I participate in a number of discussion groups, often with highly
educated experts in health policy. In recent months it has become
increasingly difficult to even discuss the health reform
proposals. There are so many versions and iterations of all these
bills and amendments that it has become nearly impossible to
discuss any of it. And some of it isn’t even exposed yet, like
Reid’s bill. CBO keeps scoring this, that and the other, and it
is hard to match up the particular CBO score with the right bill
or amendment, let alone compare specifics.
Yet every provision is critically important, and not just by
itself, but how it interacts with the other provisions.
It feels like a shell game, and it is small wonder people are
edgy about the whole enterprise. Too many moving parts, too
little clarity, too much rhetoric and jargon, and all tainted
with political ambitions.
I think we are way beyond what the legislative process is capable
of doing. There is literally no one in Washington who knows what
it is they are voting on anymore.
It would be far better to take all these topics one bite at a
time, by which I mean separate bills for —
— Medicare payment reform
— Insurance
regulation
— Assistance to the
needy
— Management technology
upgrades
— Workforce
initiatives
— Quality improvement
initiatives
— Professional liability reform
Each of these is complex by itself. Blending them all together
into a single bill is simply impossible.
For example, I agree that we need to completely overhaul the
regulatory regime currently in place for insurance. Each state
has completely different statutes for the individual, small
group, and large group markets. Some states have separate
regulations for Blue plans, commercial companies, and HMOs. Then
ERISA exempts self-funded employers from any state regulation.
Regulatory reform is an enormous challenge all by itself and the
current bills are way too vague on how, or even whether, that is
supposed to happen. For instance, it is not at all clear what
will be the state and federal roles for regulating carriers that
participate in the Exchange. Who oversees their solvency,
reserves, accounting, investment practices? If a company markets
exclusively through a national Exchange, what is its state of
domicile? Will HMOs continue to be regulated by separate agencies
than other carriers as they are in California? Who will regulate
brokers?
Or take the workforce issue. We are facing substantial shortages
of primary care physicians and nurses as the Baby Boom generation
retires. Expanding insurance coverage will aggravate the problem.
Plus there are new technologies coming on-line all the time. How
do we get enough technicians to run the machines?
It is not just
a matter of giving scholarships to med students or opening more
slots in dental schools. The whole licensure and oversight regime
currently in place needs to be re-examined. Everyone who looks at
it concludes it is a mess. Why at least could there not be
interstate reciprocity for licensing and disciplinary actions?
Why can’t a physician who is licensed in Arizona prescribe drugs
for patients in New Mexico? Or how is it that a doctor who is
disciplined in one state can set up shop in the adjoining state?
And on and on and on. Because this thing is so big, we are not
paying enough attention to the critically important REAL issues.
