Consumer Directed Healthcare

By LAURAN NEERGAARD, AP Medical Writer

WASHINGTON – Better beat the crowd and find a doctor.

Primary care physicians already are in short supply in parts of the country, and the landmark health overhaul that will bring them millions more newly insured patients in the next few years promises extra strain.

The new law goes beyond offering coverage to the uninsured, with steps to improve the quality of care for the average person and help keep us well instead of today’s seek-care-after-you’re-sick culture. To benefit, you’ll need a regular health provider.

Yet recently published reports predict a shortfall of roughly 40,000 primary care doctors over the next decade, a field losing out to the better pay, better hours and higher profile of many other specialties. Provisions in the new law aim to start reversing that tide, from bonus payments for certain physicians to expanded community health centers that will pick up some of the slack.

A growing movement to change how primary care is practiced may do more to help with the influx. Instead of the traditional 10-minutes-with-the-doc-style office, a “medical home” would enhance access with a doctor-led team of nurses, physician assistants and disease educators working together; these teams could see more people while giving extra attention to those who need it most.

“A lot of things can be done in the team fashion where you don’t need the patient to see the physician every three months,” says Dr. Sam Jones of Fairfax Family Practice Centers, a large Virginia group of 10 primary care offices outside the nation’s capital that is morphing into this medical home model.

“We think it’s the right thing to do. We were going to do this regardless of what happens with health care reform,” adds Jones. His office, in affiliation with Virginia Commonwealth University, also provides hands-on residency training to beginning doctors in this kind of care.

Only 30 percent of U.S. doctors practice primary care. The government says 65 million people live in areas designated as having a shortage of primary care physicians, places already in need of more than 16,600 additional providers to fill the gaps. Among other steps, the new law provides a 10 percent bonus from Medicare for primary care doctors serving in those areas.

Massachusetts offers a snapshot of how giving more people insurance naturally drives demand. The Massachusetts Medical Society last fall reported just over half of internists and 40 percent of family and general practitioners weren’t accepting new patients, an increase in recent years as the state implemented nearly universal coverage.

Nationally, the big surge for primary care won’t start until 2014, when the bulk of the 32 million uninsured starts coming online.

Sooner will come some catch-up demand, as group health plans and Medicare end co-payments for important preventive care measures such as colon cancer screenings or cholesterol checks. Even the insured increasingly put off such steps as the economy worsened, meaning doctors may see a blip in diagnoses as those people return, says Dr. Lori Heim, president of the American Academy of Family Physicians.

That’s one of the first steps in the new law’s emphasis on wellness care over sickness care, with policies that encourage trying programs like the “patient-centered medical home” that Jones’ practice is putting in place in suburban Virginia.

It’s not easy to switch from the reactive — “George, it’s your first visit to check your diabetes in two years!” — to the proactive approach of getting George in on time.

First Jones’ practice adopted an electronic medical record, to keep patients’ information up to date and help them coordinate necessary specialist visits while decreasing redundancies.

Then came a patient registry so the team can start tracking who needs what testing or follow-up and make sure patients get it on time.

Rolling out next is a custom Web-based service named My Preventive Care that lets the practice’s patients link to their electronic medical record, answer some lifestyle and risk questions, and receive an individually tailored list of wellness steps to consider.

Say Don’s cholesterol test, scheduled after his yearly checkup, came back borderline high. That new lab result will show up, with discussion of diet, exercise and medication options to lower it in light of his other risk factors. He might try some on his own, or call up the doctor — who also gets an electronic copy — for a more in-depth discussion.

“It prevents things from falling through the cracks,” says Dr. Alex Krist, a Fairfax Family Practice physician and VCU associate professor who designed and tested the computer program with a $1.2 million federal grant. In a small study of test-users, preventive services such as cancer screenings and cholesterol checks increased between 3 percent and 12 percent.

Pilot tests of medical homes, through the American Academy of Family Physicians and Medicare, are under way around the country. Initial results suggest they can improve quality, but it’s not clear if they save money.

Primary care can’t do it alone. Broader changes are needed to decrease the financial incentives that spur too much specialist-driven care, says Dr. David Goodman of the Dartmouth Institute for Health Policy and Clinical Practice.

“What we need is not just a medical home, but a medical neighborhood.”

 

Popularity: 1% [?]

Having staked the success of his presidency on the longstanding Democratic dream of universal health care, President Obama finally achieved victory on Sunday night, bringing an end to a yearlong partisan struggle. “This legislation will not fix everything that ails our health care system, but it moves us decisively in the right direction,” Obama said shortly after the historic vote. “This is what change looks like.” With Democrats chanting the signature line of the Obama presidential campaign – “Yes we can!” – the House voted 219-212 to send a sweeping overhaul of the nation’s health care system to be signed into law. “We tonight will make history for our country and progress for the American people,” Speaker Nancy Pelosi declared shortly before the vote. “Today we have the opportunity to complete the great unfinished business of our country.”

The Democrats passed the bill without a single Republican vote – and with the knowledge that it may well have ended the political careers of some who voted for it at a time when the public remains deeply divided over the entire endeavor. “If we pass this bill, there will be no turning back,” warned minority leader John Boehner. “It will be the last straw for the American people.”

Suspense about the outcome continued until the final hours of the debate. Passage appeared to be assured only after Michigan Congressman Bart Stupak announced in the late afternoon that he and a group of antiabortion Democrats, who had pushed for more restrictive language in the original House bill, had been satisfied that the Senate version would not allow the use of federal funds to pay for the procedure. That only came after President Obama promised to sign an executive order reaffirming that the bill would maintain a “consistency with longstanding restrictions on the use of federal funds for abortion.” In reality, that executive order was more a symbolic move than an actual concession; the bill’s supporters have insisted all along that it does nothing to change the current federal policy, known as the Hyde Amendment, which has been in effect since 1976.

The second bill passed by the House late Sunday will make adjustments to the legislation, such as lowering the impact of an excise tax on high-value insurance plans and stripping out some sweetheart deals like the now infamous cornhusker kickback, using a process known as budget reconciliation. Such changes would be filibuster-proof in the Senate, though that process could still drag on a while if Republicans choose to draw it out with objections and amendments. Even so, it will be an anticlimax to Sunday’s historic House vote, which will send the underlying Senate bill to President Obama’s desk for signature.

As the House debated throughout the day, hundreds of protesters from the Tea Party movement rallied on the Capitol lawn, chanting, “Kill the bill.” It was a dead-serious message, but on a glorious spring day, when cherry blossoms were just beginning to appear on the trees, the atmosphere felt more like a carnival – especially compared to the day before, when some protesters had hurled racial epithets at a few African-American members of the House. The crowd was stoked by regular appearances that lawmakers made on a balcony overlooking the protesters. “It’s interesting how many faces they recognize,” said Republican Congressman Steve King of Iowa. Republicans flashed handwritten signs with the word No on them, sending the crowd into rapture.

Democrats also got into the act. Sheila Jackson-Lee, a liberal Democrat from Texas, said she went down among the protesters saying, “God bless America. We’re glad you’re here.” She also flashed two fingers in a mischievous V for victory. The response? “Someone flipped a third finger,” she said.

On the other end of Pennsylvania Avenue, the President and his team were waiting and working the phones to make sure the final votes were nailed down. There was also the distraction of March Madness to pass the hours. One aide said of Obama: “He’s in the West Wing, getting updates, dropping in on staff, and like the rest of America, examining the rubble of his bracket.” At one point during the afternoon, the Commander in Chief ordered his health care czar, Nancy-Ann DeParle, to take a break and go out for a run.

With passage of the legislation, Obama has achieved the signature domestic goal of his presidency, and the most sweeping piece of social legislation since the 1960s Great Society initiatives that saw the passage of Medicare and Medicaid. Universal coverage is a goal that has eluded Presidents going at least as far back as Teddy Roosevelt, and Obama’s bill comes as close to that target as anyone has. The bill would provide health coverage to an estimated 32 million additional Americans, meaning 95% of those who are legally in this country would have health insurance, up from 83% today.

The bill also promises to rein in health costs by reorienting the practice of medicine, making it more efficient, with health care providers rewarded on how well they treat their patients, rather than how much care they give them. Whether it actually achieves that latter ambition, however, is far more uncertain.

In the early years, most Americans will see only minor changes in the health care system. It will almost immediately end some insurance-company practices, such as denying coverage to children with pre-existing conditions. And dependent children under the age of 26 would be allowed to remain on their parents’ policies if they cannot get health insurance elsewhere. Adults with pre-existing conditions would also be able to buy coverage through expanded high-risk pools.

Beginning in 2014, more far-reaching measures will begin to take effect. States would be required to set up new “exchanges,” or insurance marketplaces, that would offer a variety of health care plans for small businesses and individuals who do not get coverage from their employers. Government subsidies would be available to those earning up to 400% of poverty. Employers with 50 or more workers who do not offer coverage would be fined, and for the first time, most people would be required to obtain health coverage – either at work, or by purchasing it on their own – or pay a penalty.

All of this would be paid for in two ways: By reducing spending on Medicare by hundreds of billions, and by imposing a set of new taxes, including a 40% levy on certain high-priced insurance policies.

But while the bill is headed toward becoming law, the fighting over it isn’t going away anytime soon. Republicans have already issued notice that they plan to campaign in this fall’s midterm elections on a pledge to repeal it. There will be constitutional challenges. And in dozens of states, legislatures are considering measures that would attempt to exempt their citizens from some of its provisions, including the requirement that individuals purchase insurance.

 

By KAREN TUMULTY / WASHINGTON Karen Tumulty / Washington

Popularity: 1% [?]

Sources Say ‘Dramatic’ Developments in Late Negotiations but Vote Count Unclear
By JAKE TAPPER
WASHINGTON, March 12, 2010—

Speaking volumes about how Democrats lack the votes to pass health care overhaul legislation, President Obama has decided to delay next week’s trip to Indonesia and Australia.

The president was due to leave Thursday, which is the deadline that the White House gave Congress to finish negotiations and pass a bill.

But the White House has confirmed that Obama will leave three days later on Sunday, March 21, and without his wife and daughters as originally planned.

White House officials and congressional Democratic sources expressed confidence that the compromise House-Senate legislation will ultimately pass, but as of now, House Speaker Nancy Pelosi, D-Calif., does not have the votes.

“We’ll take whatever time is required forus to pass the legislation,” Pelosi told reporters today.

She needs 216 votes — a majority of the House’s 431 members — to pass the Senate bill and changes to it. Anti-abortion Democrats, led by Rep. Bart Stupak, D- Mich., have said they will not support the Senate bill because it has less restrictive language on abortion than the House bill.

Democratic congressional leaders had asked the president to delay his trip until after the health care overhaul vote so he could make a personal appeal to House Democrats to vote for legislation that has consumed so much of his presidency.

“I’m delighted the President will be here for the passage of the bill. It’s going to be historic,” Pelosi said.

Meanwhile, Senate Majority Leader Harry Reid, a key figure in the ongoing negotiations, is facing a personal health care crisis of his own.

Reid’s wife and daughter are recovering from a car accident Thursday that left the women hospitalized in serious condition.

Democrats Await CBO Score to Move Ahead
DemocSen. Reid’s wife, Landra, 69, suffered a broken nose, back and neck. Daughter Lana Reid Barringer, 48, has a neck injury and facial lacerations. Both are “conscious, can feel their extremities, and according to doctors, their injuries are nonlife threatening,” a Reid spokesman said.

The incident put Democrats’ intense legislative negotiations temporarily on hold Thursday as Reid rushed to the hospital to be by their sides. But Reid soon after returned to the Capitol; one sign that negotiations among House and Senate Democrats have become make-or-break.

“If Nancy Pelosi had the votes, they’d have already voted on this,” conservative commentator Laura Ingraham said on “Good Morning America” today. “Obviously, the president, he’s put it all on the line here. It’s not going to be good for Democrats, no matter what they do.”

But Democrats insisted they have the will and the votes to pass a bill soon.

“We’re in the home stretch,” Democratic strategist Donna Brazille told ABC News’ George Stephanopoulos. “There’s no question the Democrats will round up the votes.”

The White House had set a deadline for the House to pass the Senate bill by March 18, when the president was originally scheduled to leave for an overseas trip to Indonesia and Australia.

The White House has since backed off its deadline.

“Our hope is to get this done as soon as possible,” White House press secretary Robert Gibbs said Thursday. “If it … takes a couple extra days after a year, it takes a couple of extra days.”

One reason for the delay is the eagerly anticipated Congressional Budget Office score on how much the health care bill now before the House will cost. Its release is expected any day.

The Congressional Budget Office issued an updated cost estimate of the health care bill that passed the Senate Dec. 24, but that estimate didn’t include the changes being negotiated with the White House. The updated estimate was up slightly, from $871 billion to $875 billion over 10 years. And the total deficit reduction went from $132 billion to $118 billion.

‘Full Speed Ahead’ for Reid Despite Personal Matter
After congressional Democrats broke from their meeting Thursday night, White House chief of staff Rahm Emanuel told reporters, “It was a very good meeting. A lot of decisions were made. We’re getting towards the end.”

Sources described “dramatic” developments in the closed-door meetings in the past 24 hours.

As for whether Reid’s personal situation will affect the process ahead, many people close to the senator say that’s unlikely.

“This won’t slow him down, although he may have to spend quite a bit of time with his wife here in the next few days,” Sen. Mark Pryor, D-Ark., said “It’s going to be a full speed ahead for him for sure.”

The House budget committee may begin writing the “fixes” to the Senate bill Monday.

ABC News’ Devin Dwyer contributed to this report.

Popularity: 1% [?]

By Tom De Luca
Wed Mar 3, 1:14 pm ET
 
New York – The debate over healthcare reform should have been about doctors, patients, insurance and drug companies, and coverage. Instead, much of the attention has been focused on a preexisting condition.

A filibuster allows a senator to delay or defeat legislation through endless talk – or merely the threat of it. That gives the minority breathtaking power to cause gridlock and discredit the majority by stopping it from pursuing the program it was elected on. That is exactly what 41 Senate Republicans are doing to 59 Democrats right now.

The filibuster has become so potent a political weapon that President Obama is reportedly approving the use of the controversial “reconciliation” process to pass healthcare reform. Under this method, Democrats could turn the reform bill into law with a simple majority of senators instead of the 60 now needed to end a filibuster. Critics are calling reconciliation an “abuse of power,” “undemocratic,” and “the nuclear option.” The real undemocratic abuse of power, however, is the present way in which the filibuster is used.

While the use of a simple majority through reconciliation to pass legislation would restore constitutional sanity to the Senate, it does not go far enough. The Senate should rewrite the filibuster rule entirely. Full and thorough debate should be preserved, but the unconstitutional practice of requiring supermajorities to pass important legislation must be ended. 

Many of us first learned about the filibuster in “Mr. Smith Goes to Washington.”

In that classic film, the filibuster is our quintessential American hero Sen. Jefferson Smith’s last hope of stopping corruption and symbolically saving the American republic.

In the real world of American politics today, however, the filibuster has become the weapon of choice to thwart a democratically elected majority on important legislation. Once rare, it’s now used routinely. Filibusters used to be hard work. Senators had to actually stand and talk in the Senate 24/7 until they literally dropped. Now they merely need to threaten a filibuster to stop legislation from ever coming to a vote.

This usurpation is more than an unheroic partisan power grab. It is an unconstitutional change in which the entire Senate – and both parties – are complicitous.

The Framers were explicit about those rare cases, such as constitutional amendments, in which supermajorities are required. They fashioned a document that assumed the majority rule principle for legislation, and based important arguments for the constitution’s ratification on that assumption.

In “The Federalist No. 10,” James Madison defended the newly proposed constitution on the grounds that it created the kind of republic that could prevent factions from undermining liberty. He was most worried by the abusive potential of a majority faction and prescribed, not supermajority rule, but a large and strong republic supplemented by federalism and separation of powers.

Minority factions could be more easily handled, he believed, by simply applying the “republican principle” of majority rule, enabling “the majority to defeat [the minority’s] sinister views by regular vote.”

The filibuster also upends the Great Compromise of 1787 that gave us a bicameral legislature. Small-population states wanted congressional representation based on state equality, while large-population states wanted to base it on the number of inhabitants in a state (or the amount of taxes it contributed).

The deal was to have both: a Senate and a House of Representatives. In granting an extraconstitutional veto to a minority faction of senators, the filibuster increases their (and their states’) power relative to that of other senators (and states). It also upsets the balance of power with the House and its members. The filibuster undermines the state equality and proportionality principles at the same time.Â

Debates over when “extraordinary majorities” would be required were part of the horse-trading that led to final agreement on the constitution. Southern states, for example, depended on agricultural exports and some wanted a legislative supermajority to be required for passage of laws that affected navigation, something the New England shipping states opposed. They traded this demand away for a 20-year guarantee of continuance of the slave trade and a ban on export taxes. Because sectional and state interests played an important role in these deals and compromises, it is inconceivable that the back door would have been left open for supermajorities to sneak in.

Article I, Section 5 offers filibuster-defenders one slim reed to grasp: that “Each House may determine the rules of its proceedings.” However, it also says that each senator shall have “one vote” and that “a majority of each [House] shall constitute a quorum to do business.” The filibuster both deviates from the equality of power idea intrinsic to the “one vote” principle, and changes the meaning of the words “to do business” – unless they were intended by the Founders to mean “do nothing but talk.”

The filibuster “rule” is in reality not a rule at all. It is a structural change to the meaning of the Constitution itself, something even a unanimous Senate is not empowered to do. Its defenders should ask themselves this question: If the filibuster “rule” were written into the constitution’s draft, would the constitution have been ratified? Without a new round of debates and compromises, the answer is no.

As the president of the Senate, Vice President Joe Biden should rule unconstitutional any use of the filibuster to block major legislation. As a political matter, such a move would be highly controversial, but as a constitutional matter, it merely restores the Framers’ intent regarding using majority votes to move legislation in each house of congress – something conservatives should support. After all, the status quo distorts the Constitution. And it robs the vice president of the only real power he has: to cast the tiebreaking vote when the Senate is “equally divided,” an impossibility if the meaningful vote is the one that requires 60 senators to end debate.

If Mr. Biden takes this step and gets attacked, it would be a perfect time to treat his Senate colleagues to a filibuster of his own, by reading to them, in its entirety, “The Federalist No. 51,” which explains how to avoid excessive concentration of power: “Ambition must be made to counteract ambition,” Madison wrote. “The interest of the man must be connected with the constitutional rights of the place.” In protecting his own power from Senate usurpation, Biden would also be fulfilling Madison’s constitutional plan. Mr. Smith would be very proud. But not as proud as Madison.

Tom De Luca, a professor of political science at Fordham University, is coauthor of “Liars! Cheaters! Evildoers! Demonization and the End of Civil Debate in American Politics.”

Popularity: 1% [?]