the people in the pool will be the oldest ones and the ones with the highest health problems,” Ignagni said.
At the same time, the White House issued a memorandum to all government departments calling for them to use “payment recapture audits” designed to curb waste and fraud, presumably primarily in the Medicare and Medicaid system.
This would give incentives to private auditors to examine government payments and report fraud to the agencies.
This was designed to adopt a key Republican proposal on health reform, curbing fraud and abuse in government programs.
This is What I'm Talking About When I Argue for Efficient Care Incentives
Insuring Resources Commentary:
We need to improve the efficiency of care and provide doctors inentives to try less invasive and less costly tests first. The article suggests: To decide whether someone needs an angiogram, a doctor assesses a patient's medical status and symptoms, and usually tries a noninvasive test, such as an ultrasound of the heart or having the patient run on a treadmill. It is this gatekeeper process that needs improvement, researchers suggested in Thursday's issue of the New England Journal of Medicine.
The current health care reform proposals do nothing to combat this problem.
----------------------------
Study Suggests Too Many Invasive Heart Tests GivenAssociated Press
Malcolm Ritter
March 10, 2010
A troublingly high number of U.S. patients who are given angiograms to check for heart disease turn out not to have a significant problem, according to the latest study to suggest Americans get an excess of medical tests.
The researchers said the findings suggest doctors must do better in determining which patients should be subjected to the cost and risks of an angiogram. The test carries a small but real risk - less than 1 percent - of causing a stroke or heart attack, and also entails radiation exposure.
"We can do better. There is no doubt in my mind," said Dr. Ralph Brindis of the University of California, San Francisco, one of the study's authors.
Every year in the United States, more than a million people get an angiogram, in which a thin tube is inserted in the arm or groin and threaded up to the heart to check for blocked arteries that could lead to a heart attack. Dye is injected through the tube to make blockages show up on X-rays.
Angiograms are often given to patients who might be having a heart attack or have symptoms that suggest a serious blockage. They are also sometimes done on people who may have some less clear-cut symptoms, like shortness of breath, or no symptoms but some risky traits like high cholesterol and an abnormal result on another heart test. This group accounts for about 20 to 30 percent of angiogram cases.
In the study, nearly two-thirds of the patients in this second group were found to have no serious blockages.
The researchers could not establish why so few proved to have heart disease. But Dr. Harlan Krumholz, a Yale cardiologist and health-outcomes researcher unconnected to the study, said he thinks the problem arises because doctors are afraid of missing something, and also getting sued.
"We fear doing too little," he said. "I think that we developed a culture where people feel that doing more and knowing more is always the proper course. What that does is sometimes lead us to overuse."
To decide whether someone needs an angiogram, a doctor assesses a patient's medical status and symptoms, and usually tries a noninvasive test, such as an ultrasound of the heart or having the patient run on a treadmill. It is this gatekeeper process that needs improvement, researchers suggested in Thursday's issue of the New England Journal of Medicine.
We need to improve the efficiency of care and provide doctors inentives to try less invasive and less costly tests first. The article suggests: To decide whether someone needs an angiogram, a doctor assesses a patient's medical status and symptoms, and usually tries a noninvasive test, such as an ultrasound of the heart or having the patient run on a treadmill. It is this gatekeeper process that needs improvement, researchers suggested in Thursday's issue of the New England Journal of Medicine.
The current health care reform proposals do nothing to combat this problem.
----------------------------
Study Suggests Too Many Invasive Heart Tests GivenAssociated Press
Malcolm Ritter
March 10, 2010
A troublingly high number of U.S. patients who are given angiograms to check for heart disease turn out not to have a significant problem, according to the latest study to suggest Americans get an excess of medical tests.
The researchers said the findings suggest doctors must do better in determining which patients should be subjected to the cost and risks of an angiogram. The test carries a small but real risk - less than 1 percent - of causing a stroke or heart attack, and also entails radiation exposure.
"We can do better. There is no doubt in my mind," said Dr. Ralph Brindis of the University of California, San Francisco, one of the study's authors.
Every year in the United States, more than a million people get an angiogram, in which a thin tube is inserted in the arm or groin and threaded up to the heart to check for blocked arteries that could lead to a heart attack. Dye is injected through the tube to make blockages show up on X-rays.
Angiograms are often given to patients who might be having a heart attack or have symptoms that suggest a serious blockage. They are also sometimes done on people who may have some less clear-cut symptoms, like shortness of breath, or no symptoms but some risky traits like high cholesterol and an abnormal result on another heart test. This group accounts for about 20 to 30 percent of angiogram cases.
In the study, nearly two-thirds of the patients in this second group were found to have no serious blockages.
The researchers could not establish why so few proved to have heart disease. But Dr. Harlan Krumholz, a Yale cardiologist and health-outcomes researcher unconnected to the study, said he thinks the problem arises because doctors are afraid of missing something, and also getting sued.
"We fear doing too little," he said. "I think that we developed a culture where people feel that doing more and knowing more is always the proper course. What that does is sometimes lead us to overuse."
To decide whether someone needs an angiogram, a doctor assesses a patient's medical status and symptoms, and usually tries a noninvasive test, such as an ultrasound of the heart or having the patient run on a treadmill. It is this gatekeeper process that needs improvement, researchers suggested in Thursday's issue of the New England Journal of Medicine.
Tuesday, March 9, 2010
White House Holds Meeting with Top Insurers
Insuring Resources Commentary:
President Obama has said that he is incorporating GOP ideas into the final last ditch effort to enact health care reform. From the GOP he has heard repeatedly that his plan does not control rising health care costs.
Then on March 5th, as detailed in the article below, he met with Insurers that told him, and his Secretary of Health Kathleen Sebelius, that health care costs are the real problem. His chief budgetary advisor Peter Orszag has also been talking about this for a year. Let's hope its beginning to sink in.
-----------------
White House Holds Meeting with Top Insurers
Increasingly cast as the villain in the nation’s rising cost for health care, five of the nation’s largest health care insurers met with the Obama Administration to argue that they are bit players in a much larger production.
The meeting, called by U.S. Department of Health and Human Services Secretary Kathleen Sebelius, focused on premium increases by large insurance companies, the growing focus of health care reform efforts in Washington, D.C., amid a shaky economy.
The White House meeting included Sebelius and chief executives from UnitedHealth Group, WellPoint, Aetna, Health Care Service Corp. and CIGNA, along with a brief appearance by President Barack Obama.
White House spokesman Robert Gibbs said the president “stopped by” the March 4 meeting, armed with a letter from a 50-year-old woman from Ohio, diagnosed with carcinoma and struggling to find affordable health insurance, pleading with the president for help. Gibbs said the letter was “to remind everyone what’s at stake with the final push for health care reform and …what happens if we walk away.” He added that the president talked about the need for comprehensive reform with the health insurance executives, the need to stop blocking such reform on their part and echoed Sebelius’ call for actuarial data justifying large increases in premiums “at a time in which health care inflation is not nearly on the order of magnitude of what we’ve seen here.”
Following the meeting, Sebelius said the nation needs “some transparency” for “people to understand what’s going on.” She said the meeting “focused on what is happening with the kind of jaw-dropping rate increases that people are seeing,” according to media reports.
A Matter of Rising Costs
Ronald Williams, chairman and CEO of Aetna, was one of the attendees of the meeting and told PBS’ Nightly Business Report the session “was a strong focus on understanding the impact that these rate increases are having on working families and individuals who may be reaching the limits of affordability for individual health insurance.”
He added that all parties had a “constructive dialogue” on what is driving rate increases and steps needed to make individual insurance more affordable and sustainable for the future.
“But I think we have to start with the increase in the premium is based on the increase in the health care cost,” Williams said. “And so the premium is a cumulative result of how much more hospitals need and get in their renewals. Some hospitals are asking [for] 40% increases.”
Williams cited increases in pharmaceuticals, in physicians’ cost device and younger, healthier people dropping insurance, making the larger pool “progressively composed of those individuals who tend to be older and sicker and use more services.”
In a statement, UnitedHealth Group President and CEO Stephen J. Hemsley said, “To achieve true and sustainable reform, it is essential to first bring costs under control.
“Trying to focus the debate on insurance premiums masks the complexity of the challenge our country faces to effectively reform our health care system.,” he said. “The cost of insurance is driven by the underlying cost pressures we see throughout the health care system. The majority of our medical cost increases will be from hospitals and doctors charging higher prices and, to a lesser extent, from increased treatment volumes.”
Hemsley added that UnitedHealth Group knows “from first-hand experience” the financial challenges facing nearly 70 million Americans and wants to help find the solution.
“Unfortunately, up to this point the health reform debate has yet to truly confront the cost issue,” he said. “Our participation in today’s meeting affirms our commitment to constructive engagement and a desire to identify a fiscally responsible, sustainable path forward that truly bends the cost curve. If we can slow the soaring cost of care, our shared goal of expanding access and improving quality will be achievable.”
Regulators’ role
Also attending the session were four of the nation’s insurance regulators, representing the National Association of Insurance Commissioners (NAIC).
In a statement, the NAIC said its representatives stressed the importance of thorough and objective rate review, echoing the call for actuarially justified work without discriminating unfairly against any policyholders.
“It is absolutely critical that the state role in assuring the solvency of health plans and promoting competitive markets be preserved,” said Sandy Praeger, chair of the NAIC Health Insurance and Managed Care Committee and Kansas insurance commissioner. “Protecting consumers from high premiums remains a priority, but it is even more important to protect them from insolvency.”
President Obama has said that he is incorporating GOP ideas into the final last ditch effort to enact health care reform. From the GOP he has heard repeatedly that his plan does not control rising health care costs.
Then on March 5th, as detailed in the article below, he met with Insurers that told him, and his Secretary of Health Kathleen Sebelius, that health care costs are the real problem. His chief budgetary advisor Peter Orszag has also been talking about this for a year. Let's hope its beginning to sink in.
-----------------
White House Holds Meeting with Top Insurers
Increasingly cast as the villain in the nation’s rising cost for health care, five of the nation’s largest health care insurers met with the Obama Administration to argue that they are bit players in a much larger production.
The meeting, called by U.S. Department of Health and Human Services Secretary Kathleen Sebelius, focused on premium increases by large insurance companies, the growing focus of health care reform efforts in Washington, D.C., amid a shaky economy.
The White House meeting included Sebelius and chief executives from UnitedHealth Group, WellPoint, Aetna, Health Care Service Corp. and CIGNA, along with a brief appearance by President Barack Obama.
White House spokesman Robert Gibbs said the president “stopped by” the March 4 meeting, armed with a letter from a 50-year-old woman from Ohio, diagnosed with carcinoma and struggling to find affordable health insurance, pleading with the president for help. Gibbs said the letter was “to remind everyone what’s at stake with the final push for health care reform and …what happens if we walk away.” He added that the president talked about the need for comprehensive reform with the health insurance executives, the need to stop blocking such reform on their part and echoed Sebelius’ call for actuarial data justifying large increases in premiums “at a time in which health care inflation is not nearly on the order of magnitude of what we’ve seen here.”
Following the meeting, Sebelius said the nation needs “some transparency” for “people to understand what’s going on.” She said the meeting “focused on what is happening with the kind of jaw-dropping rate increases that people are seeing,” according to media reports.
A Matter of Rising Costs
Ronald Williams, chairman and CEO of Aetna, was one of the attendees of the meeting and told PBS’ Nightly Business Report the session “was a strong focus on understanding the impact that these rate increases are having on working families and individuals who may be reaching the limits of affordability for individual health insurance.”
He added that all parties had a “constructive dialogue” on what is driving rate increases and steps needed to make individual insurance more affordable and sustainable for the future.
“But I think we have to start with the increase in the premium is based on the increase in the health care cost,” Williams said. “And so the premium is a cumulative result of how much more hospitals need and get in their renewals. Some hospitals are asking [for] 40% increases.”
Williams cited increases in pharmaceuticals, in physicians’ cost device and younger, healthier people dropping insurance, making the larger pool “progressively composed of those individuals who tend to be older and sicker and use more services.”
In a statement, UnitedHealth Group President and CEO Stephen J. Hemsley said, “To achieve true and sustainable reform, it is essential to first bring costs under control.
“Trying to focus the debate on insurance premiums masks the complexity of the challenge our country faces to effectively reform our health care system.,” he said. “The cost of insurance is driven by the underlying cost pressures we see throughout the health care system. The majority of our medical cost increases will be from hospitals and doctors charging higher prices and, to a lesser extent, from increased treatment volumes.”
Hemsley added that UnitedHealth Group knows “from first-hand experience” the financial challenges facing nearly 70 million Americans and wants to help find the solution.
“Unfortunately, up to this point the health reform debate has yet to truly confront the cost issue,” he said. “Our participation in today’s meeting affirms our commitment to constructive engagement and a desire to identify a fiscally responsible, sustainable path forward that truly bends the cost curve. If we can slow the soaring cost of care, our shared goal of expanding access and improving quality will be achievable.”
Regulators’ role
Also attending the session were four of the nation’s insurance regulators, representing the National Association of Insurance Commissioners (NAIC).
In a statement, the NAIC said its representatives stressed the importance of thorough and objective rate review, echoing the call for actuarially justified work without discriminating unfairly against any policyholders.
“It is absolutely critical that the state role in assuring the solvency of health plans and promoting competitive markets be preserved,” said Sandy Praeger, chair of the NAIC Health Insurance and Managed Care Committee and Kansas insurance commissioner. “Protecting consumers from high premiums remains a priority, but it is even more important to protect them from insolvency.”
Monday, March 8, 2010
President's statement moving forward with health care reform
Insuring Resources Commentary:
It will be interesting to see if the measure includes the cost control measures on health CARE that I have promoted since the beginning. When I started this post I realized that it is the 99th post I have entered on this blog. When I started this in August I did not envision posting 99 items. I certainly did not envision this process lasting until March. There are several items I disagree with in the Senate bill, including the Cornhusker Kickback and some others. I belive there should be a stronger employer mandate. I believe the abortion language should be tougher.
But the most egregious error by far is the omission of a game changer on the way health care is financed. This is a BI-PARTISAN issue as Republicans have been shouting about this from the beggining. Obama started the whole process during his campaign talking about this but now barely utters a word on it. If this had been the center piece of health care reform I believe strongly that we would have had a bi-partisan bill passed before The end of 2009.
We must have a health care reform bill that includes, at the very least, efficiency and quality provider incentives across all payment sources- Medicare, Medicaid and the private health plans. I realize implementing this takes time but we could do it incrementally like the incentives in place right now for electronic medical records that were passed in the ARRA last February.
We should change health care financing to an EPISODE of CARE reimbursement, rather than fee-for-service. This change would create higher quality and efficiency of care. We could easily implement these changes in Medicare by 2014 and the whole system by 2017 and manintain the private health market like the Republicans want. We wouldn't need a public plan option if we followed the above prescription.
------------------- ---------------------
President Obama 3/6/10:
“This week, I asked Congress to schedule a final vote on reform that will give families and businesses more control over their health care by holding insurance companies more accountable. This comes after nearly a year of debate, as well as a seven hour summit with Democrats and Republicans where we had a public and substantive discussion on health care. Since then, I’ve said that I’m willing to incorporate some ideas offered by Republicans, and we’re eliminating special provisions that had no place in health care reform.
Now, despite all the progress and improvements we’ve made, Republicans in Congress insist that the only acceptable course on health care is to start over. But you know what? The insurance companies aren’t starting over."
It will be interesting to see if the measure includes the cost control measures on health CARE that I have promoted since the beginning. When I started this post I realized that it is the 99th post I have entered on this blog. When I started this in August I did not envision posting 99 items. I certainly did not envision this process lasting until March. There are several items I disagree with in the Senate bill, including the Cornhusker Kickback and some others. I belive there should be a stronger employer mandate. I believe the abortion language should be tougher.
But the most egregious error by far is the omission of a game changer on the way health care is financed. This is a BI-PARTISAN issue as Republicans have been shouting about this from the beggining. Obama started the whole process during his campaign talking about this but now barely utters a word on it. If this had been the center piece of health care reform I believe strongly that we would have had a bi-partisan bill passed before The end of 2009.
We must have a health care reform bill that includes, at the very least, efficiency and quality provider incentives across all payment sources- Medicare, Medicaid and the private health plans. I realize implementing this takes time but we could do it incrementally like the incentives in place right now for electronic medical records that were passed in the ARRA last February.
We should change health care financing to an EPISODE of CARE reimbursement, rather than fee-for-service. This change would create higher quality and efficiency of care. We could easily implement these changes in Medicare by 2014 and the whole system by 2017 and manintain the private health market like the Republicans want. We wouldn't need a public plan option if we followed the above prescription.
------------------- ---------------------
President Obama 3/6/10:
“This week, I asked Congress to schedule a final vote on reform that will give families and businesses more control over their health care by holding insurance companies more accountable. This comes after nearly a year of debate, as well as a seven hour summit with Democrats and Republicans where we had a public and substantive discussion on health care. Since then, I’ve said that I’m willing to incorporate some ideas offered by Republicans, and we’re eliminating special provisions that had no place in health care reform.
Now, despite all the progress and improvements we’ve made, Republicans in Congress insist that the only acceptable course on health care is to start over. But you know what? The insurance companies aren’t starting over."
Friday, March 5, 2010
If Only We Could do it like Singapore- the only way to do it correctly with HSAs
Insuring Resources Commentary:
Health Savings Accounts give individuals who buy insurance a tax deduction for money they set aside for a high-deductible plan. Since tax deductions are worth more to people in higher tax brackets, and since high-deductible plans appeal more to those with lower medical expenses, the plans attract the rich and healthy, leaving the poor and sick behind. This is why the Republican's plan is not workable for most Americans.
Singapore does it by setting affordable pricing benchmarks with which private providers compete. Supply-side rules that favor training new family doctors over pricey specialists are more extensive.
-------------------- -------------------
An article on Singapore's very effec tive health care insurance system....
by Matt Miller at the Washington Post 3/3/10
The only rich nation that boasts universal coverage with health outcomes better than ours while spending one-fifth as much per person on health care. Introducing (drum roll please): Singapore.
Yes, it's an island city-state of just 5 million people. Yes, it's more or less a benevolent dictatorship. And, yes, until recently, bringing chewing gum into Singapore could land you in jail. But Singapore, a poor country a few decades ago, now boasts a higher per capita income (when adjusted for local purchasing power) than the United States. And here's the astonishing fact: Singapore spends less than 4 percent of its GDP on health care. We spend 17 percent (and Singapore's somewhat younger population doesn't begin to explain the difference). Matching Singapore's performance in our $15 trillion economy would free up $2 trillion a year for other public and private purposes.
Do I have I your attention?
Today we can't find cash to recruit a new generation of great teachers, rebuild our roads and bridges, pay down the national debt, or invest in better airports, high-speed rail, a clean energy revolution or any of a hundred other things sensible patriots know we should do to renew the country. We can't do these things in large part because the Medical Industrial Complex vacuums up every spare dollar in sight. It's only slightly melodramatic to assert that if we could run our health-care system as efficiently as Singapore's, we could solve most of our other problems.
So how does Singapore do it?
In health circles it's always conservatives who bring up Singapore, because of the primacy it places on personal responsibility. According to Phua Kai Hong of the National University of Singapore, roughly one-third of health spending in Singapore is paid directly by individuals (who typically buy catastrophic coverage as well); in the United States, by contrast, nearly 90 percent is picked up by third-party insurers, employers and governments. Singaporeans make these payments out of earnings as well as from health savings accounts. The system is chock-full of incentives for thrift. If you want a private hospital room, for example, you pay through the nose; most people choose less expensive wards.
Conservatives are right: Singaporeans have the kind of "skin in the game" that promotes prudence.
But that's only half the story. There's also a massive public role. For starters, adequate savings for retirement and health expenses are mandated by government (employees must sock away 20 percent of earnings each year, to which employers add 13 percent). Public hospitals provide 80 percent of the acute care, setting affordable pricing benchmarks with which private providers compete. Supply-side rules that favor training new family doctors over pricey specialists are more extensive than similar notions Hillary Clinton pushed in the '90s. And in Singapore, if a child is obese, they don't get Rose Garden exhortations from the first lady. They get no lunch and mandatory exercise periods during school.
There's more (including an ample safety net for the poor), but you get the gist: Singapore achieves world-class results thanks to a bold, unconventional synthesis of liberal and conservative approaches. It's further to the left and further to the right than what President Obama or his foes now seek. The island's real ideology is pragmatic problem-solving. It works thanks to cultural traditions that let this eclectic blend flourish. The system is nurtured by talented, highly paid officials who have the luxury of governing for the long-term without being buffeted much by politics.
We obviously can't transplant Singapore's approach wholesale to the United States. But the reason we can't emulate even some of Singapore's success has to do with that iron law of health-care politics: Every dollar of health-care "waste" is somebody's dollar of income. As a stable advanced democracy, we're so overrun by groups with stakes in today's waste that real efficiency gains are perennially blocked.
Any hope for something better starts with tallying the price of today's paralysis. Think about that $2 trillion the next time you see states, citing budget woes, shut the door to college on tens of thousands of poor American students. Or when the next firm moves jobs overseas because health costs here are soaring. Or when the next bridge collapses. Thanks, Medical Industrial Complex!
We return now to our regularly scheduled political battle, which (no matter the outcome, according to some projections) will leave health costs headed to more than 20 percent of GDP by 2019.
Health Savings Accounts give individuals who buy insurance a tax deduction for money they set aside for a high-deductible plan. Since tax deductions are worth more to people in higher tax brackets, and since high-deductible plans appeal more to those with lower medical expenses, the plans attract the rich and healthy, leaving the poor and sick behind. This is why the Republican's plan is not workable for most Americans.
Singapore does it by setting affordable pricing benchmarks with which private providers compete. Supply-side rules that favor training new family doctors over pricey specialists are more extensive.
-------------------- -------------------
An article on Singapore's very effec tive health care insurance system....
by Matt Miller at the Washington Post 3/3/10
The only rich nation that boasts universal coverage with health outcomes better than ours while spending one-fifth as much per person on health care. Introducing (drum roll please): Singapore.
Yes, it's an island city-state of just 5 million people. Yes, it's more or less a benevolent dictatorship. And, yes, until recently, bringing chewing gum into Singapore could land you in jail. But Singapore, a poor country a few decades ago, now boasts a higher per capita income (when adjusted for local purchasing power) than the United States. And here's the astonishing fact: Singapore spends less than 4 percent of its GDP on health care. We spend 17 percent (and Singapore's somewhat younger population doesn't begin to explain the difference). Matching Singapore's performance in our $15 trillion economy would free up $2 trillion a year for other public and private purposes.
Do I have I your attention?
Today we can't find cash to recruit a new generation of great teachers, rebuild our roads and bridges, pay down the national debt, or invest in better airports, high-speed rail, a clean energy revolution or any of a hundred other things sensible patriots know we should do to renew the country. We can't do these things in large part because the Medical Industrial Complex vacuums up every spare dollar in sight. It's only slightly melodramatic to assert that if we could run our health-care system as efficiently as Singapore's, we could solve most of our other problems.
So how does Singapore do it?
In health circles it's always conservatives who bring up Singapore, because of the primacy it places on personal responsibility. According to Phua Kai Hong of the National University of Singapore, roughly one-third of health spending in Singapore is paid directly by individuals (who typically buy catastrophic coverage as well); in the United States, by contrast, nearly 90 percent is picked up by third-party insurers, employers and governments. Singaporeans make these payments out of earnings as well as from health savings accounts. The system is chock-full of incentives for thrift. If you want a private hospital room, for example, you pay through the nose; most people choose less expensive wards.
Conservatives are right: Singaporeans have the kind of "skin in the game" that promotes prudence.
But that's only half the story. There's also a massive public role. For starters, adequate savings for retirement and health expenses are mandated by government (employees must sock away 20 percent of earnings each year, to which employers add 13 percent). Public hospitals provide 80 percent of the acute care, setting affordable pricing benchmarks with which private providers compete. Supply-side rules that favor training new family doctors over pricey specialists are more extensive than similar notions Hillary Clinton pushed in the '90s. And in Singapore, if a child is obese, they don't get Rose Garden exhortations from the first lady. They get no lunch and mandatory exercise periods during school.
There's more (including an ample safety net for the poor), but you get the gist: Singapore achieves world-class results thanks to a bold, unconventional synthesis of liberal and conservative approaches. It's further to the left and further to the right than what President Obama or his foes now seek. The island's real ideology is pragmatic problem-solving. It works thanks to cultural traditions that let this eclectic blend flourish. The system is nurtured by talented, highly paid officials who have the luxury of governing for the long-term without being buffeted much by politics.
We obviously can't transplant Singapore's approach wholesale to the United States. But the reason we can't emulate even some of Singapore's success has to do with that iron law of health-care politics: Every dollar of health-care "waste" is somebody's dollar of income. As a stable advanced democracy, we're so overrun by groups with stakes in today's waste that real efficiency gains are perennially blocked.
Any hope for something better starts with tallying the price of today's paralysis. Think about that $2 trillion the next time you see states, citing budget woes, shut the door to college on tens of thousands of poor American students. Or when the next firm moves jobs overseas because health costs here are soaring. Or when the next bridge collapses. Thanks, Medical Industrial Complex!
We return now to our regularly scheduled political battle, which (no matter the outcome, according to some projections) will leave health costs headed to more than 20 percent of GDP by 2019.
Subscribe to:
Posts (Atom)
