Many advocates for HIV/AIDS view the health care bill as “a critically important advance” for people living with HIV, according to Chris Collins, director of the Foundation for AIDS Research. But they say many more resources need to be committed to fight the disease, especially considering it doesn’t get the attention it once did. “HIV/AIDS as an epidemic has fallen off the radar screen,” said Andy Izquierdo of the National Minority AIDS Council. “A lot of people don’t see it as an issue anymore, even though it’s hitting some communities of color worse than ever.”

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Today’s scheduledÌýannouncement by the Department of Health and Human Services comes as that provide AIDS drugs to patients with HIV grapple with growing waiting lists for the drugs. More than 2,000 patients are on the waiting lists. HHS Secretary Kathleen Sebelius announced July 8 that she will provide $25 million to states to help pay for the drug treatments, which average more than $12,000 a year. Even so, some advocacy groups said the aid “falls short” of the need.

The administration’s announcement also corresponds with the , the biennial gathering of thousands of HIV/AIDS researchers, activists and government officials, which begins July 18 in Vienna. U.S. action related to HIV is closely scrutinized at the conference.

Although most administrations over the past 30 years have set priorities in the battle against AIDS – including creating policy czars to help spotlight the efforts – advocates said this will be theÌýa different type ofÌýoverall national strategy against the disease. The U.S. has required other nations to implement such strategies in order to receive U.S. funding for HIV/AIDS programs.

AIDS programs now exist as a fractured web of resources ranging from community-based clinics thatÌýoffer free condoms to subsidized health services to federal agencies that provide massive funding programs for treatment and prevention. Advocates hope the new strategy will streamline the effort and simplify the process for patients to get such resources as education about the disease, testing, treatment and case-management. Julie Scofield, executive director of the National Alliance of State andÌýTerritorial AIDS Directors, noted that a variety of federal and state programs seek to help patients, “but not with coordination from the top that can advance our response.”

Collins cautioned, however, “There’s no quick fix for challenges in the domestic response. We’re not going to achieve the improved outcomes we need overnight. This is a long-term investment.”

Those challenges include prevention and testing, managing co-occurring infections in people with HIV, and theÌýhigher rates of poverty and homelessness among HIV patients. The Centers for Disease Control and Prevention that 1.1 million Americans were living with HIV/AIDS in 2006. The federal government is slated to spend $19.4 billion in 2010 on domestic programs and research, according to compiled by the Kaiser Family Foundation. (KHN is a project of the foundation.)

Obama, in a statement last month, said the strategy would focus on “reducing new HIV infections, increasing access to care and reducing HIV-related health disparities.” Administration officials have held roughly a dozen public meetings with HIV/AIDS patients, activists, advocates and researchers around the country as they’ve formulated the plan.

Meanwhile,Ìýadvocates also sayÌýthey hope the strategy will lead toÌýadditional funding for programs, though they alsoÌýacknowledged the current fiscal concerns in Washington. “I don’t know for sure if there will be funding, but I think we will all be disappointed about how much it is. I just believe we’re in such a difficult budget environment,” Scofield said.

Nonetheless, Izquierdo stressed, “If it’s a strategy without talk of resources or funds that are going to be allocated, then it really fails to be a strategy and just becomes a plan.”

Collins said his organization will be looking for measurable results: “What we need is a domestic response to AIDS that fits our epidemic and that’s what we don’t have right now.” Collins added, “The point of the strategy is about outcomes. We have to broaden the way we tackle HIV incidence in this country.”

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Obama administration officials and wonks call them “early deliverables.” They’re the benefits of the health legislation that would kick in this election year.

The provisions, which could just as easily be called the “Democratic Incumbents’ Protection Plan,” suddenly are everywhere-touted on liberal blogs, on the Rachel Maddow Show, in talking points by Health and Human Services Secretary Kathleen Sebelius.Ìý

They’re designed to counter Republican denunciations that the legislation is a government takeover of the health care system that will drain the federal Treasury.

But the question for Democrats is whether promoting the early changes will be more persuasive with voters than the Republican arguments. The answer may determine whether the Democrats retain their majority in the House.

James Capretta, a top budget official in the George W. Bush administration, thinks the Democrats will be badly hurt by the vote. He says he assumes the people who would benefit by the changes before November are in the “single-digit millions,” not enough to have a big impact. “There aren’t enough people in those categories to say, ‘Yes, the increased taxes are worth it.'”

But Chris Jennings, a consultant who was the Clinton administration’s senior health policy adviser, says the legislation includes “many important, immediately available policies that people will care about.” He adds: “If we can’t market them well, then we will have deserved to fail.”

Changes that would occur this year include:

• Dependent children could remain on their parents’ health insurance plans until age 26.Ìý
• Some senior citizens would get more help paying for drugs in Medicare.Ìý
• People with health problems that left them uninsurable could qualify for coverage through a federal program.

These are among the more than a dozen features of the new health care overhaul law that would take effect in 2010 under the measure passed Sunday. (Although the Senate bill approved Sunday by the House would become law with President Barack Obama’s signature, Senate action is needed to passÌýa separate measure theÌýHouse approvedÌýthat would amend that law.) Other first-year items include a ban on lifetime limits on medical coverage, more oversight of premium increases and tax credits for some small businesses.

The big changes in the law – the ones that could affect tens of millions of people – don’t kick in until at least 2014. Those include insurance marketplaces called “exchanges”; rules requiring insurers to accept all applicants, even those with health problems, and an expansion of state Medicaid programs.

Capretta says that the legislation has big downsides for Democrats, includingÌýsharp cuts to Medicare Advantage, a private plan options for Medicare beneficiaries.ÌýThe benefits in Medicare Advantage plansÌýlikely will be pared because the bill includes payment reductions intended to make the program similar to traditional Medicare. Medicare Advantage, Capretta says, “is going to get hammered, and it’s hard to see how they avoid taking the blame.”

“The public is unhappy,” says Stuart Rothenberg, editor of the The Rothenberg Political Report, a nonpartisan newsletter. “The idea that suddenly after the bill passes that Democratic leaders could start talking about it and people would be happy strikes me as Pollyannaish at best.”

Americans have been sharply divided over the legislation – Democrats hope attitudes toward it will swing in their favor as people focus on the details. While some of the more popular elements of the legislation go into effect quickly, some less popular items – such as the requirement that nearly all Americans carry insurance or face a fine – won’t occur until well after the election.

Meanwhile, Republicans are keeping up a steady drumbeat of their concerns, saying the legislation will harm more Americans than it helps by raising government spending in a time of record deficits. Many in the GOP want to build support for repealing the law.

Public opinion of Congress – aimed at both parties — and the legislative process is low. The deal-making to garner votes during the year-long health care debate, such as special payments to specific states, coupled with last-minute maneuvering after Democrats lost their filibuster-proof majority in the Senate, soured voters.

Some of the items that go into effect in the first year include:

New help for some uninsured: People with a medical condition that has left them uninsurable may be able to enroll in a new federally subsidized insurance program that is to be established within 90 days. The legislation appropriates $5 billion for this, although that may not be enough to cover all who apply; it’s not clear how much consumers would pay as their share of the cost. About 200,000 people are covered in similar state programs currently, at an estimated cost of $1 billion a year, says Karen Pollitz, a research professor at Georgetown University.Ìý

Discounts and free care in Medicare: The approximately 4 million Medicare beneficiaries who hit the so-called “doughnut hole” in the program’s drug plan will get a $250 rebate this year. Next year, their cost of drugs in the coverage gap will go down by 50 percent. Preventive care, such as some types of cancer screening, will be free of co-payments or deductibles startingÌýthis year.Ìý

Coverage of kids: Parents will be allowed to keep their children on their health insurance plan until age 26, unless the child is eligible for coverage through a job. Insurance plans cannot exclude pre-existing medical conditions from coverage for children under age 19, although insurers could still reject those children outright for coverage in the individual market until 2014.

Tax credits for businesses: Businesses with fewer than 25 employees and average wages of less than $50,000 could qualify for a tax credit of up to 35 percent of the cost of their premiums.Ìý

Changes to insurance: All existing insurance plans will be barred from imposing lifetime caps on coverage. Restrictions will also be placed on annual limits on coverage. Insurers can no longer cancel insurance retroactively for things other than outright fraud.Ìý

Government oversight: Insurers must report how much they spend on medical care versus administrative costs, a step that later will be followed by tighter government review of premium increases.

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McAllen, a Texas border town, was thrust into the national spotlightÌýafter a New Yorker by surgeon Atul Gawande showed in June that it had the highest Medicare spending per beneficiary next to fraud-plagued Miami, based on data compiled by Dartmouth researchers.

But a highly anticipated Ìýnow out from an independent agency that oversees Medicare measured the program’s spending differently, and it knocks McAllen to number 14 out of 403 locales, behind three other Texas cities and parts of Louisiana and Oklahoma.

How come? The new analysis, from the Medicare Payment Advisory Commission, or MedPAC, factors in higher costs of living and different payment rates for rural or urban areas.

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Research on health spending at Dartmouth – the Ìý– has been highly influential for its conclusion that some areas of the country spend much more than others to treat Medicare patients –indicating that there may be large quantities of unnecessary procedures or waste.

Both MedPAC and Dartmouth took into account how sick patients were. The MedPAC analysis finds less variation but echoes the conclusion that significant differences exist.

The Miami-Dade area is starklyÌýdifferentÌýthan any other in many ways. For example,Ìý2006 spending on durable medical equipment (such as wheelchairs or oxygen tanks) averaged $2,200 per Medicare beneficiary in the Miami area, while the national average was $250. Neighboring Broward county averaged $430 per beneficiary.

Three states appear at the top of both lists — Louisiana, Texas and Florida. But elsewhere, the reports differ. For instance, Dartmouth ranks Los Angeles and New York City as among the highest-spending areas. But MedPAC rated L.A. at 56, using just 7 percent more services than the national average, and NYC clocks in at 174th place, almost halfway through the pack and spending 2 percent less than the average.

Among states, Dartmouth ranked New York and Massachusetts as high spenders, while MedPAC listed a solid block of the South, including Alabama and Oklahoma at the top.

Head researcher Elliott Fisher told Ìýthat the Dartmouth Atlas data are consistent with the MedPAC findings. “The implications for health care reform remain unchanged: if all regions could avoid unnecessary hospital stays and treatments as effectively as the lower spending regions, Medicare spending could be reduced by 20 percent or more,” he said.

The Senate began debating its health overhaul bill this week, and it includes an estimated $380 billion in savings from the nation’s health insurance program for seniors. But MedPAC’s new rankings demonstrate how tricky it is to find savings in health care — even when data is plentiful.

Here is the list, by rank, (with the most expensive first) of variations in the use of health care services. These data, released Monday by MedPAC, show the range of spending per beneficiary for health care services in different areas of the country. A score of 100 is equal to the national average, so Miami-Dade County, with a score of 139, spendsÌý39 percent moreÌýthan the nationalÌýaverage. The analysis adjusted spending to take into account higher cost of living and different payment rates for rural or urban areas.

KateS@kff.org

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Consider the case of a 1990s pilot project that earned the support of a president, several key legislators and successive Medicare leaders-from both parties. A five-year testÌý that lumping together payments for doctors and hospitals for some heart surgeries encouraged them to be more efficient and reduced Medicare’s cost by 10 percent. But the project ran into relentless opposition from doctors and hospitals. The result: Congress has never approved the change for widespread Medicare use and Medicare continues to study the issue.

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Successful Medicare experiments are “certainly not enough to change policy,” said Paul Ginsburg, director of the Center for Studying Health System Change, a nonpartisan research group in Washington. Yet Democrats’ hopes to “bend the cost curve” hinge in large part on introducing successful Medicare experiments into the system. And because of Medicare’s clout as the insurer for 45 million older and disabled Americans, many private insurers follow its lead.

Medicare has conducted hundreds of tests, called Ìýor demonstration projects,Ìýsince the mid-1970s, but can’t apply them to the entire system without congressional approval. Lawmakers have made other important changes, but pilot projects have rarely been the catalyst.

Most of these experiments haven’t been expanded because they failed a threshold test; they didn’t save money or improve care. Others passed the test but were derailed by objections from hospitals, doctors and other providers — or were caught up in political fights as control of Congress shifted. Only a handful resulted in broad health system changes. Two became permanent programs. And the biggest success – a more efficient way to pay hospitals – occurred 27 years ago.

Congress is frustrated by the lack of innovation, aides said. But they note that political leaders are hesitant to make changes to the Medicare system without such rigorous study and without consensus because they fear alterations could result in unintended dire consequences on a massive scale.

Still, in the reform legislation working its way through Congress, lawmakers have added provisions that they hope can improve the odds for implementing successful demonstrations. One measure seeks to circumvent the difficulties of getting congressional approval for changes. It would give the secretary of Health and Human Services the authority to expand demonstrations that work; Congress’ permission wouldn’t be needed. Another would create an Innovation Center that would allow Medicare to pursue promising ideas more quickly. Yet another would set up an independent Medicare commission to recommend Medicare savings that would be implemented if Congress didn’t act.

Proponents think these strategies would at least partially shield Congress from the political pressures of industry groups trying to ward off changes. But some experts disagree. Joe Antos, an economist at the American Enterprise Institute, said that the Innovation Center “may make matters worse” by expanding the complicated bureaucracy that runs Medicare.

Many Paths to Nowhere

The 1991 heart surgery pilot project shows how difficult it is to prod Congress to change Medicare in the face of opposition from providers. The test was begun during President George H.W. Bush’s administration by Gail Wilensky, who was head of the agency running Medicare and Medicaid. Wilensky no longer ran Medicare by the time the demonstration results were in, but as an adviser to Congress, she said she believed the program was ripe for expansion. Her Democratic successor, Bruce C. Vladeck, agreed.

But his efforts to expand the demonstration fell flat because of broad opposition from such heavyweights as the Mayo Clinic in Rochester, Minn., and the American Hospital Association and — after Medicare officials suggested including joint replacement surgery in the program — the American Academy of Orthopedic Surgeons.

In the demonstration, Medicare combined a number of separate payments normally made to the hospital and doctors for specific procedures and follow-up care in an effort to discourage them from performing excessive services. As part of the plan to expand the effort, participating hospitals would be allowed to market themselves as “Centers of Excellence.” Critics had a litany of complaints: The term “Centers of Excellence” suggested other hospitals were less than excellent; patients in some areas would have limited access to care, and all the savings went to Medicare. None were to be shared with the providers.

Vladeck included the program in President Bill Clinton’s Ìýat a sweeping Medicare overhaul in 1997 as part of the Balanced Budget Act. But the provisions were stripped from the legislation.

The “Centers of Excellence” program wasn’t the only promising demonstration to be quashed-some were halted even before their launch for political reasons.

In 1997, for example, Congress instructed Medicare to test a plan under which suppliers of durable medical equipment–oxygen tanks, diabetes supplies and wheelchairs-would submit bids. Medicare would use the bids to generate a range of prices that it would pay and would require suppliers who wished to sell to Medicare patients to meet those prices. After the a 20 percent savings,Ìýlegislators in 2003 ordered Medicare officials to expand the program.

But by 2008, medical supply companies, worried they would lose money, pressured lawmakers to reconsider details of the program. Congress came to share the suppliers’ view that the bidding process was unfair to smaller companies and delayed the project until 2011.

In late 1999, a similar experiment to extract better prices from managed-care plans was jettisoned as well. Lawmakers had mandated the program two years earlier, but when Medicare officials chose Phoenix, Ariz., as one of the test sites for the project, local insurers appealed to Congress. Sen. Jon Kyl, R-Ariz., pushed one bill that called competitive pricing in Medicare “an important” goal but delayed its implementation. In the end, Kyl and Rep. John Shadegg, R-Ariz., brokered legislation that blocked spending on the program anywhere in Arizona. In essence that killed the whole program.Ìý

“Everyone wants competitive bidding, but nobody wants it in their backyard,” said Linda Magno, who directs Medicare’s demonstrations program. “And unfortunately, every backyard has a congressman or two.”

A 2004 demonstration in New Jersey to encourage physicians to practice more efficiently by giving them a share of hospital savings faltered when four hospitals excluded from the program convinced a judge that it was illegal. The hospitals said the project put them at a competitive disadvantage, but the judge blocked it because Congress had not specifically authorized the demonstration.

The lawyer who designed the program, Michael Kalison, said the demonstration was back on track after Congress approved it recently. “So far, so good,” he said.

A Critical Success

A rare victory came in the 1980s. Federal deficits soared following President Ronald Reagan’s 1981 tax cuts. At the same time, Medicare’s hospital costs were rising quickly. In 1981, they were up more than 17 percent. That put pressure on Congress to find a way to bend the cost curve – and it did.

Medicare had been studying ways to deal with the issue. One demonstration found that paying a flat rate for hospital services limited spending growth compared with the traditional method of reimbursing hospitals based on how much they spent, plus a small bonus.

Congress approved the change in the way hospitals were paid in 1983. By 1985, hospital spending was growing by only 5.7 percent, according to federal officials. Many private insurance companies followed Medicare’s lead to get in on the savings.

Democrats also point to other successes, such as a managed-care program for social services, and the ,Ìýwhich pays groups of providers a monthly lump sum for providing all care to frail, low-income Medicare patients. The overhaul bills include a program to reduce hospital admissions, an issue addressed in recent demonstrations. But since the hospital payment change was adopted, nothing has achieved a similar kind of cost restraint.

“There’s really not very much cost containment in the [reform] proposals, but there are the seeds,” said Stuart Altman, a professor of health policy at Brandeis University and a Nixon-administration health official. “They are these demonstrations.”

The demonstrations in the legislation include ones that would test accountable-care organizations, medical homes and combining physician and hospital payments for post-acute care. These projects could change the way health care is delivered, increase its coordination and efficiency and, over time, lower costs for consumers.

“Out of those pilot projects could come significant changes in Medicare,” said Clifton Gaus, who directed Medicare’s demonstration programs in the 1970s. “It just could take a long time. The bending the cost curve problem is now, not in five years.”

Congress’ own budget advisers agree. “Large reductions in health spending will not actually be achieved without fundamental changes in the financing and delivery of health care,” Douglas W. Elmendorf, director of the Congressional Budget Office, wrote in a June Ìýto senators. Reaping the long-term reward of experiments such as the accountable care organizations and payment-bundling programs, he cautioned, “would require tough choices to be made.”

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That language would amend the Social Security Act, which also governs Medicare, the federal program for the elderly and disabled. In 1990, when George H. W. Bush was president, new language was inserted in the Act (Title 18, Section 1866) which defined an “advance directive” to be “a written instruction, such as a living will or durable power of attorney for health care, recognized under State law and relating to the provision of such care when the individual is incapacitated.”

The 1990 language required that health care providers and organizations “maintain written policies and procedures with respect to all adult individuals receiving medical care by or through the provider or organization.” That included things like documenting an advance directive “in a prominent part of the individual’s current medical record” and providing “education for staff and the community on issues concerning advance directives.”

But no provision was made to have Medicare explicitly reimburse doctors for advance planning consultations. The new House bill changes that, requiring Medicare reimburse doctors and other practitioners for consultations covering a range of information, including information about living wills and power of attorney. Here is an excerpt of the relevant bill language:

Advance Care Planning Consultation

‘(hhh)(1) Subject to paragraphs (3) and (4), the term ‘advance care planning consultation’ means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:

‘(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.

‘(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.

‘(C) An explanation by the practitioner of the role and responsibilities of a health care proxy.

‘(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965).

‘(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

‘(F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include–

‘(I) the reasons why the development of such an order is beneficial to the individual and the individual’s family and the reasons why such an order should be updated periodically as the health of the individual changes;

‘(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and

‘(III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy).

Section 1233 goes on to describe how to apply these regulations based on state laws, what the bill means when referring to “practitioners”, how often Medicare will reimburse for a consultation, the effective date of the provisions (Jan. 1, 2011),Ìýitems on a physician quality reporting initiative and inclusion of language inÌýthe “Medicare & You Handbook.”

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1. Sen. Bernie Sanders, I-Vt.: To provide a cap on private insurance company executive compensation.

2. Sen. Tom Coburn, R-Okla.: To establish a demonstration project that uses practicing health care professionals to conduct undercover investigations of other health care providers in order to determine the quality of health care provided by such other providers.

3. Sen. Lisa Murkowski, R-Alaska: To make federal American Indian and “tribally operated” health service programs eligible for grants from the secretary of Health and Human Services to collect data on quality measures (adopted).

4. Sen. Jeff Merkley, D-Ore.: To provide employees who are nursing mothers with reasonable break times to express breast milk.

5. Sen. Mike Enzi, R-Wyo.: To allow expert advisory panels comprising doctors and other clinical experts with relevant specialized experience to advise the government how to conduct comparative effectiveness research studies (adopted).

6. Sen. Judd Gregg, R-N.H.: To ensure that health care reform does not increase the rate of growth of health care spending.

7. Sen. Gregg: To ensure the fiscal security of the United States.

8. Sen. Orrin Hatch, R-Utah: To ensure that community health teams include doctors of chiropractic (adopted).

9. Sen. Sanders: To provide student loan forgiveness or cancellation for volunteer firefighter and volunteer emergency medical service personnel.

10. Sen. Chris Dodd, D-Conn.: To require a health team established under the grant program to support primary care practices to use a medical home model based upon evidence-informed medicine (adopted).

11. Sen. Coburn: To provide for the establishment of an Office of Unborn Children’s Health.

12. Sen. Pat Roberts, R-Kan.: To protect all patients by prohibiting the use of data obtained from comparative effectiveness research to deny coverage of items or services under Federal health care programs and to ensure that comparative effectiveness research accounts for advancements in personalized medicine and differences in patient treatment response (rejected).

13. Sen. Coburn: To ensure adequate regulation of state-legalized medical marijuana (adopted).

See the full list here.

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New Yorker staff writer Atul Gawande–a veteran of the Clinton administration’s health reform efforts, a surgeon at Brigham and Women’s Hospital in Boston and author of the book “Complications, A Surgeon’s Notes on an Imperfect Science”–visited McAllen to find out why it is one of the most expensive health care markets in the country, second only to Miami. McAllen spent more than $15,000 per Medicare enrollee in 2006, which is almost twice the national average and $3,000 more than the average McAllen resident earns in a year. Yet despite the extra spending, the quality of care is below the national average.

After speaking with doctors and hospital administrators, Gawande determined that “the primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.” Doctors there prescribed more tests and performed more operations than average but had poorer results. In other words, more health care spending does not mean better quality. Gawande offers the Mayo Clinic and the community of Grand Junction, Colo., as examples of the opposite scenario–lower health care spending yielding better quality.

The resulting article is now being called one of the most influential health care stories in recent memory. The Ìýreported that President Obama made it required reading for his staff and cited it at a meeting with Democratic senators last week. His budget chief, Peter Orszag, has written two blog posts about the article. Health and Human Services Secretary Kathleen Sebelius referred to it in a speech at the John F. Kennedy School of Government last week. Lawmakers on the Hill also are discussing it. Congressman Jim Cooper, D-Tenn., for instance, says the article has “shifted perceptions on the health care industry.”

We spoke with health experts, media critics and a local physician, to explore why the article has had such impact and what they think about Gawande’s conclusions.

Robert Blendon Professor of Health Policy and Political Analysis, Harvard School of Public Health and John F. Kennedy School of Government

It’s a very powerful article in that it explained in ways that I’ve never seen before the issue about how some communities appear to use more hospital care, physician care, lab tests than [others] and why that’s such an important issue when you think about the issue of containing costs in the future.

The fact that the front of the New York Times had the president reading and discussing the article with his budget director leads me to believe the article could affect health reform.

What’s critical is this research–work has been done for over two decades and has not caught the consciousness of leading public figures involved in reform. It’s an issue they occasionally talk about but it’s very hard because it sounds very abstract. What Dr. Gawande’s article did was make it so real that people who are elected public figures can talk about this issue to anyone they meet.

I think in terms of the influence of a single article, this is one for the record. I have not seen a single article quoted by so many figures that affected how they thought about the issue. Everybody I talk to from Washington says that someone they met has been talking about that article. [It] made it possible for people to discuss this issue.

Greg Scandlen Senior Fellow, Heartland Institute

Statistics can mislead as well as inform. I think that’s a lot of what’s happening here. If it is the case that there is a physician shortage and therefore people go to the ER, then sure. But using Medicare claims as a way of evaluating the quality of medical practice around the country is itself misleading [because] the numbers are looking at all Medicare [beneficiaries] so everyone on the program is covered.

This notion that it’s physicians and hospitals that are tricking people into over-consuming is insensitive at best. Physicians and hospitals do what they’re asked to do by their patients. I think that kind of phenomenon completely escapes statisticians. It would be a fascinating study to actually spend time with the folks there and find out what’s on their minds. Ultimately health care is about people, and analysis that avoids talking to folks is a poor analysis.

Now [Gawande] did talk to and spend a lot of time with a lot of providers and hospital administrators. But his remedy–that everyone should be like Mayo–misses the point as well. The problem is that Mayo and Cleveland Clinic are outstanding . [and] while [these programs] should be held up as ideal, the notion that the entire country is going to be ideal just like those guys are is nonsense. They still get paid through Medicare. They still get paid through private health insurers. It’s clearly not the payment system that’s causing them to be great. We’ve done salaries before and HMOs. The concern is it provides an incentive to undertreat. HMOs in the ’90s were solidly rejected by the American people for this very reason. Overtreatment is only half the story. There’s also a problem of undertreatment. Salaries are not some magical panacea.

Joseph W. Stubbs President, American College of Physicians Primary Care Physician, Albany, Ga.

The real challenge as a primary care physician is convincing patients that over-treatment is not the same as state of the art treatment. That’s a key problem. Patients seem to feel if you’re not necessarily recommending the newest imagining test like an MRI or a CAT scan or you’re not referring them to a specialist, that you’re just trying to save money. Instead, we’re trying to say good care can be done without those things. It can be done by some common sense things that are more low cost. Trying to see how something works before jumping in and doing high cost procedures is a good thing.

The three things I think would help us do things better, and more like Grand Junction as opposed to McAllen, Texas, is that one, we change the reimbursement system to incentivize value instead of volume.

The second is we need to increase our base of primary care physicians. What was not said in that article, but what goes along with it, is if you look at places across the country where there’s a greater ratio of primary care physicians to specialists then the cost goes down and the quality goes up.

The third thing is the ability to communicate with each other through health information technology. We are still way behind in terms of not only using computerized records and health IT but the ability to transfer information about a patient to the hospital or to a specialist who has seen the patient. They might order a test that’s already been done or look for a disease that’s already been ruled out.

E. Linda Villarreal Past President of the Hidalgo-Starr County Medical Society Internist in Edinburg, Texas

I’ve got several copies and believe it or not, I read two hoping it would change. [Other doctors and I] read this and said we need to do something, we need to respond Even though a lot of what he said was true, there’s a lot that he didn’t say that would actually balance the story.

There are many primary care physicians who are practicing good medicine down here. I don’t think he spoke with any of them. [Some doctors are overprescribing] but it’s not 100%. There are physicians that are doing self-referrals–they own radiology facilities and they order more radiology tests or they have an interest in a lab so they order more labs. Yes, that does exist. But it’s not global. I do believe there are physicians who perhaps are looking at other business ventures and profits first and then patient care second. But it is a very small percentage of the physician population in the valley. I believe he was erroneous in simply utilizing one specific physician population or specialty because I did not identify or recognize any comments by primary care doctors who perhaps do not have financial investments in hospitals and simply are trying to work as physicians and care more about what they do than what they get paid.

This morning I woke up and thought, wouldn’t it be nice if I could send President Obama a note saying meet me for tea so I can tell you what it’s really like? Because it’s sad that they’re going to use that unilateral bunch of facts and fiction to decide how health reform should be approached in this area. That would really upset me even more than the article.

Gary Schwitzer Associate Professor, University of Minnesota School of Journalism and Mass Communication

The article was captivating. I am not surprised at the amount of attention the piece has received. The viral spread of this was amazing, and again it should have been. But none of the basic information in this article is new.

[Gawande] didn’t have garden variety interviews, he had excellent perspectives. It’s not like the Dartmouth Atlas work has been under-covered or underappreciated by journalists. It probably is one of the most covered themes year in and year out. But Gawande put names and faces and appropriate roles behind the stories. No matter where you live in this country, there is a story in the Dartmouth Atlas data.

There was a powerful and important message there for everyone in health journalism–especially young reporters, maybe older, more frustrated reporters too–that the beauty of that piece is the collection of perspectives and the storytelling he was able to weave through the narrative. It didn’t require breaking news, a new study or new data.

The enticing–and it shouldn’t be intimidating–aspect is he didn’t do anything that anyone couldn’t do. Health reporters spend too much time thinking about breakthroughs, cures and new stuff, and not enough on access, disparities and variations in policy. People often come back to me arguing ‘that stuff doesn’t sell’–well, read Gawande’s article. I think articles like this have a life for a long time. I think people will have it in their file drawers (or virtual file space) for many years.

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You can read Atul Gawande’s article, “The Cost Conundrum”, .

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It’s lottery day, and 45 county residents who lack health insurance and money to pay for medical care are competing for 30 openings on a cold afternoon in January.

Mary Gleason, a clinic volunteer, draws letters from a plastic box. Those holding matching letters will be ushered through the door for interviews. If they meet the clinic’s criteria, they’ll return in a couple of weeks to see doctors or other staff.

One by one, winners are separated from losers. Gleason plucks a Z, and a man holding a Z strides into the clinic. His broken arm had been set in a hospital emergency room, and he needs to see a specialist for follow-up care.

If You Lose Your Coverage

Lost your employer health insurance? Consider these tips:

• If your spouse has a separate plan, act quickly to get on it.
• Ask about your COBRA rights. With some exceptions, laid-off workers can continue their coverage for 18 months by paying its full cost. (Congress is considering a temporary, 65 percent premium subsidy.)
• If COBRA coverage isn’t an affordable option, explore non-group plans. Make sure that any coverage meets the requirements to protect you against preexisting condition exclusions in the future. State rules vary.
• Check out public insurance programs such as Medicaid and SCHIP, and community clinics. If you’re not eligible now, you might be later. Local health and social services departments may be helpful resources.
• When paying out-of-pocket for care, try to negotiate lower charges with doctors and hospitals.

SOURCES: Interviews with consumer advocates, insurance experts

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Chart: Public Health Insurance Programs (D.C., Md. and Va.)

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Another man, who has Parkinson’s disease and urgently needs drugs to treat it, leaves disheartened. He will have to return in two weeks and try again in the next lottery.

The lottery is just one example of the fate of the newly uninsured — the growing numbers who once had jobs and insurance and now seek treatment with neither. Although most of the clinic’s clients have low incomes, the nonprofit, privately funded operation and others like it in the region are seeing more people who used to be solidly middle-class. Victims of the deepening recession, they’re now wondering where to turn for help.

Neither rich nor poor, this group doesn’t readily qualify for public programs such as Medicaid but often can’t afford to buy insurance or pay hospital, doctor and drug bills. The Democrats’ economic stimulus package would significantly enhance options for the unemployed and their families through insurance subsidies and a possible expansion of Medicaid, a package that some experts say would ease the financial dilemma.

“How many of us can lose our jobs and pay for our health insurance? Not many,” says Gail Shearer, director of health policy analysis for Consumers Union, publisher of Consumer Reports magazine.

Where one lives matters, Shearer says. Some states make it easier than others for people with chronic conditions to obtain private insurance. Medicaid serves the poor, especially children, but eligibility criteria vary. Virginia has the most stringent guidelines for adults in the region: Working parents with a child can earn no more than $5,352 annually to qualify for coverage. Uninsured kids and some parents who don’t qualify for Medicaid may be eligible for the soon-to-be-extended State Children’s Health Insurance Program (SCHIP).

Jean Perry entered the Arlington Free Clinic’s lottery because she couldn’t afford insurance after losing her job. (Mark Gail – Washington Post)

Arlington resident Jean Perry, 57, tried her luck in a clinic lottery because she couldn’t afford insurance after losing her $40,000-a-year job as a coffee shop manager last summer. Under federal law, she could have kept her employer-provided policy, but at full cost: $400 a month.

“Of course I couldn’t afford that,” said Perry, not even with unemployment benefits, which in Virginia top out at $1,452 a month. Buying a cheaper policy also was beyond her means. She put her dwindling funds into prescriptions for treatment of chronic problems, an upper respiratory blockage and high blood pressure. They cost from $29 to $159 a month each. Monthly doctor’s visits added $72 more.

Needing help, Perry showed up for the clinic lottery on Dec. 2.

“I was quite overwhelmed, to say the least, never having been in that situation before,” she said. “Just watching the many people who were there and observing the people who didn’t get it.”

She won a slot at the clinic with the letter S. Now she pays nothing to see doctors, and her prescriptions cost $5 each, the result of the clinic’s obtaining free drugs from pharmaceutical companies.

This recession is much harder on the uninsured than on some others, not just because it’s deep and long. Health-care and insurance costs have been rising faster than workers’ incomes. As Perry discovered, buying a policy or paying for care out-of-pocket is prohibitively expensive.

“Because of increasing per-capita spending on health care,” said Brookings Institution economist Henry Aaron, “the costs of losing insurance are greater than they were 15 years ago.”

Since the recession began in December 2007, the number of unemployed Americans has increased by 3.6 million. Economists predict more job losses.

The number of uninsured is approaching 48 million, according to data from the Kaiser Commission on Medicaid and the Uninsured, and would increase by roughly 1 million if the unemployment rate — now 7.2 percent — hits 8 percent. (Both the commission and Kaiser Health News are part of the Kaiser Family Foundation.)

Proposals by President Obama and Democratic congressional leaders to overhaul the health-care system vary, but the most ambitious ultimately would require all Americans to be covered by private or public plans. Republicans are developing their plans, while debating the Democrats over stimulus legislation proposals to make many laid-off workers temporarily eligible for Medicaid and help others retain their employer health insurance. Republican critics say even temporary expansion of insurance programs will likely lead to expensive new government involvement in paying for health care.

Volunteer Mary Gleason draws the winning letters in Arlington Free Clinic’s lottery. If the winners meet the clinic’s criteria, they return to the Virginia clinic to see doctors or staff. (Mark Finkenstaedt – Washington Post)

Under a federal law known as COBRA, most laid-off workers have the right to retain employer health insurance for 18 months by paying the full premiums, which average nearly $13,000 a year for comprehensive family coverage and $4,700 for individuals. The stimulus bill approved by the House would have the government temporarily subsidize 65 percent of the cost of premiums, which many now find unaffordable. It also would enable people 55 or older, or those who have worked for a company for 10 years to keep COBRA coverage until they’re eligible for Medicare or get another job.

“COBRA is ridiculous,” said Hamilton Shoop III, who until October made a good living helping businesses negotiate favorable terms with contractors. “You go from making so much money every two weeks on your paycheck, and they send you a COBRA notice for $800 a month.”

Alternatively, many people investigate buying policies on the individual market. But such coverage often has high deductibles, offers fewer benefits than employer policies and may not cover long-standing medical problems.

Shoop, 56, a Jessup resident, ran into this problem when he shopped around after losing his job. His wife, who’d been covered under his insurance plan, has high cholesterol, and he has diabetes and high blood pressure.

For now, he’s paying out-of-pocket for whatever he can afford. Which isn’t much. He still doesn’t have insurance or a job, and in the meantime is hoping to turn his passion for playing music into income.

Shoop is postponing the blood test he needs every three months. “I don’t have money to pay for doctor’s visits,” he said.

Children fare better under government programs. After architect Marisol Hernandez was laid off in November, she and her husband obtained coverage for their 4-year-old girl and year-old boy through Famis, the Virginia version of the children’s insurance program.

Health insurance was her first concern after losing her job. “I care a lot about my income,” said Hernandez, who lives in Reston. “But my insurance, when I have kids, is something that has to be working all the time.”

Baltimore HealthCare Access, a nonprofit affiliated with the city health department, assists people trying to navigate the system. “People don’t always know — even providers don’t always know — which application they should fill out, which program they should apply for,” said Kathleen Westcoat, president of the organization.

Clarence Hooper has glaucoma and his wife Reba needs surgery for carpal tunnel syndrome. Clarence lost his job and health insurance in September 2008. (Michael Temchine – Washington Post)

Her staff is working with Clarence Hooper, a building contractor who was let go by his company in September. He has applied to the state Primary Adult Care Program, which serves people 19 and older who don’t qualify for Medicaid. Although it doesn’t offer hospital and specialty care coverage, it would be a godsend for Hooper.

He has glaucoma, and his wife has carpal tunnel syndrome and needs surgery. But they can’t afford it. “So she’s suffering,” said Hooper, 54. “It’s a big toll on you when you can’t do anything.”

Some nonprofits and public officials in the Washington area have tried to close the gap for people who don’t qualify for Medicaid but can’t afford private coverage. Howard County’s “Healthy Howard” initiative offers a broad spectrum of care for people with a wide range of incomes, up to $63,600 for a family of four. Participants pay a flat monthly fee.

Christian Akuffo and his wife, Doris, have applied to the program. A hotel housekeeping manager in Laurel, he lost his insurance last spring when another company bought the hotel. Since then, Doris Akuffo has gone to a hospital emergency room repeatedly for care but found it difficult to get follow-up treatment with doctors. “You call and try to work out something,” her husband said, “but without insurance it’s rough.”

Community clinics, some private and others federally subsidized, offer help to those who can’t get any elsewhere.

Robin Roberson, director of the Community Free Clinic in Hagerstown, says that since August she has seen a 30 to 40 percent increase in demand for services, reflecting rising unemployment. Western Maryland is losing hundreds of well-paying jobs as manufacturers of automobile equipment, boats and furniture cut back or close.

“We have people who just walk through our doors every day,” she said. ‘ “I lost my job, I don’t have any benefits, what do I do?’ ” She strongly recommends that people who can’t afford or qualify for COBRA buy individual insurance. “Coverage isn’t as good,” she said, “but may be enough to get you through a crisis — an accident or life-threatening illness. For those with chronic illness, just the cost of medicine may be greater than the mortgage payment.”

Lois Wadace participated in Arlington Free Clinic’s recent lottery because it “felt like my only option.” She worked as a full-time registered nurse until she had a stroke last May. She had started a new job, and her health benefits hadn’t kicked in.

She wasn’t eligible for COBRA, Wadace said, and couldn’t purchase insurance on the individual market because of her stroke.

Wadace, a 61-year-old grandmother, “got very worried as all the people showed up” for the lottery. But her letter was drawn. If she meets the criteria (there are residency and income requirements), she’ll have access to health care.

Like many others who have lost their jobs and insurance, she’s stunned.

“I never imagined I’d be in this position.”

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Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).