September brings the change of seasons. Football players return to the gridiron. New television programs replace summer reruns. In Washington, legislators gear up for another season of legislative brinkmanship.

What distinguishes such brinkmanship from ordinary legislating? Hard deadlines.

Such deadlines force Congress to address policy issues that might otherwise languish due to partisan differences or legislative inertia.

Last spring, for example, the repeated threat of a government shutdown forced Congress to decide how much to spend on government agencies in fiscal 2011. This summer, the debt limit forced Republicans and Democrats to reach a budget compromise before Aug. 3, the day we would have discovered what happens if America can’t pay all its bills.

Hard deadlines thus can force Congress to address major issues. But they also invite that brinkmanship.

Like students who put off writing term papers until the night before they’re due, legislators often drag out negotiations until the very end. As we saw with the debt-limit debate, the ensuing uncertainty – will the United States really default? – can damage consumer, business, and international confidence. Hard deadlines also give leverage to those legislators who are least concerned about going over the brink.

So get ready for the new season. The fall legislative season is full of deadlines that could invite such brinkmanship. Here are five.
Number 1

The first up was the Federal Aviation Administration, whose short-term funding expired Sept. 16. Congress averted a partial shutdown by extending the agency’s funding for four months, avoiding the thousands of furloughs and layoffs that occurred when FAA funding briefly ran out in July.
Number 2

Second is for a much larger item: funding for highways and mass transit. Current authority for these programs expires on Sept. 30. If Congress doesn’t act by then, new federal spending on surface transportation projects will grind to a halt, putting tens of thousands of jobs at risk.

Number 3

Sept. 30 also marks the end of the fiscal year – an especially important deadline. Congress has made woefully little progress in deciding next year’s funding. So we again face the prospect of temporary funding bills being negotiated in the shadow of threatened government shutdowns.

Number 4
The fourth deadline comes on Nov. 23, the day the new “super committee” has to deliver a plan to address government debt and cut the deficit by at least $1.2 trillion over the next decade. If any seven committee members agree by that date, their plan will get special, expedited consideration in the House and Senate.

If the committee fails to reach agreement or Congress fails to enact it by Dec. 23, however, then automatic budget cuts go into effect for a range of programs, including defense, domestic programs, and Medicare, starting in 2013.
Number 5

A final deadline comes at the end of the year, when several economic initiatives are set to expire, including the 2 percent payroll tax holiday and extended unemployment insurance benefits.

Each of these deadlines will command congressional attention. The downside of inaction will be tangible and visible. With renewed concern about jobs, policymakers will feel extra pressure to continue any funding or tax cuts that can be directly linked to employment.

These deadline-driven policy issues will thus dominate the fall legislative season. That will leave little space for any new initiatives that don’t come with a deadline.

Bill Expands Coverage to Millions of uninsured Americans, Invests in Wellness and Prevention

(Washington, DC) – Trust for America’s Health (TFAH) applauds the action of the United States House of Representatives, which passed the Patient Protection and Affordable Care Act late last night. The bill expands coverage to millions of uninsured Americans, establishes a national prevention strategy, and creates a reliable funding stream through the creation of a Public Health Investment Fund. This fund will support core public health functions, community prevention initiatives, an increased public health workforce, and public health prevention and research activities.

“Today America is one step closer towards a culture of prevention rather than one of treatment.” said Jeffrey Levi, PhD, Executive Director of Trust for America’s Health. “Prevention holds the promise of improving health and quality of life while lowering health care costs.  This bill includes the ingredients needed to ensure we get the returns that prevention offers, including a focused national prevention strategy, a reliable public health funding stream, and evidence-based programs that will be held accountable for improving health outcomes.”

As part of the National Prevention Strategy, the bill creates a Prevention and Public Health Council chaired by the Surgeon General which will provide coordination among Federal departments and agencies and create and implement the National Strategy.

“While we need a robust public health workforce to help implement the National Strategy, there are many factors that are beyond the ability of health officials to influence by themselves,” Levi said.  “That’s why it’s so encouraging that the Prevention and Public Health Council will look at ways of including health across all sectors of the government.”

The bill also includes funding for Community Transformation grants that would help leverage the success of existing evidence-based disease prevention programs, such as those that promote healthier eating and increased physical activity, or establish new programs in areas that currently do not receive funding. These interventions promote healthy environments and behaviors by making it easier for people to make healthy choices.

“The Community Transformation grants are an important, strategic investment that will help reduce rates of preventable disease and give millions of individuals the opportunity to live healthier lives,” Levi said. “These programs will have a real payoff in dollars, workforce productivity, and quality of life for all Americans.”

Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

Clement Richard Attlee, British Prime Minister from 1945-1951 once said “Democracy means government by discussion, but it is only effective if you can stop people talking.” His words came to life in a public meeting today where there was plenty of talking. But, unfortunately it is a public meeting virtually no public ever attends. Quick now, can you name one elected official to the board responsible for public health care at hospitals in Lee County?

The Lee Memorial Health System’s Governance Committee of the Whole Committee, (say that fast three times) met this afternoon at 1:00pm. In a marathon meeting the ten elected members talked mostly about when to meet and how often to meet. It was democracy at it’s messy best.

Motion after motion was made and tabled on whether to meet at 1:00pm or 3:00 pm., or 4:00 pm. When a motion was presented to meet at 3:00pm long-time member Frank T. La Rosa threw up his hands. “I’m disgusted with the bunch of you. I’m mad. We’re like a bunch of babies here.”

Sour grapes? Keep reading. The truth is, La Rosa is a court volunteer who supervises and mentors children who have been abused. He has to be in Lehigh Acres at 5:00 pm to help these kids. Many of the hospital board meetings easily go two hours or more. He would have to make a choice if all the meetings were moved to 3:00 pm. The board or the childen. Which would you choose? La Rosa made it clear he would choose the kids and be forced to resign from the hospital board if every meeting was moved to 3:00 pm.

On the other end of the meeting time discussion is long-time board member Linda Brown, an Advanced Registered Nurse Practitioner. While La Rosa is retired, Ms. Brown is still a practicing Advanced Registered Nurse Practitioner. “I have patients in my office right now waiting,” she said after the meeting had gone on more than two hours. “These meetings never used to go on this long. Can’t we meet at 4:00 pm?”

Enter Governance Committee Chairwoman Lois Barrett who has also served on the board for many years. “If we meet at 4:00 pm it will be dark by the time we leave. I can’t drive at night. I will have to resign.”

Someone suggested meeting at night so more of the public could attend. The public is not going to attend if we move it to nights another noted. Someone else commented on the cost of overtime for some LMHS employees.

“I’ve been all over this country,” said La Rosa. “I’ve never seen a board like this.” The board meets nearly every week now, either in committee or as a full board. Board member Marilyn Stout agreed. “We put in a huge amount of time.”

The solution came in a compromise. Full board meetings will continue to be held at 1:00pm, and Planning Committee and Governance Committee meetings will alternate their meeting and meet at 3:00 pm.

Noted British statesman and philosopher Edmund Burke (1729-1797) said, “All government…indeed, every human benefit and enjoyment, every virtue and every prudent act…is founded on compromise and barter.” Most would agree, democracy may not always be pretty, but it beats moving to Cuba.

Other Matters

The Board agreed to issue a proclamation on behalf of Horace Smith. Smith was the first-ever county-wide elected African-American politician in Lee County. Smith passed away last week. He served on the LMHS Board of Directors from 1980-1988. “He loved public service,” said LMHS President and CEO Jim Nathan. “Horace was truly here to represent the people. He focused on decorum in meetings.”

“He paved the way for other African-Americans in Lee County,” said James Green, a current board member. “Horace was a mover and a shaker.”

In other business, Charles Swain, Chief Compliance and Internal Audit Officer presented a detailed report on the Surge in Regulatory Enforcement, and LMHS’s effort to comply during the 4^th quarter. Dr. Linda Brown was pleased with the progress. “We are making changes,” she said. She called Swain’s efforts a form of surge protection against the explosion of regulatory enforcement now going on across the country.

The board also discussed improving evaluation forms for hospital staff, including President and CEO Jim Nathan, and developing greater clarity on board member duties.

By Patrick Comer
Editor

(Editorial)

There, I said it. I raised the question of whether the U.S. healthcare system, as it is now, favors whites over minorities. What do you think? Since unemployment is often higher among minorities, they are the first to feel the effects of not being able to afford healthcare. So, as a consequence of that reality, are whites receiving better healthcare than minorities?

Of course, I’m not suggesting that any healthcare professional makes a conscious decision to not provide healthcare to a minority. But the decision is made thousands of times every day across the county to not provide the same level of healthcare to someone without insurance as they would to someone with insurance. Even 501c3, not-for-profit hospitals and clinics still have a bottom line and finite resources. Healthcare is not a bottomless well with unending services. Someone gets left out, and sadly, those getting left out are the less fortunate among us, which certainly includes whites but very often the less fortunate are minorities.

Speaking on the subject “Institutional Racism in the US Health Care System,” Vernellia R. Randall, Professor of Law with The University of Dayton School of Law
said, “since 1975 minority health status has steadily eroded and there have been no significant improvements in the removal of barriers that are due to institutional racism.”

Healthcare Already Rationed
Is it racism or rationing? You might ask what is the difference, healthcare is apportioned now based on color. The color green. In a recent interview with the Lee County Times, I spoke with Dr. Larry Antonucci about the debate over healthcare reform. “I’ve heard people say they are concerned that healthcare reform will lead to rationing of healthcare services,” said Antonucci, Chief Operating Officer of Hospital Services for Lee Memorial Health System. “The reality is, it is already rationed on whether you have health insurance.”

If you ponder that statement for a moment, which in all honesty I probably never would have until I was thrust into that situation, it is a frightening and sobering statement of reality. Basically, someone decides ‘this person gets treatment because he has insurance or money,’ and ‘this person will not get treatment because he does not have insurance or money.’ So, does it not follow then, that if minorities often fall into a lower socioeconomic scale, they receive less healthcare? You might say “well then, pull yourself up by your bootstraps and get a better job.” Tell that to the unemployed 60 year-old Nuclear Engineer in California who called into NPR radio a few weeks ago. “I was laid off two years ago,” he said. “We’ve used up all our savings and now I’m losing my house and no one wants to hire a 60-year-old Nuclear Engineer.” He appears to have done everything right. He was educated and hardworking. Now he is unemployed and uninsured.

I’m white and always had a good job and decent health insurance. But due to the terrible economy I was laid off, am now unemployed and will soon not have health insurance because of the tremendous cost. We’re endeavoring to start our own business, but until that is successful, will my family’s quality of healthcare continue the same as someone fortunate enough to still have full-time employment? Will we still be able to afford our prescriptions? Will we still visit our doctor when sick? The simple answer to those questions is no, not without affordable health insurance. Like millions of other families we will try to stay healthy and hope nothing serious happens, until we either can afford health insurance again or get old enough to receive Medicare.

Is Medicare “Socialized Medicine?”
As a journalist, I’ve always endeavored to give a voice to the powerless, not the powerful. This is one of those times and one of those editorials. I’m not writing from the figurative ivory tower, smug and comfortable with a 6-figure income, and patting myself on the back for my work ethic. I’m writing this because it seems political rhetoric too often muddies the discussion over reform and those who suffer are the powerless.

Much of the debate on healthcare reform seems to come from two opposing political views rather than on how to reform what is obvious to most, that the current system is too expensive and too exclusive. The political argument against reform often is that it is “socialized medicine.”  But many times, it seems the ones arguing that point are old enough to be receiving Medicare. Whenever the opportunity arises I always ask someone on Medicare but who is complaining about reform they perceive to be “socialized medicine, “are you better off with Medicare, or would you rather see it disappear?”  So far, not a single person receiving Medicare has told me they would rather not have it. To the contrary they are very thankful to have it. How about you?

I’m not saying Medicare is perfect, but at least it appears to be colorblind, providing the same level of care, good or bad, to everyone regardless of race, religion or ethnic background. Unfortunately, even Medicare is going bankrupt and is in need of reform.

So, here’s my question: If you believe universal healthcare is “socialized medicine,” will you refuse Medicare when you qualify, or if you are already receiving Medicare, would you rather you did not receive it?

I would love to hear from someone who doesn’t receive healthcare benefits from their employer or former employer, and who refuses to accept Medicare and is complaining that reform is equivalent to socialized medicine. What say you?

Report by Jim Nathan
President of Lee Memorial Health System

“30% Uninsured in Lee County”

In the fall of 2000, I served on a panel for a program in Cape Coral sponsored by the Cape Coral Chamber of Commerce.  The focus was on health care.  There were seven panelists including three elected officials at the state level.  Each panelist was given an opportunity to share health care issues and concerns through their own eyes.  After a brief break we returned to the tiered auditorium for a Q&A session.

Virtually every head and eye became fixated on the three elected officials as they were rapidly bombarded by a series of questions which were more like personal observations, requests and demands such as:

• “You need to make cost of insurance more affordable!”
• “You need to make the cost of health care more affordable!”
• “You need to help me get the drugs I need!”
• “How do I get access to care for my spouse who is seriously ill?

The political leaders responded wisely:

• “That sounds like a federal not a state issue.”
• “I do not serve on a health care committee but if something comes up for debate on the floor, I will welcome your input.”
• “Please send a note to my office.  I will have someone look into it.”

Then a lady in the front row asked, “Why is no one mentioning universal coverage?”  The audience response was instant with some of the same people making demands on our elected officials rising to their feet and yelling, “We don’t need any of that damn Hillary Care!”  How interesting it was for me to observe the demands on government by the same people who were already mostly on a government health plan (Medicare) and yet opposed to exploring options to expand coverage.

This chamber program occurred roughly six years after the failure of large scale health reform at the national level.  It would be another eight years before it would even remotely be politically acceptable to discuss serious comprehensive reform of the delivery and financing of health care for our nation.

As recently as 2004, a key Florida political figure shared with me, “Any politician who chooses health care for his or her mantra is a damn fool; and, by the way, you health care people just don’t get it … the health insurance companies pay us a lot more for our campaigns than you ever will!”

Now, once again our nation finds itself torn, confused and angry over the entire health care debate.  We have become a sound bite nation that wants simple answers to complex problems.  Health care financing and delivery certainly fits at the highest degree of complexity because of the economic, political, social, philosophical, ethical, personal, and cultural issues that intertwine with the complexity of the science and the art of medicine.

When our Board met in June, I thought it was important to review the key elements that were emerging as possible reform consensus and possible financing mechanisms.  The goal in late June was to have plans in place by mid to late July.  While that was only two months ago, it is almost light years ago in the “life” of health reform.  The national debates have intensified making the emotions of that forum in Cape Coral look tame and the shoe throwing incident that President Bush encountered last year in Iraq as a yawning moment.  Education and information have ceded to misinformation and name calling.  Thee are more and more individuals questioning whether reform is necessary and even wanting to put it on hold for a while.

Regardless of any of our personal political and philosophical beliefs, it is important to step back and remind ourselves why there is a push for and need for comprehensive health reform.

Bankruptcy of Medicare

Medicare is funded through payroll taxes.  When it was in its early days, there were at least four to five workers to help fund for one Medicare eligible retiree.  Prior to the recent economic decline and America’s rapid movement toward 10% unemployed, Medicare’s funding demise was already predicted for bankruptcy in 2017.  That is almost tomorrow in the reality of finding solutions and funding.  Medicare, which presently accounts for 14% of the federal budget, is expected to go from 40 million to 78 million enrollees by 2031.

MedPAC, the national advisory board for Medicare payments, has been working to identify ways to stop this rapid demise.  MedPAC has proposed such concepts as improving funding for primary care; altering economic incentives so that providers of care would find models of collaboration designed to improve clinical outcomes while reducing unnecessary tests, procedures and readmissions; reducing payments to insurance companies exceeding usual and customary costs for Medicare in each region of the US; and strengthening negotiations for major medical supplies and drugs utilized by Medicare eligible individuals.

MedPAC recommendations have been incorporated in some ways into many health reform initiatives; however, lost in a lot of the rhetoric is that Medicare is going bankrupt at a faster pace than previously anticipated due to the current loss of jobs and economic decline.  If nothing else happens, Medicare must have revisions and what happens with Medicare is often a driver of change for most major health insurers.  Absent incentive changes, improved negotiations for drugs and medical supplies, and a reduction in Medicare payments to insurance companies, the only solution is to reduce payments to physicians, hospitals, nursing homes, rehab facilities, etc., … the people who actually provide the care.

Of note, the 2003 federal revisions to Medicare hastened the demise of Medicare as they did the following without any new funding source:

• Expanded drug coverage for seniors with a stipulation that the feds would not negotiate drug pricing;
• Increased payments to insurance companies over and above usual and customary fees in each market resulting in an average of paying 12% more than regular Medicare for the Medicare Advantage program in an effort to privatize the Medicare program; and
• Established a structured reduction in Medicare payments to physicians for nearly a decade.

Physician Payment Reform

Since the passage of Medicare reforms in 2003, there has been a statutory formula requiring annual reduction in physician reimbursement.  The formula has been adjusted every year because it is not realistic; however, the federal law has not been changed.  Absent a short term or long term fix, the average reimbursement to physicians through Medicare is scheduled by federal law to decline by 20.5% in January.  Fixing this complex issue will cost many billions of dollars; not fixing it will drive physicians away from treating Medicare patients and will impact future decisions by individuals choosing to spend many years in training to become a physician.  The next paragraph identifies a possible funding source to help with the physician payment issue.

Medicare Advantage and Payments to Major Insurance Companies

One of the most sought after current opportunities for government savings to help fund for some of our health financing challenges is to reduce payments to insurance companies for Medicare Advantage.  However, for the past couple years these same insurance companies have recognized this possibility and have worked hard to increase the number of Medicare Advantage enrollees.  Virtually overnight, there are millions of Medicare eligible individuals who are now utilizing the benefits of Medicare Advantage gained through the feds higher payments and are quick to lobby politicians, “Don’t take my Medicare Advantage program away from me!”

Insurance Reform is Essential

Insurance companies years ago moved away from “community rating” where actuaries would estimate the cost of health insurance based on the costs of care and the disease prevalence in a given community to determine premiums.  Community rating gave way to “experience rating” where a small employer or individual with a major health issue could dramatically impact the cost of an insurance policy and in fact become uninsurable due to cost of the policy.  Since this switch to experience rated insurance pricing, we have faced the rapid demise of small employer sponsored health insurance and few individuals being able to afford an insurance policy.  As recently as 1993, 61 percent of small employers were still providing health insurance for their employees; today, only 38 percent of small businesses offer health insurance.

In the early stages of the current reform debates, the major health insurance companies offered to modify their experience rating policies to some degree … reports vary as to what they would cover … in return for a massive expansion of universal coverage and no new public (governmental) plan.  Now that the insurance companies appear to be leaders in redefining the health reform debate, it appears less likely that experience rating will be modified.  In my opinion it is an essential part of any health reform effort.

In addition, requiring “guaranteed issue” of insurance coverage to those with serious health problems as pre-existing conditions, or those who may have exceeded payout limits, coupled with community rating in a large enough pool to spread the risk and associated costs, will allow access to more affordable coverage to many who are now denied.

The reality of the Uninsured and their Impact on Everyone Else

Very few politicians today would advocate for inclusion of undocumented immigrants in any type of health reform proposal.  There are no political polls showing support for this population.  However, the reality is that those who are insured … primarily individual policy holders and employer sponsored health plans … already pay for undocumented immigrants since if they present in a hospital emergency room and are in need of emergency stabilizing care, they will receive it.  Such care is not free and those who want to pretend it is not already a cost to our society are not willing to accept this simple fact.

But it is not just the undocumented immigrants issue, it is so much more.  The uninsured are not just undocumented immigrants and not just the unemployed poor.  They are people with jobs where no insurance is provided or where they cannot afford the insurance offered.  In fact, almost a quarter of the nation’s non-elderly are uninsured.

The “hidden tax” aspect of how we pay for the uninsured and underinsured is a reality of our nation’s principal financing being employer sponsored.  Each year as more employers reduce health benefits or drop them completely, more people become uninsured.   This causes those who remain insured or are providing health insurance to employees to pick up a larger and larger hidden tax.

And equally important as a “hidden tax” or “cost shift” to that shrinking few with health insurance is the unreimbursed cost of both Medicaid and Medicare.  Government funded health programs do not now cover the actual real costs of care for the patients they serve and these unreimbursed costs now exceed the costs of charity care in our Lee County area.

In our community with 13.2% unemployed and an economy based on small employers, we are in excess of 30% uninsured for those residents under the age of 65.  In 2007, 35% of Lee Memorial Health System patients paid for 100% of the shortfall from Medicare, Medicaid, uninsured and underinsured.  In 2008, 30% paid for these “hidden taxes” and in 2009 thus far it is 28%.  This is not unique to Lee County but with our demographics we are a major trend setter!

Chronic Disease Management

Roughly half of all Americans suffer from at least one chronic disease.  Nearly three quarters of our health costs go to five chronic conditions:

• Diabetes
• Congestive heart failure
• Coronary artery disease
• Asthma
• Depression

While one can have any of these chronic conditions or even all of them and not be obese, obesity is rampant in our nation.  We have become the fattest nation in the world.  Obesity heavily impacts all five of these chronic diseases.  As recently as 1990, there were no states in the US with a prevalence of obesity greater than 15% and only ten states exceeded 10%.  By 2007, only one state, Colorado, was under 20% while 30 states have 25% of the adult population now obese.

Health care providers are rarely compensated to help manage chronic diseases beyond episodic or crisis management.  Many individuals choose to let their potential health challenges go well beyond an easy to manage state.  Many uninsured and underinsured are often forced to seek care only at a crisis stage which may be life threatening and very expensive.  Guess who ultimately pays for this lack of teamwork in managing the high costs of chronic diseases?  Absent redirecting payment formulas and finding ways of changing our national culture, chronic disease expenses will far outdistance the overall current costs of care with our aging and fattening society.

The “Public Option” versus “Co-ops”

A government run public (non-Medicare) program to compete with private insurance has been a dividing point politically since the reform discussions began to emerge.  In fact, to try to find a bi-partisan compromise, this option appears to be virtually unacceptable.  Even many who see its value are concerned that if too many patients switch from commercial insurance where the “hidden tax” is presently being subsidized, then the government run plan will underpay doctors, hospitals and other providers just as both Medicaid and Medicare presently do.  Hence, the not-for-profit co-op option has begun to emerge as a “politically acceptable” option.  Unfortunately, while the insurance companies might like this much better than competing with the public option and it may sound better politically, the reality is they will be small with limited leverage to negotiate the best rates and can easily become the place of last resort for patients the big insurance companies do not want.  We will hear a lot more about co-ops versus the public option in the next few weeks!

The Death Panels!

This summary which clearly does not cover every key issue would not be complete without some reference to the supercharged issue of “death panels.”  This issue has had so much emotion when it was intended to be just the opposite … a calming “time out” to consider end-of-life planning on behalf of the patient.  Less than one third of adults have a living will.  Presently, Medicare does not pay for end-of-life consultation.  Some Medicare Advantage plans do.  The proposal was to make such consultations easily available for Medicare patients and their families.  Palliative care is an emerging service through hospice and hospitals and other programs providing end-of-life assistance and achieving dignity based on the wishes of the patient.  This consultative reimbursement concept was never intended to be a panel making life or death decisions.  This type of emotional rhetoric has damaged a vital dialogue with the American people.

Will History Repeat Itself

Health reform has died before due to many factors such as:

• complexity of the issues;
• ideological differences;
• the lobbying strength of special interest groups; and
• changes in the power and roles of the president & Congress over the years.

We are once again at the precipice of will we or won’t we?  Doing nothing because we feel we are happy with what we have does not acknowledge that what we think we have (such as Medicare or affordable health insurance) will change dramatically even without government intervention or new statutes.

The next few months will determine if once again we will go “underground” for another 15 years before there is the courage to have a major discussion on this supercharged, complex issue.  Thirty second sound bites and scaremongering won’t help us determine what is best for our nation.  Honest, open, educated dialogue is essential.  Partisanship rancor will not result in an effective outcome for our nation’s health.

Jim Nathan
President of Lee Memorial Health Systems