Health Reform

Rice-A-Roni may be the San Francisco treat, but health reform has been the topic du jour of late for the Bay City. As the San Francisco Chronicle noted, yesterday marked the one-year anniversary of Healthy San Francisco—the city’s ambitious plan to make health care accessible and affordable to its uninsured residents.

Like a cable car descending Nob Hill, there have been a few bumps along the way—the growing pains health reform—as well as uncertaintity because of a pending decision from the Ninth Circuit regarding the legality of the city’s efforts. Still, the plan is an innovative effort from one of the cities described in a recent Families USA report as being on the front lines of America’s health care crisis.

Harry and Louise, watch out for Elizabeth Edwards.

The New York Times politics blog reports that Health Care for America Now, a coalition of labor, health care and liberal organizations pushing for comprehensive health reform, will roll out a new television commercial next Tuesday, part of what the group says is a $40 million planned campaign to promote affordable health care under the next administration. The idea is to have a pro-reform media message as powerful as the insurance industry's Harry and Louise ads were in fighting health reform when Bill Clinton was president.

Elizabeth Edwards, breast cancer patient, wife of former Democratic Sen. John Edwards, health policy blogger and visible proponent of health reform, will speak at the group's inaugural event in Washington next week.

The Times reported that after the initial buy of $1.5 million for national television, print and online advertisements, the coalition plans to pour $25 million into additional advertising. The first commercial will run in national newspapers, on CNN and MSNBC and online.

If a pastor gets sick, given a choice between "a wing and a prayer" or "a wing and a prayer and health insurance," he or she would probably choose the second option—if it's available.

A recent survey by the National Association of Evangelicals found that the churches and related evangelical organizations are having the same challenges as other Americans, and jerry-rigging some of the same partial solutions. But significant numbers of pastors—the format of the NAE's survey wasn't designed to produce a precise estimate—go uninsured. Others get their coverage through their spouse's job, or by holding down a second job outside their church that gives them access to coverage. Those over 65 can get Medicare. Some are poor enough to qualify for Medicaid. Young pastors who are relatively healthy sometimes opt to get a private policy instead of buying into a church or denomination-sponsored plan, meaning the bills go up for the older and sicker.

"Only a few of our churches are adequately addressing this problem," one denominational leader was quoted as saying in an NAE report. "We tried two or three items to provide health insurance, but we have not been able to make it work," lamented another.

Sunday's New York Times's article, the first in a series on evidence-based medicine, got me thinking about how we set standards for the practice of medicine, and what it will take to get doctors to follow voluntary ones.

The extensive front-page article examed the prevalence and value of computed tomography (CT) angiography. In brief, CT scanners can generate a complete image of the heart (see NBC's Matt Lauer's here and Oprah Winfrey’s here).The technology is impressive. So is the price. A CT scanner costs about $1 million. Doctors and hospitals that make the investment have a large incentive to recoup their costs by ordering CT scans, ($500-$1,500 a test). In some specific circumstances, CT angiography provides more information than other heart studies. The Times noted certain situations in an emergency room where it could be highly useful. But in most circumstances it is more like a screening tool to search for hardening of the arteries. But the CT scan doesn't say whether someone needs the blockages opened. That has to be determined by coronary angiography, placing a catheter through a vessel in the groin and then threading it up to the heart. That's an invasive procedure that provides necessary details on the exact location and extent of blockages.

We all know Medicare has problems. What you may not know is that we really do know a fair amount about how to fix it—and part of the solution has to do with changing the kind of medicine we use to take care of our over-65 population. Inside E Street, an AARP television production, (click here to watch—and you don't have to be 50 to learn something from it) invited several experts including New America's health policy program director Len Nichols to brainstorm.

Among the suggestions: use technology not only to keep better medical records that help doctors coordinate care across several specialists, but also to take better care of people at home. We have the means—and we'll develop more in coming years—to monitor people at home, and know when and how to intervene before a crisis develops in a patient with conditions like diabetes or congestive heart failure.

Len reminds us that Medicare can be a catalyst because the program has so much influence over the whole health sector. So fixing Medicare is good for all of us—not just because of the economic implications but because by getting care right for the elderly we can probably improve health for us all.

We perk up when we hear phrases like "bipartisan support for a major healthcare initiative," especially when the bipartisan push is coming from Senator Edward Kennedy. Today's Boston Globe reports that while Kennedy recuperates from his brain tumor surgery, his office has begun a series of bipartisan meetings with an array of health care specialists to prepare for a major push to cover all Americans when the new president takes office next year. The paper reported:

Those involved in the discussions said Kennedy believes it is extremely important to move as quickly as possible on overhauling the healthcare system after the next president takes office in January in order to capitalize on the momentum behind a new administration.

Kennedy is chairman of the Senate Health, Education, Labor and Pensions Committee; Obama is a member, and his Senate staff has attended the roundtable discussions, the Globe reported. But Republican staff is also involved, as Kennedy tries to identify areas of agreement, possible starting points. Kennedy has made health care a signature issue in his 45 years in the Senate, and even before his aggressive brain cancer was diagnosed he made no secret that he wants to seize the moment and act next year.

If you're a politician, you know you've hit the big time if a late night talk show host makes fun of you. Ditto for an issue -- it's big time if it makes the leap from  think tank "Issue Brief" to a riff in a stand-up comedy routine.  At the D.C. Improv the other night, it was pretty clear that the state of the American health care system has hit the big time. Jake Johannsen had the packed house doubled-over or nodding vigorously to a series of truisms about our broken system. It was only after I left that I remembered that it's not really funny.

California now requires that hospitals inform state officials of substantial injuries to patients. The first batch of reports are in: 1,002 cases of "serious medical harm" in the 10 months starting last July, according to the LA Times. By "serious" the state means things like taking out the wrong person's appendix, patients dying after being given the wrong drug, a nine-day-old baby not getting enough oxygen when a ventilator hose is hooked up according to a diagram that was drawn backwards.

The point of error reporting isn't hand wringing or finger pointing. It's coming up with solutions to improve patient safety. The California Department of Public Health can now fine hospitals over safety errors. And increasingly, Medicare, some big health insurers and now a few states are deciding that they want to make patient safety good business—or at least they want to make safety errors bad business. They won't pay for the care needed to fix the mistakes. You break it, you pay.

The fight about how to prevent a Medicare physician fee cut from going into effect (and more importantly whether Congress will take money from private Medicare health plans to pay the doctors) rages on. The Senate stalemated last week before the July 4 break; the administration froze payments temporarily to forestall cuts. We have purposefully not ventured into the weeds during this debate (except to say that the yearly process of passing a "doc fix" is a perfect example of why we need wholesale reform of how we pay providers). Nonetheless, our ears did perk up when we read this line in Scott Gottlieb's Wall Street Journal opinion piece (subscription required), "Democrats hate Medicare Advantage and have been trying to cut it for quite some time, because they don't like health-care markets."

Even in a time of very tight state budgets, New Jersey's governor and legislature are taking major steps toward covering all of the state's residents, according to the Philadelpia Inquirer. This week the state Senate and Assembly both passed a measure that would require all children to be covered and would also cover some low-income parents. They provided $8.9 million in new funds to expand FamilyCare, (the state's health insurance program for low-income children and some adults), and moved to allow insurance premiums offered on the individual market to vary based on age to make plans more affordable for younger adults and help bring them into the health insurance pool.