Health Endgame: Time To Embrace Half a Loaf (And Learn to Love It!)
Never underestimate the power of a deadline. Twice over the weekend, time pressure has worked its messy magic -- in Copenhagen, where a last-minute session saved the international climate-change conference from producing exactly nothing, and in snowbound Washington, where Democrats facing Christmas in the Capitol finally wrangled the 60th senator they needed to pass their massive health reform bill.
The emission-reduction agreement President Obama worked out with China, India, Brazil and South Africa could turn out to be
an illusory milestone. But the health developments Saturday had the feel of a real turning point. Everything signaled momentum as Senate Democrats
nailed down the last vote needed to break a filibuster, introduced
the final package of amendments, released a
positive report from the Congressional Budget Office and said they were on schedule for a Christmas Eve vote.
The final Senate health package released over the weekend has many tweaks to please many people. Some are so crass they make you want to avert your eyes, like extra federal Medicaid money pledged in perpetuity to one state, Nebraska, whose senator happened to be the last Democratic holdout. But other elements are all to the good. Among them are removal of a limit on annual health expenses covered by insurance, and new national insurance plans overseen by the Office of Personnel Management, which runs the
much beloved plan for members of Congress and millions of other federal employees.
The revised bill also has $50 million for pilot projects on malpractice reform, to test ways of resolving medical disputes without the lawsuits that drive up the costs of both malpractice insurance and patient care. The projects were pushed by both the White House and Republican Sen. Olympia Snowe. Their inclusion robs Republicans of one of their complaints about the bill.
The right and the left know an endgame when they see it, which is why both sides have been escalating their fundraising efforts right along with their cries of "kill the bill!'' Conservatives and Republicans are a virtual monolith of opposition. But in the past few days progressives have split into two camps at bitter odds over whether the Senate health bill -- with no public insurance plan to compete with private-sector plans -- has any reform left in it.
Former Vermont governor Howard Dean, Move On.org and others have been urging Senate Democrats to start over. That's brought counter-pleas from such heavyweights as former president Bill Clinton, the last president to try for comprehensive health reform;
New York Times columnist Paul Krugman, a fierce advocate of the public option who wrote a column Friday headlined "Pass the Bill "; and Service Employees International Union president Andy Stern, who told
The New Republic that "We probably have
the best we are going to do, and trying to improve the Senate bill doesn't seem realistic right now."
Vicki Kennedy also weighed in, writing in
The Washington Post that her late husband anticipated compromises would be necessary and he
didn't want reform supporters to walk away. "He's not here to urge us not to let this chance slip through our fingers. So I humbly ask his colleagues to finish the work of his life," she wrote. Sen. Tom Harkin, another liberal stalwart, wooed progressives with a housing analogy. "What we're building here is not a mansion. It's a starter home," he said Saturday. "But it's got a great foundation for expanding health care coverage to 31 million Americans. It's got a great roof, protective roof, in protecting people from abuses by insurance companies. And it has room for expansion and additions in the future."
There have also been poignant contributions from liberals who feel deserted by their fellow travelers, including a reader of Talking Points Memo who is unemployed, has a medical problem (aka pre-existing condition) and ideally would like to see a single-payer system. "When I read or hear people from the left arguing against the bill that would likely provide me and people like me with some modicum of security, because the bill doesn't accomplish everything they had hoped it would or it doesn't help every last person or the insurance industry will benefit,
I do feel abandoned," the reader said in a post highlighted by editor Josh Marshall. The reader said the abandonment is "not by Obama and the Democratic Party, it's by those on the left advocating to kill the bill."
Obama gets assigned plenty of blame from liberals who think he somehow could have and should have brought the Senate to heel and forced it to pass a public option -- or should take nothing at all. That's the crux of the case made by my Politics Daily colleague, Luisita Lopez Torregrosa, who is
sorely disappointed in Obama across the board. He has, she writes, "abandoned his vision, his promises and his goals."
Another, perhaps more realistic way to see it is that he's eking out some progress from the cards he's been dealt. His major accomplishments so far have come not on his campaign agenda but on challenges like trying to save the economy and figure out a path forward in Afghanistan. It was hard to blame him for taking a teeny victory lap in the middle of the blizzard Saturday to hail what he called "significant progress" on two top items on his own personal to-do list: dealing with "the crushing cost of health care and our dangerous dependence on fossil fuels."
For the moment, at least, Obama's cards don't look so bad. Senate Democrats are going to get to 60 votes and pass this health bill, and it's still got plenty of reform in it. This is the big picture: New regulations on private insurers protect consumers, 31 million more people are covered, and hundreds of billions of dollars in subsidies help them buy coverage. The new legislation significantly expands coverage of preventive care, regulates exchanges to drive down costs for individuals and small businesses, and tests numerous ways to improve care and curb its soaring cost. Then there is perhaps the least tangible but most fundmental shift in this bill, its message that Americans deserve health coverage and their government will help them get it. That's progress, even if the policies are purchased from private insurance companies.
As for the public option, while there is one in the House bill, there's no point hoping it will be revived early next year in the House-Senate conference committee to merge the two bills. Nebraska Sen. Ben Nelson said straight out that he would not vote for any bill that abandoned the compromises he won. Other Democratic conservatives and moderates have drawn their own lines in the sand. Most involve saying no to a public option.
Context is key. Liberal Democrats need to stop looking at this bill and seeing phantom limbs, missing parts, all that was cut out of it under pressure. They should appreciate it for what it is, at least for a brief moment, before they return to dreaming things that never were and asking "why not?"
http://www.politicsdaily.com/2009/12...arn-to-love-i/
Thoughts? Questions? comments? complaints? backtalk?
ReplyNation
Health Care Polls Reflect Opposition and Confusion
Updated: 35 minutes ago
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Andrea Stone Senior Washington Correspondent
WASHINGTON (Dec. 21) -- The
polls are clear: A majority of Americans don't like the health care ideas proposed by Democrats in Congress.
Now, if only they knew what those ideas were.
The Pew Research Center reports that 69 percent say health reform is
hard to understand.
"It's a very complicated set of propositions for people to make judgments about because there's a fair amount of
misinformation," said Pew Center President Andrew Kohut. "Even the policy wonks have trouble with this stuff."
It is tough to keep up with a 2,000-page bill that lawmakers have tried to change with amendments that themselves run into the hundreds of pages. Especially when senators cast crucial votes in the
dead of night in the middle of a blizzard and the holiday season.
Back in July, before lawmakers turned their full attention to health care, a
Gallup poll found two in three doubted members of Congress had a good understanding of the issue. Nearly half, however, said they had the issue figured out. Still, the majority admitted they did not have a good grasp of the details.
Top presidential adviser David Axelrod
appeared confident Sunday on ABC's "Good Morning America" that, "reality, I think, will trump poll numbers in the dead of winter as this debate is going on."
Axelrod and other Democrats got some good news Monday in a
strategy memo by Mark Mellman that said opponents to their bill include many who think it doesn't go far enough.
Still, Frank Newport, editor-in-chief of Gallup, said it could take months and more likely years for that reality to sink in and for Americans to really know how they like the changes being made to their health care.
"The White House is sensitive to the fact they're doing something against the majority's will," he said. "They're saying that as time goes on, people will appreciate it is the right thing to do, which is basically saying, 'We know more than the public.' And that gets into another philosophical debate – whether Congress should lead or reflect the public will."
Theodore Marmor, a public policy professor at Yale University's School of Management who
helped create Medicare for seniors in the 1960s, said polls on health care are meaningless because most of the public doesn't understand the issue. "Principled congressional actors will discount polls that have almost nothing to do with the facts of the legislation," he said. "Opinions have been shaped by sound bites, distortions, misrepresentations and in some cases outright lies."
Or, just as likely, by political affiliation. Newport and other pollsters note a sharp partisan divide when it comes to health care. In the latest Gallup survey, more than three in four Democrats support the Senate bill, while 83 percent of Republicans oppose it. Independents are more evenly split, with 49 percent opposed and 44 percent in favor.
Democratic leaders "know it's not popular with the general public but it is popular with Democrats," said Harvard health policy professor Robert Blendon. "If they fail to get a bill enacted, it will ... show they are incapable of leading the country" when they control both the White House and Congress.
Republican pollster Frank Luntz said voters understand all too well the debate under way on Capitol Hill and will make their opinions clear in the 2010 elections. "Americans want health care reform, but not this health care reform," he said.
As the Senate prepares for a final vote on Christmas Eve, Luntz predicts the legislation will get the votes it needs "regardless of what the public thinks."
"On health care, we're not on the 1-yard line but we are on the 20-yard line, and it's close enough that Obama can kick a field goal."
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http://www.sphere.com/nation/article...ans%2F19289947
still waiting on your opinion folks..
:w:
Replysyilla
12-23-2009, 03:35 AM
Lets compare to the Malaysia ones... (let me read it first then...let lists down the pro and cons :D)
Budget 2010: What’s in it for health care? Print E-mail
Dr David KL Quek
Wednesday, 04 November 2009 02:51
Prime Minister Najib Abdul Razak’s maiden national budget 2010 must at first glance appear people-centric, but on closer scrutiny, the goodies appear much less than expected and generalities abound rather than specifics.
Still, the prime minister must be credited for at least trying to reduce the national fiscal deficit from a high of 7.4% in 2009 to 5.6% for 2010.
The overall national expenditure has been reduced by 11.2% from RM215.7 billion to RM 191.5 billion. Operating expenditure has also been cut to just RM138.3 billion, but still consumes 72.2% of the entire budget. The rest of RM53.2 billion or 27.8% is earmarked for Development Expenditure.
What is more worrisome is that the projected federal revenue in 2010 is expected to decline 8.4% to RM148.4 billion compared with RM162.1 billion in 2009. From an expected recession of 3.5% negative growth ending this year 2009, growth is expected in 2010, at a modest positive rate of 2 to 3 per cent.
Budget 2010 and health
What is there in the Budget 2010 for health care?
Well, most health economists and pundits including the Malaysian Medical Association (MMA) have always been advocating for a larger allocation of the national budget for health care services. Over the past five years, health care expenditure has been prudently but perhaps frugally low between 3.6 to 4.9% of the GDP, which many consider as being too inadequate.
Yet despite this rather low spending, over the past many years, Malaysia must be commended for having done relatively well in providing better than expected health care outcomes and importantly relatively high quality medical services. Our human development index has been above average for many years, although obviously laggard behind our more prosperous Asia Pacific front liners.
Yes, many detractors may grouse that perhaps we could have done better, and they would be right. Nearly every health system in the world could have performed better and more efficiently. But in practical terms, if we were to consider how much we actually spend on health care thus far, we have indeed done well in terms of productivity computations -the so-called better bang for the buck.
But because Malaysians are now expecting so much more in terms of better quality standards and timeliness of care, there has to be greater commitment and investment in our health care system, so that we are up to mark and comparable to the more developed nations, or even to be at par with neighbouring Singapore.
Malaysian medicine can become better, if we show greater commitment to improvements and excellence of standards in health care providers, supporting staff and properly trained use of amenities already in place in most of our hospitals and medical facilities nationwide.
There must be a greater commitment to retain and reward excellent performers, so that their talents and skills remain within the nation and preferably within the very well-established institutions and academic centres. Our medical research should be raised several notches to showcase our serious intent into becoming a world-class deliverer of excellence!
budget-2010.jpgWe should remove that all-too-common tendency of many brilliant scientists and doctors to leave our public institutions because of financial concerns, petty local politics, glass ceilings and administrative interference. We must build and sustain a culture of excellence and steadfastly protect these cloistered if egg-shelled veneered institutions.
For 2010, the health care spending has been projected and bumped up to 7.0% of the developmental budget of RM 51.22 billion, i.e. an expenditure of RM3.594 billion, from last year’s RM2.6 billion (4.9%). But, the overall health care operating expenditure is projected to be RM 11.189 billion for 2010, compared with RM 11.753 billion in 2009, a decrease of 4.8%.
National Health Accounts’ different perspective
However, if we look at our National Health Accounts (Dr Zailan Hj Adnan, Laporan Perbelanjaan Kesihatan Negara 2008, KKM Oct 5, 2009), Malaysian per capita spending on health rose steadily nearly four-fold from RM 381 in 1997 to RM 1268 in 2008.
In 2008, our computed nominal total health care expenditure was RM 35.1 billion out of a total GDP of RM 740.7 billion, some 4.7% (close enough to the Budget’s estimate of 4.9%).
Although the government spent some estimated RM 13 billion, the other major components of spending came from: other corporations (RM 4.8 billion), private insurance (RM 2.97 billion), other federal agencies (RM 1.6 billion), Ministry of Education (RM 1.05 billion), other agencies (RM 0.9 billion), but largely from out-of-pocket (OOP) private households (RM10.8 billion). Overall, the ‘public’ to private sector spending ratio is 46% and 54% respectively.
Earlier in our discussions with the Ministry of Health officials, there were plans that the government would be willing to push health care spending to reach 7.0% of the GDP in 2010. But this would mean that health care spending should reach some RM 70 billion [out of our total projected GDP (2010) of RM 1.026 trillion!] Does this seem plausible that within 2 years, our healthcare spending is projected to double from that of the year 2008?
Where’s the extra funding from?
Where is the extra funding coming from, since the government is coming out with only less than RM12 billion?
Would this projected shortfall of RM 58 billion (of the RM 70 billion) be taken up by the other government-linked agencies and the private sector? This does not seem possible. Unfortunately Najib’s Budget 2010 does not offer any light on this. Since overall there is a determined reduction in government spending and budget, it is unlikely that we can harness such a growth in our healthcare service industry for the coming year.
Although, the general tone of the Budget 2010 is one that encourages private sector investment and spending growth, for the health sector this may not be obvious. The private sector has been expected to take up the slack in this push for greater health care expenditure, but this would depend largely on the economic recovery, which is by most economic predictions going to be ‘L’ shape rather than ‘V’ shape; which means a slow and gradual drawn-out trend rather than an upsurge!
Nevertheless, this 2010 budget on health care is a better commitment than what the MMA had earlier lobbied for. And we hope the private sector is given sufficient impetus and incentive to invest more and generate greater, if not more cost-effective, spending. Perhaps, these can be made more evident as we grapple with and fine tune the implications of the new budget.
Public access: No compromise
More importantly, the public and the less well of, should not be shortchanged when it comes to access to health care. Cutting back on public health care spending may adversely affect the quality and delivery of health care service, especially those who have limited options or capacity to choose.
In hard times, most people would on reflex cut back on allocating for health care expenses, and thus may suffer consequences of neglect, noncompliance and delayed treatment. Overall health status for some people can become adversely affected.
However, our public must be enlightened that better and more prompt access to health care, demands that they too should plan and budget more realistically, i.e. they must be more willing to pay a greater share for higher quality service. Health care especially during retirement years must be adequately budgeted for. We must all conscientiously plan for it!
doctor-and-patient1.pngIt is increasingly clear that our government, our pensions, our public sector healthcare service cannot indefinitely continue to offer on demand, unrestrained superlative and quickest care for all. It’s simply just not possible. We should face it squarely, there will have to be rationing.
Healthcare costs unfortunately, will always soar outside the realm of normal economic constraints, because life extending measures and new discoveries will almost always outstrip our abilities to pay for these, especially if modern cutting edge tests and therapies are to be expected and demanded by everyone! Escalating health costs will remain an infinite limitless demand that most finite resources or public purses can never hope to match.
Of course, a single payer national health service type insurance mechanism is probably best, but this remains on the drawing board due to uncertain public and practical concerns. In the interim, our citizens must engage in greater self-preventive and health promotive measures to help reduce unhealthy lifestyle risks. They must be encouraged to take up health insurance earlier and with wider coverage.
To encourage this uptake further, our insurance agencies must improve their operating standards. They must be made more accountable that they cannot always be looking at the bottom line to limit or to deny access. They must strive to be more all inclusive, without being meticulously dismissive - no exhaustive pre-existing conditions which would unduly exclude patients. This ultimately defeats the community coverage goals of health insurances.
We now have around 40% of our population who may have hypertension, and another nearly 15% who have diabetes. Does this mean that nearly 50% of our population would be excluded from insurance cover, when they clearly need it most? The insurance industry must devise a better actuarial means testing to widen its possible scope of coverage for our citizens, even if this means higher but more realistic premiums for all.
We note that for overall insurance contribution, there has been some additional tax rebate/incentive in the budget 2010. But this appears smaller than expected to boost much uptake. For the individual this is quite marginal, and the benefit may not be immediately realised. Besides, there is a run-in lag phase even if one now agrees to take on newer health insurance, but it’s a start to encourage more to invest in their own health planning for the future.
Medical & health tourism: Not at citizens’ expense
In many recent private-public workshops and seminars, there is an unprecedented belief that medical/health tourism is the way to go, to help create a new dimension for economic growth in the service industry.
Yet the reality is that this is unlikely to become a major contribution to the nation’s coffers for foreign exchange earnings. As of 2008, only some RM 300 million has been earned from foreign patients. It has been projected that perhaps by 2015, medical tourism dollars would reach RM 2 billion. But this will still only be a small fraction of our GDP.
This cannot be used as a benchmark, an alternative key performance indicator or an ego-boosting, chest-beating symbol, of having come of age! Being a preferred destination for ‘cheaper’ medical treatment, does not necessarily mean and certainly does not imply that our health care system has attained the standards of the first world.
It simply means that some of our private health care settings, some of our selected medical disciplines are sufficiently good enough to be recognized as suitable, perhaps comparable and safe, and most importantly cost-effective choices for foreign patients.
It actually means that health care costs in some countries have escalated to such astronomical levels that many people could not afford the necessary care at home! Of course, among some of our neighbouring countries, we may attract foreign patients because our level of care has been considered as superior to their own.
More importantly, there are already grouses among many civil groups that despite this push to attract more patients through medical tourism measures, Malaysia has not yet been able to commit to a declaration to provide universal access to health care for all our citizens!
When we hear of almost daily requests for financial assistance for some tertiary (unaffordable and costly) therapies from our own citizens, this seems to run counter to our sense of equity and fair play, when on the other hand, we offer prompt access to aliens/outsiders who can offer a few dollars more!
So what about this further move to encourage greater medical tourism?
To further promote the medical tourism industry, the Government will enhance tax incentives for healthcare service providers who offer services to foreign health tourists. Currently, it is not generally known that there is an incentive for income tax exemption of 50% on the value of these ‘increased exports’. Most doctors are not really aware as to the exact mechanisms of tax rebates under such circumstances.
doctor-and-nurse-with-patient1.pngHowever, with this new Budget 2010, this rebate will be increased to 100%, to encourage private hospitals and health care facilities to promote their services more aggressively overseas. Thus, essentially all earnings from foreign health tourists will be tax exempt.
We are not too sure if this extends to earnings from the professional aspects/fees of individual doctors and specialists. This incentive is expected to enable healthcare service providers to offer high quality health services, to continually be raising standards and to promote more assertively overseas to attract greater numbers of health tourists. Perhaps, we may succeed yet.
1Malaysia Clinics: Expanding public health facilities
The purported aim of these 1Malaysia clinics is that our government cares about the well being of the rakyat. In fact, a sum of RM14.8 billion (Is this a typo? Because, this huge amount is larger than the entire operating expenditure budget for health care services in Budget 2010!) is allocated to manage, build and upgrade hospitals and clinics, although where this money is coming from is not clear as of now.
Apparently, in 2010, hospitals under construction and being upgraded include those in Kluang, Bera, Shah Alam, Alor Gajah and Tampoi.
In addition, we are informed that the EPU is the main driver for urging the government will expand these community clinic services, to be known as 1Malaysia Clinic in urban areas, similar to clinics in rural areas. For a start, RM10 million will be provided to establish 50 clinics in selected areas.
These clinics are to be located in rented shopping lots of housing areas to enable the local community to seek basic health treatments such as fever, cough and flu. What is disturbing is the stated suggestion that these clinics will be manned by medical assistants, and not by doctors. One would have thought that this model is a relic of the past!
There have been some global trends toward professional task shifting, now increasingly contemplated and advocated worldwide following WHO initiatives to reach out to very poor countries, which lack properly trained medical personnel.
This essentially means that so-called ‘simpler’ healthcare responsibilities would be shifted down to lesser (more specifically and focussed) trained, cheaper to maintain personnel e.g. nurse physicians, medical assistants, pharmacist assistants, etc.
In the pre-1980s, it is true that we had utilized medical assistants and ‘jururawat desa’ to help out in more remote rural clinics.
They certainly provided a great much needed service then. But, these are now increasingly scaled down so that doctors can oversee more and more of these services to enhance greater quality and service even to our rural or more remote locales.
Times have changed, and we are now more than advanced in our development of our personnel and health care providers, including doctors. So, we don’t really need to do this about-turn.
Therefore, MMA has immediately opposed what we feel is a hugely retrogressive approach to health care. We are saddened that this approach has been suddenly sprung upon us. We understand that sometimes ‘pork-barrel’ goodies need to be dished out, but we envision these so-called ‘1Malaysia clinics’ as simply exercises to exude political goodwill, which can backfire.
This may temporarily salve some very poor urbanites, but we fear that in the longer term, this exercise may be shortchanging the less discerning marginalized public. Regulatory and medico-legal aspects, potential medication or medical leave abuses, and possible unethical practices remain to be ironed out.
However, we have counter-offered that our already very available and plentiful GP clinics be tapped to help provide these outsourced MOH initiatives, as more suitable alternatives. We are made to understand that the Minister of Health sympathises with us in this, although it would appear that the MOH has to contend with other Cabinet portfolios for ‘public service’ projects and financial resources…
For our country, which continues to produce so many new doctors—some 2500 per annum, this will be catastrophic for our younger medical graduates, who might in future not have enough jobs to function, whose livelihood might be threatened, and whose remuneration might be sharply reduced.
We need to enlighten the government that this may not be the best approach. Standards of health care cannot be compromised or made expedient just to accommodate to some economic or short-term considerations.
Conclusions
Thus overall, the Budget 2010 for health care has been more of noise than substance, and is quite disappointing, with a few shocks and regressive suggestions which are at best impractical, but at worst even contradictory, to our existing system and regulations.
We urge the government and the MOH to help resolve some of these incongruities by tapping, perhaps integrating, existing services such as urban private GP clinics, and engage and enhance greater public-private partnerships.
We must move towards better and a more consistent maintenance culture for our existing health facilities and management so that they function at tip top, zero-defect efficiency, with enhanced quality and safety, supported and manned by adequately trained personnel and physicians.
Dr David KL Quek is president of the Malaysian Medical Association.
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