Breaking down the health care bill

Interview with Congresswoman Tammy Baldwin, by A. David Dahmer

 
Back before it was one her signature issues as a politician, health care was a very personal issue for Congresswoman Tammy Baldwin.
"As a child I had a very serious illness that required three months of hospitalization," Baldwin remembers. "The complications were called myelitis of the spine. I had an inflammation of the sheath around the spine and it was very painful.”
Baldwin, who was raised by her grandparents, would unfortunately soon learn that family policies don't cover grandchildren if they haven't been legally adopted.
"As a nine-year-old, I understood that this created a huge financial burden for my grandparents since they had to pay for a long hospitalization out of pocket," Baldwin said. 
Her grandparents could never find health care coverage for Baldwin who would not be able to obtain it until she was in college.
Baldwin began to see that her predicament was not all that rare — that families often experienced extraordinary hardships because of gaps in the health care system. Health care is the number one issue for her constituents. There is no issue is of greater concern among working families in Wisconsin than health care, and the new bill trying to make its way through Congress. Baldwin sat down with The Madison Times in an attempt to break down the 1,018-page document.
Obama, Baldwin says, has three prominent goals he wants Congress to achieve in health care reform: providing people without coverage with options in both health care plans and in the doctors they choose; increasing affordability and lowering premiums and the spiraling health care inflation; and, thirdly, preserving high quality health care for those who have it while also  recognizing that so many people don't have access to quality care and making sure that quality health care is available throughout the United States.
The measure that is working its way through Congress has three major sections, Baldwin says. The first section would set up a health care exchange. "The best way to think of it is that it's like a health insurance supermarket," Baldwin says. "You can think of this as a place to go to shop for insurance or a website you go to."
The idea is that in every region and every market in the country that people will have a lot of information about a number of health insurance options that will be available to them, and you can easily find out exactly what they do and don't cover, what your co-pay and deductible will be, and what your insurance premium will be. "So, you can comparison shop and determine what plan will be better for you and your family," Baldwin says. "There will be assistance in shopping so you can make good choices."
There will be private and public options. "The advantage of the public option is that it won't be driven by profit," Baldwin says. "There won't be a CEO who makes 8 or 9 million dollars a year. It will be focused on high-quality health care for the population it serves. It's CEO will command a high government salary somewhere around $150,000 or $200,000."
Costs can be controlled in a public plan through a number of means.  "One is just getting rid of that profit motivation," Baldwin says. "Number two, when you get 10 million people involved you are able to get better bargains."
If you are a private insurance company, you cannot discriminate against people with pre-existing conditions. "You have to accept anyone who can pay your premium," Baldwin says. "You get rid of that cherry-picking they do right now."
They also cap the out-of-pocket expenses that any patient enrolled could be subject to at $10,000. "[It's] still a high figure, but right now people have to declare bankruptcy because they get quarter-million bills when their insurance coverage is capped and they have to pay the rest," Baldwin says.
In Wisconsin last year, there were 950 personal bankruptcies because of illness or medical expenses.
In the first part of the new bill, for those who have incomes less that 400 percent of the poverty level, there is a sliding-scale subsidy.
"The exchange, in its early days, will be focused on the 47 million uninsured people and those who are underinsured in small-business settings who have been priced out of the market," Baldwin says. "Initially, probably somewhere between 80 to 100 million Americans will participate in this exchange — this supermarket that I am talking about."
The second part of the bill will focus on making innovations and in strengthening the Medicaid and Medicare programs. "Recognizing that states are really strapped for cash right now, additions to the Medicaid program will be borne almost exclusively by the federal government," Baldwin says, "so that states don't resist opening up their programs because they just can't afford it like we're seeing now."
There are 40 million seniors on Medicare right now and what they are finding, Baldwin says, is that Medicare reimburses more for quantity rather that quality. "So there's going to be a number of quality improvements — programs implemented in the Medicare program," she says. "The relevance to overall health care reform is that if you can do like a pilot program that works really well in Medicare, you can export it and say, 'Private insurance, this works and you should try it, too.’"
The third section of the bill goes beyond just thinking about individual people’s health and tackles issues about population health. "It focuses on things like obesity, helping people stop smoking, wellness care, annual check-ups, as well as interventions for serious and acute conditions," Baldwin says. "We have a shortage of private-care physicians and nurses. Let's focus on beefing that up."
There are also things like preparedness for disaster such as pandemic flu. "All of those things are handled much better by the public health arena than between you and your individual doctor," Baldwin says.
Baldwin, who was the featured speaker at the 2004 Democratic National Convention in Boston and used the opportunity to tout health care reform, says the third part of the bill will focus on health disparities. Some of the biggest of those disparities transpire along racial lines.  "We have long-standing records on health-related disparities — disparities in access, disparities in the cultural competence of the physician or nurse or health care provider that you are dealing with," Baldwin says. 
For example, in 2004, Wisconsin had the worst African American infant mortality rate of 35 states that reported deaths by race. That year, 125 African American babies died in the first year following their births, a rate of 19.2 deaths per 1,000 births. Far above the death rate for White babies, 6.2 deaths per thousand.
The health insurance system as it is right now does not have much interest in decreasing those disparities.
"Why would Blue Cross/Blue Shield or Dean or whatever say, ‘We really have to think about how we can improve these statistics in the state of Wisconsin.’ We have to really work together to do this," Baldwin says. "Individual doctors will do the best to take care of the patients they have, but that doesn't address something that is a little further afield. It really takes a focus on public health."
Laid out and actually read, the new health care plan doesn't seem that intimidating. So, why are some people getting so scared? Why are people coming to town hall meetings all enraged and shouting?
"Think about those folks who profit mightily from our current system," Baldwin says. "The average CEO pay of a for-profit health insurance — if you average the top seven in the U.S. — is 9.7 million dollars and that probably doesn't include all of the stock options and benefits. That's enough to insure 648 families for a year."
So, obviously there are going to be a lot of people protecting their turf right now whether it is through distortion, propaganda, or fearmongering.
"It appears that a lot of these disruption efforts are being funded from those whom change is scary and want to keep the status quo," Baldwin says. "The second part [of the scared public] is due to the level of disinformation where there are fewer papers like [The Madison Times] doing investigative reporting. So, people are getting e-mails forwarded from a friend of theirs about the health care bill and believing everything they read."
But Baldwin thinks that in the last couple of weeks, things have pivoted from a fear tactic to a teachable moment in the United States.
"Other countries are not afraid to talk about death as we are. But, we're all going to die," Baldwin says. "We don't talk about it here. The last thing you want at the end of life is to have somebody's wishes totally disregarded and be subject to things that are completely against their will. It's an emotional and very touchy subject, but I think that the measures that we added to the bill to promote dialog, to teach and to present people with knowledge about their options is really important; and maybe this will pivot from something that was intended to kill health care reform into something that ends up educating large numbers of people in the United States and helping them to become empowered."
But can the United States afford it?
"Passage of health care reform will not add to our deficit," Baldwin states. "In other words, the bill has to be paid for in order to move forward. Right now, it's paid for in a combination of ways. Almost half of it is paid for by savings within the existing health care system. "
Baldwin says that 15 or 20 years ago maybe five cents on every dollar was spent on things unrelated to health care. "Now, it's 20 [cents]. Some people would argue that it's even more than 20 cents per dollar," Baldwin says. "You streamline administration and direct that back into health care. Right there is an enormous amount of money when you aggregate it over a population of 300 million people."
Other innovations laid out in the second section of the bill will increase quality and reduce cost.
"Right now, there is incentive in our system to run test after test and procedure after procedure and exam after exam even if it was done last week by a different physician, because that's how people are compensated," Baldwin says. "If you have a heart attack, there is another way to do it which is to say, 'Best evidence tells us that this is how you treat somebody who presents this level of severity with a heart attack. We’re going to pay you "X" number of dollars and you guys decide how much the hospital gets, how much the cardiologist gets, how much the nurse gets, etc.' And then you have  much less incentive to duplicate and do unnecessary things."
As time begins to run low, Baldwin is not as optimistic as she once was about the health care bill passing.
"I'm still at the point where I will tell you that we will pass a health care reform bill," she says. "Three months ago if you would have asked me I would say [there’s a] 75 percent [chance] we would pass it, 25 percent [chance] we won't. I'm now down at a 55/45 split. I still think we're going to do it; I just think there is a lot of heavy lifting still to go."
Baldwin fully admits that as we look at it today, the bill does not look like the original bill that was produced. So many committees have worked on it and made modifications and improvements to it.
"Not all of them have been improvements," Baldwin smiles. "But in order to get to a majority in each house, I think additional changes will ultimately be made and some of them I'm going to like and some of them I'm not going to like.
"That's always frustrating, because I started this whole debate [saying] 'I want a single-payer system,'" Baldwin adds. "This is quite a distance from the single-payer system at this point. But we do have that public option and that public option, to me, is extremely important. We have to keep the for-profit entities honest. We have to give them competition. There are parts of the country where 80 percent of that health care market is enrolled under one health care plan."
For all practical purposes, that would be called a monopoly. "Yes," Baldwin says. "And monopolies need to be regulated. One of the ways we can do that, in lieu of all-out regulation, is by increasing competition.
"We don't want to take the process away — capitalism is good, competition is good," she adds.
Baldwin urges people in support of health care reform to make their voices heard.
"For those of you readers that care about this issue and want it to progress, now is the time to speak out — writing letters to the editor, writing to your congressperson," Baldwin says. "People are taking notice of what is happening and feel like they must respond."