Both of these gentlemen are smart and articulate students of the health care debate. But neither can seem to provide concise answers to very basic and very important questions about the bill before the Senate. The key questions –where are the Medicare cuts coming from and what will they mean for seniors, for example– should be softball questions after nearly a year of debate. The facts about what the bill will actually do to people shouldn’t be in dispute and should be widely known and easily agreed upon. Voters deserve at least that much.
Voters also deserve candor on the fact that the Senate bill’s alleged budget neutrality is built on deep cuts in reimbursement payments to doctors –cuts that Cohn and Aaron both seem to find either highly unlikely or irrelevant to the debate. (Dr. Aaron sent my producer an e-mail explaining that he had misstated the situation concerning doctor reimbursements –a conscientious effort that I appreciated.) The fact is that the Senate bill will never come close to being budget neutral unless devastating cuts are made to Medicare, particularly in the payments Medicare makes to doctors. Thus the whole debate is proceeding on the fiction that this massive new entitlement program is paid for. It isn’t. If it passes, the yawning budget deficits will grow enormously and very quickly.
I invite close scrutiny of these transcripts and encourage anyone who blogs on either or both of them to send me their analysis via e-mail or a link via email@example.com. Many doctors who listened to the interviews have already sent me passionate e-mails (some reproduced below) about the errors they detected in the Cohn/Aaron arguments. I think close examination of either conversation will reveal that neither Mr. Cohn or Dr. Aaron could not provide concise, precise, and direct answers to the obvious and straightforward questions I posed because the Senate bill is a hodgepodge of concepts lacking detail or even a summary of details. Whenever estimates of costs are no better than within tens of billions of dollars, for example, it is a certainty that no one really knows how the proposal will work.
Passing a bill this thin on detail is madness of course, but especially so when it will dramatically impact every single American, and especially seniors. Gambling with everyone’s health care on the basis of huge mirages like the savings to be achieved by productivity gains and the reduction in the incidence in infections in hospital is just nuts. What do I mean? Here’s a key exchange with Cohn on where the “savings” in Medicare are coming from:
HH: Jonathan, you were going to tell me how much are the cuts to Medicare Advantage in the present iteration of the bill?
JC: Yes, yes. And now the reason I couldn’t remember if it was closer to $100 or $200 billion is because the House and the Senate actually have different numbers. The House number is around $180 billion, so that’s closer to $200 billion. The Senate’s actually lower than I remembered. It’s closer, it’s around $120 billion.
HH: Okay, if it’s only $120 billion, where are they going to get the other $300-400 billion dollars in cuts to Medicare?
JC: Well, you know, most of these are changes, they’re sort of stacked one on top of the other, lots of little changes in the way that Medicare pays for health care. And the good news here is that as opposed to the past, now we’ve made cuts to Medicare in the past, and we’ve actually, contrary to what you may have heard, you know, we made cuts, and we actually let them stand. But in the past, often, you know, we wanted to cut Medicare spending, because we decided that the program was too expensive. We were just going to whack off, you know, the top 5, and say oh, we’re just going to cut payments, period. These changes are targeted to do very specific things, because we have…one thing we’ve learned, and really, it’s in the last ten, fifteen years, we’ve become aware of this, is that we waste a ton of money in our health care system. You know, we waste money because we send people with chronic disease to ten different doctors, when they’d be better off having two or three that communicate with each other well. And we pay hospitals the same, even if some hospitals clearly aren’t doing a very good job, and have a high rate of something like hospital infections, which is something that no hospital should have. There’s no reason you have to be…any rudimentary hospital can all but cut out in-hospital infections if they just follow the right procedures. So the changes that we’re going to see in Medicare are things like we’re going to start penalizing hospitals if they have high rates of inpatient infection. We’re going to take away, we’re going to say we’re not going to pay you as much for treating this patient, because you did a lousy job.
HH: But now that would be preventative, and hopefully they would change.
HH: And so that would not lower the cost of Medicare.
JC: Well no, it does, because you see, this is what’s great about it, is that it happens to be that actually treating those infections is really expensive. So one of two things is going to happen. Either they’re going to keep giving people the infections, or we’re just going to pay them less, or they won’t keep giving people the infections, in which case they’ll run up lower charges.
HH: And how do they get the money to prevent people from getting the infections, because that’s got to be a costly transaction, right?
JC: Well no, this is one of the…and I am giving you the easiest example here…
HH: Sure you are.
JC: …because it’s easy to explain over the phone and everything. But they have done studies that show there’s actually a very easy, five step process that you can follow to drastically reduce the number of infections in hospitals. It was actually tested here in Michigan, as it happens, pure coincidence. Somebody did a study across the state, and they found that, you know, all the hospitals, the big ones, the small ones, the teaching ones, the community ones, all they did was very simple stuff like making sure everybody washes their hands, making sure you always apply a clean dressing…
HH: Jonathan, time out for a second. My law firm has represented hospitals for a long time when they’re sued for malpractice, et cetera. Hospitals across the United States are not indifferent to infection rates. Do you really believe that hospital administrators are walking around the United States not doing simple, easy, inexpensive things that will keep down infection rates?
JC: Yeah, actually I do, because this is what they found. They looked, and you know, everybody knows what you’re supposed to do. Obviously, everybody is taught it, but then, you know, we’re talking about human beings here, and they don’t. What these studies found was that if you actually do, and this is going to sound silly, but you know how when you go on an airplane, and the pilots have a checklist?
HH: Jonathan, that’s fine. I’ve read Clayton Christenson’s book, and I know all about that sort of stuff. But I want to go back. Have you posted yet, I’ll put it in this term…
HH: Have you posted yet a detailed analysis of where these $300-$450 billion dollars in Medicare savings are going to come from?
JC: I have not gone through every single one. I can tell you where you can find one if you want. I’ve done some of them. I did the infection one last week, which is one of the reasons that it’s in my brain right now.
HH: But isn’t it fair to say, I haven’t seen it anywhere, where they actually spell out in specific detail here is where we’re going to carve up Medicare to save the money? Now how much money are we going to save from stopping infections by washing hands?
JC: I think the figure on that was, and I’m going off the top of my head here, so don’t quote me on this, or at least check it before you use it, I think it’s about $40 billion over ten years, or something like that.
HH: Okay, so we’re down…let’s just give you the $40 billion in washing hands. We’re down to between $260 billion and $410 billion.
JC: Right, right. So there’s a bunch of things like this, is what’s I’m talking about. It’s not just one. I mean, there’s a whole list of these things.
HH: How many times can you stop an infection? I mean, it’s…come on, Jonathan, where are the cuts coming? Tell us where the cuts are coming.
JC: I am telling you. There is what’s called a productivity adjustment, and a lot of that is a bit part of the bang here, which is basically saying look, we are expecting over the next several years, and this ramps up gradually, so that hospitals and doctors can sort of plan on this in advance, and not just have it hit them in the face tomorrow, that look, we’re expecting that you can become more productive using information technology, coordinating your treatments better, so you can expect that we’re going to adjust your, every year there’s an adjustment in the rates to Medicare, and we’re just going to slightly lower that curve.
HH: So they’re just going to stop sending the money they currently send, and tell them to make up the difference in productivity?
Here’s a key exchange with Dr. Aaron:
HH: How many are enrolled in Medicare Advantage?
HA: About 20% of all Medicare enrollees are in Medicare Advantage. It’s going up, because of these very, very, because of overpayments to Medicare Advantage plans.
HH: And so what, in terms of millions of people, how many does that work out to?
HA: Well, I don’t have the exact number, but 20%, there are about 35 million Medicare enrollees, so 20% is probably in the vicinity of seven, eight million, but heading up.
HH: Okay, so between seven and eight million Americans are going to get less services after this passes than they are used to?
HA: They’re going to get the same services that the rest of Medicare enrollees receive.
HH: I understand that part, Dr. Aaron. But for clarity’s purposes, those seven million are going to get less than they’ve been getting before.
HA: That may well be the case. I don’t know.
HH: And what…
HA: It’s going to vary from plan to plan, depending on exactly what the fee structure is, how efficiently they operate, and what services they’ve been providing.
HH: Has anyone studied, are you aware of any study of the impact on the quality of life of those seven million people?
HA: No, I’m not.
HH: Okay, that’s fine. That’s fair. I don’t think anyone has, actually. So I…
HA: The story is that if one is going to extend coverage as the Senate plan would do to 25 to 35 million, or currently uninsured Americans, they’re going to consume some more health care services. And the money to pay for that needs to come from somewhere. Most of the money would come from projected growth in productivity of health care delivery under Medicare. And some of it from taxing excessively generous, or very expensive health insurance plans for the non-elderly, and some of it from other revenue sources, that those sources are different in the House and the Senate bill. But there’s no free lunch. If 25-35 million more people are going to be receiving health care that they don’t currently receive, the President has sworn that he won’t sign a bill that increases the federal budget deficit, so you’ve got to pay for it.
This sort of vagueness –on the part of key and expert advocates for Obamacare– ought to scare everyone, even supporters of so-called reform. The truth is that no one really knows how this is supposed to work, but the pressure for a political win has grown so great that otherwise responsible people are just urging on anything for the sake of declaring victory.
This is a nightmare that can be avoided. I think concerned citizens best amplify their voices through contributions to ReverseTheVote.org. ReverseTheVote.org is designed to send an unmistakable message to the 24 most vulnerable House Democrats who voted for Obamacare, a message that says they will lose their jobs if this bill passes. As it progresses through the Senate, the backlash should grow, especially as the public learns that the Senate doesn’t really know what the bill will do. A thousand slogans cannot obscure the fact that this is a wildly risky scheme that will profoundly change the way Americans get their medical care.
UPDATE: One more e-mail: