health care reform

A year goes by fast: A big picture look as the health care debate accelerates

It’s amazing how fast a year goes by. Last May, when I met with the selection committee for the Kaiser Media Fellowship, I outlined my project. Several folks on the committee said I shouldn’t wait until fall to begin. The health care reform debate might be over by then – or so we thought.

Of course it didn’t work out that way. My year as a Kaiser Fellow has been amazing because it’s paralleled so much of the legislative debate. I started writing columns (or blog posts, depending on your point of view) on July 6, 2009.

The Patient Protection and Affordable Care Act was signed into law on March 23, 2010. And, now a different kind of debate begins. Federal agencies, primarily at the Department of Health and Human Services and Treasury are writing regulations to implement the new law. There will be fights over words like “quality” or how we define and measure success.

Heck, the government cannot even talk about the law without generating controversy. Republican Senate leader Mitch McConnell called a new Medicare brochure little more than propaganda. “The flyer purports to inform seniors about what the health care bill would mean for them. Much of it directly contradicts what the administration’s own experts have said about the law,” McConnell said. “So this is a complete outrage, and it’s precisely the kind of thing Americans are so angry about at the moment.”

Simple math: Health care = jobs

This is simple math: Health care equals jobs. And the new health care reform law means even more jobs. In many communities across the United States, the health care industry is the region’s top employer. Indeed, if you put this in a global perspective, the National Health Service in the United Kingdom now employs 1 in every 23 workers in that country, some 1.3 million people. (The NHS is the third largest employer in the world, only ranking behind the Chinese army and India Rail.)

The numbers in Indian Country show that same kind of growth. Look at the figures before President Johnson’s Great Society (and the expansion of federal programs):  The Bureau of Indian Affairs employed 16,035 full time employees in 1969, while the Indian Health Service employed 5,740 people. That trend is now reversed. In 2009 the BIA employed 8,257 full time workers and the IHS had grown to 15,127 employees. These are just the number of federal employees, because tribes or organizations administer roughly half of the Indian health system. 2.png" style="width: 462px; height: 281px;" />

The demand for health care workers in Indian Country represents a public policy paradox: We need jobs in communities where the official unemployment rate is about 50 percent and yet the Indian Health Service reports shortages of health professionals.

The IHS describes its employment situation this way:

“The physician vacancy rate now stands at approximately 21%, and the average length of service of the approximately 800 federally employed physicians in Indian health is 10 years.

The state of Navajo – sort of – and other health care experiments


Congress passed the health care reform legislation – and President Barack Obama signed the bill into law. The Indian Health Care Improvement Act was included – and now we can put this debate to rest. Right?

Actually no. There are many more debates about health care reform to come – probably for years – and much work remains before this law can be implemented.

“Opponents will continue, and probably intensify,their opposition. They have promised legal challenges and arelikely to seek repeal of all or part of the legislation. Moreover,formidable implementation hurdles must be surmounted if healthcare reform is to achieve its goals,” Henry J. Aaron, Ph.D., and Robert D. Reischauer, Ph.D., recently wrote in the New England Journal of Medicine’s Health Care Reform Center blog. “On the political front, Republicans unanimously opposed thefinal bill in both the House and the Senate. They have expressedoutrage at the Democratic leadership’s decision to “ram through”reform using budget reconciliation to modify the Senate-passedbill sufficiently to make it acceptable to the House. The outrageis baseless, but the fury is real and will poison future debate.”

On top of that fury there are thousands of pages of federal regulations – words that will define complicated ideas like “quality” in the legislation – that still must be written and debated in draft form, before they can be implemented. And, as I’ve written before, this bill is only authorizing legislation. The appropriations process is on a different track that requires congressional action before some of the new ideas can be implemented.

Rita Hibbard's picture

Health care reform brings a price tag worth paying

It’s historic. And it’s over.

What’s amazing is that it took so much vitriol. But change always does. Especially social change.

I need look no farther than my own extended family, where two members with a recent history of cancer, unlikely to ever get insured on their own dime without health care reform because of those pre-existing conditions, vehemently opposed the idea of health care reform. Somehow, they had been persuaded by the right that  it was in their interests to be against the very idea of reforming the health insurance system, ignoring the fact that the health care lobby fought hard and donated big to preserve the status quo.

That’s a position understandable for those safely ensconced in the shelter of a larger corporation who can count on not losing their jobs (whoever they are), or for those on the public payroll who can count on not losing their jobs (another pretty small group, I would think) , but one of these family members was recently laid off, and the other is unable to work and uninsured because of his illness. Yet the ire and bile of the fight was so extreme that they were unable to see their own benefit in health care reform. Instead, they see health care reform as a move toward socialism, as un-American. Even though implementation of health care reform offered direct benefit to both of them, they vehemently opposed it. Many of those in support of health care reform perhaps failed to appreciate the depth of that opposition.

Of course, most of those protesting health care reform had health care coverage. They were the easy ones for the right to fire up. Many of those interviewed at anti-reform rallies were on Medicare (a government plan) or were well-covered by their employer, as are most Americans.

Rita Hibbard's picture

Putting together health care reform with holdouts and back benchers

It’s a dizzying, high wire act that’s now on display in Washington, D.C. It’s called putting a health care reform bill together. And just watching it happen is crazy-making. The vote could come as soon as this weekend.

President Obama is trying to rope them in – bringing together holdouts like abortion opponents who fear the bill expands access to abortion, and liberals arguing the bill does not go far enough to expand access to health care, in support of historic reform that could overhaul the nation’s health care system. And keeping track of the moving parts is a full-time job.

 But the parts are moving. A key Democratic holdout, Rep. Dennis Kucinich of Ohio, became the first liberal opponent of the House bill to announce support for the more restrictive Senate legislation, the Los Angeles Times reported. At the same time, a key anti-abortion Democrat, Rep. Dale E. Kildee of Michigan, said he also would support the bill.

"If I can vote for this bill, there are not many others that shouldn't be able to," said Kucinich, a leader of the movement to provide universal healthcare by offering the Medicare program to all Americans. Among social conservatives, the legislation won an important new endorsement from dozens of leaders of Catholic nuns, including a group that says it represents more than 90% of the 59,000 nuns in the United States. That contrasted with the staunch opposition of the U.S. Conference of Catholic Bishops, which issued a statement Monday arguing that the bill would not adequately guard against using federal funds for abortion. The nuns disagreed, and so did a retired bishop.

Growing the budget during tough times to fund the Indian health care system

Op-ed by Mark Trahant

President Barack Obama answered an important philosophical question last week: How will the federal government fully fund a starved Indian health system?

The answer is budget by budget: The administration boosted spending by 13 percent in fiscal year 2010 and is proposing another 9 percent increase for 2011. But this budget does not resolve the contradiction between “historic underfunding” and the larger reality about federal spending. The proposed budget calls for $5.4 billion in spending for Indian health care, ranging from clinical services to facility maintenance and construction. (The bulk of that money, $4.4 billion would be from appropriations, the rest comes from health insurance collections and special grants.)

HHS Secretary Kathleen Sebelius said: “Our budget also contains a significant increase in funds for the Indian Health Service as we continue to work to eliminate health disparities. It is the principle that we are trying to establish in our healthcare system – that regardless of race, ethnicity, gender or geography every American deserves high quality and affordable care.”

But while spending on Indian health is increasing – is it growing fast enough to catch up? There remains a significant gap between what is spent on an American Indian/Alaska Native patient than a federal prisoner, $2,130 per person versus $3,985. One measure used by the federal government is a benchmark based on spending for federal employees. The Indian Health Service is currently appropriated about 55 percent of that standard on per person basis.

Indeed, last April a tribal task force recommended a $2.1 billion increase in the budget authority for IHS in fy 2011. The tribal leaders called for a ten-year phase in of $21.2 billion to reach spending parity.

Rita Hibbard's picture

Information and transparency as a tool for health care reform

Op-ed by Mark Trahant

Paul Levy’s Running A Hospital “is a blog started by a CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.” The postings started as a lark. But when the president and CEO of Beth Israel Deaconess Medical Center writes openly, that sends a message that filters down throughout the system. Other hospital professionals started blogs and more hospital data was posted in real time making transparency a core value.

TrahantPeople already use the Web to search out medical information of all kinds (several studies show it second only to porn for Internet searches). Health organizations have a natural, built in audience of people wanting to know what’s going on.

So how do health professionals by and large manage this interest?

“Effective immediately, the Hospital is blocking access to social networking sites including Facebook, MySpace, and Twitter from all Hospital computers,” says an internal memo from another system as blogged by Levy. “The Executive Team will be working in the coming months to ensure that we have written policies in place that articulate the appropriate use of social networking sites while on duty at the Hospital. Once these written policies are in place, we have educated all employees about expectations and disciplinary action associated with violating the policies.”

The message is clear. Information is scary.

Rita Hibbard's picture

Health care reform is a secret process; it's time to rethink who's in charge

Op-ed by Mark Trahant

Perhaps one reason why the massive health care reform legislation is in so much trouble is that few people understand the details. The bill is massive, complicated, packed with official government jargon and so many specifics were kicked forward to regulators at some future point (such as figuring out the real Medicare cost reductions or definitions of basic terms such as “quality”). On top of that, there was confusion about the nuts and bolts of what program was in, and what was out. Essentially it was a secret process, except when there were leaks over specific proposals.

The bill followed the time-honored way of legislating. A senator says, “yes” after the bill is sweetened. Then another senator is wooed. And another until a super majority is found and the bill itself is hardly identifiable. Political horse-trading is one of the reasons people are angry about health care reform (as well – and this is important – a genuine debate about the role of government). It looks unfair and unseemly.

But does it have to be that way in the 21st century? Can legislation or policy be forged in an open and transparent manner? This won’t resolve the debate about philosophy, but at least it allows people to have a say all through the process.

I think this is the way forward – and I’d like to see Congress, the Executive Branch and the Indian Health Service all have clear social media strategies that harness the power of an individual to help shape a larger mission.

This is not a new concept. The United Kingdom’s National Health Service is trying to harness social movement ideals.