Zwelling presentation


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Presentation at 2012 Houston Economic Summit by Dr. Leonard A. Zwelling of MD Anderson Cancer Center, about process of passing the Affordable Care Act (aka Obamacare)

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Zwelling presentation

  1. 1. RED KOOL-AID,BLUE KOOL-AID Delivering Quality Healthcare Despite Morons and Crooks on Capitol Hill and the Nation’s PremierCancer Hospital Leonard A. Zwelling, M.D., M.B.A. Graduate-The Robert Wood Johnson Foundation Health Policy Fellowship Program UT Chancellor’s Health Fellow in Comparative Effectiveness Research September 2012
  2. 2. “They were more morons than crooks, but the crooks were higher up” Michael Lewis in The Big Short quoting Vinnie Daniel
  3. 3. The Basic Thesis Of Red Kool- Aid, Blue Kool-Aid Moral relativism will trump core values and principles Good people will perpetrate, rationalize and justify performing criminal and near-criminal acts Groupthink will stifle innovation and accountability when both are most needed The unintended consequences of these activities will affect real people
  4. 4. Health Care Reform to Most Americans(M. Scott-Houston Chronicle)
  5. 5. The Agenda Is Washington, DC the best place to discuss health care reform? Is there an American Health Care System? DC Truths-No Bull Health Care Reform is….? PPACA-how did it pass and what does it mean? June 28, 2012-The Supreme Court’s decision What does this have to do with America?
  6. 6. Why Washington, DC Is the Center of the Health Care Universe (from CMS (National Health Expenditures (NHE) Fact Sheet) 2009-total NHE $2.5T;$8086/person; up 4% 17.6% of GDP Medicare spending: $502B; 20% of NHE; up 7.9% (47.7 million) Medicaid spending: $374B; 15% of NHE; up 9 % (58+ million) Private insurance: $801B; 32% of NHE; up 1.3% WHAT WAS THAT ABOUT MARKET FORCES IN HEALTH CARE?
  7. 7. Some Critical American Health Care Facts The US spends more per capita on health care than any other major country (exception, East Timor), typically about twice as much as other Westernized democracies US life expectancy ranks about 42nd. We are behind Cuba. About 50 million Americans have no health insurance, about 1/6 of the population The US is the only Westernized democracy without a system of universal health care. WHY?
  8. 8. The United States Does Not Have One Health Care System- IT HAS 4! (With full credit to T. R. Reid)
  9. 9. NAME PHILOSOPHY FEATURES EXAMPLES US EQUIVALENTBismarck Private Non-profit Germany Workers< 65 providers insurers; France with and payers uniform employer-based Japan and insurance controlled Switzerland pricingBeveridge Health Care Govt owns UK IndiansBevan as a public and Hong Kong Veterans service controls Italy Military Spain CubaNational Sense of Single Canada MedicareHealth community payer; TaiwanInsurance private South docs; Korea WaitingSelf- I got my Paid by Africa The Uninsured-pay=No insurance, patient or ER, free clinics,Insurance what’s your not at all no care, problem? bankruptcy
  10. 10. Basic Premise We can learn how to improve by studying how other countries care for their citizens. The key is “comparative policy analysis”—how Dwight Eisenhower built the interstate highway system after the German autobahn.
  11. 11. “The Window of Opportunity” in Taiwan (Tsung-Mei Cheng, economist) Public demand for universal health care Majority party was challenged by minority party that supported national health insurance Sustained economic growth made funding possible DO ANY OF THESE CONDITIONS CURRENTLY EXIST IN THE U.S.?
  12. 12. The Essential Yet Unspoken Questions for Americans Which inequalities will our society tolerate? Is it acceptable for some people to die because they cannot see a doctor, cannot pay for adequate health care, or become bankrupt due to overwhelming medical bills? IS HEALTH CARE A RIGHT?
  13. 13. In Other Words: Is health care like the police, the fire department, the right to vote and the services of the military (as in all other democracies)? OR Is health care like pork bellies, wheat futures, toilet paper and Gucci loafers (as in the U.S. today)? AND WHEN WILL WE HAVE THIS DISCUSSION BECAUSE WE HAVEN’T HAD IT YET?
  14. 14. Why Health Care Feels Like Getting Your BMW Repaired It costs a small fortune No matter what they tell you, it seems to be costing you more each time you go in The more that gets done, the more the doer makes
  15. 15. Some Basic TruthsAbout Our Government(The Rules of Life in DC by Dr. Marie Michnich- Director of the RWJF Fellowship Program)
  16. 16.  Congress is not there to make good laws, it there is to prevent the making of bad laws Never compromise your honesty. Answer a different question.
  17. 17.  Never get between a big dog and a fire hydrant The first thing a member of Congress does every morning is read his or her own local newspaper.
  18. 18. Allen Schick-The Yoda of the Federal Budget When the President and the Congress are from different parties, everyone behaves better. In the House, the majority wins IF it stays together.
  19. 19. More Allen Schick In the Senate, the magic number is 60. Congressional Budget Office (CBO) scoring means everything to a piece of legislation.
  20. 20. What Is “Regular Order” to Pass a Bill Bill originates in House or Senate except revenue bills must originate in House (Article 1, Section 7) Bills usually go to committees for discussion (mark-up) and amendment The amended bill must pass each committee Most bills do not pass both houses of Congress or their committees in identical form A conference committee is formed by legislative leaders in both houses and from both parties to resolve the different versions of the bills The new version must be passed through both houses of Congress Then it goes to the President for signature
  21. 21. As Senator Mitch McConnell’s Chief Health Staffer MeganHauck taught me when I askedher why this had to be so hard — “It’s supposed to be hard”
  22. 22. The 4 P’s of Government (in reverse order of importance)POLICYPROCESSPOLITICSPERSONALITY
  24. 24. The Devil Will Be In The DetailsEveryone’s definition of health care reform is the same--- I PAY LESS!!!! Dr. Norman Ornstein- American Enterprise Institute
  25. 25. The Bottom LineAccess-Who gets to see the doctor and where?Cost-Who pays and how much?Quality-How good is the care and how do we even measure this?
  26. 26. Friendly ReminderEvery cost reduction is someone’s income.
  27. 27. At the Dawn of 2010, Where Was the Health Care Reform Process? The new President had made the health care reform legislation his top priority despite the faltering economy For the first time since the 1960’s, a health care bill had gone through mark-up in a Congressional committee. Bills were reported out to both houses of Congress November 7, 2009: House version passes 220- 215 December 24, 2009: Senate version passes 60- 39 The two bills are not identical Regular order? YES or NO?
  28. 28. Uh-Oh!-Massachusetts-January 19, 2010
  29. 29. ObamaCare?-Nope-PelosiCare House Speaker Nancy Pelosi avoids need for conference committee by passing Senate version of bill through House President Obama signs into law on March 23, 2010 President signs letter preventing federal funds being used for abortion codifying the Stupak provision of the former House version Final package passes March 25, 2010 Violence erupts WHY?
  30. 30. The Patient Protection and Affordable Care Act of 2010 The first major piece of social legislation passed entirely with the votes of one party 32-34 million more Americans will gain access to health insurance. What about access to health care? Costs are only marginally addressed Ditto quality-demonstration projects 2409 pages plus 150 page reconciliation bill CBO scored at $143B deficit reduction over 10 years and $1.2T over 20 years 10 Titles including private insurance, public insurance, prevention, work force issues, follow- on biologics, long-term care and taxes.
  31. 31. What the Democrats MissedPelosi: constitutionality of health carereform ironclad‘PPACA is not aboutHealthcare. It’s aboutmoney-”How CongressChose to raise money toPay for it”. (Bard-HoustonChronicle-June 16, 2012)
  32. 32. The Mission Statement of the United States of America
  33. 33. The Key Concept“A ruling about whether there is explicit constitutional authority for the way Congress chose to fund a system to make health insurance affordable and accessible to all Americans…how Congress chose to fund the system it set up”. -Jennifer S. Bard Texas Tech University School of Law in Houston Chronicle June 15, 2012
  34. 34. The Devil Will Be In The DetailsEveryone’s definition of health care reform is the same--- I PAY LESS!!!! Dr. Norman Ornstein- American Enterprise Institute
  35. 35. The ‘Sleeper’ Issues Before the Supreme Court (from TR Goldman-Health Affairs 31:471, 2012) Individual mandate-Is it constitutional? Individual mandate-Is it a penalty or a tax? Obama Administration has taken both sides (1867 Tax Anti-Injunction Act) Severability-if mandate out is it all out? Does Medicaid expansion commandeer the rights of the states? (all under 65 at 133% of FPL or less)
  36. 36. OR—Could The Supreme Court Kick the Can Down the Road? Tax Anti-Injunction Act Reconstruction era law Cannot bring suit to injoin the collection of a tax Only bring suit to get refund after tax is paid (not until 2015!!!!!) Is the individual mandate penalty a “tax”?
  37. 37. Some of the Enumerated Powers of Congress from Article I, Section 8 of the United States Constitution Taxes Borrow money Regulate commerce (clause 3) Naturalization and bankruptcy laws Money and post offices Patents and copyrights Declare war and raise an army “To make all laws which shall be necessary and proper for carrying into execution the foregoing powers” (clause 18)
  38. 38. SUPREME COURT OF THE UNITED STATES Syllabus NATIONAL FEDERATION OF INDEPENDENT BUSINESS ET AL. v. SEBELIUS, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL. CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE ELEVENTH CIRCUIT No. 11–393. Argued March 26, 27, 28, 2012—Decided June 28, 2012* In 2010, Congress enacted the Patient Protection and Affordable CareAct in order to increase the number of Americans covered by health insurance and decrease the cost of health care. One key provision isthe individual mandate,which requires most Americans to maintain“minimum essential” health insurance coverage. 26 U. S. C. §5000A.For individuals who are not exempt, and who do not receive healthinsurance through an employer or government program, the means ofsatisfying the requirement is to purchase insurance from a private company. Beginning in 2014, those who do not comply with the mandate mustmake a “[s]hared responsibility payment” to the Federal Government. §5000A(b) (1). The Act provides that this “penalty”will be paid to the Internal Revenue Service with an individual’s taxes, and “shall be assessed and collected in thesame manner” as tax penalties. §§5000A(c), (g)(1).Another key provision of the Act is the Medicaid expansion. The current Medicaid program offers federal funding to States to assist pregnant women, children, needy families, the blind, the elderly, and the disabled in obtaining medical care. 42 U. S. C. §1396d(a). The Affordable Care Act expands the scope of the Medicaid program andincreases the number of individuals the States must cover.
  39. 39. THE DECISIONS-June 28, 2012The mandate is a tax: 5-4 (4 said OK under Commerce Clause)The Medicaid expansion is upheld but limited: 7-2The shared responsibility payment is a penalty under the Anti-Injunction Act 9-0
  40. 40. Roberts on Medicaid Expansion Medicaid expansion violates the Constitution by threatening States with the loss of their existing Medicaid funding if they decline to comply with the expansion.
  41. 41. Key Takeaways and Remaining Issues The “constitutionally ironclad” ACA survived by a whisker If the “shared responsibility payment” is a tax, and the House passed the Senate version, did this tax really originate in the House as all taxes must? If a state rejects the Medicaid expansion and DSH and other supplements to safety net hospitals are gone, can the academic centers survive? Will the results of the presidential election affect this? Will the next Congress be any better at finally addressing the health care reform issue for Americans?
  42. 42. The ‘Sleeper’ Issues Before the Supreme Court (from TR Goldman-Health Affairs 31:471, 2012) Individual mandate-Is it constitutional? (YES, but not under Enumerated Powers) Individual mandate-Is it a penalty or a tax? Obama Administration has taken both sides (1867 Tax Anti-Injunction Act) (Both) Severability-if mandate out is it all out? (NO) Does Medicaid expansion commandeer the rights of the states? (all under 65 at 133% of FPL or less) (YES, optional now)
  43. 43. Why Is Everyone So Angry? What does the Tea Party really want? If they are “taking back our country”, who from?
  44. 44. Why Is Everyone So Angry? What does the Tea Party really want? If they are “taking back our country”, who from? “It’s still the economy,stupid!-Was this really agood time to reformHealthcare?
  45. 45. Cost in PPACA (But….) As long as doctors and hospitals work on a fee-for-service basis (last of the guild system), with variable prices for the same activity (depending who is paying) Using for-profit intermediaries that negate true market forces (insurance companies) not to spread risk or promote health, but to please shareholders… COSTS WILL NOT BE CONTROLLED
  46. 46. From Woody Allen’s Zelig (1983)“You are a great inspiration to the young of this nation who will one day grow up and be great doctors and great patients.”
  47. 47. What’s the Problem Like the Massachusetts bill of 2006 (mandates, subsidies and exchanges), this does not really control costs (Does RomneyCare = ObamaCare?) The “fee for service” system is unchanged We pay more for doing than for thinking (remember our BMW?) If you want to change delivery, change reimbursement. This bill does not change practice, delivery, reimbursement, teaching, work force control, remuneration or measures of quality
  48. 48. What Still Worries Me Where are the doctors going to come from? An insurance card is not healthcare Why won’t the insurers simply raise premiums? What happens when we realize that birth is a pre- existing condition? Genomics What happens when we realize that death is inevitable—no, I mean we really believe it! Who decides? Could Sarah Palin have been right all along?
  49. 49. Can We Turn This Around?-The Betty Ford Clinic Plan for Kool-Aid Rehab• Moral relativism-The 10 Commandments and the Golden Rule. WWYMWYTD?• Criminal Acts-Conflicts-of-interest, nepotism, self-dealing, lobbying, and big money have all got to go. No waivers!• Groupthink-If you see something, say something!• Unintended consequences-Remember your Hippocratic Oath-put your patients first and you will probably do just fine, and so will they!
  50. 50. Drinking the Kool-Aid Embracing a philosophy Completely buying into an idea or system, whether good or bad Going along with what the crowd desiresJim Jones led over 900 people totheir suicide from drinking cyanide-laced Kool-Aid on November 18, 1978
  51. 51. Health Care Reform?-The TSA Is In! (Austin American Statesman-Nov. 30, 2011) Who’s going to provide health care to the newly insured? Why not put the time on the TSA security line to good use? iPad when showing boarding pass for history Update vaccination, medication and allergy records Physical exam by newly-trained TSA agents Real CT scan=MRI (more radiologist income) Cancer screening (mammography, DRE, exposed skin exam) for first class and frequent flyers More health care; More security; More jobs!