Consumer Directed Healthcare

Anita Raghavan – Forbes.com

As a young man working for Suhrkamp Verlag, the renowned publishing house in Berlin, Michael Prolingheuer bought private health insurance. Coverage was then relatively cheap (though it now costs $905 a month). It also promised greater choice of doctors and easier access to care than Germany’s statutory quasi-public plan, which consists of 187 nonprofit insurers closely supervised, but not run, by the government.

Today, 28 years later, he’s having second thoughts. In January 2007 Prolingheuer, now 54, was diagnosed with amyotrophic lateral sclerosis (also known as Lou Gehrig’s disease), a progressive disease of the nervous system that paralyzes and ultimately kills a patient. Not long after he got the grim news, the fight with his insurer began. At first his carrier, Allianz, balked at paying for the respirator that helps him breathe, arguing it wasn’t specified in his policy. It only relented after a doctor at Berlin’s Charite-Universitaetsmedizin, a teaching hospital, sent a letter saying that without the machine he would die. Then Allianz suggested cutting the amount of time Prolingheuer was hooked up to the respirator, which would lower treatment costs by eliminating round-the-clock home nurses. In a letter dated June 10, 2009 it asked him for a medical report that would state “to what extent your daily breathing treatment could be reduced to heighten your quality of life” and inquired to what degree his wife assisted him in his daily routine, as “she has been trained in using these machines.”

“We deeply regret causing Mr. Prolingheuer distress,” says an Allianz spokesperson. She adds that while his policy “does not cover the particular medical equipment he requested, Allianz nevertheless provided it after confirming with his m.d. that this was needed.”

Prolingheuer isn’t having any of it. “My insurer would like to see me dead,” he taps out on his black laptop. Lying in a short-sleeve black sports shirt and striped pajama bottoms, Prolingheuer can no longer speak and is mostly confined to his bed. He paid insurance premiums for many years. “Now that I need the basic care, they say no.” He figures his care costs as much as $370,000 a year, of which his out-of-pocket cost is $21,000 in addition to his monthly premiums. If he had to do it over again, Prolingheuer says, he would be part of Germany’s public insurance system–the choice of 90% of the population, 74 million or so people.

People like Angela Jansen, 53. Diagnosed with ALS in March 1995, her care is covered by public insurer Barmer, which, together with the government, pays $360,000 or so a year to support round-the-clock nurses. Jansen, too, can no longer speak or use her hands and legs but relies on a computer with a laser camera that captures the movements of her left pupil as it scans letters on the keyboard. “This thing called Eyegaze the insurer paid for, the wheelchair, the breathing machines … the things I need to live,” she writes. Where it skimps: on medicines, offering generics, which “are not always the best. Sure I get what’s on the list, but not everything is on it,” she writes. One excluded item is a cream that might prevent her bedsores.

This pair of patients with extreme needs represents the two faces of health care in Germany and its mix of private and quasi-public insurance plans. More than any model in the world, the German system offers a glimpse of what health care could look like in the U.S. That’s assuming any bill survives the popular revolt. Unlike many countries with national health–Canada, say, or the U.K.–where private insurance generally supplements public coverage, Germany has two separate systems that coexist, with private plans indirectly benefiting from the cost controls of the public system.

Whether they have public or private coverage, most Germans love their care. In a recent survey by m&m Management & Marketing Consulting 84% of private insurance clients expressed satisfaction; so did 85% of those who rely on the public system. Tough to find that in America. Germany spends $3,588 per capita, per year, or 10.4% of its GDP, on health care. The U.S. shells out $7,290 per person, 16% of economic output. This difference is not because we have more old people. One in five Germans is 65 or older, compared with one in eight in the U.S.

“If you want a health care system where you don’t have to worry that you could go broke, where you could lose your health insurance or get off-the-charts doctors bills, look at the German model,” says Uwe Reinhardt, economics professor at Princeton University. He believes that German and Swiss systems, which offer near-universal care without rationing services, come closest to something that Americans, long used to a private system, could stomach.

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Senate Finance Committee Chairman Unveiled An $856 Billion Proposal
By HUMA KHAN and Z. BYRON WOLF
Sept. 16, 2009—

Senate Finance Committee Chairman Max Baucus today released a 10-year, $856 billion health care proposal, which is already being met with criticism on both sides of the political aisle.

The Montana Democrat dubbed his bill as balanced and fiscally responsible. At a news conference, Baucus expressed confidence that the final bill will get bipartisan support, despite his appearing without any fellow party members or Republicans.

“Everyone should understand it’s just the beginning, but it’s a good beginning. The choice is now on those on the other side of the aisle,” he said. “At the end of the day, there will be Republican support for this bill.”

The nonpartisan Congressional Budget Office estimates the Baucus bill would cost a total of $774 billion over 10 years. But the bill would, in effect, cost more than $800 billion, Finance committee staffers say, because of differences in scoring between the CBO and Finance committee. That would not account for the $900 billion in federal revenue raised by taxes on insurance companies, employers who don’t offer coverage and assumed cost savings in Medicare that are envisioned to pay for the bill and keep it deficit neutral.

The White House had little to say about the plan, except that it would provide momentum to the president’s goal of achieving health care overhaul in the near future.

“Last week, the president laid out his plan to bring stability and security to Americans who have insurance, and high-quality, high-quality, affordable coverage for those who don’t have insurance,” White House spokesman Reid Cherlin said. “The Senate Finance Committee [proposal] released by chairman Baucus is another boost of momentum for the president’s effort to reform the health system.”

Baucus’ Health Care Plan
Under Baucus’ plan, all Americans would be required to purchase health care or pay a fine if they don’t. It also includes provisions barring insurance companies from prohibiting care based on pre-existing conditions, and prevents practices such as charging more to people with more serious health problems. But, at the same time, the language in the bill suggests that those rules could be relaxed based on tobacco use, age and family composition. It would also place caps on yearly health care costs.

Baucus’ proposal includes a provision to create an insurance exchange system on the Internet, an idea President Obama also proposed last week during his joint address to Congress.

The “state-based Web portals, or ‘exchanges,’… would direct consumers purchasing plans on the individual market to every health coverage option available in their Zip codes,” according to the plan. “The exchanges would offer standardized health insurance enrollment applications, a standard format companies would use to present their insurance plans, and standardized marketing materials.”

Much to the chagrin of some Democratic lawmakers and liberal groups, the proposal does not include any language for a government-run insurance plan that would compete with the private sector. But it opens the way for health care cooperatives — member-owned, non-profit companies providing health insurance. All other bills produced in Congress so far — three in the House and one in the Senate — include a public option.

The proposal also outlines measures to improve and expand Medicaid. Baucus’ plan would make all parents, children, pregnant women and childless adults at or below 133 percent of the federal poverty level eligible for Medicaid. The plan would be paid for with $507 billion in cuts to government health programs and $349 billion in new taxes and fees.

“The Finance Committee has carefully worked through the details of health care reform to ensure this package works for patients, for health care providers and for our economy,” Baucus said in a statement. “We worked to build a balanced, common-sense package that ensures quality, affordable coverage and doesn’t add a dime to the deficit. Now, we can finally pass legislation that will rein in health care costs and deliver quality, affordable care to the American people.”

Under Baucus’ plan, illegal immigrants would not get insurance, a point that became increasingly contentious after South Carolina’s GOP Rep. Joe Wilson’s outburst during Obama’s speech last week.

Senate Majority Leader Harry Reid, D-Nev., said the Democrats are going to hold a special caucus Thursday to discuss the package put forward by the Finance Committee. Baucus’ bill will be voted on next week in the Finance committee before it goes on to the Senate floor.

Since returning from recess last week, the “gang of six” senators of the Finance committee have been working for hours behind closed doors to reach a bipartisan solution. Baucus had set today as his deadline for the bill, despite outcry from both his party members and the GOP. Some Democrats said they would not vote for the bill in its current form because it lacks a “public option,” a government-run insurance program that would compete with private insurance companies. Republicans say the plan is too costly.

Despite the differences, the bill that would pass the Senate Finance Committee has the best chance at bipartisanship. Bills proposed by three House committees and the Senate Committee on Health, Education and Labor led to backlash by conservatives and a rowdy recess for many Democratic lawmakers.

Democrats, Republicans Unhappy With Health Care Proposals
As some Democrats start the difficult task of rallying support in their own party for Baucus’ health care plan, Republicans are lining up against it. Even those who were involved in the negotiations with Baucus, including Sen. Olympia Snowe, R-Maine, and Sen. Charles Grassley, R-Iowa, say additional talks are needed before they can get on board.

“I believe the chairman’s legislation moves in the right direction away from a government-run system contained in bills that have passed other Congressional committees, but a number of issues still need to be addressed — including cost assumptions and ultimate affordability to both consumers and the government as well as ensuring appropriate competition in the health insurance exchange,” Snowe said in a statement.

Other GOP leaders are complaining that the plan would lead to a government takeover of health care in the United States but, at the same time, they are also raising alarm bells that the plan would cut benefits for seniors, who already receive government-run health care in the form of Medicare.

Senate Minority Leader Mitch McConnell, R-Ky., gave Baucus’ plan a thumbs down, saying that it will cut Medicare and set up government-run health care for others.

“This partisan proposal cuts Medicare by nearly a half-trillion dollars, and puts massive new tax burdens on families and small businesses, to create yet another thousand-page, trillion-dollar government program,” McConnell said in a paper statement. “Only in Washington would anyone think that makes sense, especially in this economy.”

McConnell added that it’s just another “trillion-dollar” bill, although the Baucus bill is only $856 billion in its current form. As for Medicare cuts, the bill assumes those savings will be realized with greater efficiency.

Republicans are making a talking point of all the “thousand-page” bills Democrats want to pass, including the other health care bills and the stimulus package. The Baucus bill, as written, is only 223 pages long, but it will get longer when it’s translated into legal language.

But Republican opposition is not the only issue that supporters of Baucus’ plan will have to face. Even before the release of the proposal, Democrats expressed their disapproval with the lack of a public option in Baucus’ proposal.

“There is no way, in its present form, that I vote for it unless it changes in the amendment process by vast amounts,” Sen. Jay Rockefeller, D-W.V., said in a conference call with reporters Tuesday.

Others expressed concern about the proposed taxes on higher-end insurance plans, expected to rake in about $349 billion in new taxes and fees.

“They tax the sort of wealthiest benefit packages, and you’ve got some health insurance, you know — quite a bit of health insurance policies in America that during the next couple of years will top the $16,000 and $21,000 mark that exists in their bill that triggers taxation,” said Rep. Debbie Wasserman Schultz, D-Fla., on ABC News’ “Top Line.”

Democratic Oregon Sen. Ron Wyden said the plan would cost lower-income Americans too much and give many people too little choice of insurance plans.

“If the Baucus proposal passes,” Wyden said in an interview with the Washington Post. “They’re going to say, ‘Huh? Health-care security means I pay a whole lot more than I’m paying today or I get to be exempt from it, or I pay a penalty?’ They’re not going to say that meets the definition of health-care security.’”

ABC News’ Teddy Davis contributed to this report

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By SHERYL GAY STOLBERG – The New York Times

WASHINGTON — The conventional wisdom, here and around the country, is that the centerpiece of President Obama’s domestic agenda — remaking the health care system to cut costs and cover the uninsured — is on life support and that only a political miracle could revive it.

Here’s why the conventional wisdom might be wrong:

While the month of August clearly knocked the White House back on its heels, as Congressional town hall-style meetings exposed Americans’ unease with an overhaul, the uproar does not seem to have greatly altered public opinion or substantially weakened Democrats’ resolve.

Critical players in the health care industry remain at the negotiating table, meaning they are not out whipping up public or legislative opposition.

Despite tensions between moderate and liberal Democrats, there is broad agreement within the party over most of what a package would look like. Four of the five Congressional committees considering health care legislation have already passed bills. Each would require all Americans to have insurance and provide government subsidies for those who cannot afford it. Each would bar insurance companies from refusing coverage for pre-existing conditions; imposing lifetime caps on coverage; or dropping people when they get sick.

Getting a bill through the Senate remains a big challenge, but even there, the Obama administration has a reasonable chance of corralling the 60 votes it would need to pass legislation more or less on its terms. One wavering Democratic moderate, Senator Ben Nelson of Nebraska, signaled over the weekend that he might be able to go along with one of the compromise proposals under discussion. Senator Olympia J. Snowe, the Maine Republican whose vote would be vital to Mr. Obama, remains deeply engaged in negotiations, and there are indications that one or two other Republicans, like Senator George V. Voinovich of Ohio, might be in play.

Politically, there is an imperative for Democrats to act; they remember well the disastrous political fate that befell them in 1994, when they lost control of the House and Senate after failing to pass a health bill under President Bill Clinton. Rahm Emanuel, the bare-knuckled political operative and former Clinton aide who is now the White House chief of staff, has wasted little time in reminding his fellow Democrats that, as he said in an interview Tuesday, “the inability to act here will have political consequences.”

None of this is to understate the magnitude of the task facing Mr. Obama as he begins a final drive for the legislation with a nationally televised address to Congress on Wednesday night. The size and complexity of the legislation, the deep partisan divide, the undercurrent of concern among voters about whether government is getting too big and intrusive, opposition from special interests — all create land mines that could still blow up the effort.

But even after weeks filled with seemingly ominous portents for Mr. Obama’s ambitions, there is evidence that public opinion remains basically supportive of him. Despite intense controversy over the “public option,” a government-backed insurance plan that would compete with the private sector, a CBS poll at the end of August found that 60 percent of Americans still support the idea, down from 66 percent in July. And half the respondents to the poll said Mr. Obama had better ideas on health care than Republicans, down from 55 percent.

Mr. Obama likes to say that in the 100 years since President Theodore Roosevelt began advocating universal health care, “we’ve never had such broad agreement on what needs to be done.” On Capitol Hill, it is possible to see how a compromise could come together; Mr. Nelson indicated over the weekend that he could back a provision known as a “trigger” to create a public option if private efforts to cover the uninsured failed.

And despite the fracas of August, the major stakeholders in the health care debate — hospitals, doctors, insurers and the pharmaceutical industry — have not abandoned the negotiations. Ralph G. Neas, chief executive of the National Coalition on Health Care and a veteran of Washington legislative fights, said this was especially significant.

“They’re saying to themselves: ‘We’re going to get 30 to 40 or 50 million new customers. This is in our economic self interest,’ ” Mr. Neas said. “That, as much as anything else, could propel this forward to a law that does provide quality health care for all.”

Mr. Obama still clearly has not closed the deal, which is a major reason he will be making his case directly to the American people and their elected representatives on Wednesday night. The CBS poll found that 6 in 10 Americans say Mr. Obama has not clearly explained what his plans for health reform would mean.

That is a problem for the White House, though it also presents the president with an opportunity to reframe the debate on his own terms. In his address on Wednesday, Mr. Obama has promised to outline what he wants to see in a bill; Republican leaders say the message from August is that Democrats and the president need to start over.

“At this point, there really should be no doubt where the American people stand: the status quo is not acceptable, but neither are any of the proposals we’ve seen from the White House or Democrats in Congress,” Senator Mitch McConnell of Kentucky, the Republican leader, said in a statement, adding: “It should be clear by now that the problem isn’t the sales pitch. The problem is what they’re selling.”

Yet Mark McClellan, who ran the Food and Drug Administration and later Medicare under President George W. Bush, said he saw the churning in August as a part of the public’s education, a “necessary step in the process” and not a fatal blow.

Whether or not Mr. Obama gets the kind of comprehensive bill he is hoping for, Dr. McClellan said, Congress is all but certain to take up health legislation by early next year to fix a measure that would impose a draconian 21 percent cut in Medicare reimbursements to doctors. And once it is tinkering with health care, he said, it is not that big a leap to imagine lawmakers using that bill to take smaller steps toward expanding coverage and passing insurance market reforms.

“Everybody is talking about how the public is very concerned about some of the specifics that they’ve heard,” Dr. McClellan said. “But the public is also very concerned about some aspects of the health care system, including the cost, including the security of their coverage. So depending on how this plays politically, I think there is the foundation for building support for broader legislation.”

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