CQ HealthBeat Policy Preview Conference

The CQ HealthBeat Policy Preview Conference includes some of the country’s top health-care policy analysts.  Speakers include: former U.S. Sen. Tom Daschle; Nancy-Ann DeParle, White House Office for Health Reform; DeAnn Friedholm, Consumers Union; Dr. Arthur Garson Jr., University of Virginia; Dr. Nancy Nielsen, American Medical Association; Ron Pollack, Families USA; John Rother, AARP; Dr. Reed V. Tuckson, UnitedHealth Group.

This discussion is over, but please read the transcript below.

• KJS from California: We all know health care costs are out of control and too many Americans are uninsured. But for those who are insured, won't a tax on employer-provided benefits make it even more expensive? What's the likelihood of that happening.
• HealthBeat Policy Guests : Hi, this is Tom Daschle.
  
  Here is my answer to your good question:
  
  Yes, we have to be concerned about the implications of taxing health benefits.
  
  My hope, however, is that by taking all of the other steps we can to reduce costs, the overall impact of those actions will far exceed any change in the tax treatment we enjoy today.
• HH from DC: Sen. Wyden's proposed health care overhaul would be expense-neutral. Why is this not being seriously considered?
• HealthBeat Policy Guests : This is Tom Daschle.
  Here is my answer:
  
  Ron Wyden deserves immense credit for showing that you can have meaningful and comprehensive reform that is budget neutral.
  
  I believe his bill has set a standard that is a major influence on how legislation is being considered now.
  
  His elimination of the tax exclusion is probably the reason why more Senators haven't signed on, but it has made a big difference already in the debate.
• Tracy from Kingsley: Why are single payer systems being outright ignored and dismissed when a majority of Americans are supporting a single payer system and streamlining and digitalizing medical records?
  
• HealthBeat Policy Guests : This is Tom Daschle.
  
  As you may know. Senator Baucus is meeting with single payer people today.
  
  They deserve to be at the table.  They deserve to be heard.
  
  Many of us think that they have a lot to contribute to this debate and I am pleased that the meeting today is now scheduled.
• Audience member: If the public plan is included in the Senate-reported bill, would that not result in a filibuster, leading to using reconciliation in the fall, and therefore a partisan bill? Is a partisan bill a long-term sustainable reform solution?
• HealthBeat Policy Guests : This is Tom Daschle.
  
  There are many ways to create a public plan.
  We are working on innovative solutions for compromise at the Bipartisan Policy Center right now.
  
  We may or may not be successful, but I haven't given up on the determination to find common ground.
• Audience member: Why shouldn't we be concerned that the ultimate goal is to move -- or push -- the U.S. to a single-payer system?
• HealthBeat Policy Guests : This is Tom Daschle.
  
  That is a concern for some.
  
  However, an even greater concern is the status quo and the implications of doing nothing.
  The Council of Economic Advisors reported yesterday that at current rates, the typical family of four will spend 25,000 dollars on premiums in 2025. 
  
  We can't accept that prediction.
• Audience member: Our rural areas face unique challenges in access to health care and are hit particularly hard by shortages in primary care providers. What do you see as the most important step in addressing these issues?
• HealthBeat Policy Guests : This is Tom Daschle.
  
  The most important step is creating the pools and exchanges for rural Americans to access better coverage.  From a cost, quality and access point of view, there is little that is more important.
  
  It is also critical that they have access to broadband to enable HIT applications as broadly as possible.
• Audience member: What steps can we take to ensure that the provider workforce is sufficient in number and distribution to handle the millions of newly insured patients? (Specifically primary care providers.)
• HealthBeat Policy Guests : This is Tom Daschle.
  
  We have to be very concerned about the tendency in this country to employ providers who obtained their training in developing countries.  1/4 of the health care work force today is foreign born.
  
  Oftentimes, they come from countries whose health conditions are far worse than ours.
  We need to do at least three things:
  Incent new medical students to be primary care providers.
  
  Provide the resources to schools to train them.
  
  Use our current providers more effectively...nurses, physician assistants, pharmacists.
• Audience member: What is the likelihood that comprehensive long-term care will be included in health reform?
• HealthBeat Policy Guests : Tom Daschle:
  
  The likelihood is that we will begin to address long term care, but that more will left to be done.
  
  It is one of the biggest challenges we face in the coming years and will require remedy.
  
  Moderator note: Thank you Sen. Daschle for your time and participation in this conference and our Live Online.
• Ken Sands, moderator: Karen Pollitz, research professor at the Georgetown University Health Policy Institute is with us now. She's going to be speaking in a breakout session on "Eliminating gaps in coverage." Karen, what can you tell us about the uninsured and the underinsured and other failures of the current system when they're sick?
• HealthBeat Policy Guests : Too often, our current system of private health insurance coverage fails people when they get sick.  Effective health care reform will need to address this problem.
  
  In particular, today some 57 million Americans are struggling with medical debt - and 75% of them have health insurance.  As we ensure that everybody has health coverage, we must also take care to ensure coverage is adequate.  That means important benefits must be covered and cost sharing (deductibles, co-pays, etc.) must be modest.  Research shows that when patient out of pocket costs reach just 2.5% of familly income, people get into trouble financially.
  
  Another key problem to address is the fact that private health insurance today competes to avoid people when they are sick.  In a reformed system, there must be rules to prohibit health plans from discriminating against people when they are sick, and strong oversight to ensure these rules are followed.
  
  
• Audience member: Looking specifically at children, what need to be done as part of health reform?
• HealthBeat Policy Guests : This is Karen Pollitz again. Children and adolescents have unique and important heath care needs.  They are not just "little adults."  Health coverage must include benefits important to healthy development of children - such as vision, dental, and hearing care, mental health care, screenings.  These benefits are often viewed as 'extras' for adults, but for children and adolescents they are key to growing up healthy, able to learn and thrive.
  
  We must also remember that children tend to get coverage through families.  Consequently  we must keep in mind how family coverage is structured and what it costs and make sure reform policies make it possible to obtain adequate and affordable family policies.  Today, for example, a typical family policy costs about 3 times the premium for an individual policy.  Yet, in the past, proposals to provide health insurance subsidies, such as tax credits, allowed families subsidies worth only twice that for individuals.
  
  Family policies also typically impose cost sharing that is two to three times that applied for individuals.  If we think a $500 deductible is 'affordable,' is it necessarily also true that families can afford to pay $1,000 or $1,500 out of pocket for benefits before coverage kicks in?  When a child is sick, parents ought not to have to think twice about seeking care because they worry about the expense.
  
  Over the years, we developed the Medicaid program to specifically address the health care needs of children.  Medicaid covers virtually any health care need a poor child may have with little or no cost sharing.  As we consider health reform options, it will be important to continue and even expand access to Medicaid for children.  Private health insurance policies will also need to be modified so they are more 'family-friendly.'
  
  
• Ken Sands, moderator: Sabrina Corlette, director of the Health Policy Programs for the National Partnership for Women & Families, also is part of the panel on "Eliminating gaps in coverage." Sabrina, what's the role of your organization in health care overhaul debate?
• HealthBeat Policy Guests : The National Partnership for Women & Families is a 35-year old non-profit, national advocacy organization dedicated to promoting quality, affordable health care for all, fairness in  the workplace, and policies that help men and women balance the competing demands of work and family.  Many may know of us through our work on family leave policy; one of our staff attorneys drafted the original Family and Medical Leave Act, and we led the 9 year campaign to get it passed.  Over the past 15 years, we have been increasingly engaged on health care issues.  Women are the primary health care decision-makers and caregivers for their families - choosing doctors for their children, and increasingly, elderly parents and relatives and providing tremendous amount of unpaid care for family members with chronic conditions.  All this while, as they age themselves, dealing with their own chronic conditions and the problems with a dysfunctional health system.
  
  Over the last decade or so we have led efforts to reform the insurance market to end discrimination based on health status, gender, or age (a common industry practice), and promote a meaningful benefit package so that coverage is really there when people need it most - when they get sick.  We also are leading efforts to promote a health care system that works better for women and their families.  Today, care is fractured, siloed, and not coordinated, particularly for those with chronic conditions.  Today, the average person has only a 55% chance for getting the right care for their condition, and the numbers are even worse for women and people of color.  We're promoting policies to support a system grounded in primary and preventive care, in which we pay for value as opposed to volume of services, dramatically reduce medical errors, and elimiinate shameful disparities in care.
• Audience member: What is the role of comparative effectiveness research in overall reform?
• HealthBeat Policy Guests : This is Sabrina Corlette:
  
  We believe any health care reform package should include a robust federal commitment to comparative effectiveness research.  Patients and their doctors need to have an unbiased resource to compare the benefits of different treatment options and know what works best for their condition.  Knowing what works will help patients get the right care, at the right time, for the right reason.
  
  Currently a full 1/3 of our health care spending is wasted on unnecessary, ineffective care.  While investing in comparative effectiveness research will require some federal spending in the short run, we believe it will help keep cost growth down in the long run by providing unbiased information about treatments that are ineffective or pose risks to patients that outweigh their benefits.
• Ken Sands, moderator: Helen Darling, president of the National Business Group on Health, is part of the breakout session: "The Public-Private Equation." Helen, what's the most important thing that reform needs to accomplish?
• HealthBeat Policy Guests : To reduce the crushing burden of health care costs on working families, employers, governments and the economy.
  
  In addition, making certain that every citizen of the United States has access to high-quality, affordable, subsidized-if-necessary, health coverage.
  
  Improve the quality and safety of American health care, and eliminate waste, which is estimated at $700 billion per year. What I mean by waste is care that does not improve the health of the individual or provide valuable information for treatment decisions. As opposed to duplicative tests, errors, sins of commission and ommision, and treatment that does not improve health because it's not evidence-based. The lack of 21st century health information technology and records means we cannot improve care in an effective and efficient way.
• Audience member: Will mental health be included in the benefit?
• HealthBeat Policy Guests : This is John Rother, executive vice president of policy and strategy of AARP:
  
  The answer is yes, because mental health now is so essential and all of the plans include mental health in the benefit.
• Audience member: What can we do to lower obesity in school children?
• HealthBeat Policy Guests : This is John Rother again:
  
  There are many factors outside of health care, such as physical activity and diet that are crucial. One thing that we can do is to place an excise tax on sugary drinks and to make sure that all schools have daily physical activity built into their schedules.
  
• Audience member: What is the single greatest challenge to getting meaningful reform passed this year? Insurance industry agreement on public option? Funding? Other?
• HealthBeat Policy Guests : Hi, this is Ron Pollack. I believe that the biggest challenge will be securing adequate financing to ensure that the upfront investments are paid for. Without such adequate financing, expansions of Medicaid and substantial, sliding-scale subsidies for moderate-income families will fall by the wayside. In turn, this will mean that we won't get an individual mandate and won't secure needed insurance market reforms. We MUST secure adequate financing through cost efficiencies and additional revenues.
• Audience member: The rhetoric is that only the rich will pay more but shouldn't everyone who participates pay some portion of the cost?
• HealthBeat Policy Guests : This is John Rother again:
  
  Yes, everyone should pay something, but those payments should be scaled to income. Those who are poor should not have to pay. Others should have a sliding scale of premiums and no one should be forced to pay more than 10 percent of their income for health care.
• Audience member: Is there an opportunity to shift incentives to encourage home-based care over institutional care?
• HealthBeat Policy Guests : This is John Rother again:
  
  For millions of Americans who are disabled, home-based care clearly is the preferred alternative. We advocate for the federal government to provide a greater Medicaid match for home and community based srevices as a way of promoting these alternatives.
• Laura from Norman, Oklahoma: What are the 'reform' plans out there involving Medicaid: expansion of services? Delinking of IV-E eligibility to 1996 TANF? Mental health services for Medicaid eligible children? What else?
  
• HealthBeat Policy Guests : Hi, this is Ron Pollack. The key change in Medicaid will be to establish a national floor on Medicaid eligability, probably at or around 133 or 150 percent of the federal poverty level. Today, due to the confluence of Medicaid and the Children's Health Insrance Program, children are eligible for public health coverage in virtually every state if their family incomes are below 200 percent of the federal poverty level -- roughly $36,000 in annual income for a family of three, $44,000 for a family of four. (Some states have eligibility standards well above this level.)
  
  For parents, on the other hand, the median income standard in the 50 states is only 67 percent of the federal poverty level. For adults without dependent children, in 43 states there is simply no coverage at all, irrespective of income. This is like and hopefully going to change with a natioanl floor on eligibility irrespective of family status. Obviously, this will have to be financed by the federal government, and I believe it will be.
• Audience member: If health reform goes forward via the budget reconciliation process, what impact would the Byrd rule have?
• HealthBeat Policy Guests : This is John Rother again:
  
  The Byrd rule requires every reconciliation provision to be directly relevant to the federal budget. So under reconciliation, some elements of health reform might drop out if they are objected to as not effecting long-term federal spending. In the Senate, such objections could be overrruled only with a 60-vote majority. So this is a real concern.
• Audience member: In what way will chronic illness be handled in health care reform? Will there be a generic alternative for biologic drugs to bring the cost down?
• HealthBeat Policy Guests : This is John Rother again:
  
  Drugs, including the new biologic drugs, are essential for proper treatment of many chronic illnesses. Congress has not yet decided whether to include provisions establishing generic or follow-on biologics to include them as part of health reform or whether to address them in a standalone bill. Either way, the critical issue is how long the biologic drug will be granted market exclusivity before a generic is permitted.
• audience member: For Ron Pollack: On your inevitability comment - Is the status quo in anyone's interest? Who benefits if nothing happens?
• HealthBeat Policy Guests : In the long term, no one will benefit from the status quo -- even the groups that are generally associated as being possible opponents of reform. Businesses and families will continue to get hurt by escalating costs that are increasingly unaffordable. Even the health industry groups -- which might oppose certain aspects of reform -- will ultimately be hurt. Those businesses will be required to achieve various efficiencies and may receive somewhat lower payments, but they will more than make up for it with increased volume as we move toward universal health coverage.
  
  If, however, health reform fails, there will continue to be incremental and periodic cutbacks in payments to these groups, but those cutbacks will not be offset by coverage expansion that achieves something close to universal coverage. So, in the long run, I don't see anyone benefiting by the failure of health care reform this year.
• Audience member: Right now the average primary care physician is seeing 30-35 patients per day with eight minutes of face time. What do you advocate to fix this problem?
• HealthBeat Policy Guests : This is Arthur Garson, Jr., MD answering. 
  
  1.  Need a better understanding among physicians and patients about who needs to be seen when -- and whether a doctor is really necessary.  Could a nurse or a community health worker not do as well or better?
  
  2. Patients need to take more responsibility for their own care -- some of these visits are not necessary at all.
• Audience member: Rand has produced studies showing lapses in quality, such as only 50 percent of people getting needed care. How can improving quality or access not exacerbate the cost problem?
• HealthBeat Policy Guests : This is Arthur Garson, Jr., MD, MPH
  
  1.  There is approximately 300% variation in practice with no difference in outcomes -- this means that those on the high end are doing too much.  We can save money and improve quality by eliminating that variation.  This has been estimated at $50-$100 Billion per year.
  
  2.  Correct, that the McGlynn study you reference is 80% too little care -- but this is largeley preventive care.
  
  3.  Access will exacerbate the cost problem -- and so must be paid for with #1 above.
• Ken Sands, moderator: Because of scheduling difficulties, Nancy-Ann DeParle was unable to take questions from the audience following her speech. DeParle is counselor to the President, and director of the White House Office of Health Reform. She was one of two luncheon keynote speakers. The other keynote speaker, Rep. Michael C. Burgess, R-Texas, and a medical doctor, is delivering his keynote address now. Rep. Burgess is the final speaker at the CQ HealthBeat Policy Preview Conference. Thanks for joining us today.
• HealthBeat Policy Guests : Video of today's keynote speakers and the "super session" panel will be available on CQ Politics and CQ HealthBeat.