Asking the Wrong Questions

For the first time since 2000, Gallup has found a majority of Americans now feel it is not the federal government’s responsibility to make sure all Americans have healthcare coverage. According to a recent poll, 54% now feel it is not the government’s responsibility as opposed to 44% who say it is. 

Gallup also found most of those interviewed still think health care system has some major problems, don’t like the costs, but are generally satisfied with the care received when needed.

Whether or not it is the federal government’s responsibility to make sure American’s have health insurance isn’t the real question. If the question was changed to, “Is it the responsibility of the federal government to make sure American’s have access to affordable health care?” the answer results might be different. Considering the fact that health care costs are now impacting the entire economy, I know I’d say it is.

It’s pretty amazing that after all that has happened we’re still having separate discussions around these topics and haven’t put them together. Health insurance financing of health care and an affordable health care system are related.

The Health Care system is moving in the right direction but is resisting the change any way it can. It’s going slow. Until we bring the general public on-board, making the changes that are going to be required is going to be much more difficult. If we used Gallup’s numbers and assume over half the country may be resist the changes that are coming because they don’t understand them, the challenge may be overwhelming.

That is why educating the public about what is going on and getting them engaged critical. They are going to need to be more engaged than they are today to make the change happen.

Now Fix the Affordable Care Act

The election is over. It was close, but not as close as some thought it might be. At least we now have an idea of the direction we’re heading as we try to fix health care. The Affordable Care Act (ACA) is certainly not perfect and not too many folks actually like it (it’s expensive and very few understand how the pieces of the law are all supposed to fit together). But it’s what we have to work with.


The House of Representatives continues to be controlled by the Republicans and the Senate by the Democrats. And we have a Democratic President. No change from where we were before. The respective numbers changed slightly in both the House and Senate, but the overall picture looks the same. Hopefully, the two sides will start working better together more than they have been the last four years.

The pundits are analyzing the results. Some think President Obama has a “mandate” from the general population. I don’t think so. He was simply given more time to deliver results. This wasn’t a mandate, it was a message. Most of the general public is exhausted from the process and simply wants Washington to start fixing what needs to be fixed and quit the political warfare that has already cost us our debt rating has brought us close to the “fiscal cliff” that will occur on January 1 if some pretty bold actions aren’t taken, and the debt and costs continue to grow and the average citizen continues to feel the results. We won’t fix our problems if the two sides don’t start working better together. President Obama needs to lead by example.

Now would be a good time for both sides to sit down and re-evaluate the intent and status of the Affordable Care Act implementation. They should get rid of the costs and unnecessary bureaucracy that may not make sense considering our current economic picture. Some of the ideas that might have seemed logical in 2009-2010 may not be all that logical today.

The Affordable Care Act has some good ideas but in many ways misses the point on the fundamental problem we need to address. The ACA focusses on access (getting everyone into the health insurance pool; mandating health insurance) and doesn’t really deal with the costs until we’re further down the road. Cost is the issue. Including more people in a system that doesn’t immediately address the costs of health care is going to make the Affordable Care Act much more expensive than anticipated- ultimately losing any support from the general public it might have had.

Consumers/individuals will need to get on board at some point if the Affordable Care Act is going to work. Those in Washington can set the tone by doing what is right and doing what makes sense for us today.

Both sides need to have open minds. Instead of barreling “full steam ahead” regardless of the costs just to meet deadlines, DHHS (Department of Health and Human Services) should step back and (as a good Top Gun quote goes) “evaluate what has happened so you can apply what you’ve learned.”

Washington needs to work together to fix what needs fixing.

That’s what we elected them to do.

Election 2012- We've Only Just Begun

The election is Tuesday. Most are going to be glad when it’s finally over. But it’s really not going to be over- no matter who wins. It’s only the beginning.


We have some serious issues to address in this country. We can continue to kick the can down the road like we’ve been doing but we’re running out of road. And the stakes just keep getting bigger. We’re sitting here like the proverbial frog in the slowly boiling pot. We feel things getting hot, but we are not able to ask for a helping hand to get us out. Our politics won’t allow it.

It’s very likely that deciding the Presidential election on Tuesday may be a drawn-out affair. It is going to be close and could result in a president who has won the electoral college not the popular vote. That is not necessarily unusual. George W. Bush, Harry Truman, Woodrow Wilson (both times), Grover Cleveland (both times), Rutherford Hayes, Thomas Jefferson, and others have experienced the same thing. But this one may be different. Boatloads of lawyers are standing at the ready to challenge any and all aspects of the results. It could pull the country further apart rather than pulling us together.

At this point, it looks like the House will continue to be controlled by the Republicans and the Senate controlled by the Democrats. This hasn’t worked out all that well over the past four years. The emotions, the events, and the politics have created the most partisan Congress we’ve ever experienced in this country.

While the political process becomes more polarized we look ahead to “fiscal cliff” and the suffocating costs of health care we still have to address. Addressing them the right way will require real teamwork and collaboration between the parties and their constituents to reach some consensus on how to move forward. That’s the way a democracy is supposed to work. If we decide to keep growing further apart, every American is going to feel the consequences in some way or another.

So, no matter who ultimately “wins” the presidency on Tuesday (or whenever it is finally decided) this is only the beginning for the rest of us. Just because the election is settled doesn’t mean we can all shut-off our minds and move on to other things. There is too much at stake. We have a role we need to play to continue to hold those we have elected accountable and setting a direction that is good for the country and not based solely on a single political ideology. Believe it or not, both sides have some good ideas to share. Neither one has a lock on being right. While the elections may set a direction, we (the citizens) can do a lot to set the tone and demand the results.

We have a choice- not only about who is leading our country but about how it is going to be led. Now more than ever we need to stay involved and stay engaged and remain an integral part of the political process. If we continue to let individual party-ideology reign as the key determinant of how we're going to work in America- we're all going to lose. The choice is ours.

Romney Won The Debate- But Still Not Clear About Health Care

There’s no doubt about it- from a political scorecard point of view, Mitt Romney “won” the debate last night. He was clear in his remarks and came across as the executive you would expect him to be; a very solid performance. President Obama didn’t seem like he just wasn’t into it and would rather be somewhere else. He didn’t go on the attack like his more liberal followers expected. Chris Mathews and Ed Schultz (MSNBC) went into a tirade after the debate lamenting the fact that Obama missed an opportunity to put Romney away. Today, Rush Limbaugh and Shawn Hannity are declaring victory and triumph for the other side.

While the pundits may have expected more fireworks (particularly from Obama) I actually enjoyed the debate. I know I’m in the minority but I like it when a debate includes a factual discussion of the issues that are relevant to those watching it.

Jim Leher (the moderator) had his critics as well. Once again, I didn’t think he did that bad. I enjoyed the free flow of the discussion as opposed to the game-show atmosphere that was prevalent in some of the debates we watched during the Republican primary. Once again, in today’s world my view is certainly the minority. Our culture today seems to want the fireworks, the vitriol, and the entertainment as opposed to a no-nonsense factual debate of the issues to educate the general public.

While Romney performed well when addressing the topic areas (the debt, the economy, taxes) he still didn’t address the question of how he was proposing to fix health care. He talked about RomneyCare and premium support for Medicare but didn't address how it was all supposed to work. The facts he used to summarize his position were generally misleading, lacked context, and he didn’t provide the specifics needed for the average citizen to make an informed decision about the best approach to use to fix the crisis we’re in.

For me, it’s pretty simple: Addressing the unsustainable increasing costs of health care is one of the most critical issues facing our country today. If we fix health care, we can go a long way to addressing our debt. If we address our debt we can go further in growing the economy. If we grow the economy we can create jobs. And that’s the issue for many.

Obamacare (the Affordable Care Act) is too expensive and doesn’t go nearly as far as we need to go to change how health care delivery works in this country. Obamacare needs to be fixed but it’s a start. In my view, Mitt Romney and Paul Ryan still need to present a plan (not just talking points but an actual plan) that makes sense as an alternative to the Affordable Care Act- then, voters like me (who believe health care may very well create the next economic crisis in our country if something doesn’t change) can make a clear decision on which approach is best.

And that will determine the way we vote.

9-11; Eleven Years Later

Let us never forget

And always remember those who have sacrificed and continue to sacrifice to fight for our freedom.

New IOM Report- Will We Listen This Time?

The Institute of Medicine was created in 1970 as a subgroup of the National Academies and Sciences. The Institute is an “advisor to the nation” on the relevant policy and social issues of health and of the challenges facing our health care system and. It includes a lot of smart people from all areas of the health care system.


The Institute has already produced hundreds of studies and papers on a number of health care-related topics. Two of the most notable:

In 1999 the Institute produced “To Err is Human: Building a Safer Health System.” The research highlighted the number of deaths that are the result of medical errors in our health system.

In 2001 it released “Crossing the Quality Chasm; A New Health System for the 21st Century.” This paper emphasized the need for health care to become more “patient centered” and encouraged an entire restructuring of the delivery system. It stated, “What is perhaps most disturbing is the absence of real progress toward restructuring the health care system to address both quality and cost concerns. . .”

It just release another; “Best Care at Lower Cost; The Path to a Continuously Learning Health Care In America.” This study builds on the message it has tried to communicate to the general public for the past 13 years- the health care system is still in need of a fundamental restructuring in how it works and consumers need to be a fundamental part of the new system.

“Best Care at Lower Cost” estimates $750 billion was wasted in our health care system in 2009. Keep in mind Obama and Romney (regardless of what they say) are recommending to reduce Medicare payments (mainly through payment reductions to health plans, hospitals, home health) by $716 billion over ten years.

Eliminating the waste identified in the IOM report could reduce annual health expenditures by $750 billion in a single year or 30% of what we’re spending today. Not bad.

When “To Err is Human” was released in 1999, and “Crossing the Quality Chasm” was released in 2001 the media jumped on the conclusions for a short time, just like it did with the release of this report. Then health care went back to being health care. Our costs continued grow at unsustainable rates, our quality measures haven’t improved much, and somewhere between 75,000 and 100,000 people die unnecessarily each year due to medical errors.

One of these days we’re going to need to start listening to those prophesizing the reality of what we’re facing. The answers are out there and the general public needs to have a better understanding of the alternatives. Health care can be fixed- but is going to require a lot of changes. And we are all going to need to be part of the solution.

Cheesecake Factory Health Care

Atul Gawande is a doctor who likes to write. He has presented some interesting ideas over the years. Health Care may be listening but it certainly hasn’t openly embraced his concepts; at least not yet. His 2009 article in the New Yorker about the high cost of health care in McAllen, Texas is sometimes credited with starting the whole health care reform discussion. His book, The “Checklist Manifesto”, presented the idea of using checklists (similar to the checklists used by pilots) to simplify the decision-making process in making medical decisions. His most recent article in the New Yorker, “Big Med”, discusses the processes used by the Cheesecake Factory and other “volume-based” food preparers and how they might be used to improve both the efficiency and quality in health care.

Health Care takes a long time to accept change. In the New Yorker article, Gawande references a study that examined how long it took several major health care discoveries to reach even half of Americans. On average, it took more than fifteen years.

In 2009, Americans spent over $200 billion in medical tests that were not needed. At the end of life an individual may see anywhere from 15 to 80 different medical specialists. Medical errors and quality challenges add billions more to a system that is already too expansive. While good medicine might not be able to be reduced to a recipe- Health Care could certainly use more effective processes to eliminate the waste and improve the quality of care delivered to the patient.

The Cheesecake Factory model is relatively simple; study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute.

We may not be able to create a Health Care Cheesecake Factory overnight, however, the system needs to start to be much more open to doing things different than it has in the past. There are some other ideas out there that can work- but it can’t take Health Care another fifteen years to make the changes that are needed. The individual, the patient, doesn’t have that much time.

Minnesota Health Care- A Model For Other States?

I had the opportunity to provide testimony to the Minnesota Health Care Reform Task Force last week. This group was convened to develop new ideas and solutions to improve the health care in the state. Minnesota has always been looked upon as one of the “innovators” in the country when it comes to health care. It is the home of the Mayo Clinic, Medtronic, United Health Group, HealthPartners, Red Brick Health, and many other business model and product innovations that have been used as examples for other states in developing a more effective health care system for themselves.

The Task Force was certainly handed a huge task and must now integrate the federal requirements of the Affordable Care Act into its work. Despite the health care system that has developed in Minnesota over the years, it is still too expensive, too confusing, and many times inefficient.

The Task Force was provided updates from several of the work groups: Access (defining the benefit structures and pricing models to increase the number of individuals “covered” under a private or public health care financing program). Workforce (making certain the health care workforce is prepared to meet the future demand of health care). Health Insurance Exchange (developing the tools to implement a health insurance exchange market in Minnesota).

The four hour meeting was filled with handouts and presentations from the different groups. It was obvious to most that what was being discussed was going to cost a lot of money. It was also fairly obvious of the continuing confusion regarding the “rules” that must be followed to meet the requirements of the Affordable Care Act. Health care is complex- but these discussions made it even more confusing. There was very little (if any) discussion about how the average individual was going to understand any of it.

My testimony tried to at least bring the consumer/individual back into the discussion. I hope they were listening.

As I said, Minnesota is viewed as an innovator when it comes to health care. But Minnesota also struggles with the same challenges as other states to get consumers and individuals engaged and involved. With the complexity we are continuing to create- it’s no wonder.

Until groups like these begin to accept the economic realities we are facing, develop approaches based on a set of quantifiable objectives not utopian dreams, simplify the entire process, and include the perspectives of the “average citizen” in all of their discussions and decisions, we will probably just end up with a nice set of recommendations we can’t afford, that cost a lot of time and money to put together, and that we’ll just put on the shelf. We may move forward a little- but not nearly as far as we need to. But at least we're doing something.

The Supreme Court Decision and GSK; Which Way Will We Go?

It was fun to watch the cable news channels trip over themselves as they initially incorrectly reported the outcome of the Supreme Court decision last week. In their quest to report first- they reported wrong. Such is the price we have to pay when we want the news instantaneously. We’re going to need to be even more cautious when we’re determining what to believe; especially when it comes to deciding what to believe about health care.


Since the decision was made- the pundits have been trying to figure out what it really means. For all practical purposes, the guts of the law were upheld. It’s just that what things are called, and how things will work are going to change pretty substantially.

Even with the decision finally made, the health care debate is going to continue. The country is still divided on it view of the law. But the intensity of the division has intensified. The rhetoric behind the discussion will get even uglier than before. Just like we should have learned as the cable channels first reported the decision, what is reported will not necessarily be the truth.

The fundamental question we will continue to grapple with is this: how much should the government organize the health care mess we have created this country versus how much can we really rely on the “free market” in its ability to fix it.

Today, pharmaceutical company GlaxoSmithKline (GSK) agreed to a $3 billion settlement essentially resulting from health care fraud. The company was selling pharmaceuticals to markets where the drugs were not intended, and for conditions that had not been tested. The general public was exposed to some very substantial risks. But the GSK sales folks, some physicians, and others made a lot of money in the process; just following the American Dream. The GSK annual report states the ultimate aim of GSK’s business strategy is “to deliver sustainable improved long-term value and returns to shareholders.” There is no mention of delivering quality products at an affordable price to their customers. These companies are big, and the focus is financial. In an article about the fraud for Forbes Mathew Harper writes, “Criminal fines for giant drug companies, no matter how big, are less a deterrent than a cost of doing business.”

The free market left on its own can be dangerous.

So, we are still left to decide between a bloated and expensive health care law generally administered by the federal government that few understand and many people still don’t like, and uncertainty as to whether it will work, and a free market approach that continuously struggles to put the patient, the individual, ahead of profits.

I’ve said all along the answer is somewhere in-between. We just don’t have the right leaders in place to put a middle-ground approach together. The debate will continue.

Do Health Plans Have A Heart After All?

United Healthcare, Aetna, and Humana all stated they would continue with some of the provisions required in the Affordable Care Act regardless of what the Supreme Court decides about the constitutionality of the law itself. United Healthcare specifically said they would continue to allow children to stay on their parent’s plans until the age of 26, eliminate all lifetime limits for health care expenses, streamline appeals and complaints, and not allow the cancellation of health insurance after-the-fact (rescissions).

United Healthcare CEO Stephen Hemsley said in a statement, “The protections we are voluntarily extending are good for people’s health, promote broader access to quality care, and contribute to helping control rising health care costs.”

Do health insurance companies have a heart after all?

Make no mistake, they are making these decisions for business reasons not for the general welfare of the population. If the Supreme Court strikes down the law (or portions of it) taking these provisions away would be a public relations nightmare. Health plans don’t need any more negative p.r. And don’t think paying for them will be free- we will all be paying the cost.

While this is a smart business strategy I am left to wonder. If these protections are good for people’s health, promotes broader access to quality care, and contributes to helping control rising health care costs, why weren’t they providing them before?

Maybe the “free market” needs some help and guidance after all.

Creating More Informed Health Care Citizens

                                                         We’re waiting to hear the outcome of the Supreme Court's decision about the Affordable Care Act. We should get the word before June 28. The odds are (from what I’ve heard and read) the most contentious part of the legislation (the requirement for everyone to have health insurance) will be declared unconstitutional by a 5-4 vote. Nobody really knows, but that seems to be the scuttlebutt. The question we are then going to face is if that part of the law goes away, how will the rest of the law work? Or will it at all? And if Romney wins in November and succeeds in repealing the entire law (a campaign promise), will all of this be for naught? Nobody said changing the way health care works was going to be easy. But it has to be done.

Americans are going to need to understand that the status quo is not an option. The way our health care system works needs to change. It’s simply too expensive. It is going to need to be different than it has been in the past no matter what approach is used to try to fix it. Individuals are going to need to step up to the plate more than they ever have before and be informed, take responsibility, and participate. They are going to need a basic understanding of reality instead of relying on their emotions to form opinions and make decisions.

Many states (Minnesota included) are already trying new approaches without federal involvement. While some states may be taking some action, others don’t have the funds, the will, or the expertise to take on the challenge. This is a national issue that needs everyone involved. The key to success in any effort is to get individuals engaged to become part of the solution- not be part of the problem.

The Citizens League and Bush Foundation are holding a series of “conversations about health care” across Minnesota to receive citizen input about their perspectives of what needs to be done to address the health care challenges we face. The information they gather will be used to help state policy-makers make decisions about health care in the state. I took my US Health Systems class to one of the events. I was once again amazed with the lack of understanding of the general public as to what is really going on. (You can link to the Bush Foundation blog post I was asked to write by clicking here).

We need to teach and train the general public better about health care better than we have. The logic and details of the Affordable Care Act were communicated poorly and have since been buried in politics. The system we have created is complex and confusing- but can be explained. The health care system itself has tried some education efforts but has a trust issue with the general population. So the problem of a relatively uninformed general public remains.

If we can create a better informed public by teaching the facts, the options, and the roles they will need to play discussion just might be more productive. Until then, we’re simply going to continue to tread water. You can only tread water for so long before you sink. I hope we don’t get to that point, but you never know.

When Employer Behaviors Change

The House Ways and Means Committee released a new report that has received some media time over the past few days. The report, “Broken Promise: Why Obamacare Will Force Americans to Lose the Health Care Coverage They Have and Like” provides a summary of the results of a Fortune 100 survey concluding many employers will simply drop their employer sponsored insurance (ESI) because of the way the rules and fines established by the Affordable Care Act and move their employees to the Health Insurance Exchanges to purchase their coverage. Paying the fine imposed in the Affordable Care Act is cheaper than providing coverage.

The report states the Affordable Care Act “threatens the stability and sustainability of the employer-based health insurance system.” As if it is stable and sustainable today.

The report estimates employers will save nearly $29 billion in 2014 alone and over $422 billion between 2014 and 2023 using the fine-paying approach. Sounds to me like those savings could be a great boost to the economy, to the global competitiveness of employers, and in creating jobs. The report doesn’t talk about that because it is intended to deliver a different message.

The report should probably have an addition to the title to really clarify what we’re dealing with for the general public; “Broken Promise: Why Obamacare Will Force Americans to Lose the Health Care Coverage They Have and Like--- But Won’t Be Able To Afford for Much Longer.”

Anybody who might have thought “nothing will change” for the employees with any health reform model (Republican or Democrat) was simply naïve. “Nothing will change” is the politically correct way to talk in an election season- hopefully, the American people know better.

Things are already changing and they have to keep changing if we’re going to head off the real health care cost crisis before it actually happens. The sooner the politicians and the media can start to talk straight with the American people, the sooner they will get on board and help to become part of the solution.

The information and subject of this report is important. Employers are going to change their behaviors when the incentives of the game are changed. When employers change their behaviors, things are going to change for the employees. It’s not complicated. What is complicated is coming up with alternative solutions to address the changing behaviors and at least help the employees plan for what may be coming down the road. Unfortunately, this report didn’t get that far. And, probably didn’t try.

Health Care and the Supreme Court:: All Bets Are Off

Before the Supreme Court arguments began I was pretty confident they would rule as follows: The Anti-Injunction Act wouldn’t apply (they would move forward on the other items), they would narrowly determine the individual mandate to be Constitutional (requiring everyone to have some type of protection for health care costs), the Severability provisions wouldn’t apply (since the individual mandate would remain in place), and the expansion of Medicaid would move forward (since states aren’t necessarily “forced” to participate in Medicaid in the first place). After this week, I could be wrong on three out of four.

While oral arguments are seldom indicative of what the final results will be in a Supreme Court decision, the picture that emerged last week was less than optimistic for the Affordable Care Act. All Justices seemed to indicate the Anti-Injunction Act does not apply so there was little disagreement between the sides. However, the government simply could not defend its position for requiring the purchase of health insurance for everyone, why the rest of the law should remain in-force even if the mandate was repealed, and why the Medicaid expansion is not a “coercion of federal power.” At times, listening to the government blurt its incoherent responses to questions was painful.

If the Affordable Care Act is thrown out in its entirety, we will once again be starting over with health care and it’s not going to be any easier the next time around.

Republicans will continue to push to rely on the free-market which simply will not work in health care today. Democrats will move to a single-payer argument which will not be accepted by most of the population. We will once again be at a stalemate. In the meantime, individuals and families will continue to struggle with the system we have patched together and be destroyed by its rules and its costs. We have lost precious time and millions of dollars fighting this fight.

Hopefully, the Supreme Court will come to a legal and yet rational decision. If the individual mandate is ruled unconstitutional, let’s hope they keep some of the provisions in the Affordable Care Act that make sense and let Congress piece together a plan that can work- by fixing the delivery of health care first- and then worry about getting everyone in the game.

It’s what they should have done from the beginning.

Buying Health Insurance Is Going To Change

The Congressional Budget Office released an update of their thoughts on the impact the Affordable Care Act might have on the way health insurance is delivered in America. The numbers are a little different than what they thought back in 2010 when the Act was signed into law.

In their report (you can get it off the CHCI web site by clicking here); "Estimates of the Effects of the Affordable Care Act on the Number of People Obtaining Employment-Based Health Insurance," the CBO attempts to determine the impact all of the new rules of the ACA will have on the different “systems” we have (and will continue to have) to pay for health care in this country. This includes trying to estimate how many individuals will continue to obtain health insurance from their employer; how many will go to the health insurance exchanges, and how many will gravitate to an expanded Medicaid program. In 2010 the CBO thought 8-9 million individuals would lose their health insurance from their employer (primarily small employers) and either purchase health insurance through the health insurance exchange or Medicaid or remain uninsured and pay the penalty. The new number is 11 million.

CBO spent quite a bit of time in this report explaining all the reasons making any projections are so difficult. Behavioral economics plays a large role in what will happen, but, as illustrated by behavioral economist Dan Ariely, we are all “predictably irrational.” We have no idea how all of this is going to change the mix.

Regardless of what the number is, the health insurance market is about to go through a huge shake-up. While today's discussion continues to focus on purchasing “health insurance,” the real discussion should be centered on how we will individually finance the health care services we will inevitably use. An even bigger issue will ultimately be the training and educating of the 11 million (or whatever number it ends up being) individuals who will leave the world of employer-based health insurance to begin making these decisions on their own.

The CBO still has no idea of what will actually happen when/if the ACA moves forward. Suffice it to say the world of health care will continue to change in dramatic ways. The individual and their families are going to need to be engaged whether they want to or not.

Update- Women's Preventive Health -Starting At The Wrong End

The health care system in this country is a reflection of our culture. The profit-motive is there, the amazing advances in medical science and technology is there, bloated costs are certainly there, inefficiency is there, and what the system decides to pay for and not pay for is decided by trying to weigh the costs and benefits of the marketplace with the needs of the society in general. It’s no wonder the system is so messed up. The pieces aren’t aligned.

The Obama Administration changed its tune on dealing with the preventive women’s health issue that was created by the Affordable Care Act; (specifically, requiring contraception services be provided at no cost to the individual). The original position and employer mandate was ludicrous (even to those not involved with politics) as the perception of infringing upon religious rights looked very real. The Administration should have known better on this one.

From a pure public health standpoint, the logic of the original mandate made some sense. Religious institutions provide a significant portion of health care in this country. Catholic hospitals make up twenty-percent of all hospital beds and in many geographic areas are the only hospitals around. To address the desire to reduce abortions and unwanted pregnancy, the Administration felt these institutions had to be included in the original mandate- women’s health is a large cost item in health care and whatever final rules were developed needed to include all major players.

The decision created an outcry and the Administration had no choice but to change their approach.

Now, instead of requiring employers to provide these services- the Administration shifted the responsibility to the health insurers. Nobody really knows how this is supposed to work but the “religious freedoms” argument for employers was theoretically resolved.

Instead, the new decision creates another administrative layer to add to an already confusing and complicated health care structure. And, don’t think anything is “free.” Somebody is going to be paying for it somewhere.

Our health care costs reflect our society. In many respects, the costs are a scorecard on how we live. A significant portion of our costs reflect our lifestyles and using contraception could be considered a lifestyle if you really want to get into it. Don’t get me wrong, reducing unwanted pregnancies and abortions is important. However, a large part of today’s unwanted pregnancies and abortions reflect lifestyle more than anything else. That's what really needs to change. Providing access to necessary health care services is one thing. Providing free access to health care services that encourage irresponsible lifestyles is another.

We need accountability in our health care system today- not encouragement to just continue what we’re doing because it’s free. Some may argue the Administration's decision was a "step in the right direction." Unfortunately, this was only a baby step if a step at all. As usual, we’re starting from the wrong end.

"Women's Preventive Health" We've Gone Too Far

Even though I didn’t agree with the overall concept from the beginning, I’ve tried to be a supporter of the Affordable Care Act. Since its passage in March, 2010 I’ve been a passive supporter- but an avid advocate for overall change in our health care relationships. I never did understand why the primary focus of the Affordable Care Act was to first get everyone insured (see previous blogs going back to 2009). I understand the theory of it- but getting more people into a broken system without focusing on what was broken made no sense. We should have learned a lesson from Massachusetts. However, the Affordable Care Act was the law we enacted, I was ready to get on-board to help make it work.

In the beginning, I respected Obama for using so much of his political capital to finally address a crisis that is coming (and is still coming) in health care. He’s certainly paying for it now.

I followed all of the legal challenges, watched as stakeholders grumbled, tolerated the huge government bureaucracy being created, and listened to the political rhetoric both for and against the legislation. All the while, I tried to continue to see the positives associated with what we had to do to address the crisis at hand.

And then the rules for “women’s preventive health” were released. Here again, I tried to look at the "bigger picture." I certainly understood the need for prevention and the use of our health care system to address broader social issues. I agree with the focus of the Affordable Care Act to address prevention as opposed to sickness.

But the legislation crossed the line for me with these new rules as it now infringes upon the fundamental religious beliefs and practices of others.

The idea of providing contraceptive resources to prevent unplanned or unwanted pregnancy certainly makes sense given the world we live in today. This is a huge cost to our society in many areas. However, to require religious organizations to now compromise their beliefs to comply with a government-mandated law is simply not who we are as a country.

The intent of the Affordable Care Act is to fix a major economic problem our country is facing. I had hoped, despite all of the complaints and criticisms, the Act could provide the framework from which to work. I tolerated all of the government rules and regulations as a necessary evil to incent stakeholders to finally begin work in different ways. I supported the cause because I know that change is necessary.

However, when the Act now is requiring individual citizens to compromise their religious beliefs for rules established by the government, it’s time for me to get off the bandwagon. The government has simply gone too far. I hope our legislative process is able to correct what I believe is a fundamental infringement on our personal rights. Until it does, the Affordable Care Act has one less supporter than it did before- and from the sounds of it, it can't afford to lose many more.

Atul Gawande- Remembering What We're Fighting About

When you are in the middle of a fight, very seldom to you ever stop, assess, and confirm that you remember why you are fighting in the first place. Most of the time we just keep on fighting.

That’s what we’re doing with health care. Even though legislation has been passed to change the way things work, we’re just continuing to fight because many adamantly disagree with the approach that is being used to make the changes and most don’t really understand what is going on. If you didn’t understand the health care system before- you really don’t understand it now. If we don’t change, it is very likely the end-result will cost a lot more and create more damage before we are through. The health care debate has become a part of a much deeper discussion our country is having with itself and still hasn’t quite figured out the right answer.

Atul Gawande’s June 1, 2009 New Yorker article had quite an influence on getting us where we are today. (It’s a good article- You can link to it Here) Sometimes it’s important to step back and reflect on why this fight started in the first place.

The health care system Gawande describes is influenced by many different incentives both internally created and externally driven. The influence of the incentives and the personal make-up of the health care stakeholders determine the type of health care system that is developed in a local community. The health care system then determines the economics (how much it costs and how it is delivered). Gawande believed the health and age of a population have little to do with significant variations in the cost of health care we are experiencing today; it’s the system used to deliver health care that really matters.

Yes, critics have challenged some of the facts but the challenges don’t erase the picture of health care the article constructs. The challenges don't negate the reality.

Even as we continue to fight about it, we should also take some time to step back and reflect on the health care system described by Gawande almost 3 years ago. We need to take a moment and remember what we’re fighting for- and hope we are making some progress to come to a solution as we fight.

At this point, the progress seems questionable.

Iowa Caucuses- Health Care IS an Economic and Debt Issue

The Iowa caucuses are over and it’s on to New Hampshire. To nobody’s surprise, it was a close contest, a lot of money was spent, and a lot of negative advertising was used in the strategies. Republicans still aren’t united behind any single contestant- but the field will narrow over the next few weeks.

Iowa gave us the first look at the results of the Citizens United decision made by the Supreme Court last year. There is going to be even more money spent, with candidates hiding behind the covers of the “super PACs” created on their behalf. Free speech? We’ll see.

Iowan’s are a rational bunch. They look at things from a different perspective than those in Washington D.C., New York, California or the other highly populated areas. They care about community, about agriculture, and about things that are relevant to themselves. They don’t usually like the negativity associated with politics- but the Iowa caucuses proved the negative ads work. We’ll see a lot more of them.

Interestingly, Iowa Republican’s participating in the caucuses listed the economy and the debt as their primary issues of concern. Health care and abortion listed in the distance.

The Iowa caucuses proved that we continue to keep health care as a separate and distinct political issue even though fixing our health care mess is directly related to both the economy and the debt. A Pew Research Foundation study in April, 2011 determined the unfunded liabilities associated with pensions and health care for state governments increased 26% (to $1.6 trillion) in one year alone. Health care IS an economic and debt issue.

Iowa has always been the starting point of the presidential election process and used to either gather momentum or begin the elimination of candidates. Iowa also provides lessons as to what works and what doesn’t work in the campaign process.

The Iowa caucuses taught us: The Republicans are still not sure who to get behind to run against Obama in 2012, Super PAC negativity works (unfortunately)- and we’ll see a lot more, "retail/door-to-door" politics is still effective, and we still don’t believe reforming health care has much to do with jobs, the economy, or our debt.

We’ll see what we learn in New Hamphshire.

2011 Government Financial Report- Unacceptable

Right before Christmas (December 23) the Government Accountability Office (GAO) released its “2011 Financial Report of the United States Government.” The GAO works for Congress and operates as a bi-partisan watchdog to monitor how taxpayer dollars are being spent.

The press release associated with the release of the report stated, “The U.S. Government Accountability Office (GAO) cannot render an opinion on the 2011 consolidated financial statements of the federal government, because of widespread material internal control weaknesses, significant uncertainties, and other limitations.

Specifically, the press release cited; 1. Serious financial management problems at the Department of Defense (DOD) that make its financial statements unauditable, 2. The federal government’s inability to adequately account for and reconcile intragovernmental activity and balances between federal agencies, and 3. The federal government’s ineffective process for preparing the consolidated financial statements.

The report identified a material weakness of $115.3 billion in improper payments, information security issues across government, and tax collection activities.

I’ve posted the study in the Library of our site. It discusses some of the basic numbers ($1.3 trillion deficit compared to $2.1` trillion in 2010; 1.9 million new jobs compared to 350,000 in 2010) and an overview of some of the actions taken to try to get the country on the right track. You can look at the numbers and decide how well they are working for yourself. The numbers indicate some progress was made- just not nearly enough.

From a health care perspective- the report makes two significant points- Medicare, Medicaid, and Social Security are big parts of the problem (representing 45% of all spending), and the Medicare Trust Fund will run out of funding in 2024- five years earlier than was projected in 2010.

While many are calling for “cuts” that usually impact the “boots on the ground” citizen, this report shows we would likely find huge opportunities to reduce spending simply by putting accountable accounting systems in place to track where money is going and how well it is being invested.

In a nutshell, the accounting controls and books used to measure how well we’re doing financially as a country are a mess. In all honesty, we probably don’t have a real clue how big our debt really is- and its inexcusable. The financial managers associated with such a report in the private market would likely be fired.

We should expect no less from those responsible for the allocation of our taxpayer dollars- including the Congress (both Republican and Democrat alike). They need to be held accountable for the results of their efforts. This effort is unacceptable.