December 7th, 2009
02:06 PM ET

Controlling the cost of care? Something had to give – and it did

By Caleb Hellerman
CNN Medical Senior Producer

The fight over changes to the health care system has been so fierce for so long, the turning points aren’t always clear. But for me, the past two weeks answered a big question: Are Americans willing to sacrifice their health care to try to hold down costs? To me, it’s clear the answer is no.

This question has been hanging over the debate all along. President Obama and Democrats in Congress are selling the bill as cost-control. Health care costs have risen much faster than wages or inflation over the past two decades, and these Democrats (along with some Republicans) say that if we don’t get that under control – soon – it will crush the economy, and force drastic cutbacks for all kinds of health care. Supporters of the bills say we don’t have to sacrifice, as long as we emphasize preventive care – catch problems while they’re minor– and if we’re more “efficient,” avoiding unnecessary tests and treatments. Just like that, they say, we can save almost $500 billion from Medicare alone. The Congressional Budget Office, the definitive bean counter, agrees.

But one person’s “efficiency” is another person’s “rationing.” That led to accusations about “death panels” and unelected boards withholding vital care. In fact, the bills do set out a big role for government experts to shape what procedures are covered by insurance. Many people don’t like this, on ideological grounds. Others, right or wrong, fear the government will be stingier than private companies that currently administer insurance for two-thirds of the population.

We were reminded recently that we live in a democracy - and that Congress doesn’t like controversy. This tension started coming to a head with something that wasn’t even part of the health care bill: a recommendation from a federal health advisory panel that said most women can wait until age 50 to have regular mammograms – instead of starting at 40, as most doctors now recommend.

Opponents of the health care bill, mostly Republicans, called this evidence that the federal government is hankering to ration care. No matter that the mammogram panel has no power over insurance – for weeks, members of Congress have been jumping over one another to denounce its recommendations and to say – in effect – that only over their dead bodies will there be limits on mammograms.

A few jumped the shark into outright falsehood, like Florida Rep. John Shadegg, R-Arizona, who asserted that the health care bill would prohibit millions of women from purchasing mammogram coverage. But the result was a Senate vote, 61-39, to expand preventive health screenings for women, and a unanimous vote to prevent the panel’s recommendation from restricting mammogram coverage – a non-existent power in the first place.

The details of the mammogram debate are beside the point. The bottom line is that the recommendations were deeply unpopular, and so Congress stepped up to avoid even the hint of limiting coverage. That’s a good sign for democracy, but it doesn’t suggest we’ll be cutting the cost of care, any time soon.

To see how your senator voted on amendments to the health care bill, you can click right here.

Do you trust the government or private insurance companies more, to decide what treatments should be covered?

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soundoff (9 Responses)
  1. Darryl

    My experiences with insurance companies provide little reason to trust them – it seems like death by a thousand cuts. It takes months, and numerous emails, letters, and calls to get prior coverage recognized, and then various bills have to be submitted multiple times, seemingly random things are not covered (or not paid until numerous follow-ups are made), and so on. It would appear that a major revenue stream for them must just be making it too difficult for people to understand and follow-up to get what they are supposed to. And that is before any of the big problems, like rescission, payment caps, doughnut holes, etc.

    Regarding trusting government plans – perhaps if Congress had the exact same plan as the average person, then it might be made to work. Until then, squeezing medicare costs is just going to reduce the number of doctors that accept it, not provide better care.

    Regarding rationing, and the arguments about health care being 1/6th of our economy and growing – I believe better health care is worth paying more for. For example, how many people would really object if half of our economy was just health care, but aging, cancer, and other issues were dealt with? The real question is if we are getting reasonable value for our expenses – and the bill by procedure, with many different parties involved, and no real price transparency, would seem to indicate that we are not getting good value.

    December 8, 2009 at 00:50 | Report abuse | Reply
  2. valentine cotton

    I would rather have the right to purchase my own private insurance, and I decide what I want covered. The government, through the US Preventive Services Task Force has no business telling us what should and should not be covered. This government bill is too costly for the country, and government bills, like Medicare, never keep costs down. The government should repeal the legislation which allowed the insurance companies to be monopolies(which was passed in the 1950's), so that they can sell across state lines and compete. Second, CNN did a story a few weeks ago about an American woman whose insurance company couldn't afford surgery for her in America. They looked around and found she could have the surgery for half the cost in Singapore. At the end of the story the reporter asked how they could do the surgery so inexpensively and the answer was that they had no significant malpractice suits brought. Our government could do tort reform. Third, the government could go after fraud, waste and abuse in the government medical systems, Medicare, and Medicaid. I believe that these policies would be far more helpful to lowering costs that this gigantic, costly bill which will create more bureaucracies and bureaucrats.

    December 9, 2009 at 08:37 | Report abuse | Reply
  3. jodigirl

    Note to Dr. Gupta:

    There is a difference between "costs" and "spending". This legislation seems directed more at cutting spending, rather than costs.

    They are cutting $500 billion from Medicare, and claim it will not impact services (ABOVE the already 21.5% cuts coming in January, and the greater cuts over 4 yrs to oncology and cardiac services). Yet, Medicare already reimburses at rates often lower than what it costs to provide the service. They want us to believe that physicians and providers are going to be able to continue to provide their services at further reduced reimbursement rates (note: Medicare rates lead the reimbursement rates, when Medicare reduces, so do private insurers – but you know this already).

    So, here we have it....They are going to cut reimbursement rates and lower the amount of spending, yet costs for drugs will continue to soar each year (and at an even higher rate now, given the sleazy deal the drug companies got for the measly $80 billion over 10 years), prices for medical equipment and devices are allowed to continue to rise uncontrolled each year, medical malpractice will sky-rocket because we will be adding 31 million onto an already government acknolwedged system of physician shortage leading to greater possibility of error and therefore more lawsuits and higher premiums (no wonder trial lawyers are pushing for this reform!!). They're reducing outpatient physician office services by significantly reducing payments to non-hospital facilities, forcing an onslaught of patients to get their services in hospitals, which costs more than outlier clinics. Costs for education/training for doctors and nurses will continue to climb each year, etc., etc.

    In short....Costs to provide care are STILL going to climb out of control every year, while reimbursement goes in the opposite direction. AND, they expect us to believe that this will not significantly diminish our benefits, access, and services? Seriously, Dr. Gupta, you can't believe this?

    December 9, 2009 at 15:02 | Report abuse | Reply
  4. Fred T. Potter

    As I read the blog about health care and the controversy, I felt necessary to pass this story along. Today,December 9,2009 I took my wife to the University Health Center in San Antonio for an appointment she had made in order to get a refferal for a mammogram, something that required a doctor referral. Now my wife is never sick, goes to the Doctor only as necessary, is not on the edge of poverty, does not get any government assistance, has no insurance, always pays for it visits/treatments etc. but today instead of honoring the appointment told her flat out, "the doctors here will not see you if you don't have insurance" . I know that happened I was there. I called the administrator and started complaining. We were soon taken by the clinic manager and she saw the doctor. He then took us to a case worker that was supposed to help us with a program to assist us with payment of charges, one problem, we are not on welfare, we have jobs, and we do not get government assistance. We were then informed that we could make payment arrangements and we would get a fifty (50%) percent discount for paying cash over insurance. I don't necessarily agree with all the things in the Health care reform bill, but I do believe it is time to remove the FLUFF from doctors/hospitals/clinics/etc. I have just begun to make what happened to day a public airing, I will e-mail, phone, and even take out ads to show everyone what is happening. STAY The Course and reform HEALTH CARE!!!!!!!!!!!

    December 9, 2009 at 18:49 | Report abuse | Reply
  5. jodigirl

    Fred – I am not sure I understand your grievance, exactly, but you have to understand that providing health care in this country is extraordinarily expensive to do. When you look at what hospitals/doctors charge, you have to factor in huge overhead costs (which could be lowered at some hospitals I know by getting rid of the beautiful waterfalls in their entrance, etc.), medical device/equipment, salaries, malpractice, etc., etc. Administrative costs are very high and require a lot of clerical staff. The costs to train nurses/physicians, etc., are much higher than other countries. Our health care system treats a great deal of illegal immigrants at cost to the system overall – care that often gets written off by the provider. We deal with huge malpractice costs that other countries do not deal with (Canada has award caps, Europe has "loser pays"). Providers have to pay huge costs for drugs, devices, and medical equipment as well. And everybody wants this service with a pretty hospital that serves good food. They also want social workers, many different language interpreters, clergy, etc. at their hospitals. Moreover, our hospitals and clinics are also often bound to unreasonable demands of unions, which other countries do not deal with. Costs for drugs will increase under the current legislation, as the deal they made allows drug company's freedom from government price controls with a lot of non-Medicare drugs – they will be free to gouge as they please. Costs for devices will likely go up as well as the excise tax will means those companies will increase their prices too to cover that loss (they are left free to do that). Executive salaries are also likely too high in many hospitals (executive salaries are not just too high in medicine). However, is the answer to just get rid of wealth in this country, not allowing it? I don't know the answer, I like the concept of the American dream of EARNING and achieving your way up the socioeconomic scale to wealth and prosperity. However, I do not like the idea of people corruptly gaining wealth (like politicians, for example).

    I am a nurse, and as far as doctors are concerned....No career choice REQUIRES the huge intellectual, financial, and lengthy commitment that medicine requires. There is not a career choice that is matched in intensity and required level of intellect and skill, not to mention length of training. Doctors spend, minimum, of 11 years post high school to do what they do, and specialists another 3-5 years more (that's into their 30's before they start their wage earning careers, over 5 years later than their professional counterparts, less time paying off debt, less time saving for retirement and kids college, etc.) Lawyers and CEO's spend a maximum of 7 years post high school to do what they do, and their career doesn't face high lawsuit possibilities, in the hospital at nights for emergencies, life and death decisions, watching families cry frequently, etc., etc. This career choice MUST, in my opinion, remain highly rewarded financially as long as other career choice incomes are so high. Creating an environment where the brightest people cannot have access to the American dream through a career in medicine, only through a career in business or politics is a dangerous recipe. The very population we need the MOST to be the BEST should be highly rewarded by our population.

    Also, just so you know, when patients come in saying they want to see a physician without health insurance because all they want is a referral for a mammogram, it is not that simple. Medicine and the decisions that go into treating patients is never that black and white. It is not to YOUR benefit either to see a physician without health insurance – as they will not be able to guide your treatment and plans without worrying about how you will pay for it. It is unreasonable to except ANY business to give away their products and services at cost to the business. Surely you understand businesses cannot survive that way.

    The fact that you got a 50% discount to pay cash is a big deal, too. It is terrific they gave you a 50% discount, in my opinion. They cannot give their products and services away for free.

    December 10, 2009 at 11:53 | Report abuse | Reply
  6. marin pitu

    Jodigirl, the world you describe is a jungle world, jungle mentality adapted to the human world and create and unfair, inhumane health care system, a for profit business that victimise around 50 millions Americans. In the many years of education you mention, a lot was missing, therefor I want to informe/educate you and the rest Americans that are under the delusion that we have “the best health care system in the world or provide the “best medical care in the world. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.
    There is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.

    The World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. Recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analyses ranked the United States last or next-to-last compared with five other nations — Australia, Canada, Germany, New Zealand and the United Kingdom — on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.
    All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs. And Jodigirl, those aren't my own words. Educate you self, search and you will find out that you and your "world" is a jungle that "you" manage to impose on us for so long and are terrified now about the changes that hopefully will place United States in the top, not in the bottom of the civilized world.

    December 13, 2009 at 18:34 | Report abuse | Reply
  7. Jonathan Lieblein

    As a heath care provider serving a generally very impoverished community, I see on a daily basis the need for something to give. People seem to have developed unrealistic expectations of the health care system, always asking us to do more with less. From my perspective as a Paramedic I see on a daily basis, a hugely wasteful practice of people using the emergency medical system for primary care because they have, or feel they have, nowhere else to turn. These patients are mostly uninsured, and the care we provide has to be subsidized by charging those who do pay to cover the losses. Emergency care in general hemorrhages money, and everything else costs more to make up for it. Until we have a strong program of primary care, things are going to continue to as they are, with simple, inexpensive issues becoming complex, expensive issues that cost us all money.

    We also need to realize as a nation that there are some things medicine simply cannot do. A huge amount of money and effort is wasted on treating patients who are clearly not going to recover. Call me cold all you want, but some rationing is probably going to be an unfortunate necessity in the future. We also need to learn to let people die with dignity, and not wring every last second out of the end of a life artificially extended with machines breathing for you and feeding you for days, weeks, or years.

    I have to agree with jodigirl regarding the compensation of doctors. Talent goes where the money is, and I am sure that I am not alone in wanting the best and brightest being pulled into medicine. Try living you life without being able to ever leave work all the way behind you. Most medical specialties live at the mercy of a pager or cell phone, having to make life altering decisions in short order, often with incomplete information. Spend a night in the ER, managing as many as 30 patients with any and every kind of injury or illness, with families pulling you in every direction. With a very few exceptions, the doctors I know earn every cent they make.

    What needs to happen, but probably never will is let people on the front lines of medicine have real input on the way things are run. History has shown that it will probably take an epic failure to get the environment ready for the major changes that will have to occur.

    Marin, please don't blame those of us who actually provide heath care for the way things are. Talk to almost anyone who is responsible for direct patient care, and you'll find out that we hate the system as much, if not more than most other people. Most of us do genuinely want to help people, and the system as it presently exists is a pretty significant hindrance to that

    December 15, 2009 at 23:54 | Report abuse | Reply
  8. jodiRN

    Due to the pending 2010 cuts in Medicare, many cardiology groups are being forced to close, as they will be taking a 30 to 40% reduction in revenue for their services. As such, many staff including myself will be out of work. Higher yet unemployment. Moreover, and worse yet, those outpatient facilities that provide vital cardiac care will mean many rural areas will have diminished access. People will no longer have the spread out outpatient clinics to turn to, and will be forced into one place (a hospital, where it's more expensive) for the same services now provided in a wider range of outpatient settings. The years it took to build-up these outlying facilities – closed – just like that.

    I think hospitals will fare well, as will the insurance companies, drug companies, and medical device companies. The drug companies and medical device companies will pass on their excise taxes to the consumers, causing an increase in consumer costs. The insurance companies will still be free to arbitrarily deny claims. Drug companies received even more leverage to gouge Americans who need non-Medicare drugs for decades to come.

    Physicians will be faced with an onslaught of 31 million more regular consumers, during an agreed upon physician shortage, leaving them more prone to error and at a greater risk for lawsuits. This, of course, will increase the lawsuits in this country, therefore increasing malpractice premiums – which will get passed along to the consumers.

    The government's new task force will make its decisions about which services they will score an "A", "B", "C", or "D" – effectively highjacking the patient-doctor relationship because the services THEY choose to score a "C" or "D" will no longer be covered by our insurance, and therefore not at our discretion to use – and we won't be able to shop around for an insurer who does cover it – because they'll all be regulated by the same government task force.

    If there is a public option, private insurers will ultimately be squeezed out leaving only the government and therefore even less choices, zero competition, and zero competition means less service incentives.

    Medicare will still go bankrupt, because a system that has 38 trillion dollars in unfunded liabilities, 60-90 billion dollars in waste and fraud, cannot be saved by cutting $470 billion in payments to providers. AND, even if they do cut Medicare reimbursements (even MORE than what is already pending that will sink cardiology, for example) access will diminish for everyone, not just those on Medicare (Medicare drives the reimbursement rates. When Medicare cuts, private insurers follow-suit. And Medicare/Medicaid often pay less than what it costs to provide care. CMS states the Medicare Economic Index – ie., inflation for cost to provide care, rose 54% between 1992 and 2010, while reimbursements rose only 11%). Access will diminish for everyone because of my example above, clinics will be forced out of business, and the affects everyone, not just those on Medicare. True Medicare reform and health insurance reform will fail to happen.

    December 22, 2009 at 10:51 | Report abuse | Reply
  9. Don S.

    You have made some very good points and you know what's going on in the real world of medicine. We definitely need to let healthcare providers make the critical choices. They need a strong voice in how reform is being handled.

    Uneducated, careless patients cost the system billions per year. Education by healthcare coaches, general practitioners and others on the front lines could prevent so many unnecessary conditions. Arteriosclerosis and diabetes are examples of conditions that are preventable or manageable with diet, exercise, and some lifestyle changes. Prevention and re-education is key to controlling spiraling healthcare costs and saving the system.

    I want to see a new plan that advocates prevention first and a simplification of all the players so that healthcare providers and patients can re-establish the relationship. That would save money.

    December 22, 2009 at 17:44 | Report abuse | Reply

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