Harold Pollack, Author at �鶹Ů�� Health News

It’s Not Just The Money: Cost Control In Cancer Care (Guest Opinion)

Harold Pollack — Sun, 17 Jul 2011 19:00:19 +0000

Health reform raises central ideological questions about the size and scope of government, about progressive taxation, about the individual mandate and more. It’s easy to forget that cost control will be a huge challenge, no matter how these ideological matters are resolved, indeed under any health system. Finding the right combination of humanity and restraint will be particularly hard in addressing life-threatening or life-ending illness. Economic incentives, American culture, a changing doctor-patient relationship and fundamental uncertainties at the boundaries of clinical care conspire against our efforts to provide more humane, more financially prudent care.

The necessity and the difficulty of these tasks were underscored by a beautiful New England Journal of Medicine essay, , by Thomas Smith and Bruce Hillner. Their essay received from health . Yet because it didn’t push the usual partisan buttons, it didn’t receive much wider attention. That’s too bad, because Smith and Hillner raise many issues that apply beyond the realm of advanced cancer care. For instance, they offer a brave model of skilled providers identifying specific opportunities to reduce costs within their own specialties. They also present suggestions to address the burdens imposed by cancer overtreatment and undertreatment on patients and society as a whole.

Their first, deceptively simple recommendation is to target cancer testing and imaging to situations of proven benefit. Measured at the population level, the survival benefits of such imaging — routine mammography screening for asymptomatic young women or early lung cancer screening, for example — are often minimal or unproven. Such imaging is also quite costly. The annual direct costs run into the billions of dollars. Indirect costs include patient anxiety and follow-up treatments that can be expensive and intrusive. And, at the other end of the life spectrum, . Providers also implement follow-up scans searching for relapse, such as frequent PET-CT scans, that are not supported by guidelines or by clinical trial evidence.

In part, these problems reflect powerful incentives on providers, device manufacturers, and others which promote aggressive care. The problems go deeper, too.

Dr. Vivek Murthy, president of , e-mails that physicians spend less time with patients (not always for reasons of their own choosing) and are less likely to have important discussions with patients and families about priorities or tradeoffs in care. It takes less time to consent to an intervention or to prescribe a medication than it does to persuade a patient that an intervention or procedure is unwise. Murthy notes that one cumulative effective of millions of missed conversations is to reinforce the intervention mindset among patients. So, alongside efforts to alter physician incentives, medical schools and health care settings must equip physicians with the knowledge, the interpersonal skills and other supports to conduct these important conversations well.

Another problem may be even more challenging. We, the public, display a strong bias toward the most aggressive and costly care, often at the expense of other things. The , even as , exemplify the imbalance in urgency and priorities. Continued Medicare reimbursements for costly yet dubious medications raise inevitable questions of cost-effectiveness. Whatever your ideological perspective, Medicare should not and cannot provide a blank check to the supply-side of the medical economy, especially in a political and regulatory context in which private payers are under strong pressure to follow suit.

Smith and Hillner’s essay also raises sensitive issues regarding overly aggressive chemotherapy for patients who face fatal metastatic cancers. Given anxieties captured in the crystalline phrase “death panel,” I would not commence a national cost-control discussion within the frightening and divisive arena of end-of-life care. On the merits, though, Smith and Hillner cite much evidence that both patients and American society would benefit from less toxic and less aggressive care. When further chemotherapy is unlikely to be successful, they suggest that symptom-directed palliative care provides a better treatment course.

Ironically, the inclusion of palliative care elements within standard care may also prolong life. , a found that metastatic non-small-cell lung cancer patients assigned to early palliative care lived almost three months longer, on average, than their counterparts receiving usual care. The earlier palliative care group experienced higher quality of life, was less likely to display depressive symptoms and was more likely to be spared toxic side-effects of futile therapies. Some imperfectly understood combination of these benefits prolonged survival through provision of more cost-effective, less-punishing care.

Here again, we, the general public, must alter our own mindset to improve the quality of care. Metastatic lung cancer may be the most straightforward case. The majority of patients with this condition die within one year. Inclusion of palliative care and the turn away from further futile therapy are thus most compelling. Even here, though, many families hesitate to embrace palliative care because they regard loss of hope as the entry ticket. A definitive bleak diagnosis should not be required to receive services commonly associated with palliative care. All patients require effective pain management. All patients require open communication about prognosis and, often, advance care directives.

Such discussions aren’t easy, especially when families don’t fully trust the care team. Years ago, my father-in-law was diagnosed with advanced lung cancer. At one point, his doctors discussed the possibility of a punishing thoracic surgery. They were unenthusiastic. Yet our family wasn’t really ready to give up on the prospect of substantially life-prolonging care. Moreover, we weren’t very confident in his doctors. They had done a pretty poor job in the early stages of his care. They lacked the authority to say: “There’s nothing more we can do.”

Fortunately, one of my own physician colleagues mapped the options with me. He explained that surgery was unlikely to prolong my father-in-law’s life and the most likely outcome was that he would spend his few remaining months in recovery from a painful and failed surgery. A different path was chosen. He died soon after, at home, under dignified and humane circumstances in the care of his family and a local hospice.

We all must face these issues to control costs, and for other reasons, too. We can treat our loved ones, and ultimately ourselves, more effectively, more efficiently, and more decently than we often do.

�鶹Ů�� Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at �鶹Ů��—an independent source of health policy research, polling, and journalism. Learn more about .

This article/health-industry/071511pollack/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

/?republication-pixel=true&post=9457&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

The Real Impact Of Cutting Medicaid — Just When We Need It The Most (Guest Opinion)

Harold Pollack — Thu, 05 May 2011 15:07:00 +0000

An excellent story by Rex Huppke details the impact of cuts to home and community-based services in Illinois. Huppke recounts the story of 81-year-old Lorraine Phifer, who cares for her son William, who has cerebral palsy. Phifer has a wheelchair van, but she can’t maneuver him into it by herself anymore. He has also required help with a wheelchair lift to get into and out of bed. Staff from the University of Illinois at Chicago Assistive Technology Unit have come out to the Phifer home and provided valuable help. That unit now faces a 70 percent budget cut.

UIC’s intellectual disabilities family clinics, which offer a range of services that are hard to access elsewhere, also face deep cuts. My intellectually disabled brother-in-law occasionally uses these facilities, too. I’m not a disinterested observer.

Few of my fellow policy wonks have occasion to write these last words. Most policy debate occurs at great personal distance from the world of safety-net care. To be sure, every policy debate has its quantitative dimension. Congressional Budget Office projections and actuarial reports matter, because there are real human consequences when the numbers don’t add up. When the numbers are all we talk about, though, policy debate bears discomfiting similarity to arguments among armchair warriors maneuvering toy soldiers on a plexiglass board.

Debates about health care for seniors generally acknowledge these elemental realities. Nearly everyone involved has a parent or other relative who receives Medicare. And most expect to rely on Medicare, too, when they grow old. Seniors are a powerful constituency. If they find a proposed policy too unsettling, it probably won’t happen.

The tone and the politics change when things turn to Medicaid and related safety-net services. Dozens of states are making painful cuts right now. The disadvantaged people most directly affected are playing conspicuously small parts in the accompanying political process. In Washington and in state capitals, too, few influential stakeholders have any strong personal stake in such matters. Few have sat on either side of the counter in some welfare office, county hospital or public health clinic.

Thus, the New York Times Lizette Alvarez that Florida’s Republican-dominated legislature is set to scrap traditional Medicaid services and shift Medicaid recipients into state-authorized for-profit HMOs or provider sponsored networks. Florida also seeks permission to deny recipients some benefits now being offered. These changes could occur as quickly as next year. For those immediately affected, this program represents a more radical experiment than any provisions of last year’s health reform. Florida legislators are quite explicit that their purpose is to save money: “The Medicaid system is irretrievably broken,” State Sen. Joe Negron (R) says.

Florida indeed faces growing Medicaid burdens. These arise in a state hammered by recession and the foreclosure crisis, and which has one of the nation’s . Concerns that the state’s predicament is driven by lavish benefits and inefficiencies can be put to rest. Florida ranks 43^rd in per-recipient Medicaid costs.

Florida’s proposed Medicaid changes are based on a dubious pilot project that has disrupted life for thousands of Medicaid recipients. Part of the problem was that for-profit HMOs proved unable or unwilling to serve many disabled or medically complicated recipients. WellCare, one of the largest participating HMOs, exemplified these problems. WellCare encountered legal difficulties over alleged Medicaid fraud and charges of “cherry-picking” the healthiest recipients, as the Miami Herald .

Ultimately, low Medicaid reimbursements led WellCare and other HMOs to precipitously exit much of the market, forcing tens of thousands of families to change health plans. A Georgetown research team released a of these operational problems, concluding:

The five-year pilot program has yielded little in the way of concrete evidence of either efficiencies or cost reductions. In fact, the pilot has raised significant questions about the ability of its managed care model to effectively meet the needs of beneficiaries.

Despite this track record, Florida lawmakers seek to expand this program statewide. Whether Medicaid recipients would actual benefit seems beside the point.

Politicians in Washington are following a similarly unpromising path. The that Republicans’ proposed plan to block-grant Medicaid would reduce federal program expenditures by 35 percent by 2022 and by 49 percent in 2030 relative to current law. In return, states would have greater flexibility to restructure Medicaid benefits.

How governors would actually use this flexibility is another matter. Medicaid is flexible right now. The Center on Budget and Policy Priorities that about 60 percent of state Medicaid spending consists of expenditures to cover people or to reimburse services that are not required under federal law.

Given Medicaid’s and its relatively restrained projected cost growth, there’s little room to comfortably cut. Safety-net services are already shoestring operations. Under-funded and stressed, they have many shortcomings. There is no way to meet the above spending reduction targets without , covering markedly fewer people and services, or further underpaying Medicaid providers.

No one can firmly say how states would respond to the reduced federal support. I fear that’s precisely the point. Block grants provide both states and the federal government with useful political cover to cut important benefits. If a particular state eliminates Medicaid home care services or by dropping the working poor from coverage, Congressional Republicans can say: “Don’t blame us. That’s what this state chose to do.” Meanwhile governors can say, with equal justification: “Don’t blame us. We’re doing the best we can, given limited federal resources.”

I wish that Rep. Paul Ryan, R-Wis., architect of the House Republican budget plan, could accompany my wife and her brother to waste hours sitting in a gritty welfare office. I wish he had the responsibility of helping an intellectually disabled person with a nasty toothache, when the state Medicaid program no longer covers dental care.

Ryan’s proposals won’t become law anytime soon. Still, they exemplify this political moment’s misguided mood and priorities. During the worst recession in decades, we are cutting needed services precisely when the need for them has grown.

Despite heated rhetoric about federal debt, this proposed budget to reduce the deficit. Even if this plan did more, Americans would be wise to reject it. Our policy debate seems predicated on the philosophy that we must sharply shrink government despite the accompanying human costs. That vision is mighty appealing, especially to those who feel comfortable and safe without public help.

President Barack Obama helpfully identified what Republicans left out: our collective obligation to protect one another against misfortunes that could crush any one of us left to face them alone. When I consider the 81-year-old women gutting it out to care for her disabled son, or the aged and disabled people in South Carolina losing their due to current Medicaid cuts, I can only tell Rep. Ryan: “There are more things in heaven and earth than are dreamt of in your philosophy.”

This article/health-industry/050511pollack/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

/?republication-pixel=true&post=9423&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

The Donald Berwick Predicament

Harold Pollack — Fri, 11 Mar 2011 07:30:00 +0000

Dr. Donald Berwick runs the Centers for Medicare & Medicaid Services. He now serves under a recess appointment that will expire at the end of this year. And, although the president could take the politically risky step of extending his tenure with another recess appointment, officially naming him to run the agency for the long haul would require Senate confirmation. News reports suggest that this won’t happen. Berwick may not even receive a hearing.

We can’t evaluate the backstage politics, but one thing is certain. Both Democrats and Republicans should be dismayed at the sight of a partisan campaign driving yet another distinguished figure out of American government.

In a recent letter, 42 Republican senators harshly urged that Berwick’s permanent nomination by withdrawn, citing his “lack of experience in the areas of health plan operations and insurance regulation” as well as “his record of controversial statements and general lack of experience managing an organization as large and complex as CMS.” Because 42 votes is enough to block his approval, Berwick has been described by some as a bureaucratic dead man walking. As one supporter : “Everybody here admires Don and the work he’s done, but he is not going to be confirmed. That’s inevitable. There’s not a lot of optimism that the White House can do anything about it.”

You might think there is some genuine issue regarding Berwick’s professional stature, his experience, his integrity or his job performance. There isn’t – any more than there is such an issue regarding whether Federal Reserve Board nominee (and Nobel Prize-winning economist) Peter Diamond .

Berwick has greater management experience than many previous CMS administrators. Few have matched his knowledge of the American health care system or his high standing within the medical profession. He is one of the world’s leading experts in patient safety and quality improvement. A pediatrician and health policy researcher, he has authored hundreds of scholarly articles. He has spent decades in the trenches of the American health care system seeking to improve it.

In 1999, he co-founded the Institute for Healthcare Improvement, which has provided guidance in the U.S. and abroad regarding strategies to improve health outcomes. Most famous is the , which disseminates best practices to prevent hospital-acquired infections and avoidable deaths.

He is intimately familiar with many of the nation’s best (and worst) health care organizations. The new federal health law finances critical demonstration projects to expand coverage, improve chronic disease management and to improve care quality. He has virtually unique credibility among physicians, hospital leaders and health services researchers in leading these efforts.

He is exactly the type of health policy wonk who, if circumstances were different, might have been appointed to the same job under a Republican administration. Thomas Scully, CMS administrator under President George W. Bush, : “He’s universally regarded and a thoughtful guy who is not partisan. You could nominate Gandhi to be head of CMS and that would be controversial right now.” Berwick’s nomination was supported by Gail Wilensky and Mark McClellan, two prominent Republicans who ran CMS in two Bush administrations.

But, like every seasoned and serious health policy researcher, he has provided a few sound bites that political operatives can spin . For example, Berwick recommended that physicians “reduce the use of unwanted and ineffective medical procedures at the end of life.” One can present such statements as supporting death panels. In fact, these comments reflect a sensible and humane perspective shared by most physicians who provide end-of-life care.

President Barack Obama’s adversaries are pursuing Berwick because he provides a valuable political scalp in attacking the health law. Last year, opponents of the measure waged against him immediately following its passage. In this climate, the most likely outcome of Berwick’s nomination would have been for it to linger for months and then to finally die under a filibuster. Rather than see this happen and to waste months in the implementation of one of the most complicated policy reforms in American history, Obama gave Berwick a recess appointment.

Though not ideal, this was the proper response to escalating, bluntly partisan abuses of the Senate confirmation process. The proper purpose of the confirmation process is to scrutinize nominees, to question them and then to approve or reject them through an up-or-down vote. If senators continue to exploit ossified procedures to simply obstruct opposing administrations, presidents of both parties will pursue recess appointments with greater frequency.

They will be right to do so. Berwick serves a Democratic administration, but you can bet that policy experts in the next Republican administration will receive similar rough handling. Imagine what skilled Democratic operatives could do to any Republican nominee who had genuine private-sector “experience in the areas of health plan operations and insurance regulation,” say because they worked for an insurer or an HMO.

Imagine what would happen if Democrats were to pursue the same sound-bite fishing expedition that was pursued against Berwick. He stands accused of praising Britain’s National Institute for Health and Clinical Excellence (NICE), which examines which therapies the National Health Service should finance based on efficacy and cost-effectiveness. in rather similar terms in addressing America’s escalating medical expenditures.

Does this mean that McClellan supports death panels and rationing? No. Virtually any policy expert who has had the courage to discuss delicate issues of financing, palliative care or cost control has said something that can be ripped out of context and used to politically embarrass or destroy them.

Politics is a rough business. Some rough and tumble personal criticisms come with the territory. Still, the long-run consequences of blocking a highly-qualified official such as Berwick are quite damaging – especially at this critical point in time.

As the new health reform law is implemented, it will require many adjustments and fixes along the way. Much public attention is focused on ideological differences between Democrats and Republicans regarding expanded coverage, the accompanying taxation, and more. Alongside the ideological divide, it also poses technical challenges that are less ideological but no less difficult to resolve.

The Obama administration will need to work with the states and with both parties in Congress to implement health insurance exchanges, to regulate insurers, to expand Medicaid and more. This won’t be easy. It will require good faith collaboration in a very difficult and polarized national moment. This task will also require public managers and policy experts on both sides of the table who have the experiences, the professional standing and the expertise to get the work done.

Our worst fear is that the people best-equipped to do these jobs will view Berwick’s predicament and decide: It just isn’t worth it. After all, people at Berwick’s or McClellan’s level can pursue many other lucrative and challenging opportunities that bring a lot less trouble and stress. For government to succeed, we need such experts who can do their work at least somewhat shielded from the immediate partisan fray.

Our cable-TV political culture provides too little space for this. If we don’t fix this, we will all come to regret it.

This article/news/031111pollack/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

/?republication-pixel=true&post=9310&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

Political Gridlock And The Challenge Of Implementing Health Reform

Harold Pollack — Fri, 11 Feb 2011 12:36:05 +0000

Health reform is one of the most intricate and wide-ranging laws in recent American history. It transfers billions of dollars down the income scale. It alters the operation and regulation of private and public insurance markets. It creates new structures such as health insurance exchanges and pre-existing condition insurance plans.

Amidst all of this change, one thing is certain. The new law will need repairs and fixes along the way. There will be glitches. Specific legislative and regulatory provisions will require adjustment once they are tested. None of this means that the measure is a bad law, or one that should be repealed. I believe the opposite is true. That’s just the nature of overhauling a system that affects one-sixth of the U.S. economy.

Unfortunately, our currently polarized politics makes it hard to address or even to acknowledge this basic reality. In their pursuit of an unrelenting “repeal and replace” effort, health reform critics have created a climate in which the possibilities for bipartisan pragmatic compromise are so limited that it’s hard to imagine Congress implementing a negotiated legislative fix beyond small and obvious matters such as the current effort to abandon the law’s 1099 business reporting requirement.

The new Community Living Assistance Services and Supports program underscores the dangers of political gridlock. CLASS — a bold attempt to address some of our nation’s long-term care and disability challenges — will provide participants and their families with daily cash payments for needed support in the event of disability. It is particularly valuable because it provides concrete help for disabled people who wish to remain in their family homes. CLASS is not an entitlement. It is a voluntary contribution program, required by law to be fiscally balanced over the next 75 years, with projected costs financed through participant premiums.

Because CLASS is voluntary and does not charge higher premiums based on individual health status, it includes several provisions to guard against the possibility that only people who face high risks of disability will sign up. Most important, individuals become eligible for benefits only after they have paid monthly premiums for at least five years and have been employed during three of those five years. The success of such measures in minimizing adverse selection — and thus the program’s required monthly premiums — will play a huge part in determining CLASS’s long-term fiscal balance.

During the health reform debate, the Congressional Budget Office a . CBO analysts also estimated that CLASS’s average monthly premiums will be about $123. (For further details regarding CLASS, see , as well as Howard Gleckman’s columns for KHN.) Actuaries from the Center for Medicare and Medicaid Services , projecting that the required monthly premiums would be about twice as large. Why the difference? The CBO predicted that CLASS would attract about 3.5 percent of the adult population. CMS actuaries predicted that the program would attract only about 2 percent — and this 2 percent would be a sicker and more costly group.

Now, 10 months after health reform passed, some serious budget analysts — including some respected Democrats — worry that projected monthly premiums will prove too low to meet CLASS’s long-term obligations. Most recently, Boston College’s Alicia Munnell and Josh Hurwitz produced a concerning policy brief: These authors estimate that “an average premium of $194 is required to ensure solvency to the year 2087.” That’s about halfway between the CBO and the CMS estimates.

Such 75-year extended forecasts are both necessary and inherently tragicomic. When one looks under the hood at and by others, it’s obvious that there are big uncertainties regarding the program’s expenditures and enrollment 10 years from now, let alone the challenges it will face 66 years after that. Researchers have reasonable data to describe and forecast the nation’s distribution of disability over the next decade or two. But the impact of monthly premiums and individuals’ disability risk on enrollment are inherently uncertain, as are long-term forecasts of the price of disability services. Also, Medicaid will undergo significant changes between 2011 and 2030, which will alter CLASS’s financial impact on government expenditures and individuals’ incentives to participate in the program.

The secretary of Health and Human Services has broad discretion to modify CLASS to maintain actuarial balance. Will firms participate in the new program? Will they aggressively market it and advise employees to join? Unlike private policies, CLASS benefits are backed by the full faith and credit of the United States. Will that sway hitherto reticent consumers? None of these factors are explicitly considered in the above models.

You might ask who is right: CBO, CMS actuaries, or Munnell and Hurwitz? In one sense, probably no one is exactly right. The uncertainties are just too great. And that’s the wrong question anyway.

One should forecast now as best one can, design CLASS to be as effective as possible given current predictions and to be as flexible as possible in accommodating new information.

One should also consider how the program could be designed to maximize the chances for success. If employers’ attitudes and marketing are critical to CLASS’s success, working closely with employers to maximize these opportunities will be critical, especially regarding younger or healthier workers. The program also could by tightened — perhaps by lengthening the benefit vesting period, and revisiting certain aspects of eligibility or premium costs.

This week, HHS Kathleen Secretary Sebelius acknowledged some of these issues and indicated the Obama administration’s openness to such revisions and improvements.

I’m not terribly confident that we’ll see pragmatic compromise resulting from the secretary’s signal. Republicans have pledged to repeal CLASS rather than sand down its rough edges. Democrats, for their part, face little incentive to open this program up for fundamental revision before creating political facts on the ground to ensure its survival.

On CLASS, and surely on other matters, there is just too little political space to implement midcourse corrections or enact programmatic improvements. That’s a price Democrats paid by achieving their dream of near-universal coverage on a party-line vote. That was a price Republicans paid, too, through their implacable opposition to just about everything Democrats proposed, including many ideas Republicans traditionally supported.

Each side had plausible strategic and ideological reasons to pay that price. For now, anyway, our politics give us the choice between health reform that is less flexible and less carefully crafted than it really needs to be, and no reform at all. If this is the political choice presented to us, I strongly prefer the first option. I still wish we had a better way.

This article/news/021111pollack/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

/?republication-pixel=true&post=9236&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

A Defense Of High-Risk Insurance Pools — From One Critic To The Others

Harold Pollack — Mon, 17 Jan 2011 00:30:17 +0000

From the beginning, I’ve been a persistent, of the high-risk insurance pools set up in the new federal health law. The title of my recent commentary in the Journal of General Internal Medicine, “,” summarized my general view. I’m not retracting any of these tough assessments. Yet in noticing the ironic partisan tinge to the criticisms now being leveled at this program.

The Obama administration, having unwisely acquiesced in the back-loading of spending in its effort to overhaul the health system, had pressing political and human reasons to support the Preexisting Condition Insurance Plan. This network of state-federal high-risk pools is a stopgap measure, which will serve a total of perhaps 375,000 people before health insurance exchanges and the other main pillars of the health law become operative. The money made available for the program — $5 billion over about four years — was not close to what is required to help more than a small minority of the medically uninsured. Many sick people can’t afford the accompanying premiums, which, though subsidized, still often cost several hundred dollars a month. All this was pretty obvious from the start.

The Washington Post’s Amy Goldstein describing the administrative challenges facing the new program. It’s costing a lot of money. Moreover, and perhaps counter-intuitively, fewer people have signed up in many places than was originally expected. Republicans are attacking the program — rather hypocritically — since their criticisms apply with greater force to their own health reform proposals.

Conservative health policy expert John Goodman presents one of . Noting the high-risk pools’ low initial enrollment, he concludes:

“We now know how many people have the problem most often cited as the reason for last year’s health overhaul legislation. Answer: 8,000. No, that’s not a misprint. Out of 310 million Americans, only 8,000 people have the problem given as the principal reason for spending almost $1 trillion, creating more than 150 regulatory agencies and causing perhaps 150 million or more people to change the coverage they now have.”

Leaving aside that “150 million or more” number, I’m puzzled that Goodman would take low initial enrollment as a sign that problems of the medically uninsured were “hyped and exaggerated from the get go.”

My own work and the work of others documents that a significant number of Americans face the dual challenge of uninsurance and serious illness. , data from the 2005-2006 National Health and Nutrition Examination Survey (the most recent complete data available when this research was done) indicate that 440,000 uninsured Americans have been diagnosed with strokes. Almost 1.3 million have a history of cancer. More than 500,000 were diagnosed with congestive heart failure. In many cases, such conditions pose obvious obstacles to obtaining affordable health insurance coverage.

Several million other Americans who successfully obtain health coverage through the individual and small-group markets . Then there are the of Americans deemed sufficiently ill or injured to qualify for federal disability benefits, yet who are currently uninsured during the two-year waiting period for Medicare coverage.

Across a diverse population of Americans facing serious illness or disability, many hundreds of thousands of people are waiting for 2014, when they will become eligible for subsidies and regulatory protections through health insurance exchanges or Medicaid. The health law’s preexisting condition insurance plans are simply too limited, too new and too complex to address these huge economic, medical and administrative challenges.

And yet I can’t help thinking that the initiative is taking some unfair political hits. In evaluating its trajectory thus far, it’s important to note that the program faces inherent administrative challenges. On a short time-frame, HHS needed to initiate complicated partnerships with insurance providers and regulators in 50 states in an environment of fiscal crisis, political acrimony and uncertainty.

The medically uninsured are an inherently varied and complicated group. You may find it perverse that these high-risk pools are under-subscribed in many places, given that their funds can only cover a small fraction of the underlying needy group. Yet this, too, is not hugely surprising. Precisely because resources are so constrained, states and the federal government face difficult challenges tuning outreach, eligibility criteria and premiums to make this thing work. Does one focus on a small number of high-cost hospital ICU patients? Does one focus on the cheapest people to attain the largest feasible enrollment? Does one focus on patients at the most financially-stressed providers? Does one hold back a bit on the initial outreach given uncertain expenditures and budgets? Each of these choices is reasonable. Each has its own implications for enrollment and cost.

The program’s stopgap nature poses another challenge, as governors must commit to a complicated new program that will sunset within a few years.

The Department of Health and Human Services has hired some of the best insurance administrators and policy wonks in the business to implement this. There are bound to be growing pains and glitches. The same was true of Medicare Part D. The same will be true of health insurance exchanges, which will face many unexpected challenges and occasional embarrassing snafus. We must show a little patience as some very talented and embattled people work these things through.

This is small consolation to desperately ill people who need help. Yet if we want to get angry, we should be angry at the process last year that produced only $5 billion when maybe five times that amount was really needed. And as Republicans try to defund this or other aspects of health reform, we should understand what such funding constraints can do to the quality and to the humanity of American government.

This article/news/011411pollack/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

/?republication-pixel=true&post=9300&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

Long-Term Care: Another Tough Subject For The Next Round Of Reform

Harold Pollack — Thu, 23 Dec 2010 00:30:00 +0000

Democrats and Republicans may spend the next two years fighting about what to jettison or retain in the Affordable Care Act. In whatever fashion these conflicts are resolved, we’ll be back — at some point soon — to address another looming challenge: long-term care.

This is a big problem. Less than 4 percent of American adults, and only about 10 percent of seniors, possess LTC insurance coverage. As Michelle Andrews previously noted for Kaiser Health News, such policies are costly. So most Americans do not purchase them. And there’s a reason why these policies are expensive. The average nursing home stay is 2.5 years. The cost of such care would deplete the finances of most senior citizens, at minimum leading them to seek Medicaid assistance.

The health law includes some valuable components for long-term care. As regular readers know, the Community Living Assistance and Social Support Act is a voluntary disability and long-term care insurance program for workers. Slated to begin next year, the CLASS act will be financed through monthly insurance premiums. After five years of vesting, qualifying beneficiaries will receive a cash benefit for qualifying expenses that will vary with disability and will be sheltered from Medicaid asset tests. Over time, CLASS has the potential to keep millions of people off Medicaid and out of an institution. It will also cover many expenses that disabled people and their caregivers would otherwise bear without help.

The health law also includes other provisions and demonstration projects to improve home- and community-based services. For example, it includes improved medical bankruptcy protections for the spouses of disabled persons receiving home or community-based services. Unfortunately, these humane measures are not scheduled to take effect until January 1, 2014, and will expire on December 31, 2019.

Despite these components, the overhaul left much undone. CLASS addresses the risk of future disability among current workers. It does not help people whose disabilities prevent them from working in the first place. Its benefits also are modest when compared with the cost of nursing-home care. CLASS’ voluntary contributory structure limits its reach, though no one at this delicate stage really knows how many people will take up this benefit or how employers will react to the new program.

Health reform did not address other prominent concerns. States face large and growing burdens for Medicaid, the single largest payer for long-term care services. In part in reaction to these burdens, and in part in reaction to political battles over health reform, some states have announced at least the prospect of significant cuts to programs for the elderly and the disabled. For example, South Carolina has announced that its Medicaid program will stop covering hospice care and that the state will cut its meals- on-wheels program.

Individuals who require long-term care services face other burdens, too. They and their caregivers require more access to home- and community-based services, and greater help in choosing services that are most effective for their specific circumstances. Individuals and families face big financial risks, including the genuine risk that one could lose one’s life savings in the event one requires long-term care. Each of these problems is likely to worsen in the years ahead.

Moreover, the firms that provide long-term care insurance also need help. One of the largest players in this market, Metropolitan Life, recently that it would not offer new long-term care insurance policies after Dec. 30. Other firms have left the business or seek steep premium increases.

The Met Life story didn’t get much play. I believe we will see more stories like it, given increasingly serious economic challenges that beset the long-term care insurance market. Fundamentally, private insurance is just poorly suited to providing reliable and effective coverage for long-term care.

Why is this? Private insurance markets work best to protect individuals against well-understood idiosyncratic risks. Insurance markets work poorly when risks are strongly correlated across the population, and when people don’t trust insurers to cover what will become the reasonable standard of care.

Nearly 20 years ago, David Cutler noted that the above challenges are particularly daunting in long-term care. Many of the biggest risks are systematic: How much will it cost to care for dementia patients in 2040? No one really knows.

Adverse selection also is a key concern. Will individuals with chronic illnesses be able to buy coverage when they need it, and at what cost? There is wide variation in people’s health status. Moreover, a relatively small fraction of people now own such policies. It is a big challenge to ensure that relatively young and healthy people are willing to buy coverage. At the moment, anyway, the American public seems allergic to the individual mandate, the single most powerful mechanism to address this problem. If anything, an explicit or implicit mandate is more important for LTC than it is in addressing the issues that dominate the current health reform debate.

There is also a delicate trust issue. When I buy a LTC policy today, I have no idea what the reasonable standard of care will be in 2040 for dementia or heart failure. Tens of millions of Americans do not trust this industry to exercise its discretion fairly in deciding what should, eventually, be covered.

One’s insurer might also go broke over the coming decades. How will these firms’ investments perform, relative to medical care cost growth, over the years ahead? Will future financial crises damage insurers? American International Group’s commercials featured the tagline: “.” AIG’s travails remind us of the obstacles and risks that can arise within the overall economy.

Finally, there is the role of Medicaid — whatever it will look like 30 years from now. Incentives to buy long-term care insurance are lessened by real or perceived possibilities that patients may be bailed out through public coverage.

For these reasons and more, our current arrangements for long-term care and financing are badly frayed.

Many to restructure these arrangements have been presented. The best of these approaches embed private insurance within Medicare and Medicaid. All of these models include marked expansion of the public role, particularly the federal role, relieving states of a difficult burden. At minimum these arrangements provide a catastrophic insurance backstop for private coverage. At maximum, they provide more expansive universal public coverage. None of these approaches presume that private coverage, in its current form, can provide a viable financial foundation for long-term care, except within a minority of rather affluent Americans.

Health care reform is a continuing project, not something that can be enacted in a single bill or a single congressional session. Long-term care is one of the biggest agenda items left unfinished in the health care law. We’ll have to face it. Better sooner than later.

This article/aging/122310pollack/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

/?republication-pixel=true&post=8601&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

The Texas Medicaid Scenario — Why It’s Never Going To Happen

Harold Pollack — Thu, 18 Nov 2010 07:35:00 +0000

Flush from their midterm victories, conservative lawmakers around the country are musing about whether their states should withdraw from Medicaid. The talk sounds most serious in Texas, where the idea receives favorable mention from Republican Gov. Rick Perry and from leaders in the state legislature. As :

“We know how to deliver healthcare to more people in a less expensive way than what the federal government does,” Perry said in Dallas last week while promoting his new book, Fed Up! He said states “need to stand up and say, ‘We don’t want your strings attached. We don’t want you down here telling us how to run our business.'”

Meanwhile, liberals charge that Perry would .

When I first heard about this controversy, that deserves greater play: This is not going to happen. Withdrawing from Medicaid would be political suicide. Despite post-election bluster, no governor or legislative majority will seriously attempt such a politically, administratively and economically preposterous maneuver.

For many reasons, this proposal resides within the realm of thought experiments and ideological gestures. Still, like other such ideas, the discussion it triggers is instructive.

Withdrawing from Medicaid would be political suicide, not merely because it would anger poor people, or because the heads of the Texas Medical Society and the state’s nursing home association have lambasted the idea, or even because Texas would give up the $15 billion it receives annually This would be political suicide for two other reasons one might overlook.

First, withdrawing from Medicaid would create administrative chaos. Many hospitals would go bankrupt if a large chunk of their patients lost public coverage. Suddenly transitioning these patients from Medicaid into health insurance exchanges or into some other, as-yet unspecified program would create a host of other challenges and unintended consequences. For instance, medical and social service providers have spent untold sums developing the capacity to comply with Medicaid requirements and procedures. From a purely organizational perspective, withdrawing from Medicaid would be much more radical than this year’s health overhaul.

Second, stereotypical poor people would find that they had a surprising amount of company as they stormed the statehouse to scream at whoever messed with their Medicaid benefits. Although the majority of Texas’ Medicaid recipients are low-income women and children, most of Texas’ Medicaid dollars go to the elderly and the disabled.

My University of Chicago colleague notes that Medicaid is a central component of the medical safety-net for middle-class people. It finances care provided to our aged parents, disabled friends, neighbors, and sometimes children or siblings who might need a wheelchair, a visiting nurse or other help. Two-thirds of Texas’ nursing home patients rely on Medicaid. These men and women represent a broad cross section of the Texas community. Autistic youth receive Medicaid financed services in school. Intellectually disabled adults receive Medicaid-funded services in group homes and sheltered workshops. Much of the real cost growth occurred in services to such sympathetic and connected constituencies.

There is talk that Texas might carve up its Medicaid program, sparing the most politically secure constituencies, while curbing benefits for nondisabled low-income adults, children and maybe pregnant women. The legal foundations of this maneuver seem dubious. Even if some way were found to accomplish this task, it would defeat the purpose of saving the state money. Texas Medicaid would retain the most costly patients and leave on the table generous amounts of federal matching funds that would otherwise finance much of the health care provided to these populations. The federal government will pay for people made newly-eligible under the new health reform law, for example.

I don’t see Texas turning this money down, .

Though this thought experiment is impractical, it suggests some lessons. Michael Tomasky notes the disjunction between Americans’ professed belief in limited government and our actual support for specific programs to protect people we care about. Once we acknowledge this reality, we might ask whether we provide this protection in a way that is genuinely effective and sustainable.

State Medicaid programs are in trouble. They cause trouble, too. Medicaid’s state-federal partnership was a defensible financing structure in 1965 when per-capita health spending was much lower, and when Medicaid itself was a much narrower program. States can no longer carry the load. Thus, many implement Medicaid badly and begrudgingly, while growing Medicaid burdens crowd out key services such as education and even . Rather than force states to do something they will not do well, Washington should plot a different course.

Ironically, Republican governors and President Obama share common ground. The governors criticize federal policies that burden the states. The president notes that sound policy and basic decency require steps towards universal coverage embodied in health reform. Federalizing the Medicaid burden, , is essential to stabilizing state budgets and providing more humane and sustainable health policies.

From this perspective, health reform remains flawed, not because it overstepped, but because it stopped short of what really needed to be done.

This article/medicaid/1118pollack/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

/?republication-pixel=true&post=8782&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

Yeah, Those Emergency Rooms Are Crowded

Harold Pollack — Thu, 21 Oct 2010 00:30:13 +0000

Almost everyone understands that our emergency medical care system has real problems. Yet a surprising number of people, on many sides of the policy debate, wrongly view reducing emergency department use as a key measure of health reform’s success. To many liberals, crowded ERs exemplify a lack of access to basic care — a lack of access which ironically results in more costly care. To many conservatives, those same crowded ERs exemplify patients’ expensive and irresponsible misuse of scarce medical resources.

Although these arguments reflect very different ideological perspectives, they actually reflect surprising agreement on several things: Inappropriate, avoidable, or excessive emergency room use is unduly costly; health reform could and should reduce such use through some combination of incentives and the provision of alternative services; and reforms that reduce emergency care could therefore save a lot of money through the provision of more cost-effective care.

These arguments contain some element of truth. Yet they leave an overall impression that misidentifies the true problems facing our emergency care system. The real problem is not overuse. Rather, the problem reflects our lack of a financial and administrative infrastructure to properly support emergency care.

Why is the conventional view so wrong? For one thing, “inappropriate” emergency department use turns out to be and than you might . Patients seek emergency care for . Some are frightened by ambiguous symptoms. Some are sent by their primary care doctors, perhaps out of concern that this is a true emergency or because the required tests can’t be administered and read during the normal schedule. Other patients don’t like their regular doctor or are embarrassed to admit that they haven’t been taking their medications. Some just want a warm and safe place to sit.

True, emergency room use can be reduced by imposing stringent financial constraints on patients. Unfortunately, this approach reduces appropriate use, too, .

The above is in , as is evidence suggesting that universal coverage might actually increase both appropriate and inappropriate emergency department use. Notwithstanding this evidence, policymakers and voters seem determined to regard reducing ER use as a touchstone of the health care reform effort. This misguided focus provides a poor guide to health policy. It also makes it harder to nurture a realistic public conversation about what we should really do to make ERs effective and financially sustainable, given the ways that patients will actually use them.

People are right that something must be done to align the supply and demand for emergency care. ER’s are indeed overcrowded. At the same time, many hospitals are closing these centers. Predictably, average wait times are creeping up, sometimes to dangerous effect. More often, hospitals cannot provide the timely and humane care that each patient deserves.

In part, this problem arises because so many patients do present with complaints that could be addressed more cost-effectively in other settings. A recent study suggests that . We should realize, however, that these behaviors are hard to change.

In the scheme of things, $4.4 billion is small change in the context of 120 million emergency room visits every year, let alone our $2.6 trillion medical care system. Heavy-handed efforts to reduce ER use are likely to bring unintended, negative effects. They also divert attention from the most serious problem associated with this heavy use: the likelihood that patients are receiving poor medical care.

Of course, we can be more creative in developing attractive venues for well-managed primary care — efforts the health law appears to promote. We must modify emergency departments themselves to more effectively and efficiently meet patient care needs. A more sound approach would place less emphasis on influencing patients’ behaviors, and more on making our emergency care system financially and organizationally sustainable, given the patients who are actually likely to show up.

Although hospitals don’t always like to talk about this subject, inappropriate or excessive ER use are not the only or the most financially burdensome challenges facing our network of emergency care. These departments are the chink in the armor in allowing the uninsured and underinsured access to costly, often-unreimbursed services.

When hospitals lose money on emergency room patients, when they fear they will have to admit people they can’t afford to treat, or when these patients simply overwhelm the capacity of hospitals to provide such care, care will be rationed by waiting time or by other means which are not always pretty. This isn’t the fault of any specific hospital. It is an inherent problem of a system that must serve millions of uninsured people.

I have a modest proposal. By all means, let’s build primary care options and medical homes that provide effective and attractive alternatives to emergency care. Let’s find and finance alternative chronic care models that reduce the need for certain avoidable forms of emergency care. Let’s experiment with urgent care models that might lighten the ER load. Along with these efforts, let’s also make sure that emergency department’s receive-through insurance and through other means — proper supports for the care they deliver.

Then let’s let the volume of emergency care be what it’s going to be. We’d make better policy if we spent a little less time and energy trying to coax patients out of the emergency room, and spent a little more time and energy making sure that the system effectively treats the people who still come.

Whatever we do, two things are clear. We need more capacity for emergency care. And whether or not we build it, the patients will come.

This article/health-industry/102110pollack/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

/?republication-pixel=true&post=8846&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

Social Security’s Disabled Adult Child Program: A Key Option Often Below The Radar

Harold Pollack — Mon, 06 Sep 2010 00:30:00 +0000

Imagine that you are a middle-aged gas station manager with a worrisome health problem and a disabled child. Have you ever wondered how you would provide for that child in the event of your own death or disability? Now fast forward the tape. Have you ever been to the supermarket and spotted a balding man with Down syndrome pushing a shopping cart for his elderly mother? Have you ever wondered how he pays his medical bills or his rent?

In truth, no single or entirely comfortable answer exists to these questions. Intellectual disability is often accompanied by costly illnesses and social service needs. Even if someone spends his entire life in the house he grew up in, his family may eventually need public help to make ends meet. For many families, a little-known aspect of Social Security, awkwardly labeled the Disabled Adult Child program, makes a huge difference. I never thought much about this assistance until February 2004, when my mother-in-law suddenly died and we moved my wife’s intellectually disabled brother Vincent into our home. Moving him 700 miles from Oneonta, N.Y., to suburban Chicago was . His New York Medicaid suddenly wasn’t much use. His connections to local services were severed. There were forms to fill out, waiting lists to join, lawyerly letters to be written and more.

Exactly two things continued seamlessly: Vincent’s Social Security and Medicare benefits. If you pay Social Security taxes, you know that you earn credits toward your retirement benefits. You may not realize that you also have bought the largest life insurance and disability policy most Americans ever own. If you die or become disabled, your dependents will receive a monthly payment, indexed to the cost of living. Most child recipients receive such payments until adulthood. Those with severe and lasting disabilities receive these payments for their entire lives. In Social Security parlance, these latter recipients are considered “disabled adult children.”

. Almost half, 430,000 people, are diagnosed with Down syndrome or other intellectual disabilities. Benefits are hardly lavish. Still, they can make the difference between poverty and self-sufficiency for hundreds of thousands of recipients. These benefits are important to caregivers, too. When my wife left the paid workforce to care for her brother, that Social Security check made a real difference. These same benefits now cover Vincent’s room and board at a modest group home a few miles from our family home.

As I ponder the quiet success of this program, four broad lessons stand out.

First, Social Security is a good deal. As late-night TV commercials might note, no medical examination is required, and you can never be turned down. People with preexisting conditions or with sick children pay no more than anyone else. By one 2001 calculation (updated for inflation), are equivalent to a $496,000 life insurance policy, and a $434,000 disability insurance policy.

Second, such generosity is possible because Social Security is provided through effectively universal social insurance. Everyone is protected against unlikely but scary risks because no one can opt out from helping. To the uninformed public, such a requirement that everyone purchase insurance appears to infringe individual freedom. Actually, by allowing us to act collectively, this mandate allows us to protect each other from bad outcomes in life’s lottery that would crush any one family forced to bear that burden alone.

Third, the Disabled Adult Child program, like other aspects of American disability policy, was implemented by both Democrats and Republicans . Though hardly free of ideological conflict regarding the proper role of government, the politics of disability have been spared the worst partisan acrimony that disfigured our recent health care reform debate.

Consider this brief history: Disability insurance and related dependent coverage were added to Social Security during the Eisenhower years. Other key changes to Social Security were added in 1972. This Nixon-era legislation established Supplemental Security Income (SSI), a critical pillar to provide income security and health coverage to disabled Americans. Over time, Democrats such as Edward Kennedy and Hubert Humphrey worked effectively with Republicans such as Lowell Weicker and George H.W. Bush to enact the Americans with Disabilities Act and other key measures. Many politicians had children or siblings living with serious disabilities. Others, such as Robert Dole, brought very personal experiences of disability and rehabilitation.

Finally, programs such as the Disabled Adult Child program, admirable as they are, do not provide the economic and health security that people really need. Disabled men and women require diverse medical and social services that Medicare does not cover, or that Medicare covers only with punishing cost-sharing imposed on recipients.

These problems are especially acute in the arena of intellectual disability. Medicaid, not Medicare, finances most required services at the boundaries of health care, education, and social services. Families must therefore confront the many indignities and logistical challenges associated with means-tested public aid. This is not wise or humane social policy. During our current economic downturn, many people living with intellectual disabilities and their families are also enduring painful service cuts, as cash-strapped state and local governments are forced to trim .

Despite these limitations and challenges, this 75th anniversary year of the Social Security Act provides an opportunity to celebrate the ways America has opened its heart and its wallet to help our fellow citizens who live with physical or mental disabilities. We must build on this platform. We have a long way to go.

This article/medicaid/090610pollack/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

/?republication-pixel=true&post=8757&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

High-Risk Pools: A Rare Opportunity For Bipartisanship

Harold Pollack — Thu, 08 Jul 2010 06:00:00 +0000

This month a key program created by the new health overhaul law, the Pre-Existing Condition Insurance Plan, becomes operational in many states. Over the next 40 months, this high-risk insurance pool will provide $5 billion to cover Americans who face the dual challenges of chronic illness and uninsurance. (The government’s new web portal provides specific information for people wishing to apply for coverage.) The high-risk pools are a temporary measure that will operate between now and 2014, when health insurance exchanges, affordability credits and the other pillars of health reform become operative.

As the high-risk pool program goes live, Republicans and others have been asking pointed questions. Senator recently sent Health and Human Services Secretary Kathleen Sebelius a regarding the high-risk pool roll-out, design and operation, and the adequacy of the initiative’s funding.

Sen. Enzi and his colleagues cite from the Congressional Budget Office and the chief Centers for Medicare and Medicaid Services actuary Richard Foster suggesting that the high-risk pool funding cannot reach the full population of the medically uninsured. The letter goes on to ask whether the new program will be implemented on schedule, how many people the high-risk pools will serve, how soon states will receive funds and what happens to these participating states if the pools are oversubscribed or run out of funds. Finally, it rather darkly suggests that Democrats have “attempted to disguise the true cost of the proposals.”

By any reasonable account, two things are true.

First, the high-risk pools will indeed serve a small minority of the medically uninsured. In a recent conference call for reporters, Richard Popper of the HHS Office of Consumer Information and Insurance Oversight suggested that the high-risk pools will cover roughly 200,000 individuals at any given point in time, and roughly 350,000 individuals over the life of the program.

Popper’s estimates, which match those developed by others, indicate that program will serve . Many low-income people in this group are unlikely to enroll because of the required premiums and out-of-pocket costs. This problem has received less attention; some of these patients may be helped by the new law’s strengthened investments in community health centers.

Second, it seems that Enzi and his colleagues are rather disingenuous about both the purposes of the high-risk pools and the legislative history of health reform. The Obama administration has consistently presented the risk pools as a stopgap measure that provides some relief before 2014. But they have real shortcomings. These arise from the back-loaded, financially constrained structure of the final health reform legislation.

Perhaps Republicans were concerned by these underlying dilemmas. If so, there is little evidence of that concern in the legislative record. There is especially little evidence if one examines Republicans’ rather similar to those created by the health overhaul law. These pools were not intended to be a stopgap measure. Rather, they were a permanent component in Republicans’ proposed health reform. Over the same 2010-2014 period, Republicans would have allocated even that the new law allocated for the high-risk pools. Given such low proposed funding, the very same access problems noted in Enzi’s letter would have been more acute had Republican proposals become law.

The high-risk insurance program does not rely on budgetary chicanery or unfunded mandates. It was designed and was funded to roughly double the population served by state high risk pools. That’s what it will do, providing welcome assistance to 350,000 people. The health overhaul law grants HHS Secretary Kathleen Sebelius broad authority to control many program details to honor the $5 billion funding constraint. Officials hired to implement the high-risk pools rank among the nation’s most experienced government and academic experts in this area.

Yet Enzi is right that there are real problems here. The new high-risk program lacks the resources to insure every uninsured American who suffers from a costly illness or injury. Implicitly or explicitly, needy people will likely be turned away. That’s not right, particularly in the wake of a historic debate which established the principle of universal access to affordable health insurance coverage.

The Obama administration will be understandably tempted to dismiss this letter as partisan posturing. I hope they greet it as an opening bid in constructing a bipartisan bill. Enzi : “Given the importance of the high risk pool program and the reliance on this program of millions of Americans with pre-existing conditions and life-threatening diseases, it is crucial that this program be fixed and fully funded.”

Although HHS officials have been reticent to request more money, they would surely welcome additional resources. Governors-particularly Republican governors, who have conspicuously declined to set up their own risk pools, instead ceding the task to HHS-may have other interests of their own that might be addressed.

In a different political moment, these concerns might be addressed through bipartisan legislation. In our own moment, such a compromise seems a heavy lift. After all, Enzi himself was part of the unsuccessful “gang of six” negotiations that never panned out.

But there’s still a possibility for compromise. Now that the fundamental ideological issues were debated and health care reform has passed, there may be more scope for bipartisanship to tidy things up. The at times bipartisan Obama should give Sen. Enzi a ring. It’s worth a try.

Harold Pollack is a public health policy researcher at the University of Chicago’s School of Social Service Administration, where he is faculty chair of the Center for Health Administration Studies

This article/news/070810pollack/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

/?republication-pixel=true&post=8516&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">