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.