National Health Reform

May 24, 2010

Transcript:

Ted Simons:
Two months ago, congress passed, and the president signed, historic healthcare-reform legislation. It's an effort to make health care more affordable and cover more people with health insurance. Parts of the plan go into effect soon; others aspects will take years to implement. Of course, that depends on the outcome of various lawsuits challenging the plan. Joining me with their take on national health reform are two Arizona doctors. Dr. Jane Orient, a Tucson physician who serves as executive director for the Association of American Physicians and Surgeons, a group that has sued to stop health reform. And Dr. Nicholas Vasquez, a doctor of emergency medicine at St. Joseph's Hospital in Phoenix. Good to have you both here. Thank you for joining us. Let's start, Doctor, with the idea of overhauling health care. Good thing? Was it necessary?

Jane Orient:
I think reform might be a good thing but this is about compulsory insurance, forcing people to buy a very expensive form of insurance, the provisions of dictated by the federal government and think this will have a deleterious effect on the cost and quality of medical care.

Ted Simons:
So much so you would rather not have seen this kind or any kind of health care reform?

Jane Orient:
When you're standing on the edge of a cliff and you're not in a very good situation, the options to jump or not jump, not jump looks pretty good and maybe you can figure out ways to better your situation later.

Ted Simons:
Talk about whether or not this was a necessary move for the country to make.

Nicholas Vasquez:
Well, she references, appropriately, the problems of cost, quality and access. Health care in my mind is an equation with three variables, cost, quality and access. And in the last 30 or 40 years we've tried to square two against one, tried to fix either access or quality or cost or access and could never get all three together. The problem is that with Medicare, what we have is an uncontrollable source of cost and the need for reform this year, given political realities and other realities, the need for reform this year was paramount. We had to find a way to get our system to work together a little better, rather than driving up costs, trying to find a way to drive down costs, and increase the value that people get from their health care system. I challenge a lot of people to try and come up with a better way that could have gone through congress and gotten the various health care factions together in the way that this president did.

Ted Simons:
Was this something, as the doctor mentions, that may not be perfect but when you have so many players in the field, you take what you can get and this is what we got?

Jane Orient:
I think what we need is freedom for the different players to figure out solutions to their problems instead of having people in government who know nothing about medicine imposing the problem, or even people in government who are academics who think they know a lot about medicine, I agree Medicare is unsustainable so what are we going to do, cut a trillion dollars or half a trillion dollars, $500 billion out of a program that's bankrupt? How is that going to help anything? You can't do away with costs by refusing to pay them.

Ted Simons:
How do you respond to that?

Nicholas Vasquez:
I would say at the end of the day, all of this is a very nice academic debate we could have had 40 years ago around the same tenants, and what has changed is the economy, and what we do with the health care programs is largely due to what happens in our economy. The effect of the health reform is to pull people into the system that weren't there before. Insurance does not equal access but insurance equals a measure that people can use to pay for the kind of care that they need. I think it's all about the implementation, though. You can say I've got these wonderful plans. If you don't implement it appropriately, if you don't find ways to get appropriate feedback, you are going to fail. And the open implementation is still an open question.

Ted Simons:
How better is there an idea out there of getting 30, 40, the numbers range of folks who don't have insurance, get them on those insurance roles and make health care easier for them and ostensively for the rest of us?

Jane Orient:
Why do we think insurance is the answer to the problem? I think having too much insurance is the cause of the problem. We have a third party payment system where 85 percent of all medical bills go through a third party. This drives up costs. This decreases access. To have true insurance is very affordable for most people, and true insurance is practically being outlawed by this program because now everybody has to go into a managed care program that has third party payment for almost every transaction.

Nicholas Vasquez:
I would say, though, that this is a little bit of a specious argument I think because at the beginning insurance was bought and paid for by individuals and also bought and paid for by employers. There was enough social utility in the idea of insurance that it became wildly popular. A lot of people chose with their own money, with their own wages, to choose to have insurance. This wasn't a government-mandated plan in the beginning. We found, like most markets, markets don't respond to people that don't have money and to find a way to incorporate social utility or what's best for all into insurance is what is at the heart of reform. That's a hard thing to do and I'm not saying we did it well but I'm glad at least we're trying to address the needs of some people to be able to access health care.

Ted Simons:
But is it not a valid point that, as the doctor mentioned, most people can afford health insurance?

Nicholas Vasquez:
Most people do, but like vaccinations, the program requires a step for mandating. If we go back to the polio epidemic and say if we didn't mandate this behavior, we will leave it up to your own recognizant, there was a significant cost and significant benefit. The same will say about insurance, there is a significant cost, I'm not going to lie, there is definitely a significant cost, but we hope the value is greater and requiring people, the mandate, is the only way to get insurance companies to agree to play ball. It is not so that we can bilk, I hope, our people, but I hope so that our people can get some coverage. And if you look down the road, insurance is really insurance against a specific threat, and if we get very good in genetics, and perhaps this is a little off topic, but if we get very good in genetics and get very good about who will get what disease, there is no random threat, there is a specific threat and you can't get insurance. We're not that far from this, defining people's risk much greater and they will have to pay greater cost.

Ted Simons:
We've heard this in the debate, certainly I have from a variety of guests on the program and one side said everyone has to be in the pool for this to work. If you don't make it mandatory, if there are, you know, if, ands and buts, then the whole thing isn't going to work. Valid argument?

Jane Orient:
If you make it mandatory and have everybody in the pool it's not insurance, but insurance is not the same thing as medical care. If you want to provide access to medical care for people who can't afford it, it is much less expensive just to do that and not try to force insurance on everybody. As the doctor said, the insurance companies bought into this. In fact, they probably bought the plan, they probably wrote the plan. What better way to expand your business than to force people to buy your product, which many of them have declined to buy because it is too expensive and because it is too invasive and because it dictates what's good for the insurance company's bottom line instead of allowing patients and physicians to make their own choices.

Nicholas Vasquez:
I might say I agree but it is hard to press the pause button and completely rearrange the table. This is an on-going, real time problem. We can't just stop and say, philosophically, I would like to have this way or that way. I would like to reward people for work, rather than saying we're simply going to mandate that everybody get it through work, if you have some type of employment you'll get it, and if you don't we'll pay for it. At the end of the day, we have people that are going to represent a portion of our population that we have a vested interest in their health now. If we all are mandated to have insurance, if we all are part of a community, we have a vested interest in their outcome. And it's a problem to stop and say we're going to put, you know, just primary care and not treat some of these more extensive diseases, you have to get everybody into this payment mechanism we call insurance.

Ted Simons:
The idea of regulating private insurers more closely, that's in the law. Good thing?

Jane Orient:
I think it is going to drive a lot of products out of the market and restrict the market to a very narrow range of products, which are very expensive products that use managed care methodology that people are already objecting to, such as capitation where there are winners and losers and there's a zero sum pie. There is no way of having innovation or of improving services, just a way of trying to divide them up according to the brains on high deciding what is the best way to do it.

Nicholas Vasquez:
Funny thing is that Medicare has a dominant position in insurance because it is the largest buyer. It also is the leader and everybody sort of follows suit. When it says, okay, we are going to pay for fee by service, all the others follow along and say we will pay for fee by service. When Medicare says we will set the fee for X, everybody follows along. Medicare wants to get out of that game I think, they want to find a different way which we pay for care and that is the implementation that I'm talking about. That's the part that can change the dynamics of what we do every day but it is dangerous, at times, if poorly implemented. It is also really powerful and can fundamentally change the way our system works. Imagine, if you will, a system rather of less specialization but a system of more specialization where you have a system that is interdependent where people have different specializations and different skills and focus in on that and there is a chain where you can move along. It is as if you were to ask our medical system by saying we need to go back to generals and not pay for all types of care, we have to pay for only specific things on a charge master. It's almost as if you were to say, I only want to pay for the lapel on my suit, I don't want to pay for the suit. You buy the suit because other people know how to make it and it is a value to you. That's the kind of system we need to have, an interdependent connected system that works together two create value.

Ted Simons:
How do you respond to that, the threat of specialization running amok, if you will?

Jane Orient:
What we have here is designed by philosopher kings that think they will make everything better for everybody, and if you don't go along with it, you are a deviant or outlier. They assume they know what is better for people, what if they don't? If you have no freedom to innovate or to make your own decisions, but everybody is stuck in the system managed from on high. The results could be a disaster, just like they have been all over the rest of the world. What Medicare is trying to do is figure out how to not pay for a lot of services, and not pay for fee for service. They're going to be ranking people on the basis of their worthiness for society so that they don't have to pay.

Ted Simons:
The idea that there are folks on high making these decisions and these folks are in government, those who support health care reform and support this law saying those decisions were being made by insurance companies right now. So somebody out there who is removed from you, the physician, is making those decisions anyway. What's the difference?

Jane Orient:
Well, the difference probably isn't a whole lot of difference. We are putting in rigid stone the things about the status quo that are really so miserable and that is that third parties are in charge because they have 85 percent of the dollar flowing through them. We need to demote them back to the role of true insurance, which is just to pay for catastrophes and that most medical encounters are outside their domain.

Nicholas Vasquez:
That would work, I think, for some people in this country, work for personally myself, works fine, but it doesn't work for all people, and when you're trying to make decisions on a government level, you're talking about social equity and you have to be able to consider the fact that some people are not going to be able to get by just on catastrophic insurance alone, that they have ongoing needs. In this country, if you are poor, you're more likely to have diabetes, more likely to have hypertension, more likely to be obese and more likely to be burdened by chronic diseases that require you to have insurance to get the kind of care you need. Otherwise, we all pay a bigger bill. It is not that I enjoy the bill that Obama passed and signed, but I think it's the right step in moving forward to try and pull people into getting medical care. Because frankly, I think they need it.

Ted Simons:
The idea of uncompensated care hits emergency rooms very hard. How much of a problem do you see?

Nicholas Vasquez:
20 to 25 percent.

Ted Simons:
Does the bill address that?

Nicholas Vasquez:
Yes and no. There are difficult realities that the bill does not address, but if people were to come to the emergency room after having gone through the process of getting insurance, we would have a different payer. I think a lot of people are going to opt for the penalty and not buy insurance. It's not a panacea. The other problem is that a lot of people in my emergency room, a majority of them are insured and have interests, and we have an access problem and that is a whole different issue.

Ted Simons:
How do you see that issue as far as uncompensated care, the access problem, state Medicaid, the whole nine yards? What are you seeing?

Jane Orient:
What we used to do is we had county hospitals with access to care. When the access program went into effect in Arizona, we created this nitch group that made it a whole lot harder for people who are poor but not eligible for access to get care. Insurance is not the same thing as medical care. It is much cheaper to provide medical care directly to people who need it than impose this third party to every transaction.

Ted Simons:
Was it a mistake to drop the public option?

Jane Orient:
Public option is like another Medicare government insurance thing. That's another insurance mechanism. I don't think it was a mistake to drop it at all.

Nicholas Vasquez:
In the debate, I used to say I never saw a bus company that put a limo company out of business, when I was thinking about the public option verses a private insurance, but there was a lot of people who disagreed with that, and inevitably, the public option went off to the wayside. I think, at the end of the day, whatever we do, it is really important to watch the implementing details. That will determine what we do, whatever the rhetoric. How we implement this to try and find a fair way to create an equity of access or an equity of opportunity for everyone is the most important thing. You can't guarantee that everyone is going to have a good outcome. Medicine has too much uncertainty in it, and life has too much uncertainty in it, but equity of opportunity.

Jane Orient:
Medicare did put out of business all insurance company for senior citizens over the age of 65 because Johnson cohearsed them to cut off all those policies, and he did that because he wanted his program to succeed and he felt the public program could not compete with the private programs that people had chosen for themselves.

Nicholas Vasquez:
Can seniors opt out of Medicare? I've heard conflicting things.

Jane Orient:
No.

Nicholas Vasquez:
My understanding is they cannot.

Jane Orient:
Only if they give up all their Social Security benefits and give back all the Social Security benefits they've made, they can get out of Medicare Part A. Why would they want to do that? Because of more and more draconian restrictions put on their care.

Ted Simons:
We have to stop it there. Thank you both for the discussion.

Nicholas Vasquez and Jane Orient:
Thank you.