Congress faces a basic dilemma over "health reform lite." If it chooses only the politically popular reforms, they won’t work in practice. If it chooses practical ideas, they won’t go far politically.

For example, it might be very tempting for Congress to pass a package of insurance reforms only. However, those reforms won’t work without an individual mandate to bring more healthy people into system, which in turn requires subsidies to make coverage more affordable. In the absence of those complementary pieces, insurers will raise their premiums on the middle class to cover the cost of covering newly insured sicker people. Likewise, limited coverage expansions aimed at the working poor will not benefit middle class Americans who usually have coverage until they lose their job. Such an approach would turn health care reform into a welfare program.

In the aftermath of the Massachusetts election, President Obama has righty asked Congress to focus on the essential elements of reform. For most Americans, that comes down to three key questions:

1. Will reform control my health care costs and make health care more affordable?

2. Will I have coverage if I lose my job or if my employer does not provide it?

3. Will I always be able to get health care and coverage if I get sick?

Comprehensive reform is the only way to address the concerns of the middle class. In addition to offering the middle class stable coverage, the Senate bill will save employers and employees $814 billion over the next 15 years based on reports from the Congressional Budget Office and Medicare’s actuary. Comprehensive reform is also the only path to creating a workable health insurance exchange that will provide coverage to employees who are between jobs, without coverage at work, and who are sick or have a pre-existing condition.

These middle class benefits had been lost in the weeds as legislators debated thorny questions about abortion, the public plan option, and immigrants. Such tough questions are unavoidable, but doing nothing won’t just resign us to the status quo, it will tie an anchor around our economic growth. For that reason alone, we should be thankful that the Massachusetts election provides an opportunity to return to the fundamentals of reform.

There has been some hilariously bad advice to Congress in the wake of the MA election – “do not scale down, ram it through, work faster, avoid bipartisanship.” How about this instead: Start listening to your constituents. This morning Gallup released a poll, where they asked Americans if Congress should keep working on their health care bills, or drop it and find a better way forward with GOP support.

The people have spoken, clearly. Congress should not pretend they aren’t sure what the MA election was about or that they think Americans want them to move forward with the toxic current bills. The people want Congress to start over.

Health reform should be straightforward, bipartisan, affordable, and fiscally responsible. Don’t spend a trillion dollars, or even half that much – and especially don’t raise taxes in this already tough economy. To this end, we suggest a simple framework for Congress to use:

1. Reform the insurance system.

· Eliminate the use of pre-existing conditions or health status
· Guarantee that any individual or entity will be issued a policy that will not be revoked
· Place reasonable limits on rating differences, but don’t rob the young to fund the old
· Explore ways to prevent free-riding or gaming the system

2. Get costs under control. Use an all-of-the-above strategy.

· Meaningful medical liability reform – not just pilots
· Reform Medicare and keep the money in a real Medicare trust fund
· Comparative effectiveness research
· Wellness and prevention
· Coordination of care and medical homes
· Pay-for-Performance reform and accountable care
· Combat fraud and abuse
· Preserve and expand consumer-driven health options
· Small business pooling
· Real long-term care reform, not a new entitlement
· Tax parity: Let individuals/small business deduct the full cost of insurance expenses

3. Create a vibrant market place.

· Create a connector/exchange that allows individuals and businesses from anywhere in the country to enroll
· Facilitate improved pooling mechanisms, choice, and competition
· Allow any person or business to buy any insurance policy they want

When the business community sees a bill like this – we will help you pass it. If we see more taxing, irresponsible spending, entitlements, rifle-shots, and class warfare, we will fight.

We should consider a less ambitious health reform plan that we can fall back on if Congress fails to enact major expansions in health coverage. This fall back bill would not include coverage expansions through Medicaid and the premium subsidy programs, and there would be no mandate for individuals and employers to purchase insurance. With no expansions in subsidized coverage, there is no need for excise taxes, a surtax on high income people or potentially unsustainable cuts in Medicare and Medicaid funding.

Instead, the bill could focus on: 1) direct services programs to address the health care needs of the uninsured; 2) insurance reform in the individual market; and 3) several delivery system reforms for Medicare that are already in the existing health reform bills.

Some of the most creative proposals to address the needs of the uninsured appeared in the Senate Finance Committee “white paper” on reform options from December of 2008. The program would provide access to primary care services by increasing funding for free clinics. It would also establish programs to identify uninsured people with chronic health problems to receive additional services as needed, with an emphasis on primary and preventive care. These programs would be phased-out once affordable coverage is available to all.

The individual market could be reformed so that coverage is available to people with preexisting conditions. The best way to do this is to require all Americans to have insurance as under the current health reform bills. This spreads costs for high cost individuals across a much broader risk pool, thus making it possible to cover all of the sick without greatly increasing premiums. Without universal coverage, guaranteed issue would add only sicker people to the market resulting in large premium increases as occurred in states that have already required guaranteed issue in the individual market.

We can still achieve guaranteed issue without increasing premiums by expanding upon the high risk pools that now exist in 32 sates. Individuals who are denied coverage due to health status may enroll in the risk pool by paying a premium equal to 150 percent of the average cost of insurance for average individuals of a corresponding age. Federal funds could be used to pay for losses in excess of premiums, which could be raised through tobacco taxes, an assessment on insurance or some other source of dedicated funding. For example, a $2.00 per pack cigarette tax would raise nearly $292 billion over ten years while also discouraging tobacco use.

The existing health reform bills include several provisions designed to reform the Medicare delivery system. These include medical home and pay-for-performance programs that reward physicians for efficiency and good quality care rather than the volume of services provided. The bills also implement bundled payment systems that create incentives for providers to reduce costs while improving quality. While these changes are expected to save little in the near term, they provide a foundation for cost control in the future.

This is a short list of items that would address many of the worst features of our health care system without adding $850 billion in new federal spending over the next 10 years. While it does not expand coverage, it does direct assistance to those whose health is actually suffering due to a lack of coverage. It also assures that people will be guaranteed access to insurance even after they become sick. Medicare is also improved without the huge provider payment cuts that would be used to pay for coverage expansions.

To many, health reform without a large increase in coverage is no reform at all. But we are once again in danger of losing an opportunity to make a real difference in our health care system. While it is hardly a substitute for universal coverage, a scaled back reform bill could still make huge improvements in health security for Americans. We should have it in our back pocket in the likely event it is needed.

As we turn the page to the next stage of debates around health reform, we should remember there is a whole lot in the current Senate and House bills that is popular, already in close agreement, and could be the impetus for moving forward.

The prevention and wellness sections of the bills could help do just that.

A public opinion survey released in November 2009 by Trust for America's Health (TFAH) and the Robert Wood Johnson Foundation (RWJF) found that disease prevention is one of the most popular parts of health reform. In fact, 71 percent of Americans favor an increased investment in disease prevention.

Investing in disease prevention receives majority support from across the political spectrum (85 percent of Democrats, 59 percent of Republicans, and 68 percent of Independents) and across the country (72 percent in the Northeast, 73 percent in the South, 71 percent in the West, and 69 percent in the Midwest), according to the poll, conducted by Greenberg Quinlan Rosner Research and Public Opinion Strategies.

The prevention provisions in the two bills are also not far apart - meaning quick consensus could be possible. These sections focus on improving the health of Americans - and moving us away from a "sick care" system to a true "health care" system. Some of the key measures that are similar in the House and Senate bills include:

• Establishment of a Dedicated Funding Mechanism for Prevention and Public Health. The Senate bill includes a combined $25 billion for a Prevention and Public Health Fund and a Community Health Center Fund, and the House bill includes a total of $33.9 billion for a Public Health Investment Fund.

• Creation of a National Prevention Strategy. The Senate bill includes the creation of National Prevention and Health Promotion Strategy to set goals and objectives to improve the health of Americans through federally-supported prevention, health promotion and public health programs, including accountability measures for determining results. The House bill includes the creation of a National Prevention and Wellness Strategy, directing the U.S. Secretary of Health and Human Services (HHS) to submit a national strategy to improve the nation's health through evidence-based clinical and community-based prevention and wellness activities by setting goals and priorities and a plan for implementing the strategy.

• Coverage of Effective and Affordable Preventive Health Services. The Senate bill would require coverage in the essential benefits plan of preventive benefits defined by the HHS Secretary, such as chronic disease management and maternal and newborn care, and eliminates cost sharing. It also requires group health plans to provide coverage, without cost sharing, for services recommended with a grade of A or B in the current recommendations of the US Preventive Services Task Force and vaccines recommended by the U.S. Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices. The House bill includes minimum coverage of services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and vaccines recommended by the CDC, and also eliminates cost sharing. Both bills also include waiving cost sharing (both co-insurance and deductibles) for preventive services in Medicare.

We know that Americans understand and overwhelmingly agree about the value of prevention. They know that millions of us suffer from diseases that could have been prevented if we spent more time trying to keep people healthy in the first place instead of treating people after they are already sick. By coming together over the areas where we agree, we can move forward with reforming what is sick in our current health care system.

Real Health Care Reform

Health reform had a tough day. But we are not giving up yet. As we go forward we must focus on two facts that shape the expectations about health care reform. First 85% of Americans have health insurance and second 96% of voters in the last election had health insurance—their expectation is that reform would make insurance less expensive. By refocusing the attention on insurance reforms, and affordability those with insurance would have a major stake in the bill. And yes the proposal moves us along the path toward universal insurance.

Below are three ideas that are bipartisan, common sense and substantive. Making progress relies on moving forward clear, commonsense reforms likely to attract bipartisan interest. These include reforming the health insurance market to protect children and adults, making health care more affordable for the 180 million Americans with private insurance, improving the quality of care for all Americans, and moving forward along the path to expand coverage to the most vulnerable uninsured that cannot afford coverage. If embraced, the ideas below would reduce health care costs, have federal costs of about $500 Billion and cover about 20 million uninsured by 2018. This proposal could take key elements from the current legislation and with some modest modifications we could move forward very quickly to pass reforms.

1. Push the insurance reforms that will most protect patients and alleviate fears. This is critical for getting buy-in from Americans and is clearly something they care about. Eliminating pre-existing conditions and making sure insurers cannot rescind coverage (i.e., throw you off your policy when you are sick) are two of the best examples of changes that will make a major difference for Americans. These deserve to be preserved and are reforms that have wide bipartisan support.

2. Make health insurance less expensive by providing better value per dollar spent. In this regard the bills already offer a lot – but we need to be bolder, do it faster, and spell out what Americans will get in language they understand. This means:

• Helping Americans manage illness and stay out of the hospital: Rolling out payment reforms nationally within 3 years (post acute bundling, high readmission policy, home health care policy and others), aggressively pursuing quality initiatives (hospital value-based purchasing), and changing the reimbursement and delivery model by embracing community health teams, accountable health organizations and medical homes will help us to better coordinate care and manage transitions out of the hospital. If we can do this right the evidence shows us we will reduce costs and boost health among those Americans who have the highest burdens of disease and cost the system the most.

• Boosting health networks in communities across America: On a related note, delivery system reforms need to extend into the community setting, so that Americans have the support they need to make changes outside the hospital that encourage healthy behavior and “sticking to” treatment regimens, reducing weight and with it the prevalence of chronic disease. Rolling out community health teams nationally within 5 years will help patients manage their illness outside of the hospital.

• Promoting prevention: Prevention is one of the areas that Americans want to see emphasized the most in health reform – that’s why reform should preserve all the clinical preventive cost sharing reductions made in current legislation as well as the Prevention Trust Fund. It should be funded not just for primary prevention but for other equally important types of prevention, including effective management of disease.

• Create a consumer-oriented marketplace: Move forward with the exchanges – including the reforms related to protecting patients – and capture the administrative savings that would be produced for those currently with high cost individual and small group insurance.

• Spur malpractice reform: This is rhetorically one of the areas of greatest appeal to Americans, and one of the few places of bipartisan agreement. As such, we should at the very least beef up the state grants for medical malpractice reform.

3. Expand Insurance, But “Don’t Let Perfect Be the Enemy of the Good” Getting to 100% coverage right out of the gate is impossible. But let’s not prevent that from letting us make progress. The lessons from 1994 should be kept in mind here. What I have in mind is:

• Keep temporary high risk insurance pools (perhaps closer to Republican plan) through 2012—this will provide immediate benefits for Americans that cannot get insurance at any price in many states due to pre-existing conditions;

• Expand Medicaid and CHIP as in Senate bill;

• Apply subsidies to families through 300% of poverty for the “bronze plan” (keep the cost sharing subsidies as well);

• Scrap the individual mandate (per the original Obama plan) but keep the Senate’s modest employer mandate for larger firms;

• Start the plan in 2013.

And set some goals. If 94% of the population is not insured by 2016, those in charge of overseeing implementation of the exchanges (or one of the new super Medicare commissions) and other reforms would make recommendations to the Congress (up or down vote) to assure we achieve this level of coverage.

These reforms are focused on the key issues that the public expects—making my health care less expensive, improving the process of how I actually get my health care and it moves us along the path toward universal coverage. Adopting these three proposals would represent a major improvement over the status quo.

http://www.fightchronicdisease.org/media/blog/

In a certain sense, nothing really changed last night after the special election in Massachusetts.

The need for health care reform today is as great as it was yesterday. Thousands continue to go bankrupt due to medical costs. Insurance companies still deny care to their customers. People still die because they can't afford the care they need. Thousands of people lost their health care yesterday, and thousands more will lose it today. The fact that health care must be a human right in this country is no less true than it was yesterday.

And voters still want change as much today as they wanted yesterday. In 2008, America voted for change. We voted to stand up to Wall Street. We voted to clean up Washington. And we voted to guarantee everyone quality, affordable health care.

Last night, voters stood up and said loudly and clearly, "We still want the change we voted for in 2008. And politicians in Washington must deliver, or else."

Will those politicians in Washington hear that message? Or will they shrink from history and decide passing real, comprehensive health care reform is too risky?

The American public wants to finish health reform, and they want it finished right, by holding insurance companies accountable and making health care affordable for everyone.

As David Plouffe said this morning, "If you run away from [health care], you're still going to get attacked." He's right. Democrats have been handed a historic opportunity, and if the election last night makes one thing clear, it's that voters still want Democrats to deliver on that opportunity. Speaker Nancy Pelosi and Majority Leader Reid have both pledged to get health reform done. We've got to make sure they get it done right.

Congress needs to hear from voters today with this message. They need to know it's not acceptable to scale down or not pass health care reform. They need to know we expect them to get it right.

However you communicate with your elected officials, communicate with them today and tell them to stand up for real principles, give the voters what they want, and finish health reform right.

The real winners in last night’s election were the American people who had rightly become frightened about the sweeping health overhaul legislation that Congress was within a breath of passing. The more people learned about the legislation, the less they supported it. Scott Brown had the energy of the country behind him in Massachusetts because millions of people understood what was at stake. His promise to vote against the bill was a key issue in his victory.

While the leadership in Congress still is talking about pushing forward to get overhaul legislation enacted, I don’t see how they can get the votes in their own caucus to prevail. The only path to passage of reform legislation now is for the president and the leaders in Congress to work with members from both sides of the aisle to come up with a smaller, more reasonable bill.

The American people have made it clear they want health insurance that is reliable and more affordable and that does not exclude people with pre-existing conditions. We could start by helping states to create more functional high-risk pools, by giving people more choices of how and where they purchase health insurance, and by assuring people that if they have coverage, they can keep it. We need to create a path toward ownership of health insurance and genuine competition among insurers. And now that people know how much wasteful spending there is in Medicare and Medicaid, they want that fixed.

There is a world of policy complexity behind these initiatives, but if we start by respecting that people value private health insurance, don’t want huge disruptions and losses of freedom, or massive new taxes and entitlement costs, we can begin a new conversation.

Ceasefire Is Another ‘Once in a Lifetime’ Chance for Reform

By Thomas P. Miller

(as posted on The Enterprise Blog

blog.american.com/

January 20, 2010, 9:05 am)

The most honest analysis of last night’s shocker in Massachusetts is “Wow, I didn’t see that one coming (until everyone else did just a few days ago).” But there will be no shortage of profoundly updated analyses (and excuses) by the many pundits who got most of this past year’s health policy debate and its larger political context wrong. On the other side, one can find exaggerated claims of a mandate to move in an opposite direction, rather than simply calling a timeout and reflecting before reloading.

Hence, before the next round of clichés and conventional wisdom, a much humbler reflection would start with recognizing the profound disconnection between, on the one hand, the relentless push of the White House and the current congressional majority’s leadership for a sweeping and contorted mix of healthcare overhaul provisions by any means necessary, and, on the other hand, the growing majority of overburdened Americans hoping for something better someday but willing to accept a political ceasefire. We do not have sustainable political majorities for any destabilizing policy changes. Trying to do less in Washington would accomplish more everywhere else.

We will know more over the next week about the calculated response of the president and Democratic leaders to seeing their defeat on this front snatched from the jaws of imminent victory. The temptation to double down, Vegas-style, on an unwise bet to make health policy history through more procedural shortcuts and backroom deals remains great (at least inside the central command bunker), but pursuing this course would not only be self-defeating, it would stress the larger political culture in which all parties must live and succeed. The alternative of cobbling together a scaled-down, less partisan compromise amid the overcharged atmosphere of 2010 remains equally unlikely.

For the moment, we are stuck in another stage of political stalemate despite a serious need for limited, but essential, health policy reforms. However, there remain several past historical examples of health policy changes that followed initially disastrous overreaches by majorities that misread their mandates. In 1996, a more limited set of reforms under the Health Insurance Portability and Accountability Act was passed on a bipartisan basis—just two years after the collapse of ClintonCare. In 1997, the Balanced Budget Act incorporated many of the Medicare policy changes so vigorously resisted when proposed by a new Republican-controlled Congress in 1995. (To be sure, these were much more political process accomplishments, because the actual policy provisions were of neither great value nor catastrophic harm . . . which often is close enough for government work.)

If and when the adults re-enter the health policy discussion, I hope they will encourage an end to the artificial urgency and apocalyptic desperation of the current debate. We need to restart with neither a blank page nor an overcrowded pile of 2,500 pages. After we listen more carefully to the often-contradictory messages coming from anxious voters and count more of their ballots this November, a healthier restart and reconnection with them is both possible and necessary—next year. That will be the next annual “once in a lifetime” opportunity.

Last night, Scott Brown reminded us that “we can do better.” This past year, we’ve already nearly done much worse.