Friday, April 02, 2010

The Prognosis for Massachusetts...

Days before the historic vote in Washington, Independent Gubernatorial candidate and current Treasurer Tim Cahill denounced Massachusetts' health care reform as bankrupting the state.  The story, reported in the Globe, did not seem to pick up much national attention.  However, his comments proved controversial here as Massachusetts is the center of the health care debate in more ways then one.

The commonwealth's legislation is a model for the national plan.  The federal legislation mirrors the Massachusetts reform in significant ways, which is particularly ironic since Mitt Romney, then governor both signed Massachusetts reform and opposes national reform.  However, the national debate on health care also turned on a different fact.  When the Bay State elected Scott Brown, the GOP tried to spin the reason as anger over health care.  If in fact, that was the case, then voters were misinformed.  Most analysts agree that Massachusetts will see some of the smallest changes of any one state.  However, voters did not install Scott Brown over health care alone.  Rather it was anger at Beacon Hill politicians, of which Coakley was one, and far more importantly, the Attorney General's taking voters for granted.  Regardless of voters' reasons, it stripped Dems of their filibuster-busting majority and stalled efforts to pass health care.

With health care passed, Scott Brown is suddenly without an issue.  Health care may or may not have been part of what got Brown elected, but far more importantly it was the issue he planned to make his priority once sworn in.  The Globe reported today how he inadvertently flip-flopped on both the reconciliation measure and perhaps exposed his complaints that the bill will hurt Massachusetts as false.  Had Brown stuck by his comments from after the bill was passed Sunday, in which he said he had not read the reconciliation, he could give himself cover to maintain that he wants to assure Massachusetts gets a fair deal.  Then he could still vote against the reconciliation bill for the same reason he opposed health care reform in general: it would hurt Massachusetts (even though the bill will affect remarkable few individuals while infusing money into the states Medicaid and subsidy programs).  Rather he backpedaled yesterday and said he would back GOP efforts to repeal the bill and oppose the reconciliation bill.  Given the lack of evidence that the bill would hurt Massachusetts particularly, Brown's only reason for the "clarification" could be a desire to remain a GOP celebrity or a more naked attempt to placate the Bay State's medical manufacturers who will face new taxes in future years.

Going back to Cahill, his comments were far more incendiary than those of Republican gubernatorial hopeful Charlie Baker.  While Baker has criticized Massachusetts health care reform, he has not used the same language as Cahill.  Indeed, Baker has been trying furiously to differentiate himself form Cahill, whose candidacy, which is very unlikely to succeed, seems like a sham to give incumbent Deval Patrick a win by plurality with Cahill and Baker splitting the anti-incumbent vote.

Realistically, health care reform has cost Massachusetts a great deal.  However, the state's present budget crisis has more do to bad financial planning that goes back decades and overspending on failing or fraudulent social programs and grants.  Social agencies and human services groups, whose work extend beyond health care, bleed the state for millions if not more, at the expense of infrastructure and other issues.  Their leaders openly defend the dangerous practice.  Nonetheless, health care reform is not to blame alone.  There may be sacred cows within health reform that both Baker and Cahill have promised to cut, but it is not nearly the bankrupting bomb that Cahill claims it to be.  To Gov. Patrick's credit, the state is looking into quality not quantity pay schemes for health providers to keep premiums down.  This will probably be DOA in the legislature since doctors and hospitals have tremendous power on Beacon Hill, but who knows?

Another country heard from was our former ever on-the-road governor Mitt Romney.  He, too, has joined the chorus of repeal and replace from Republicans.  However, Romney has an extremely fine line to walk.  He signed health care reform when he was governor and he defends this day.  Still he tries to say it is a prescription for national disaster.  Although there are real differences between the federal and Massachusetts reforms, the highlights (coverage on parents plans for young adults, exchanges, and subsidies) exist in both.  Romney cannot even say the issue is cost since real concerns about how to fund both federal and state efforts abound today in Massachusetts and tomorrow across the country.  Neither he and Beacon Hill in 2006, nor Congress in its health care bill this month made any effort to tamp down on the cost of health care itself.

Addressing  health care costs rather than health insurance costs is extremely difficult politically.  Nobody likes insurance companies particularly those in health insurance, except maybe employees of such companies.  It is easy to beat on them because they engage in incredibly snarky business practices.  Although it need not be a government enterprise and it should be competitive health care cannot be a totally for-profit venture and many agree with this view making health insurance reform even easier.  Indeed, the national bill passed by Congress focuses far more on the insurance companies than the providers.  However, the providers are the source of major cost hikes.  Some attribute it to defensive medicine, ordering more tests to protect a doctor or health establishment from lawsuits, but given the huge expansion of the health field as the nation moved onto post-industrialism that cannot explain it alone.  There is simply more medicine that Americans can indulge in and doctors and hospital administrators are all too willing to offer it.  While most  medical professionals would not push harmful products and procedures (drug companies might though, remember Vioxx?), they are not above offering a treatment, test, or drug that might help knowing full well it will do nothing.  The saying is "do no harm" not "do only what is necessary or effective."  However, how to get in between doctors' consciences and their wallets without having government appear to get between a patient and his doctor?

As for malpractice suits, there does need to be reform in this area, particularly in Massachusetts, but more out of principle rather than as a cost control measure.  Whether for profit or not, the health care system is a business and therefore does cost-benefit analysis.  A larger establishment (doctors in private practice are unlikely spend the cost to make such analyses) may choose to risk complications willfully if avoiding them would affect the bottom line.  Therefore, malpractice torts have an important role to play.  It is not unlike the ability to recover damages from somebody who punches you as a deterrent beyond the threat of arrest.  However, the system is still rife with problems.  Unlike most common law nations the US lacks a loser-pay system that would dissuade more frivolous or dubious suits.  Moreover caps on certain payouts for economic damages and emotional distress may be prudent.  Opposition largely comes from trial lawyers who earn quite a bit from litigation often working on contingency.  Still, malpractice litigation eats up relatively little from health costs and in some states like Texas that have tough malpractice claims, insurance and health costs can still be high.  Any effort to control costs this way must be done to protect the injured as some charge Texas' system fails to do, but does not permit runaway law suits that leave nobody the winner, but the lawyers.

As such malpractice reform must be a part of future tweaks to the Massachusetts and federal legislation in addition to a host of other ideas.  Many of these proposals are unlikely to move anytime soon.  Washington will probably not revisit the health care bill until next year, if not until after the 2012 election.  Beacon Hill legislators cannot afford to alienate either trial lawyers or the health care field in an election year when it comes to campaign support.  However, Beacon Hill will need to make some very tough choices just to keep the state's head above water.

More likely than not, legislators must make cuts to other popular programs since taxes this year are politically unlikely.  Even if casinos pass the General Court, it is almost certain that money from construction and licensing will not hit the state's coffers till FY 2012.

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