Health Care Reform

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President Obama and legislators are holding town halls across the nation on health care reform. Join Horizonte for a discussion on the President’s ideas for comprehensive health reform.

José Cárdenas:
Good evening and thank you for joining us. President Obama and Democrats in Congress continue to push for an overhaul of the healthcare system. The nation is divided between people who think reform is needed versus those who think the government should not have too big a role in our lives. One of the latest new points in the fight over this issue is the quote, public option, a taxpayer-sponsored medical insurance plan that Democrats want to offer as an option alongside a menu of private insurance plans. In a town hall last weekend in Colorado, the president said the lack of a public option does not mean it's a deal breaker.

Barack Obama:
This is a legitimate debate to have. All I'm -- all I'm saying is, though, that the public option, whether we have it or don't have it, is not the entirety of healthcare reform.

José Cárdenas:
Joining me tonight to talk about healthcare reform is Dr. Eduardo Alcántar, past president of the Arizona Latin-American Medical Association, Dr. Beth Purdy, president of the Arizona Medical Association, and John Rivers, president and CEO of the Arizona Hospital and Healthcare Association. Welcome all of you to "Horizonte."

John Rivers:
Thank you.

José Cárdenas:
John, everybody talks about an Obama plan and we did too in the introduction. But there's no Obama plan. Just principles he's articulated. Give us your assessment of those principles as set forth by the president.

John Rivers:
I think -- first, you're right, there's no Obama plan despite the fact we hear every day from somebody that there is. And I think the principles he has articulated primarily are number one, getting coverage for the uninsured. We have about 42 million in this country with no health insurance and he wants that problem addressed. And I think he wants to change the way we finance and deliver healthcare in this country so it's more efficient and I think he wants to make more use of health information technology that will protect patient safety and provide a more efficient way of delivering healthcare. And I think he wants to frankly, rein in the insurance companies and provide them with more competition. How is yet to be -- competition. How is yet to be defined and those are the broad principles that most support. The devil is how you do those things.

José Cárdenas:
Beth, do you agree those principles are appropriate to at least frame the discussion of healthcare reform?

Beth Purdy:
Yes, and I think no matter which side you're coming to this from, it's good that we're coming to this and we're paying this attention to the problem. I think the -- shining the light on it is a very good thing and we need to take this opportunity to -- to empower ourselves to make differences as John said, this is a time of tremendous uncertainty and one of the main uncertainties is how are we going to accomplish the things that we dream about having happen.

José Cárdenas:
Now, in the segment we showed, the president speaking in Colorado, he said the public option wasn't necessarily the be all and end all of a new healthcare reform proposal. The latest news, liberal Democrats are pushing back on the president and may push for a public option to be abandoned and any attempts at bipartisan and get something through -- that has a public option. First, could explain your understanding of what a public option is and if you think it's a bad thing, why?

Beth Purdy:
It's tough to pin down because the definition of it hasn't been strongly given to us. There's everything ranging from some sort of healthcare exchange to some sort of an expansion of entitlement programs that already exist and in the absence of something that we can actually dig our teeth into and understand it's hard to come up with an absolute strong position.

José Cárdenas:
For the most part, many organized groups seem to be opposed to the concept of a public option, concerns about competition with insurance companies and what it might mean in terms of the quality of healthcare that's delivered. Are those concerns your organization has right now?

Beth Purdy:
Absolutely. One of the challenges of being the head of an organization of physicians, we've been characterized -- anyone trying to lead us is herding cats and so we represent many, many different perspectives. I would say it's my sense that the vast majority of physicians are very worried about a public plan, especially if it is tied to Medicaid reimbursement rates which are clearly inadequate to provide the care that Americans expect and if it ultimately overshadows and eliminates private insurance, and the presence of that competition.

José Cárdenas:
Eduardo, as we noted, there's no Obama plan as such. But congress has made proposals. There's, I think its house bill 3200. What do you see there that's good and that your organization might support and are there any major concerns?

Eduardo Alcántar:
First of all, this is the house senate -- I mean, the house bill and there's not yet a Senate Bill. Second, I have had the opportunity to review the bill. It is a very comprehensive bill and not only talks about physician service, payment for physician services but also talks about many different aspects of healthcare.

José Cárdenas:
About a thousand pages or so.

Eduardo Alcántar:
That's correct, but it talks about nursing homes and how we're going to become an aging population and how they'll spend money and benchmarks and once they implement the reform, but how they want to monitor and evaluate the progress of this reform. When we talk about the public option, I think we as physicians have to meet certain qualities, certain standards of quality in order for us to be able to practice as physicians. I believe my understanding is that the public option is trying to put a little more structure on credentialing, the health insurances, first of all, so they can provide the quality and continuation of care that the payers of paying for. If we get coverage for a number of people not currently under coverage, I don't believe we have enough resources that they'll be able to meet the demand. In the beginning, I expect whoever doesn't have insurance or the insurance companies cannot meet that demand, this will be a place where most of people will sign. And this is one thing that I think is happening because with all the changes that are happening in healthcare, healthcare is something that tags along to the economic changes we're experiencing and when we are experiencing the economic changes we are now, having moved from an agricultural society to industrial and now information society and the thrust of how we're going to be the world leaders as far as economic development and I think this bill is tied into this type of evolution of the economy. By the same token, I agree with John and Beth that there are so many uncertainties and so many questions that we don't have an answer for, that that's where I see there could be a little bit of a problem and in my organization, being physician, we're -- it comes down to ourselves taking care of the patients and that's the main thrust of our work. But as a group, we have groups of physicians that have preferences for the bill; we have a group of physicians that would rather have one payer. And there's a group that is completely opposed to any type of government intervention in the delivery of healthcare.

José Cárdenas:
If we're going to have universal healthcare or anything close to it, don't we have to have some deeper government involvement than what we have right now?

Beth Purdy:
If I had my druthers, I would ask for government involvement to be in making my ability to give care for me as a person to my patient as a person with less interference and that interference can come from the government itself, it can come from insurance companies, and it's not a level playing field right now for me to provide the care that I think is best for my patient. I'm constrained in a very asymmetrical fashion. With respect to antitrust laws, and with respect to the constraints of stark, and other regulations.

José Cárdenas:
The federal regulation that governs a variety of matters in the delivery of medical care.

Beth Purdy:
Correct, and bases its assumption I cannot maneuver through a maze of a conflict of interest that will hold the patient's interests as supreme. That I'll make a decision that's in my best interest.

José Cárdenas:
Government involvement that maybe does something in respect to not only increasing competition for insurance companies but what makes the relationship between insurance company and physician, John, different, and if so, what would that be?

John Rivers:
I think it could. Insurance companies, everybody likes to beat up on them.

José Cárdenas:
And that seems to be the present approach by the administration.

John Rivers:
It's everybody's favorite sport. And I think the insurance industry should be given some credit, frankly, for having stepped up and made some significant concessions in this debate. They've said in exchange for universal coverage, they agree in every market they operate, to offer a product that's guaranteed issue, that's commuted, rated and portable. Which means a person cannot be medically underwritten and denied because of preexisting conditions. That's a big concession and that will benefit everyone and that's an example of the devil being in the details here and I think the reason that this other issue you brought up, the public option, is so polarizing, because everyone is viewing this issue, in my opinion, from a -- everybody's coming at it from a very different place. In you're unemployed, for example, and you have no health insurance, and you have an aging parent or a sick child, a very sick child, I guarantee you, you'll look at this issue differently than someone who has a job, has insurance, is healthy, likes their doctor, their hospital and doesn't want anything, you know, to change. The same is true in the employer market. If you're an employer who provides health insurance to your employees today, you're going to look at this issue very differently than somebody who doesn't and somebody who thinks that added expense might put his or her out of business. We're seeing self-interest play out here to an extreme degree. I'm not saying that's bad, just that's what's playing out here and everybody is using the public option issue to try and drive a wedge through the public in a way to get their point across. You know, the liberals -- I don't know, use the term liberals and conservatives, pejorative terms. What it is? Liberals saying you can't have fair competition without a public option. Conservatives saying that's a foot in the door to a single payer where the government will pull a plug on grandma after hauling her in front of a death panel and prescribing euthanasia. You've got --

José Cárdenas:
We should point out that is not in the proposal.

John Rivers:
Not in the bill. But you know, I've heard lawyers, God bless them, say if you have the facts on your side, you argue the facts. If you have the law on your side, you argue the law. In this debate, if you don't have anything on your side, you make it up and scare people with it. And that's really what I see playing out. There may be more politically correct ways of saying it.

Beth Purdy:
I think there's consensus on both sides of the aisle that it's unacceptable, the current situation with regard to what happens if you do have a preexisting condition and other issues such as that. But the fact of the matter if you're going to impose on the insurance company that is they have to cover people, then almost by definition, you're talking about a mandate and at what point are you going to assign the mandate? Because if an insurance company can't deny you when you're sick, why would you have insurance when you weren't sick?

José Cárdenas:
How can you explain, Dr. Purdy, the fact that the American Medical Association has publicly declared its support for healthcare reform, generally along the lines of what the president has outlined and your organization has come out against it?

Beth Purdy:
My understanding of their position was they looked at the principles that had been given to them by their house of Dell gates of what they were -- delegates. Certain elements they found in the bill, one of the most important of which, the fix of SGR, the sustainable growth rate. The formula that looks at physician compensation for Medicare and comes to a crisis every year because of massive cuts and right now we're looking at January of 2010 greater than 20% cut. This bill contains a fix for that formula to allow more equity and get rid of this yearly panic state that medicine gets into. So they -- their position, as I understood it and as explained to me, was they wanted to empower the representatives that were wedded to that as the process went on, while they continued to work on the elements that they didn't like. Arizona medical association did not find that palatable because there were so many things they found unacceptable, one of which is any tying of a public option to Medicare reimbursement rates is by definition unacceptable.

José Cárdenas:
Why is that?

Beth Purdy:
Because -- and this is -- this is proven again and again in study after study. Medicaid reimbursement does not cover the cost of providing the care and that's where -- whether it's a physician, whether it's a hospital. It simply doesn't. The only way that Medicare patients are receiving the excellent care they're receiving is by cost shifting.

John Rivers:
Do you want a different point of view on that, José?

José Cárdenas:
Why not?

John Rivers:
I think we're talking about two different issues. I think -- how a public program is structured, what's its basic structure, is a different issue than how providers are paid under that program. I think they're both important issues but I see them as very separate issues. We would not support a public program that pays inadequately. We have an old saying --

José Cárdenas:
In the hospital?

John Rivers:
If you're losing money on patients, you can't make it up on volume. That's true in any business. If you're losing money on every widget, you can't make it up. We're in sync with the medical association on that issue. But it doesn't follow that it has to pay health providers in that way. There are other ways of paying. Based on their cost, a Medicare rate plus ten or any number of things. So I think it's important to keep the issues separate and not let the detail of how it could be done poison the well on whether it's a plausible idea or not in the first place. I don't know if that's clear, but --

José Cárdenas:
Doctor, you've indicated there's demographic changes going on this country that are going to force reform no matter what.

Eduardo Alcántar:
I believe so. In all the studies of healthcare, there's a variation of how -- around the country. Having to do with whatever level of economic development, each geographic part of the country. Second, recently the University of Arizona College of Medicine did an evaluation of physicians supplies. If you think about it, one of the issues we're facing right now is that the median age of the physician population in Arizona is my age. I'm 55 years old.

José Cárdenas:
I wasn't going to ask you that, but --

Eduardo Alcántar:
Thank you. Just to let you know that biological delivering the care for the patients coming in Arizona, we'll hit a situation where there may not be enough providers, physicians, physicians' assistants, what have you to take care of the situation.

José Cárdenas:
What can there be in any of the healthcare proposals that deals with that precise problem?

Eduardo Alcántar:
I think one of the things that prompted this thing are a couple of things. The institute of medicine reported -- the RAND Corporation about the issues of lack of nurses to provide the care in the hospitals. There have been a series of events in the past, two of them, being an example, of why this situation happened. At the same time, now, for example, we're having patients that get their medications from out of state because they have a benefit that allows them to have 90 days of medication supply and instead of being a single structure that takes care of the patients here in Maricopa County, we're having to connect in sort of a -- the care these patients are receiving is not in one geographic location but many and I think that the most important driving force of this happening has been the internet. Now, the internet, in addition to the changes in the population, meaning, that we're now an aging society, those two things combined have created two things. One, we have seniors that are healthier and more knowledgeable about taking care of their problems and we have consumers, meaning people that will consume healthcare, not only physicians' services but natural medicine, nursing homes and pharmacies and so on and so forth, they're more knowledgeable and have more options and now the business of healthcare is not only hospital care and physician care, but the spectrum has enhanced. And for example, in Arizona, 40% of our kids don't have access to dental care because neither the government insurance nor the private insurance has that as a benefit. Now we have a very large group who are going to be taxpayers and also the economic force for this state having a big problem with dental health.

José Cárdenas:
Dr. Purdy, how would you deal with that -- with that situation that the doctor just pointed out?

Beth Purdy:
I think doctors have been accused along the way of healthcare reform of being nothing but obstructionists because we can shoot holes in just about every plan. What I don't have is the answer to that question. I feel like as a physician, I'm sort of accountable, the sergeant level in a war. I hope the head of the defense department and the person -- persons above me are listening to what I'm telling them about what's actually happening on the ground, but I couldn't design the supply chain and certainly can't run the defense department. I think one of the main points getting back to your question as to what is not in the bill, is addressing the workforce issues. And that has to happen from graduate medical education funding and encouraging a greater influx into medicine. And that isn't happening.

John Rivers:
This is really an important issue because I think -- think about it. 42 million people with no health insurance. Suddenly or maybe not so suddenly, have health insurance. Think about the additional demand that's going to put on the healthcare system and a question I'm glad you raised because I don't see many raising it. Do we have the infrastructure we need to take care of that increased demand? Do we have enough doctors? No. Especially primary care.

José Cárdenas:
The proposals out there don't address that?

John Rivers:
They do in some ways. There's some funding for graduate medical education. That's the federal financial support provided for how we train doctors in our residency programs once they get out of medical school. They go on to residency schools to become a family physician or hand surgeon, whatever. And this is where they get the specialized training and the funding is for the most part provided by the federal and state governments and it needs to be preserved and increased and we need more of an emphasis on training primary care doctors because one thing I think most think -- think need to happen in a reformed system is we need more emphasis on preventive care. An ounce of prevention is worth a pound of cure. Right now, doctors don't get paid to keep people healthy. They get paid to take care of them when they get sick and that's a profound change. We need to pay doctors to keep people healthy in the first place. That may sound simple, but it's not the way our system of financing and delivering welcome today is oriented. It's toward treating illness, not keeping people healthy.

José Cárdenas:
Last question. Dr. Purdy, you met with -- where do you see the congressional delegation going on this?

Beth Purdy:
I think the crux of the matter isn't who represent the far right or left. It's the moderates in the middle and which way they're going to go. I don't think the votes are there for 3200 to go through.

José Cárdenas:
Apologize to you for cutting you off. That's our show for tonight. I'm José Cárdenas for everybody here at "Horizonte." Have a good evening.

Dr. Eduardo Alcántar:Past President, Arizona Latin-American Medical Association;Dr. Beth Purdy:President, Arizona Medical Association; John Rivers:President and CEO, Arizona Hospital and Healthcare Association;

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