Like many Americans, I was first stunned and then unsettled by the shootings that took place last week in Tucson. Since then, we’ve heard lots of debate about Jared Lee Loughner's motivations. Partisan media hyperbole? Targets on an election map?

Most recently, there has been a chorus of pundits singing about the ills of the mental health system. Michael J. Fitzpatrick, Executive Director of the National Alliance on Mental Illness, said, “The plain truth is that America's mental healthcare system is horribly broken and horribly underfunded. And across the nation, budget cuts continue to eviscerate community mental health programs that reach out to vulnerable individuals and put them on a path to recovery.”

But more surprisingly, have been the statements of key Republicans:

• Republican advisor Mike Murphy said on the Bill Mahar Show on January 14, 2011, "I'd like to see a better linkage between the gun control stuff we have now and the crazy-filter. Because if you look at Virginia Tech and you look at this guy, it is too easy for mentally ill people to get guns; because there’s no mental screening anymore."
  
• Virginia Republican Senate candidate Jamie Radtke (and head of the Richmond Tea Party) told ABC’s Top Line that "instead of it being about the political part, it’s really about needing to get our arms around our health care, the mental health policy here."
  
• Representative Mike Rogers (R-MI) said, "What we have to do is intervene earlier in that cycle of violence when they have this kind of disability. . ."
  
• Newly-elected Representative Allen West (R-FL) said, "The shooter was a very disturbed individual and it appears there were so many warning signs that he was going to do something horrible.  We should be focusing on the mental health crisis in our country, not politics."

Well, I have a simple piece of advice: if we want to stop tragedies like this from happening again, we should not repeal health care reform. Two years ago, national legislation passed that (finally) guaranteed that most individuals with insurance will have coverage for assessment and treatment of mental illness. The health care reform legislation builds on that non-discrimination parity legislation and assures that most Americans will have some form of health coverage that includes coverage of mental health conditions.

Earmarked funding for community mental health services will not solve the problem. We need to end fundamental discrimination against people with mental illnesses, and ensure that they have consistent access to the health care services that they need.

Like many of you, on Monday I saw the news that a federal district judge in Virginia ruled that the insurance mandate in the health care reform bill exceeds the authority granted to congress under the Commerce Clause of the Constitution. (It apparently is Constitutional to mandate that employers provide health insurance, but not individuals – a distinction I don't quite get.)

But that is not the purpose of this missive. To all of my colleagues who are applauding the death of the individual mandate, I would like to give a quick remedial course in health care financing. In order for our health system to eliminate preexisting condition clauses and exclusionary enrollment in health plans, the current mandate for individuals to buy health insurance is a necessity. It is financially impossible to have one without the other; if there were no mandate, everyone would simply wait until they were ill to get health insurance – something akin to allowing an individual to buy homeowners insurance the day after they have a fire.

So what is the answer?
 

#1. Fight the Virginia Court decision to the Supreme Court (likely), and restore the individual health insurance purchase mandate within health care reform.

#2. Accept the Virginia Court decision and allow the return of preexisting condition clauses and exclusionary enrollment in health plans. I think this is poor (and penny-wise, pound-foolish) policy choice. We have many Americans who forced into bankruptcy paying for treatment for devastating acute and chronic health conditions.

#3.  Accept the Virginia Court decision and have the federal government provide health insurance for all uninsured persons, which would keep the ban on preexisting condition exclusions in health plans.

For those of us trying to find the “middle ground” in health care reform, I'd like to point out that ruling that individual purchase mandates are unconstitutional is likely to spur an increase in federally-financed coverage.  I'm not sure this is the outcome that many of those organizations financing the anti-health care reform lawsuits will want.  But, as they say, be careful what you ask for. . .

I’ve been a bit perplexed by this election season. I’ve decided we’re stuck in a real-life version of the 1989 film classic, Indiana Jones and the Last Crusade. You remember the one—the globe-trotting, action-packed search for the Holy Grail. I’m reminded of those prophetic words near the end of the film, “...choose wisely, for while the true Grail will bring you life, the false Grail will take it from you...”

These would be good words for voters to heed on November 2nd. Unfortunately, we’re caught between a false set of choices due to the political messaging that we’re bombarded with via every type of media on a 24-hour basis.

The Republican messaging, with its recent “Tea Party” flavor, is generally “All government is bad.”
The Holy Grail – Eliminate government and let the free market rein. 

The Democratic messaging, with its recent panic attack at the loss of the public popularity contest, is “Save government. It’s best for the little guy.”
The Holy Grail – Let’s keep our government operations on track.

I think the Republican Party is at its most disingenuous these days when compared to the past two decades, using those poor “Tea Party” chumps (most of whom are on Social Security and Medicare) to try to prevent government from curbing the worst of the free market abuses (I’m a free market person – and I can tell you that the ethical among us want protection from all of the unethical business entities).

I think the Democratic Party seems to be populated by fearful sycophants. They’re afraid to be the party of ‘good government’ (which is what we need) because introducing a accountability and good business practices would cause consternation among their traditional supporters.

My advice to voters: Choose wisely. Look for candidates who believe in good government – government that provides reasonable protections (regarding health, land use, safety, economics, etc.) to us all – government that is willing to apply standards, accountability, and good business practices. The candidates are out there in both parties, Republican and Democrat.  But we need to turn off the campaign advertising and look beyond the party-line messaging. If you take the time to explore each candidate’s positions and background, you should be able to choose wisely.

Remember the story of the blind men and the elephant? In varying versions of the story, a group of blind men/men in the dark touch an elephant in an attempt to determine what it is; however, each one feels only one part of the creature, such as the tail or the leg. The men then compare notes and learn that all disagree on what they felt—the man who felt the tail thinks it is a rope, while the man who felt the leg believes it to be a pillar.  The story originated in India and is used to demonstrate the relativity of truth.

Well, such is the reporting on the fate of one insurer, Assurant Health, in an era of health care reform.  And, I’m certain that similar reports of facts, resulting distinctly different perspectives, will become more common as health care reform is implemented.

The facts: Assurant Health, a Milwaukee-based health insurance company, announced last month that it was laying off 130 employees in Milwaukee and Minneapolis.

The first perspective comes from “ObamaCare Has Failed,” an article by Grace-Marie Turner, Chief Executive Officer of the Galen Institute.  Ms. Turner writes:

“The wheels are coming off ObamaCare even sooner than most had predicted. The American people are not being fooled by the sugar-coated sales campaign, jobs are being lost, health costs are rising, and the first program to be launched is a dud […] 

Do liberals really believe that people aren't going to pay attention to double-digit premium increases that are coming, $575 billion coming out of Medicare to pay for massive new entitlement programs, the $500 billion in new taxes that are driving up health costs, the barrage of new regulations putting employers and the health sector in a straightjacket, and the despised individual mandate that will force Americans to purchase expensive, government-dictated health insurance?

Today’s news has direct evidence of jobs being lost as a result of ObamaCare. Assurant Health, a health insurer based in Milwaukee that specializes in individual and small group policies, announced that it is laying off 130 workers as of October 1. Assurant is a terrific company that was the first to sell a Health Savings Account policy and has continued to be responsive with innovative products to serve customer needs.

But new one-size-fits-all regulatory requirements are forcing insurers to slash personnel to meet new ‘administrative’ tests, rules that present real challenges to a company that focuses on direct customer service rather than selling policies thousands at a time. Assurant is highly adaptable and will survive, but many capable employees and their families can thank ObamaCare for losing their jobs.”

The second perspective comes from “As Reform Improves The Overall Market, Inefficient Insurers Could Take Hits,” by Jonathan Cohn, Senior Editor of The New Republic.  Mr. Cohn writes: 

“When Assurant Health, a Milwaukee-based health insurance company, announced this month it was laying off 130 employees in Milwaukee and Minneapolis, it blamed the health care overhaul for its struggles […].  The carrier is Assurant, which specializes in selling policies in the individual and small business markets […] – the place you find carriers that aggressively avoid people at risk of getting sick […]

The health law forces insurers to cover basic benefits […] And it limits the money they can spend on administrative overhead or broker commissions. Once fully implemented, reform will also prevent these carriers from avoiding people with pre-existing conditions. Make no mistake: These are all good things. They mean insurance is becoming more accessible, more comprehensive and more efficient.

Alas, that may […] be bad news for Assurant. If the company's name sounds familiar, that's because it was in the news early this year when a Colorado jury slapped it with a $37 million judgment for wrongly refusing to pay the bills of a woman in a car accident. (The company claimed the woman had hidden evidence of a pre-existing condition. The jury, obviously, disagreed.) And when the layoffs were announced, an article from the Milwaukee Journal-Sentinel noted that reform would ‘undercut one of Assurant's strengths – determining which customers are the best risks.’ I have no idea whether Assurant can find other ways to survive as a business. But, if it can't, then we're better off relying on competitors that can.”

I was struck by the difference in “perspective” on the facts...and would welcome your own unique perspectives.    

You may remember one of the few moments of levity in the incredibly complex and partisan discussions of health care reform came from Rush Limbaugh (surprisingly). In January, Mr. Limbaugh ended up in a Hawaiian hospital with chest pains. At a press conference after his recovery, he said, "Based on what happened here to me, I don’t think there’s one thing wrong with the American health care system. It is working just fine, just dandy.” What Mr. Limbaugh apparently didn’t know is that since 1974, Hawaii has had a statewide employer mandate for health insurance and near universal coverage for health care—a key provision of the now-signed health care reform bills. It was irony worth a chuckle.

Roll forward a month, and Mr. Limbaugh added another moment to remember when answering a caller's question on his radio show. The caller asked what he would when the health care reform bill passed. He responded, "I don’t know. I’ll just tell you this, if this passes and it’s five years from now and all that stuff gets implemented — I am leaving the country. I’ll go to Costa Rica." The irony is that Costa Rica has universal, publicly-financed health care—and one of the highest life expectancies on the globe (78.8 year). The very 'socialized' medicine that Mr. Limbaugh has long opposed. It was a great bit of humor in a very intense public discourse.

But, now the day has come. March 23, 2010, the health care reform bill was signed by President Obama. We have the countdown to March 23, 2015 to look forward to.

The December 17 issue of Business Week had a provocative headline—The Coming U.S. Doctor Shortage: Health-care reform will mean 30 million more patients—and bigger crowds in waiting rooms. I thought the positioning of this piece played into the 'fear of health care reform' camp that looks at the nation's health as a zero sum game. If you give minimal coverage to all, the rest of us with insurance will suffer. But the piece did raise some interesting points:

• In 1997, lawmakers placed a cap on the number of medical residencies in order to contain costs under Medicare, which pays for most of these training slots.Medicare pays $100,000 a year per residency, at a total cost to the program of about $9 billion. The funding began in 1965 when the U.S. was preparing to extend government health coverage to 19 million elderly Americans. As the Medicare rolls grew—to 45 million by the end of 2008—a cap was placed on the number of medical residencies to control spending.
• According to the U.S. Department of Health and Human Services, last year there were nearly 17,000 fewer primary-care doctors than needed in inner-city and rural areas. The Association of American Medical Colleges predicts that by 2025 there will be a shortage of as many as 159,300 doctors.
• An amendment to the health-care reform bill—proposed by Senate Majority Leader Harry Reid (D-NV), Charles Schumer (D-NY), Bill Nelson (D-FL.)—would add 15,000 residencies at a cost to Medicare of about $1.5 billion to anticipate and prepare for this shortage

What caught my attention in the article was this handy chart—showing the growing demand for services and the almost-flat supply line. I believe we can flatten the demand line for physicians and increase the supply line with just a few policy changes.

On the demand side, if we encourage individuals to take more control of their own health care, demand for physician time will decline. There are also a variety of technological substitutions for physician office visits and an array of non-physician health professionals that can fit the bill.


On the supply side, there are two major ways to enhance supply. First, use technology to increase physician productivity—less paperwork, e-health to extend reach, and more. The other way is to pay primary care physicians more. Payment policies have favored procedure-oriented specialists—and the physician’s choice of specialties reflects this.

A few weeks ago, Newt Gingrich with the president/CEO of the National Center for Policy Analysis John C. Goodman jointly responded to President Obama's challenge for Republicans to show him a better idea on health care reform. Their ten ideas, outlined in the Wall Street Journal’s “Ten GOP Health Ideas for Obama” are as follows, with my reactions in red.

1. Make insurance affordable. This could be done by reforming the "arbitrary and unfair" taxation on health insurance. (Read: no more tax exemptions on employee health benefits)
2. Make health insurance portable. Employers should give employees insurance that can be brought from job to job, and people should be able to buy insurance across state lines. (Read: eliminate state-specific regulation of insurance comapnies and move to interstate insurance)
3. Meet the needs of the chronically ill. Help them take charge of their own care with Health Savings Accounts. (Not sure what this means)
4. Allow doctors and patients to control costs. Doctors and patients should be liberated from government-imposed payment rates that reward physicians for treating the sick but not for keeping healthy people healthy. (Not sure what this means)
5. Don't cut Medicare. Medicare's on an unsustainable course, but the $500 billion in cuts the Democrats propose are not the answer. (Interestingly odd for Republicans)
6. Protect early retirees. A bridge to Medicare can and should be built to help the millions who retire before they qualify. (Not sure what this means)
7. Inform consumers. Government data on cost and quality should be made public. (Of course. . .)
8. Eliminate junk lawsuits. "We do not need to study or test medical malpractice any longer," Gingrich and Goodman write, pointing to Texas' liability protection efforts as a model. (As a consumer, I'm skeptical of eliminating legal redress for medical malpractice without more regulation to 'disbar' bad physicians. As a health care analyst, the savings are only in the 1.5% range.)
9. Stop health care fraud. Approaches including third-party liability verification, and electronic payment can help cut the $120 billion lost to fraud every year, (Of course...)
10. Make medical breakthroughs accessible to patients. Red tape should be cut to get new drugs and treatments to patients faster. (Good on paper but full of practical, legal, and scientific problems.)

So what do you think? Can this GOP hit list be married with the existing bills to give us something resembling universal coverage with cost containment? Let me know what you think!

The burden of uncompensated care looms large for most health care organizations—especially with the press pronouncing the "death" of health care reform. For the most part, the term 'health care reform' refers to some package of legislation that has two elements—increasing the number of Americans with some form of health care coverage (particularly catastrophic coverage) and putting in provisions to reduce overall U.S. health care costs. The first is of particular interest to health care provider organizations and the second to small employers like my organization.

Now, you may be like one of my many friends who is celebrating the death of the current set of health care reform proposals. You may say that the free market alone is enough to both reduce costs and provide expanded coverage (one leading to the other)—by having individuals pay for their own health plans and health services. While I'm a fan of many free market elements in health care reform (including consumer vouchers for purchasing plans), I would caution those of you in that camp that the free market alone won't solve the coverage and cost challenges that face us (for many reasons too numerous to list here).

The rumors of the death of any health care reform proposal are going to continue to destabilize any organization in the health service delivery system that is not solely a private pay operation. The rising number of uninsured and inexplicably underinsured Americans will overwhelm the charitable capacity of the delivery system without some paradigm shift. But, I would caution my friends in the health care field to realize that we can't afford universal coverage without cost containment. It's just not a fiscal possibility.

And, as a small employer that provides health coverage to our team, I can state unequivocally that no health care bill will cause increasing stress—both financial and ethical. Over the past two years at OPEN MINDS, we have had two proposed increases in the cost of health care coverage—15% in 2008, and 40% in 2009. So, I wasn't surprised (though the press seemed shocked) at the recent decision by Anthem to raise their premiums by 30-39%.

I hope you'll join me in pushing our representatives of both parties to take action—to move toward a system of universal coverage (even if only for catastrophic coverage) and to come up with rational solutions to reducing health care costs.

“Making College ‘Relevant’”, a piece in the December 29, 2009, edition of The New York Times, was a classic example about how new college graduates are ‘missing the boat’ about being hired. As the CEO of a company that hires both college interns and new college graduates, I want to give some free advice:

1. Learn to write (it doesn't matter what your major is—this is the universally necessary skill for most businesses)
2. Computer skills are a must—and I'm not talking about using Twitter; the basic skills you need are word processing, spreadsheets, and web searches (others are a bonus)
3. Be able to do basic math and understand the meaning of charts and graphs
4. Remember that in the information-based economy workplace, attention to detail matters—your mother isn't there to clean up your work for you
5. Keep in mind that most of your personal preferences are not relevant on the job—if you're not happy with what you're doing, save your comments for after work or find a new job.

For college graduates (of whom there are many) who cannot master the first three items, it is really a systemic fault at the college level. No one should graduate from an academic institution without those basic skills.

The future of institutions as long-term residences for persons with mental illness is certainly an integral part of the discussion about mental health policy. Usually those discussions focus on state budgets and Medicaid reimbursement and compliance with Olmstead. But, I was intrigued with a recent piece on Scott Hensley's blog on npr.org “A Peaceful War on Mental Institutions”—coverage of a different chapter in the history of mental institutions.

I never realized that many conscientious objectors in World War II were assigned to mental institutions in lieu of military service. Their experiences are documented in a recent piece on NPR ("WWII Pacifists Exposed Mental Ward Horrors") and in two books—Acts of Conscience: World War II, Mental Institutions, and Religious Objectors (by Stephen Taylor and published by Syracuse University Press) and The Turning Point: How Men of Conscience Brought About Major Change in the Care of America's Mentally Ill (by Alex Sareyan and published by American Psychiatric Press).

As I read this tale of the evolution of human conditions within our mental institutions, I was first struck by how much had changed. Then my thoughts wandered to the millions of Americans with mental illness in our corrections system. If we had the same undercover reporting of conditions of these citizens, would the photos be far different?

For more information on mental health in the corrections context, check out:

• Three Times as Many People With Serious Mental Illness in Prisons Than in Psychiatric Hospitals
• Consensus Panel Develops Performance Measures for Correctional Mental Health

Regardless of the final direction health care reform legislation will go, comparative effectiveness research (CER) will be a part of it. While many see CER as a vital piece of the puzzle, some in the health care industry are on the fence about its actual value in improving health care as a whole. A New England Journal of Medicine piece I read recently, by Alvin I. Mushlin, M.D., and Hassan Ghomrawi, Ph.D., M.P.H., “Health Care Reform and the Need for Comparative Effectiveness Research” gave four straightforward reasons for how/why CER is both valuable and necessary in our existing system:

1. Findings from CER will provide a buffer against “blind” cost containment.
2. CER can identify preferred therapies, promoting changes in care and outcomes by identifying and validating such treatments. Such research suggests ways for new financial incentives to be applied both safely and effectively.
3. CER should enable innovation in medicine, by creating ‘disincentives’ for the development of “me too” drugs and devices, and by raising expectations and demands for clear evidence of superiority.
4. CER serves as what the authors call the “first line of defense against blind cost containment,” and can serve as a stimulus for the academic medical and public health communities, thus resulting in greater demand and more opportunities for physicians-scientists to get in on the research.

Let’s wait to see how CER fares in the final health reform bill—and if either side stifles the progress in science and service delivery that CER can bring about and that the health care system as a whole desperately needs.

I was heartened to see that the Senate version of the health care reform bill would set the medical loss ratio for health plans at 85% for large group plans and 80% for small group and individual plans, and that the House set everyone's rate at 85%. The original proposal by Senator John D. Rockefeller of West Virginia had the ratio at 90%—a number rejected as unrealistic.

And, the reform bills have a penalty clause built in for insurers failing to hit the prescribed medical loss ratio (MLR)—they have to rebate the difference to their customers. See "To Your Health: How Congress plans to get insurers to spend money on actual health care" by Slate writer Christopher Beam. For major insurance companies, this wouldn't change much. The average MLR of for-profit insurance plans offered to large employers is about 84%. Small employers, or companies with 50 or fewer workers, have an average MLR of 80%. But, in the individual insurance market, the MLR is around 70%.

While this is a great start, I think 80% is too low. And, the devil is in the details, so to speak. The reform bills are still defining what exactly 'health care spending' is—a critical set of definitions. Stay tuned

The health care reform bill tug-of-war currently happening between the House and Senate is too much for many of us to keep up with. I took interest with an article in Slate by Christopher Beam that includes a hit-list of those health care reform issues that still need to be ‘hammered out’ in the final bill. His six issues include:

• The exchanges—while the House bill would create a national exchange, the Senate bill would create a series of state-based exchanges. There’s no happy medium. It is either state or national.
• The mandates—what will be the real penalty for not buying health insurance? The House bill would charge a 2.5% tax on all income above the filing threshold ($9,000/individuals or $19,000 for couples), while the Senate bill would impose a flat penalty, which itself fails to acknowledge the wide variance in American income levels and their ability to pay up. The employer mandate is a big one as well; will employers pay an 8% tax on total wages or levy a $750 fine per employee? Who will be eligible for exemptions?
• Medicaid expansion and subsidies—the House bill would make Medicaid available to individuals earning up to 150% of the poverty level, while Senate bill would expand it 133%. The differences are in the subsidies, in that the House bill provides far more support for families at or below 300%, while the Senate bill seems to focus more on middle income families between 300% and 400%.
• CHIP—key questions posed by Beam: “Does Congress really want to end the Children’s Health Insurance Program and push kids into exchanges and Medicaid, as the House bill would do? Or does it want to extend CHIP until 2015, as the Senate bill would do?
• Narrowing the ‘donut hole’—the gap in Medicare coverage known as the ‘donut hole’ is addressed far more in the House bill, which phases it out altogether by 2019 by ‘filling’ it with money from the pharma industry. The Senate bill would only close the gap halfway (and only temporarily).
• Paying for it—the House would levy a 5.4% surtax on individual income above $500,000 while the Senate would tax plans that cost more than $8,500 for individual and $23,000 for a family; Senate would also tax indoor tanning services (yes, seriously).

As our eyes dart back and forth between this legislative ‘volley,’ I will be interested to see how flexible the House and Senate are on certain issues—and which issues they refuse to compromise on.