The Affordable Care Act and HHS Oversight of Unreasonable Health Insurance Rates: Is It Good Versus Evil?

Check out this New England Journal July 21 "Truth and Consequences" article that reviews the Affordable Care Act's (ACA) language on the Fed's new oversight of "unreasonable" health insurance premiums. Regrettably, it portrays the folks at Health and Human Services (HHS) as the White Knights come to rescue America from the Black Empire of the Health Insurance Companies. Think of the derring do of a ray-gun toting Princess Leia versus a sociopathic Darth Vader. The good news is that because you read the Disease Management Care Blog, even the Journal's one dimensional storyline can be turned into a short efficient learning opportunity.

If you go online to the ACA and look at Section 1003, you'll see that the HHS Secretary is supposed to establish a "process" to annually review or "monitor" the "justification" for any "unreasonable" health insurance premium increases. This process will not only include the health insurers, but the State Insurance Commissioners. To help them on their way, the Commissioners are invited to dip into a pool of $250 million and, in exchange, give the Secretary their recommendations, including whether an insurer should be listed on their exchanges.

According to the Truth and Consequences article, the ACA is a stand against the insurers' "disproportionate" profits, will buttress the outmatched Commissioners' ability to review rate hikes and provide enlightened and disciplined consistency across the States' regulatory efforts. Yet, the article notes, the ACA ultimately does NOT give the Secretary the power to deny insurance premium increases, which is described as a "lack of regulatory teeth." Another problem is that, now that there's a new HHS sheriff in town, insurers will be tempted to keep premiums down by taking it out on physicians with decreased fees, more administrative hassles, utilization management, a potential return of 1990's style managed care and capitated fees with the inevitable accusations that medical care is being withheld.

The Secretary is now gearing up for this with the announcement that comments are being accepted to help craft the specific regulations that will clarify the "process," "monitoring," "justification" and "reasonableness" language. The DMCB thought it was quite clever when it actually found the web site that is accepting the comments, until it realized that about 230 other groups and individuals have already taken advantage of it.

The DMCB recalls that Ms. Leia could be unpleasant at times. Furthermore, didn't Darth ultimately turn out to be a cuddly saint of a man? Let's look at the world through his black helmet goggles......

The health insurance industry may be making gazillions of dollars but its overall return on investment has been quite anemic. States view the regulation of insurance as one of those powers included in the Tenth Amendment and it still remains how much control they'll cede to the HHS Secretary's potentially intrusive overtures. Critics may charge that health insurers can abandon a State but there are examples of States' wrecking the marketplace with unsustainable demands for low premium levels. The terms "process," "monitor," "justify" and "reasonable" are vague and the final regulations that define them promise to be an overlawyered miasma that will do little to stem our national appetite for more health care. Finally, the insurers were mostly defanged in the 1990's. It'll ultimately be up to the physician community to figure out how to deliver higher healthcare value. If the docs are not up to the task, Plan B won't be the managed care insurers or an evidence-base courtesy of the wise editors of the New England Journal. It'll be the judgment of distant Medicare mandarins holding court in windowless rooms just outside of Baltimore.

Somewhere between all that white and black is a color called grey. To get a sense of that, check out the comments web page mentioned above. The submissions make for interesting reading and run the gamut from pleas to rely on actuarial soundness (the insurers) to demands that they be put out of business (cancer survivors). Hopefully the Obama Administration will put aside its public hostility to the insurers, recognize the Journal's Truth and Consequences article for what it is and steer a middle path.

We'll see.

A Contrarian Nominee Suggestion for the Secretary of Health and Human Services

The DMCB feels sorry for its fellow bloggers who boned up for Czar Dashcle’s reign by memorizing his blueprint or forwarding the minutes from those holiday home-based healthcare confabs. While y’all were getting ‘engaged,’ the DCMB was involved in other far more rewarding holiday pursuits. The silliness is not done, however, thanks to the speculation fever over the identity of the Obama Administration’s ‘Plan B’ HHS nominee. Examples are here, here and here.

Not wanting to miss all the fun, the ever contrarian Disease Management Care Blog would like to present its own favorite candidate:

Gloria James.

NBA sports fans may recognize the name of the mother of the Cleveland Cavs’ superstar forward LeBron James. She’s something else. She had LeBron at the age of 16 and as a single mom moved from one menial job to another while keeping a roof over her head and her son from disappearing into the street violence of Akron, Ohio’s streets. This is a woman of grit, determination and hard work.

So, why is she qualified you ask? Well, says the DMCB, consider the following:

It's not just her mettle, she’s a mom. That is a huge advantage, not only because of her gender (which remains underrepresented in DC) but because of what the Fat Lady teaches us in this story from the 15th Chapter of Matthew: ‘Have mercy on me,’ said this anonymous mother to Jesus, ‘my daughter is grievously vexed with a devil.’ When rebuffed, she repeated her plea, saying ‘Lord, help me.’

Curious, isn’t it? The child is ill but it is the mom that is personally suffering and is begging for mercy and help for herself. The DMCB finds this story once again demonstrates the Bible’s special insights about the human condition: mothers feel their children’s pain. What’s more, they understand other moms’ pain and they’ll (and in this example, literally) move heaven and earth to fix it. The DMCB asks: wouldn’t this special skill of selflessness for others’ suffering be a refreshing ingredient inside the beltway? Go to ANY home and school association meeting, any school sports game or Sunday school and you’ll find qualified candidates for the job. You’ll find Ms. James.

Speaking of moving heaven and earth, Ms. James would be a tireless and energetic advocate. There is no better demonstration of this than this clip of Ms. James rigorously debating the finer points of NBA officiating with a referee during a Boston-Cleveland game. The DMCB thinks our President and his team of rivals would benefit from having a person like this who won’t be afraid to tell the Big Man the way it is. By the way, Mr. Obama’s love of basketball will only further cement their mutual respect.

Last but not least, Ms. James has allegedly amply demonstrated her preference to not to take advantage of limo rides at the taxpayers’ expense, expressed by kicking out car a window, if necessary, to make her point. No last minute tax issue surprises here: with Ms. James, what you see is what you get.

But she has no background in healthcare policy you reply? Well, it’s not just the DMCB that thinks it’s possible to have too many economist/PhD experts cluttering up the White House. What’s more, just because you are one doesn’t mean you’ll be very successful. Secretary Ms. James can surround herself with her own team of rivals. What’s more, if common sense and hard work don’t allow her to understand what’s being proposed, I think we can count on her to keep our healthcare laws regulations from being gummed up by even more gobbledygook.

But she has no chance you think? Well, she has about as much of a chance of being named as this guy does.

You GO Ms. James!

A Crisis-Driven Reorganization of Health and Human Services?

Remember when, in response to a large crisis, the Federal government reorganized over 20 separate agencies into a new Department called ‘Homeland Security?’ How about the recent meltdown-driven foray of the U.S. government into banking and insurance? Now that there is growing consensus that there is a healthcare crisis, think the Department of Health and Human Services (HHS) will go unchanged? How can Congress resist?

And here's its cover for it to do something. The Institute of Medicine has released a report to Congress at the request of the House Committee on Oversight and Government Reform. Recall that HHS is a cabinet level Department that includes not only Medicare and Medicaid, but the National Institutes of Health, the Food and Drug Administration, the Centers for Disease Control, the Indian Health Service, the Agency for Healthcare Research and Quality (AHRQ) and a host of others. It occupies about a quarter of the entire Federal budget. Think the one-time $700 billion bailout is a lot of money? That’s HHS’ yearly budget. Given the coming Administration’s appetite for ‘change’ and the leading role of HHS in leading that change, the IOM report could catalyze crisis-style reorganization the Department.

You can access a ‘brief’ of the IOM report here. That’s free. For a full report, you’ll need to go here. That's not free, but the DMCB suspects members of Congress won’t need to pay for it.

Here’s a quick summary of the brief for you.

HHS needs to define a modern ‘vision, mission and goals’ to help persons inside and outside of the Department to understand its work. The IOM recommends the number of individual department heads within HHS be reduced and that the remainder be ‘re-aligned’ to fulfill the new mission and goals. In addition, the office of the Surgeon General needs to be revitalized and AHRQ needs more dependable budgeting. When there is overlap with outside Federal agencies (an example being food safety), it should be brought entirely within HHS. HHS also needs to begin studying and reporting on the comparative effectiveness of medical interventions and procedures. It should also invest in its own workforce recruitment and professional development. Congress should increase HHS’ accountability by getting regular reports but allow greater flexibility to fulfill a ‘new compact.’

The Disease Management Care Blog likes what it’s reading. If that sprawling bureaucracy known as HHS can be even slightly more efficient, mission driven, attentive to outcomes and modeled after entities in the private sector, patients and their providers might be better off for it. Of course, the devil is in the details of the enabling legislation. Let’s hope that Congress follows through on the IOM Report.