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Outlook: Health Reform That Only Hurts a Bit

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Ceci Connolly
Washington Post Staff Writer
Monday, June 22, 2009; 11:00 AM

Washington Post staff writer Ceci Connolly, was online Monday, June 22, at 11 a.m. ET to discuss her Outlook article about health-care reform.

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Archive: Transcripts of discussions with Outlook article authors

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Ceci Connolly: Good morning everyone.

Thanks for joining us to chat about health reform.

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Boston: How are we going to keep healthcare costs from rising even further if passage requires more payments to doctors to get their key support and we are adding millions of newly insured patients?

Ceci Connolly: Great question. In the short-term, health reform will cost money up front, largely because of the goal of covering most of the 46 million uninsured Americans. Over the long term, many believe that squeezing out waste, modernizing with digital records and changing payments to reward quality will help slow the increase in spending.

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Arlington, Va.: How satisfied with their health plans are the majority of Americans who have coverage?

Ceci Connolly: The vast majority of polls show that Americans like their doctors but do not like the system overall. They are frustrated by insurance company bureaucracy and do not like the high--and rising--cost of insurance premiums, copayments, etc.

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Central Mass.: I keep hearing that the cost of health reform will be a trillion plus, as if it's all new spending. What I have yet to see is any explanation of how the hundreds of billions now spent on health care will be shifted, redistributed, refunded, or ... whatever. It's not as if we'd actually be starting from scratch... many of those billions are being wasted or spent inefficiently, and could be shifted to a better purpose under a reformed system.

Have you seen any proposals that address this?

Ceci Connolly: There are certainly proposals that attempt to bring some rationality to the payment system. Right now the incentives are all wrong -- doctors and hospitals are paid per procedure, rather than outcome. Several lawmakers are looking at ways to change that approach so that teams of physicians receive financial incentives for keeping you healthy. The first place they'll try to start is Medicare, because the government controls that system.

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New Jersey: Ceci, I appreciate all your insightful articles relating to health care. My simple question to you is when will Americans start looking at their doctors as businessmen and women and not just doctors? Light needs to be shed on the practice of doctors circumventing the insurance system for their personal gain. Doctors that own ambulatory surgery centers are making windfall profits by insurance companies being forced to pay 10-20x what they would have paid under a contract and that is one of the many reasons for the rise of the medical bankruptcy rate.

Ceci Connolly: I understand your frustration. There are clear cases of physicians circumventing the system for personal gain, but in many more instances doctors are as frustrated by the system as we patients.

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New Milford, Penn.: With over 70 percent of the American people in favor of a public option, like Medicare, I can't understand how this is considered a controversial issue.

Ceci Connolly: The polls are mixed on attitudes toward a government-sponsored option, known as a public plan. (Keep an eye out for the Post poll results this week.) Much depends on how exactly this would be structured. Opposition tends to spike when the proposal involves giving a new public program the ability to set rates (similar to Medicare). Other approaches, perhaps a non-profit cooperative, may draw a broader cross-section of support on Capitol Hill.

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San Diego, Calif.: Why can't the government cut more spending? Does Medicare need to pay for those silly scooters? Do we really need WIC? Free school breakfast and lunch? Dept. of Education needs all those administrators?, etc.

Ceci Connolly: Excellent question! I guess I would offer two observations. The first is that Medicare and WIC are two different budgets in two different federal departments. Second, history has shown it is hard to cut federal spending because there is a constituency (and a lawmaker) for almost everything.

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Washington, D.C.: I'm a federal worker on the government's FEHB plan. For a single plan, I pay less than $75 a month, with the government kicking in 72 percent of the remaining cost, which is supposed to continue when I retire. I don't get taxed on the government's contribution, and I pay my premium out of pre-tax dollars, along with my flexible spending account.

I'm trying to figure out how I would end up better under President Obama's health care proposals, and I don't see how I would be. In fact, everything I've heard indicates that I would be worse off, especially if the government reneges on its promise to continue to pay 72 percent of my total health insurance premium tax-free and/or takes away my FSA by removing its tax-free status.

Can you give a single reason why I should support Obama's health care reform? This is a serious question, not merely snark. I just don't see what's in it for me. Thank you.

Ceci Connolly: The short answer is I don't know. There are still too many moving pieces, but I believe proponents of reform would suggest you and fellow citizens might be better cared for. Our nation spends more per capita than any other in the world, with awful outcomes.

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San Francisco Bay Area: The only significant difference in the domestic policies advocated by Senators Obama and Clinton during the primaries was over the health care mandate advocated by Clinton. The hardship waiver Obama says he insists upon is vague, as nobody can fairly determine an arbitrary figure as to what an individual or family could afford.

Obama seemed to many people to be an honest, different kind of candidate during the primaries and election. However, he will be seen as a typical politician who makes promises to win, then does the opposite when elected, if he reverses himself on a health-care insurance requirement and/or taxing employer paid health care benefits. Do you agree?

Ceci Connolly: Gosh, I couldn't say. Major legislation generally requires compromise and the question always arises how far one should be willing to go in those compromises. Obama laid out 8 principles for reform and says he will measure any bill by those 8. On the other hand, we know that he has already made a major concession on the individual mandate.

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Ashland, Mo.: Does the Goldilocks strategy have any potential for poisoning the well in the long run if people believe they were promised something that, in the end, couldn't happen in order to get the bill?

Ceci Connolly: Absolutely. There are risks in this approach, namely that by working closely with industry he may alienate some core supporters. Another problem I anticipate is that even if legislation is signed this year, it will take a long time to implement -- perhaps two years. So folks may not see the impact for a while.

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Marietta, Ga.: Ceci, I just want to say, you are my health-care coverage angel. No one have I heard transform this complex and confusing process in such a simplistic -- not dumb downed, but simplistic -- and lucid manner. Thank you for your work, and continue to educate the American public with your masterful comprehension of this ongoing health care debate and your journalistic prowess.

Ceci Connolly: Folks, I'm publishing this because it has brought a big grin to my face. And it is not even my mother!

Thank you Marietta. You are very kind.

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Prescott, Ariz.: Has anyone had the heart to tell Republicans and Republican-leaning Democrats that the VA system, DOD, Medicare, and Medicaid are all part of "government-run" healthcare? Which one of them is going to offer up the bill privatizing these programs they claim are "devastating for this country", as Republican Lindsey Graham put it on ABC this Sunday morning?

Ceci Connolly: That's an excellent point. In America today, almost half of all health care is provided by the government, as you rightly point out. Each of those government programs operates a bit differently and each has its fans and detractors.

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Norwich, N.Y.: No one wants to talk about "rationing" of care, but don't we need to face up to the fact that we can't afford to pay for every test and every procedure for every person? For example, should we pay for a hip replacement for an 80 year old with lung cancer? No, but if it is my grandmother...

Ceci Connolly: This is an excellent--and very sensitive--topic. We have rationing in this country today, but it is not always obvious.

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Atlanta, Ga.: Good Morning,

What I often find the most disturbing about the health care debate is that the reporters covering the issue do not understand it at all. As an expert in this field I can tell they don't know what questions to ask and the reporting devolves into "the Republicans advocate this, the Democrats advocate that." What is your background and what qualifies you to report on health care? Do you understand the nuts and bolts of your health coverage at WashPost? Do you understand the current laws, both federal and state, that govern the industry? Thank you.

Ceci Connolly: As I tell folks all the time, I am not a physician or a scientist. I have been writing about health policy since fall 2001. I have attended courses at the NIH, the CDC and Harvard. I spend a great deal of time reading and listening to the "experts." But we also try in our coverage to listen to average Americans who have great insights into the subject as well. It is very complex, and we at the Post welcome material, tips, etc.

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Each of those government programs operates a bit differently : Of course, if we had a single payer system, there would be no need for all these different programs.

Ceci Connolly: Yes indeed. That is true. So far, this country has not embraced that approach. Leaders such as President Obama and Senate Finance Committee Chairman Max Baucus have indicated they are not likely to pursue it and instead speak of a "uniquely American" solution.

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New York, N.Y.: Ceci, have these "non-profit cooperatives" ever been tried in health care before? Or are they just a germ of an idea that Conrad brainstormed in his office one day? I've read these kinds of co-ops would actually need to immediately get over 500K members in order to compete? Is that likely?

Ceci Connolly: To the best of my knowledge, they have not been tried in health care. Sen. Conrad's model are electricity and telephone cooperatives in the West.

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New York, N.Y.: Ceci, in your article last week you described the AMA as being "the nation's largest physician group," but for some reason you didn't note that that of the 800,000 doctors in America, just 1/3 are AMA members, nor did you mention that the AMA gets at least 20 percent of its budget from drug companies. And those same drug companies are in the midst of a multimillion dollar advocacy campaign against many progressive health reform ideas. Why did you and your editors choose to leave out this extremely crucial context?

washingtonpost.com: In Pitch to AMA, Obama Paints Mixed Picture

Ceci Connolly: I don't think the two points are mutually exclusive. The AMA is the largest doctors' group, but it obviously does not represent every physician. That's the tricky part with any trade group.

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Washington, D.C.: Forgive me such a silly question, but how do we "reward" doctors for outcomes? Wouldn't this just lead to people with pre-existing conditions finding it impossible to have a doctor treat them, as in all likelihood they will die from their condition? Why would any physician get into geriatric care, when the certainty their patients will die soon is nearly 100%? I fail to understand how on earth one measures outcomes with any quantifiability. Is it just patient surveys and their satisfaction with their care? It seems to me we'll end up with a boatload of pediatricians who can show growing, smiling children as outcomes and very few doctors treating cancer, progressive neurological disorders like Parkinsons, the elderly, etc. Please help me understand this more clearly.

Ceci Connolly: If you look at places such as the Mayo Clinic and Geisinger and Intermountain you'll get an idea of how doctors, nurses and entire medical teams can be oriented to focus on results rather than just procedure after procedure. Moving to such a system would be difficult and take time, but many experts say it can be done. The approach would also include "weighting" to account for an individual patient's age and underlying health. The overall goal, however, is to do the right thing for the right patient at the right time. And skip all the unnecessary, duplicative stuff.

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Monroe, Conn.: The pain felt already is starting to dismantle the nation's ability to deliver cancer care. Continuous cuts to Medicare over the past 5-6 years are having a real impact on community cancer clinics, which treat over 80 percent of Americans with cancer. If a public plan paying Medicare rates or nominally higher, as proposed by House Democrats, pulls private insurance rates down to that level, the country will have a full-blown cancer care crisis in less than two years. No clinic can keep its doors open getting paid Medicare rates -- or even 5-10 percent above. As it is, we are losing oncologists relative to demand for cancer care. This is a very serious situation.

Ceci Connolly: We periodically hear reports about one particular area of care that is not being reimbursed adequately. I am not well-versed enough in the Medicare cancer payments to comment extensively. But this is worth investigating further.

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Columbus, Ohio: People say they do not want health care rationed, but the current system rations health care every day. It denies health insurance to some people based on age, who they happen to work for, and their personal wealth. We must develop a protocol to say no that is morally, ethically and constitutionally sound, and will promote care quality, effectiveness and economy. It's clearly possible, and we are not even talking about it.

Ceci Connolly: I'm not sure I have much to add, but this is an observation I hear often in my reporting across the United States.

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Boston: All I hear is that we have the best healthcare system in the world, yet a lot of the mileposts (mortality, infant deaths, longevity, etc.) are not as good as other countries. All politics aside, how would you rate America's system? What system would you like to participate? If you were diagnosed with cancer, where would you like to get treated?

Ceci Connolly: I think the reviews on the U.S. health system are mixed. Empirical data shows we have many great successes here, particularly in terms of innovation and cutting-edge therapies. On the other hand, we know that other countries often fare better on measures such as infant mortality, obesity and heart disease.

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New York, N.Y.: So let me see if I've got this straight: a government-offered public health care plan would provide insurance much more efficiently and cheaply than private carriers could. Is that about right, Ceci? I presume that if there were quality advantages to the private plans, the insurance carriers wouldn't be so worried that everyone would switch to the public plan. Given how hard they're trying to put the kybosh on the public option, the private insurance carriers (and wholly-owned congressmen in their pockets) sure don't seem to have much confidence in what they're selling, do they?

Ceci Connolly: Hard for me to say. It seems this will all depend on which insurance company you ask and how they would adjust their products if they had to compete with a new government-run player.

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Alexandria, Va.: What we need to do is a complete overhaul of payments to specialists. I went to a plastic surgeon once just to see if I had an obstruction inside my nose. He looked inside and said nope. The bill: $500 for "surgery"! My sister, an internist, said that's because it's considered an "invasive procedure." I thought it was highway robbery.

Ceci Connolly: We hear those sorts of stories often. One of the things being discussed in Congress and at the White House is finding ways to encourage more physicians to go into primary care and how to shift attention and resources to prevention.

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Columbus, Ohio: Two Questions. 1 Why is no one doing something, or even talking about the wastage in the health insurance companies, whose own financial statements show an annual wastage of several hundred billion dollars? 2. Why is no one even talking about the way the current system rations health care by denying coverage to many people and by limiting services provided in a way that encourages wastage and exploitative pricing?

Ceci Connolly: I do hear discussion about these questions, but there's always room for more. Advocates of a government-run system say their approach would eliminate the overhead we see today in the insurance industry. On the other hand, many say that the industry is a reflection of our capitalistic society.

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Ceci Connolly: I'm afraid we have run out of time. Thanks very much to so many of you who took the time to write. We'll do this again soon.

Stay healthy!

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Editor's Note: washingtonpost.com moderators retain editorial control over Discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions. washingtonpost.com is not responsible for any content posted by third parties.


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