Entries Tagged as 'health care'

How to Fix Obamacare

David Frum October 5th, 2011 at 1:00 pm 108 Comments

In my column for The Week, online I discuss ways in which the Affordable Care Act could be streamlined into a workable solution for health care reform:

If the election were held today, for sale President Obama would probably lose. The Republicans would very likely score gains in the Senate, see but probably lose seats in the House – maybe even lose their majority altogether.

In such a case, after January 2013, the US would have a president committed to the repeal of the Affordable Care Act (aka, “Obamacare”) – but lacking the votes to carry out his pledge.

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Sweden’s Health Care Pays Off

David Frum June 10th, 2011 at 11:12 am 29 Comments

More casual Swedish empiricism:

The people of this industrial town look much better cared for than their US or UK counterparts. I haven’t seen a single obese person in 24 hours of walking and running through this small town. Some of the young people wear tattoos, but none have slashed and studded themselves with the piercings and disfigurements you see on British working class youth. Nobody seems to have the idea of using clothing to assert membership in some subculture, or to stand out from the crowd, or even to seem alluring or sexy by local norms. The girls’ clothing is as formless and drably colored as the boys’. The teenage girls wear the same easy-care hairstyles as the grown women.

Lots of kids, lots of strollers, not infrequently pushed by men, but almost always pushed by people who look older and grayer than the stroller-pushers in an American industrial town would be.

On the verandah outside the senior citizens center, the old people do not push oxygen tanks or support their bulk on motor scooters.

Consumer money visibly appears to be lavished upon cars, which are newer and larger and more numerous than you’d see in an industrial town in southern Europe.

What Swedes Really Think About Their Health Care

David Frum June 10th, 2011 at 7:55 am Updated38 Comments

The audience at the conference is about half Swedish, half not. The Swedish attendees are as you would expect drawn from the more elite strata of Swedish social life. Interestingly, when asked about the Swedish healthcare system, they express generally positive views – with specific comments that sound very similar to what equivalently positioned Canadians would say about Canada.


  • if a Swede gets very sick, he or she can expect a very high degree of care.
  • everyday care (the strep throats and twisted ankles that send parents to the pediatrician twice a year) is done adequately, if with more waiting and fewer prescriptions than affluent Americans would expect
  • the real gap in the system is the care of the chronic ailments of older age: delays for hip replacements, eye surgery, etc.

But even affluent Swedes of mostly right-of-center views find it shocking that a society could abandon a seventh of its population with no guarantee of care at all. And the thought of spending 17% of GDP to buy such leaky coverage seems to them just utterly irrational.

Swedish politics are shifting very subtly to the right. The country has what here counts as a conservative government, with avowed intentions of opening more space for private initiative, lowering taxes, and decentralizing.


An answer to commenters:

Since 2008, I’ve posted numerous statements of the reasons that have led me to revise some of the opinions I held 20 years ago, for example here and here.

Is it really too much to ask commenters to do a 5-minute Google search before complaining that I have offered no such explanations?

Posted at 10:49am

Can Seniors Really Handle a Medicare Cut?

David Frum May 17th, 2011 at 11:56 am 34 Comments

Jared Bernstein makes the point that Social Security provides more than 60% of the income for Americans over age 65. (h/t “Debs”)

There are a lot of implications here, but here’s one more to consider:

The Paul Ryan plan endorsed by so many GOP thought leaders is premised on the idea that sometime after 2021, we can begin to ask senior citizens to pay a large and ever rising share of their Medicare costs. Looking at Bernstein’s estimate of senior citizen income, one has to ask: How? Especially when we consider that the people now aged 54 are going to have to save up that money over a decade of slack job markets and presumably weak income growth.

Fast-Tracking the FDA

May 13th, 2011 at 9:00 am 10 Comments

In a previous blog post, I noted that while the FDA is currently releasing directives to put calorie information on vending machines, there is little being done to expedite the FDA’s process of approving new drugs and medical procedures. Washington ought to consider the “Free to Choose Medicine Initiative” popularized by the Heartland Institute to achieve this.

The principle feature of “Free to Choose Medicine” goes directly at the shopworn and inefficient FDA drug approval process by redefining it away from its currently impossible task: ensuring the absolute safety of all new drugs brought to market.

Currently, rather than admit that 100 percent safety can never be achieved, the FDA keeps coming up with ever more rigorous, time-consuming and costly standards of review that keep new drugs off the market even though there is a demonstrated need for them. There are literally hundreds of cases where a drug that would ultimately prove safe and effective was delayed for months or years – and tragically, patients who needed the drugs died before they could be made available.

The “Free to Choose Medicine” initiative would reform the FDA by creating a second drug and medical device approval track.  On this second track, doctors and patients would play a more direct role in determining the utility of new or experimental treatments.

By creating two tracks, the status quo is maintained for anyone who still wishes to rely upon the existing approval process while providing an alternative for others that could save lives.  Patients with either a terminal diagnosis or a chronic illness could have access to drugs submitted to the FDA for review and judged to be generally safe but not yet ready for formal approval.

In order for the 2nd track to work, pharmaceutical companies would have to make available all existing relevant information on the drug that is waiting for approval.  Patients, in consultation with their doctors, would agree to accept that there are some risks associated with using the unapproved drug.

These patients in consultation with their doctors would keep track of their medical progress with the results submitted to a nationwide Trade-Off Evaluation Database – a database that would be open to medical practitioners nationwide. The FDA would be legally authorized to use the results as a way of either approving or denying the drug for public use.  This process could reduce by 4-6 years the amount of time that drug approval takes.   And lower drug approval times means lower costs for patients.

Patients will have access to more treatment options sooner and doctors will be able to better understand the results of various treatments.  Moreover, since companies’ research costs are lower, everyone can benefit from the reduction in drug costs.

Romney’s Health Speech Venue: Another Misstep?

May 12th, 2011 at 1:30 pm 9 Comments

Former Speaker Newt Gingrich got off to a not-so-great start yesterday with some website problems just as he announced to 1.3 million people on Twitter that he was running for president. Mitt Romney seems to have bungled a few of the details of his campaign’s first few weeks too.

As National Review notes, Romney is giving a major health care speech today at the University of Michigan Cardiovascular Center:

Two interesting tidbits about the Center: it’s affiliated with a university that provides abortions Planned Parenthood cannot do and it helped fund new embryonic stem cell lines — which requires the destruction of human embryos.

Since Romney is both pro-life and opposes embryonic stem cell research – as is a large proportion of the Republican primary electorate – this presents a bit of a problem.

This comes on the heels of two other missteps that have come with the launching of Romney’s campaign: the announcement of his presidential exploratory committee on the fifth anniversary of Romneycare, and the adoption of a campaign slogan – “Believe in America” – that was once the slogan used by John Kerry’s cross-country tour in 2004.

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Can Mitt Move Beyond Romneycare?

May 11th, 2011 at 8:13 am 37 Comments

It’s perhaps hard not to feel some sympathy for the situation Mitt Romney has found himself in. By the close of the 2008 Republican primary, he was seen as the standard-bearer of conservatism, picking up the support of the likes of Ann Coulter and Jim DeMint. Yet now, he finds himself attacked as a lefty RINO and utter traitor to the conservative cause—for Romneycare, a measure he backed in 2006. Romney’s record as governor did not change from 2008 to 2011 (he stopped being governor in 2007), but the perception of the conservative commentariat has. Notoriously derided as a flip-flopper, Romney has now found that some in the right-leaning punditocracy have flip-flopped on him. And these attacks on Romney emphasize not merely how the partisan optics have changed since 2008, which they have, but often criticize his politics on a much deeper, ideological level.

The Massachusetts health-care law has become an albatross around the neck of the man who could maybe almost be the Republican front-runner. The passage of Obamacare made health-care reform a central litmus-test issue for grassroots conservatives. The fact that the Obama White House boasts of similarities between Romney’s reforms and Obamacare is not going to endear Republicans to Romney.

From the perspective of free-market conservatism, the reforms Romney sponsored have not been a resounding success. The rate of health-care uninsurance in the Bay State has dropped significantly, which is good (over 98% of the Commonwealth has health insurance). Wait times have potentially increased a little, though trends for longer delays for receiving care were in place before Romneycare passed. But costs are exploding. Romney’s Democratic successor, Deval Patrick, is now looking to create a regulatory infrastructure to control insurance rates (and thereby doctor pay) as a way of coping with these skyrocketing bills. With unchecked Democratic power in Massachusetts, further state control of health-care delivery may be only just around the corner. Unless further reforms are made, Romney’s health-care reform may prove to be quite the shot in the arm for private health-care in Massachusetts: a lethal injection.

So Romney’s big speech on Thursday may prove to be a necessary but also somewhat desperate gamble. Faced with the (perhaps unfair) public perception that he is an opportunist who will shift in whatever direction may benefit him the most, Romney seems to have decided that he cannot utterly repudiate the Massachusetts health-care law. The fact that he has spent so many years defending these reforms would give a repudiation now an especially high political price.

Either a total defense of Romneycare or a total repudiation of it could damage his image in the eyes of grassroots conservatives and potential swing voters. Successfully resolving the health-care issue could help scrape away some of the veneer of artificiality so many voters have doubts about while also burnishing his conservative bona fides. Here are some thoughts about what Romney might want to achieve politically in this address:

Make clear the distance from Obamacare: Romney may attack Obamacare as inefficient, destructive, problematic, and so forth, but he should particularly emphasize those features of it (such as the 50-state mandate) that differ from the Massachusetts reforms. Attacking Obamacare is bound to win applause from righties. But Romney’s attacks will ring hollow if he has not posed enough plausible distance between his policies in Massachusetts and those of Obama.

Build on the strengths of Romneycare: There are some positive, free-market features of the Massachusetts health-care law, which the Heritage Foundation praised. Romney could tout those.

Show technical expertise: The ability to maneuver through complex bureaucracies will be key for any potential Republican administration. Romney has a wealth of experience in running large organizations and a considerable proficiency with the details of policy. His speech on Thursday can showcase those skills. This speech doesn’t have to be—and probably shouldn’t be—a total wonkfest, but a suggestion of Romney’s wonky tendencies would play to his strengths as a credible, center-right technocrat.

Move the debate forward: This is perhaps the most important political objective for the speech. If Romneycare dominates his Republican primary narrative (including both his campaign and what is said about his campaign), Romney loses. Game over. In this speech, Romney needs to change the topic to present a forward-looking approach to federal health-care reform (which he looks likely to do). Romney knows that even the all-out repeal of Obamacare will not be enough for our nation’s health-care system, which does need reform. Moreover, every serious Republican candidate is probably going to talk about repealing Obamacare. By focusing on a specific set of policies for a way forward, Romney can distinguish his candidacy from the rest of the pack. For his political survival, Romney must make this campaign about the future.

Moreover, the right does need creative ways of trying to reform the health-care system to make it more affordable and efficient. Such a tangled web of government/non-profit/for profit institutions has been set up that any reform will have to be as careful as possible to avoid any drastic and unpleasant unintended consequences. By focusing on the future of health-care reform (both for the private market and for Medicare, Medicaid, and other government programs), Romney can keep the past from sucking all the air out of present debates.

This could be a pivotal speech for Romney. If Romney can prove his viability on the health-care issue, he could start to solidify a core of support. If he cannot resolve the public perception of his health-care policies, he may find himself limping along and find the path to the nomination that much harder. Moments of testing can make or break a candidacy, and this may be one such moment.

Originally published at A Certain Enthusiasm.

A Health Care Race the U.S. Shouldn’t Win

April 30th, 2011 at 11:20 am 12 Comments

A new study by the Kaiser Family Foundation comparing U.S. healthcare costs with the rest of the world is providing ammunition to both sides in the health reform debate.

The headline from The Hill’s report highlights how the study is being reported in the press:

Report: U.S. healthcare costs growing faster than elsewhere

The initial reaction by many is likely to be that the blame lies with the insurance companies and their outrageous profits. Wrong. The major rate of growth in costs is in those in the Medicare system over the age of 75 with an increase 8 to 12 times greater than those aged 50-64 as found in earlier studies by the National Bureau of Economic Research.

It’s true that private health insurance premiums have risen at essentially the same rate as the growth in total national health care expenditures.  The problem though is not exclusively in private or employer sponsored insurance but is attributable to all elements of the U.S. healthcare system, generic and particularly to Medicare. This point is emphasized by the fact that public spending on healthcare in the U.S. rose faster as a percent of GDP than in any other developed country according to OECD data.

One of the key talking points for the left on Obamacare is that is preserves Medicare, sovaldi supposedly unlike the Ryan plan.  These data points though are really bad news, as preserving “Medicare as we know it” is unsustainable.

To make matters worse for the single payer gang, the percent rate of growth in healthcare costs in Spain, Belgium, Sweden, The Netherlands, and Great Britain were all greater than in the U.S. Of course, we start from a dramatically higher baseline, mostly attributable to much higher prices in the U.S. Nonetheless, simply adopting a government-run health care system didn’t solve the problem in those five nations.

Certainly, the published assessment of the data is always open to further analysis. The Hill’s headline that the growth of costs in the U.S. is greater than any other country is totally predictable given our much higher baseline costs. This is the power of compound interest: If you have a higher baseline, equal per cent increases compared to other nations will lead to ever higher absolute dollar cost increases. Moreover, these data require complex adjustments for currency exchange issues as well as the underlying growth rate of the entire economy in each nation.

However, regardless of how one approaches health care reform the study makes one thing clear: cost control has to be addressed.

Mitt Romney’s Achilles Heel

David Frum April 21st, 2011 at 10:27 am 47 Comments

The Onion identifies it:

“Every day I am haunted by the fact that I gave impoverished Massachusetts citizens a chance to receive health care,” Romney told reporters Wednesday, adding that he feels ashamed whenever he looks back at how he forged bipartisan support to help uninsured Americans afford medicine to cure their illnesses. “I’m only human, and I’ve made mistakes. None bigger, of course, than helping cancer patients receive chemotherapy treatments and making sure that those suffering from pediatric AIDS could obtain medications, but that’s my cross to bear.”

“My hope is that Republican voters will one day forgive me for making it easier for sick people—especially low-income sick people—to go to the hospital and see a doctor,” Romney added. “It was wrong, and I’m sorry.”

According to Romney, if he could do things over again, he would do everything he could to make certain that uninsured individuals got sicker and sicker until they died.

The Health Cost Fix Obama Won’t Accept

April 21st, 2011 at 7:31 am 20 Comments

The Patient Protection and Affordable Care Act (PPACA) — Obamacare–  is coming under new attacks as the constitutionality of the individual mandate nears the Supreme Court. In particular, there are new questions about the president’s preferred cost control mechanisms. Yet, the one possible solution for the president’s health cost worries is still off the table.

The new criticism has focused on two particular mechanisms from the PPACA: the Independent Payment Advisory Board (IPAB) — the group affectionately known as the “death panel” — and the Accountable Care Organizations (ACO). (It’s imperative that any complex government program has an array of acronyms, preferably three letter ones, or TLA’s.)

The President has recently proposed that the IPPB be expanded and empowered to determine the payment for and nature of medical care provided to Medicare recipients. This board would have incredible and essentially unregulated power and require a supermajority of Congress to overturn its mandates.

Democrats in Congress have objected to its independence and lack of accountability to the electorate. Republicans have objected to the overwhelming likelihood that this group will be the implementers of rationing and would look to control the costs of healthcare through price controls (which never work). Moreover, the claim that this unelected group would be immune to political pressure is another example of the triumph of hope over reality.

ACOs, the other cost control proposal, are described in the health care bill as “groups of providers of services and suppliers meeting criteria specified by the Secretary [of Health and Human Services who] work together to manage and coordinate care for Medicare fee-for-service beneficiaries.”  The bill’s language goes on to describe the financial hope that “ACOs that meet quality performance standards established by the Secretary are eligible to receive payments for shared savings.” Previously, the ACOs were pretty much universally praised but lately important deficiencies have become more widely noted.

First, as I recently pointed out, demonstration projects conducted as preludes to ACOs were praised by Dr. Donald Berwick head of CMS (Centers for Medicare and Medicaid Services) as proof of cost-saving success.  In fact, analysis from Robert Berenson of the Urban Institute shows that there were no real savings in the entire demonstration project, merely more clever data  and diagnostic coding manipulation.

Furthermore, as pointed out by Michael Millenson writing in the Kaiser Health News, the new rules CMS is imposing on the ACOs make it almost impossible that the program will succeed. Participants will be forced to report on 65 various quality measures, get approval for any marketing materials, follow highly complex risk adjustment schemes (to prove that the sick patients are really sick), and have payment plans that may require the Madoff backroom to keep track of it all.  The organizational complexities imposed by the governmental bureaucracy will overwhelm the model, a problem which still undercuts many aspects of Obamacare.

ACOs have also come under attack from the right. Rita E. Numerof of the Heritage Foundation draws attention to more deficiencies: First, there’s no component that empowers consumers to be stakeholders in their own care. In fact, patients may not even know they’ve been assigned to an ACO for their care and that they may go to whichever physician or hospital they like. They certainly won’t have an economic stake in choosing one delivery group over another. It’s the lack of market discipline applied to healthcare that increases complexity and reduces the likelihood of efficiency.

Second, the current ACO model doesn’t really encourage provider accountability since it maintains the fee for service payment system. The impetus to be efficient is the possibility of a bonus later, rather than a true financial risk although risk may be incorporated into the payment system at a later date.

Finally, ACOs will require a highly sophisticated organization with costly infrastructure (for example, electronic health records). This feature will favor very large groups.  Numerof fears that ACOs could actually create an unfair competitive advantage for large organizations which could lead to a consolidation of market power in these groups and hence further drive up health care costs.

In case these three observers aren’t sufficiently intellectually or politically pure, John Kastor, a professor of Medicine at the University of Maryland writing in the New England Journal of Medicine also has doubts that academic medical centers — the dominant health care systems in many if not most urban centers — will succeed as ACOs because of many of the issues cited above and the long-standing culture of independence that characterizes the American medical workforce. There aren’t enough economic incentives in the ACO model as envisioned by Secretary Sibelius to overcome these cultural barriers.

The secret that dare not be discussed by the administration is that current large, managed care organizations are really the enterprises that could monitor and administer ACO-like models. In fact, the staff-model HMOs like the Kaiser Permanente system have already shown that they can provide less costly, high-quality care with high patient satisfaction. Such enterprises have the systems and organizational structures to manage risk.

Rather than acknowledge this reality and anger the physicians and hospitals systems that see such organizations as the “enemy”, Obama continues to vilify the insurance companies and to demean Paul Ryan’s proposal for considering the possibility that such a managed care model could work.

The president’s demagoguery of the health insurance industry may be good election year politics but it may also result in him failing to successful implement his signature program.