(AV17530) Health Care Reform

(AV17530) Health Care Reform


well good evening I’m very pleased to
welcome all of you to this Iowa State University faculty forum this is a the
first in a series of forums that we will hold this fall that will address current
issues and the purpose of these forums is to better educate all of us students
at the university faculty staff members of the community about the various
perspectives on important current issues and of course there’s no better place to
start then the topic of tonight’s forum healthcare reform that’s it’s such an
important topic that is under so much discussion right at this moment later
forums will address economic recovery on October 13th and global climate change
on November 3rd I want to thank the Provost office in particular for taking
the lead and organizing these forums and several of our academic departments for
providing the faculty experts the ISU Committee on lectures for their work and
the detailed organization particularly our student leaders on the committee and
I’d like to thank Diane by Sturm who is going to serve tonight as moderator
Diane is director of the Carrie Chapman Catt Center for Women and Politics she
will introduce our panelists and then we’ll moderate the question and answer
period after the panelists have spoken and I’d again like to thank all of you
for joining us and I’d like to ask Diane to come to the podium well thank you president Jeffrey and I’m
really excited to be here tonight there really couldn’t be almost a better night
to have this forum than the night after President Obama’s address to Congress
last night on the issue of health care reform and of course in this environment
where we’ve had so many public forums on health care reform and the media
coverage has followed it the political rhetoric surrounding this debate
especially is played out in the media has been often marked by outburst
arguments tensions incivility and even physical fights I think I can assure you
tonight that tonight’s discussion will be civil in Iowa we have a long history
of civility in our political discourse and we have a long tradition I love
treating each other with respect even if we disagree and I assume that that would
be the course tonight the political rhetoric rhetoric surrounding this
debate has also been marked by catchphrases anyway I think we’ve all
here heard them such as death panels pulling the plug on grandma and asking
one citizen who asked a question to a senator what planet had she been living
on tonight we hope to shy away from the political rhetoric and instead focus on
the reality of health care reform with our panel of experts joining me on
tonight’s panel our four experts on various aspects of health care reform
each has been asked to give a five minute opening statement in the
following order order Marc emmerman is an economist and director of recruitment
services for the College of Liberal Arts and Sciences he grew up in a family
without healthcare insurance and a community that made sure it was not an
issue although Marc does not consider himself
an academic student of health care reform or healthcare issues cost he has
conducted a number of studies on labor issues patient choice and facility
viability on the basis of existing problems and the need for solutions that
can be implemented our next speaker is Liesel Essington she’s the director of
the regional capacity analysis program and an assistant science
in the Department of Economics at Iowa State in her 11 years at Iowa State she
has researched and analyzed various aspects of Iowa’s economy and its
population including population growth migration patterns poverty and income
levels including health care insurance coverage she recently authored a report
on Iowa’s uninsured next is Doug Walker who is an assistant professor of
marketing in Iowa State’s College of Business within the context of health
care he has investigated issues related to pharmaceutical marketing prescription
data availability and resource allocation in a health maintenance
organizations otherwise known as HMOs our last speaker is from the community
dr. Michael Kitchel he’s a physician at McFarland clinic in Ames and president
of the Iowa Medical Society he’s a member of the American Academy of
Neurology which is medica his medical specialty and director of Mary Greeley
hospitals a centers rehabilitation unit dr. Kitchell has testified before the US
House of Representatives Energy and Commerce Subcommittee on health and I
believe he was just in Washington yesterday so has really up-to-date
information as I said I’ve asked each panelist to start with a 5 minute
opening statement and I’ll give you a little subtle nod when you’re toward the
end of your 5 minutes following the opening statements from the panel we
will be opening the forum to questions from the audience so first we’ll begin
with Mark immerman Thank You Dario you probably won’t have to give me a subtle
nod as Diane said I’m marking Ramona I’m happy to be here tonight thank you all
for coming I’m not going to tell you how this should play out tonight I’m not
going to tell you what I think the right and wrong thing is to do with health
care reform I’m a person that tends to think that there’s a thousand right ways
to do everything and if we all get together we’ll find one that most of us
can agree on I think there’s there’s three things about the current
discussion that strike me as noteworthy and that might be something you’d think
about as you think about kind of questions you want to ask and
and what you want to follow-up on tonight the first is is that we’re
really looking at two things we tend to talk about healthcare reform but there’s
two parts to doubt at least two parts in the current debate one is how do we
provide insurance for the uninsured okay the other is how do we change the system
to control the increase in healthcare costs
those two are not very much separated in the debate but they are two very
different issues and there are two things that we could address separately
if we wanted to the first of those I think how to ensure the chronically
uninsured is probably the easier of the two to solve okay I’ll just leave that
at that the second thing that I think should be
thought about is we think about health care is that it appears and it was
reinforced last night that the solutions that have a chance of rising to the top
here will be based on a continuation of the current foundation of employer-based
health insurance that doesn’t need to be so there are advantages and
disadvantages to doing that and not doing that but employer-based health
insurance has implications for the cost structures that we look at it has
implications for the cost of goods we try to export it has implications for
our options when we deal with Medicare so it’s a bigger issue than just saying
we don’t want to disrupt insurance as it stands now I think the third important
thing that I see when I think about healthcare reform is were debating it
now is that instead of trying to find common ground
on what actions we need to take to make something work
we tend and we tend on both sides to define this in personal terms if you are
for health care you might be called a socialist or any number of things if you
are for health care you might call tell your opponents that it’s a moral issue
and a social justice issue and on the one hand you’ve got one side telling the
other side that they’re economically or maybe politically really responsible and
on the other hand you’ve got the other side saying that that their opponents
are immoral or somehow not as socially civil as they are and as long as we
decide to couch this in personal terms and we make this a personal argument
we’re pretty much as shirring ourselves that we will do this again and again and
again the trick here if we can’t find common ground right now is to at least
find parallel paths to a common horizon and that’s something that we as a nation
are having a harder and harder time doing but if we’re going to solve health
care I think we’ve got to quit putting it in personal terms and we just got to
start coming down to what we can agree about with the numbers and what we will
find as maybe not first best but acceptable second best of solutions
I’ll just leave you with that there will be facts and figures enough tonight
we’ve all seen millions of numbers on what it cost and what it won’t so and next we’ll hear from little Ethel to thank all of you again for coming
tonight before I start I want to go back a little bit and tell you about what I
do I have a great and fascinating job and the reason I’m telling you is it
helps explain my approach to looking at this issue I study Iowa’s economy and
its population and in doing so I look for how things are changing and what the
implications of those changes might be the information that I find I share
maybe four people in a public policy setting for a business decision making
or for just people who are curious want to know about their communities and how
they’re changing I study a wide range of issues anything from manufacturing job
losses poverty rates in different places school enrollment declines and my
approach to each one of these issues is usually pretty much the same I first
look at the where and the who and so that’s what I’ve done with this
particular issue I’m not a health insurance or health care expert but what
I was interested in is who are the uninsured in Iowa and where do they live
what are their characteristics and where can we find them so that’s what I’m
prepared to talk about tonight the reason that we look at the where and the
WHO on things like this is if we can start to identify patterns in the where
and the who then hopefully we can start to find out some of the why and if we’re
lucky maybe we can get to the how isn’t out of how to fix it so another
important reason that we look at the where and the who if we can find
differences in the incidence of something across space across
communities of different size maybe in eastern versus western parts of this
State or if we can identify differences in the incidence of something by kind of
people whether that’s by their age or their race it might help to explain both
public attitudes about that particular issue and public policy approaches and I
think on this particular issue it’s become quite polarized especially when
we hear people talking about insuring unauthorized immigrants or taking care
away from the elderly so that’s why I think the where and the who are very
interesting here my report I’m just going to share with you a couple of the
key points from that report first of all I oh it does have a relatively low
fraction of uninsured residents compared to the national average so that might
suggest that public attitudes in this state we don’t think it’s as much of an
urgent issue or the opposite could be true because they’re a relatively few of
them we may not have as hostile attitudes towards certain groups and so
we’re a little bit more amenable to changes at the federal level another
thing that the report found is we do have pretty interesting differences
across the state just by region in the incidence of uninsured population a lot
of people might think of it as a big city issue where we have most of our
immigrants maybe where they concentrate or where we have high fractions of
low-income residents what I found was that actually as a percentage of the
population under 65 the incidence of uninsured population is highest and our
most remote rural counties so it’s not just a big-city issue it’s a rural issue
as well and then the third thing that I want to point out is in terms of the
types of people who might be uninsured we hear a lot of people suggesting that
it may be by choice that they don’t have insurance or that it’s only the low
income or that it’s only the recent immigrants that are causing this problem
what I found based on the estimates that I used from the Census Bureau is that
over a third of Iowa’s uninsured residents are white non-hispanic people
between the ages of 18 and 65 whose incomes are at or above 200% of the
poverty level so these are not your typical people that you might think of
as uninsured so finding all of these things raises possibilities for studying
what are some of the causes behind these populations or these areas that have
higher incidence of uninsurance and I think that’s maybe a less polarizing way
to approach it thank you thank you next we’ll hear from Professor Doug Walker thankful to have the opportunity to
speak with you tonight thanks for coming um feel like we’re shooting a moving
target here a little bit on this issue so if any things happen in like the last
15 minutes don’t don’t hold us accountable we were already in the room
here what I want to do in my few minutes I have here is first just tell you a
little bit about some of the resource I’ve done and then hopefully along the
way suggest a few a few areas in the general debate that I might be able to
make some kind of contributions along the way I’m a marketing guy I look at
the pharmaceutical industry and last year in the United States 291 billion
dollars were spent on prescription medications and what I looked at
particularly is what is the effect of detailing 7 billion dollars were spent
on detailing in the US detailing and is when a salesperson shows up at a
physician’s office and promotes their particular brand of medication to them
what I have found very generally speaking is detailing does contribute to
physician learning at some level but it is conditional and if there’s any
interest in that we can talk about some of those things in a little bit more
detail but I think more interesting maybe for the general debate is there’s
this overriding question from a public policy perspective related to detailing
and is this does detailing increase the probability of a physician choosing the
breast best brand for their particular patient on that particular prescribing
opportunity in other words does detailing help the physician make better
prescription decisions and if so is it worth the cost
details cost seven several hundred dollars per trip and eventually that’s
all going to show up in the cost of our medication so that’s kind of the way I
have looked at that that particular pot problem I think the the methods that I
use in the research I think would contribute to some of the more general
questions and that is structural mullet modeling for structural modeling for
policy evaluation is complex we are trying to say if we do this this is
going to happen and we are looking at an extremely complex problem here with a
lot of moving parts and those predictions are very difficult and what
are the ramifications if we’re a little off on some of those inputs to those
decisions so I think there’s some interesting things there too another
thing I’ve looked at is data availability the way it works in the
pharmaceutical industry is when you go to the pharmacy and you give them a
prescription I do the same you do the same all of those are consolidated and
then they’re distributed to the pharmaceutical firms researchers whoever
wants to purchase that data now the the patient level data is scrubbed but we
know by physician by brand how many prescriptions that each physician wrote
in each period so that as compared to most industries I look at the data is
very rich right now there is a lot going on in this industry there’s three states
where there is a privacy First Amendment battle going on and in those three
states one has banned the practice the data is no longer available one has
banned and that’s been overturned and then a third banned it it was confirmed
on appeal and now the Supreme Court has refused to hear the case so there’s a
precedent now where we can expect for this data to become less and less and
less available so the question is this if detailing now is done allocated by
these pharmaceutical firms without knowledge of what prescribing is going
on out there assuming there’s value in this detailing in the first place the
the primary question is will pharmaceutical firms be as efficient as
they previously were is it just going to continue to be more
inefficient and add to the cost of the drug so there’s a lot of things we can
talk about there and I think when you talk about these privacy issues some of
the things about electronic records comes into play I think some of those
issues can be someone interesting too so anyway thanks look forward to discussion
thank you and finally we will hear from dr. Michael Kitchell thank you
I wrote a 13 article series last year in the Ames Tribune and they were pretty
lengthy articles if those of you who read them remember them it’s gonna be
hard for me in five minutes to kind of summarize those articles and obviously a
lot has happened too over the last year I wrote about the coming crisis in
healthcare but it’s really been here for quite a while we have about one out of
one sixth of our Americans who are not carrying insurance either because they
can’t afford it or some of them choose not to have health insurance there are
too many gaps in health care in this country we have some of the finest
doctors and the finest hospitals in the world but not everyone gets access to
those hospitals and doctors the uninsured in this country are sicker and
they die earlier because of their uninsurance we have the most expensive
health care system in the world we spend 2.3 trillion dollars every year when you
hear the health care reform bills when they talk about a trillion dollars
that’s over ten years we spend 2.3 trillion each year on healthcare now 800
billion of that is in Medicare and Medicaid a lot of that 2.3 trillion is
subsidized by the government because we get our health insurance through our
employers and that is generally tax deductible so over half of that 2.3
trillion dollars is really going through the government
the government is funding 1.2 trillion dollars in health care as I said we have
the most expensive health care system in the world and we spend almost
one-and-a-half to two times as much as other countries like us one and a half
to two times as much money per person and unfortunately even though we spend a
lot more than other countries we don’t have that good results we’re spending a
lot of money with pretty mediocre results when you compare us to other
countries last night President Obama said that there was agreement on about
80% of the issues in healthcare and I’m going to talk tonight to try to clarify
where some of the biggest differences are in the healthcare issues before I do
that though I need to make sure that the audience here knows what I’m talking
about and so I’m going to have a little pop quiz here so how many of you are
pretty sure of what I’m talking about when I talk about a public plan or a
public option how many of you are pretty sure what I’m talking about
pretty sure okay so the rest of you are not too sure about what I’m talking
about so a public option is a government-run plan okay it’s a
government-run plan we have government-run plans right now they are
Medicaid which is state-run but funded partly by the federal government and we
have Medicare which is obviously pretty well known to most senior citizens
Medicare works very well for our senior citizens but Medicare is partly
government-run and partly government-funded 22% of Medicare
patients are covered by private insurance so you need to understand the
difference between government-funded health care
and Medicare has government funding and government-run so some of Medicare is
private insurance administered Medicare has about 25 Medicare and Medicaid have
about 25 mil 25% of the population covered 25 percent of the population is
covered by Medicare Medicaid about 56 percent of our citizens are covered by
employer sponsored insurance only about 7 or 8 percent of Americans actually buy
their own insurance insurance bought by an individual is extremely expensive
it’s about 3 times as much as people are paying through their employer you’ve
heard about the term rationing of health care I’m gonna try to not take a
political side tonight but I do have some comments about that and I’ll talk
about them later as I said about 1 in 6 Americans is uninsured about 16 percent
population is uninsured so there are more uninsured people than there are
people on Medicare there are more uninsured people than there are people
on Medicaid Medicare and Medicaid lies there about 12 to 13 percent of the
population apiece so a 16 percent is greater than 12 or 13 percent so I’m
gonna talk a little bit about the public option because I think that’s what a lot
of people need to understand a little bit more about so again a quiz some of
you have heard about a federal program an insurance product that our Senators
Congressmen and federal employees have and it’s an excellent plan I hope
everybody could get this federal employee health benefit plan now the
quiz is is that a government-run plan or is that a government funded plan so who
thinks it’s a government-run plan it’s not it’s actually a
government-funded plan the government funds a health exchange so people who
are federal employees can get on this exchange and they can choose from a
cafeteria menu of private insurance plans so this is private insurance our
government employees and our congressmen have federally funded health care
delivered by private insurance Medicare is government funded and like I say 22
percent of Medicare is run by private insurance that’s called Medicare
Advantage plans now some of those arguments in Washington revolve around
the public option a public option as I said is a government-run plan so the
quizzes is the federal employee health benefit plan a public option no it’s not
it’s run by private insurance now you may say well what about the efficiency
of our government and what about the efficiency of private insurance
companies and I’ll talk a little bit more about that later I don’t have time
to get into all the details right now but I want you to know why some people
are violently opposed to a public option government-run plan and this is simply
yet for us in Iowa if you had a public option and that public option said that
the doctors receive 30% less pay than California doctors and the hospitals in
Iowa receive 50% less funding less pay for equal work
would you think that would be a pretty good public option for Iowans to pay the
doctors 50% less or the hospital’s 50% less than the hospitals in California I
don’t think you’d think that is a very good public option well now you know why
senator Grassley and a number of other Iowa congressmen are opposed to a public
option because the concern is that if there is a public option they will
choose to follow that public option of 30% less pay for doctors 50% less pay
for hospitals and that public option is present right now that public option is
Medicare we’ve been complaining about Medicare for years at the Iowa Medical
Society I’ve taken that on as a personal crusade so I will be nonpartisan tonight
and I know better care as a wonderful insurance product for our senior
citizens but if you look at the hospitals and the doctors in Iowa we
simply have to cost shift the government doesn’t pay enough for our care let me
give you an example I’m sorry if I’m running over five minutes here I want to
give this example you may know some people have defibrillators these are
nice little electronic devices that are implanted in the chest of people who
have cardiac rhythm disturbances they might have sudden death if they don’t
have a defibrillator so that defibrillator the machine itself
cost $30,000 $30,000 for that machine guess what Medicare pay is the hospital
here at Mary Greeley for that entire episode of care the patient going into
the hospital the nursing care the room the heating the air-conditioning the lab
the x-rays the equipment in the lab and the lab where they put the machine into
the chest of the pain what do you think Medicare pays for that
thirty thousand dollar piece of equipment and all the nursing and all of
it not the doctors fee but everything else for that patients care $29,000 so
now does that mean that Iowa’s hospitals are donating thousands of dollars for
Medicare every time a patient comes into the hospital yes that’s absolutely true
we have the same problem those doctors we have a mammogram machine which costs
two hundred and fifty thousand dollars for the state of the art digital
mammogram equipment two hundred fifty thousand dollars Medicare pays
California doctors forty four dollars for a mammogram they pay us in Iowa
twenty six dollars for a mammogram now you can do the math I think we have some
economists here you can do the math twenty six dollars a mammogram and two
hundred fifty thousand dollars for the machine and of course you have to have
some text to run the Machine and you have to have some space to put the
machine gun and you know it’s pretty hard for an economist to come up with a
good reason for us to do mammograms at $26 a mammogram now you may say well how
are the doctors in the hospital staying open in Iowa it’s because we cost shift
cost shifting and health care is the name of the game
we have cost centers and we have profit centers and the cost centers are
basically the Medicare patients the hospital makes money off some patients
usually private insurance patients and loses money on Medicare patients if we
had a public option in Iowa and we traded those private insurance patients
for those money losing Medicare patients I’m sorry we just would have to close
our doors or we’d move to California of course but in any case cost shifting is
very serious problem the private insurance companies in Iowa pay doctors
70% more for the same services as Medicare does some doctors for example
anesthesiologists they get paid eighteen dollars per unit of care it’s about 15
minutes of work 18 dollars per unit the insurance companies pay $50 so in other
words Medicare is paying 36 percent of what the private insurance companies
will pay now as the president of McFarland clinic you might imagine how
do you get your doctors to see those patients when they get 36 percent for
this patient and a hundred percent for that patient it’s a challenge and you
can see where if we didn’t have cost shifting in Iowa we wouldn’t have too
many doctors left so I’ll try to wrap things up here I’m going to talk a
little bit more about what I think is the serious concern like Mark talked
about and that is we’ve got the problem of the uninsured but we also have
unsustainable costs and those unsustainable costs have to be addressed
if there is one thing we have to do is get these costs under control
the first way we can do that is reduce preventable disease we have an epidemic
of obesity we have too many cigarettes smokers we have too many people who
don’t do the right thing to keep themselves in good health secondly we
need to reduce costs that don’t contribute to patient care there are
administrative costs and private insurance that are not helpful for the
patients we need to have value-based decisions I’m an expert on paying for
value if you want to pay for the most expensive health care in the world
that’s what you’re getting is the most expensive I’ve been a proponent of
paying for the most effective care in the world and in Iowa we are rated
numbered by the Commonwealth Fund in quality and
efficiency there is no other state that has a higher ranking of quality and
efficiency than Iowa’s physicians we need to base our decisions on health
care on value and we need to make health care more efficient to keep the cost
down I can answer questions about the bills in Congress I have a lot of the
details if you want to know about them again I wanted to tell you what are some
of our concerns about the public option as you know President Obama last night
said that he would be agreeable if the public option was not part of the health
care bill so again all I answer some other questions if you have some sorry
that I ran over okay Thank You panelists now we’re gonna turn to questions from
the audience as you can see there’s a mic in the center and I think Pat Miller
is also going to help I don’t know if she is gonna pass a mic around but we’d
like you to come to the center just as our panel of experts were asked to be
brief in their opening statements those who asked questions also need to be
concise in interest of time and the fact that we would like to allow as many
questions as possible we ask that you ask a question and not give a statement
we’re really interested in your questions not in your statement so
please put your answer in the form of a question I guess to say you may direct
your question to an individual panelist or the entire panel or a couple of the
panelists and we’ll begin with questions now and you can just come again to this
or I guess past that’s gonna pass the mic around so since I think I was the
only one that answered that question him correctly and I frankly was covered by
FEMA so your question was clearly stated but the brain was obviously not in gear
I would like to throw a pop question at the experts at the table what how many
of you get explained to me the medical system in Rochester New York
that was in existence from the middle of 1930s till the middle 1990s yes rocking
about the Kodak company sponsored HMO that’s a very bad description of it but
you’re on the Iran there in the general part of the state okay am i right the
other three of you are ignorant of that so my question is why don’t we take what
worked at one time and implement it and get on with it
the system in Rochester is too long to explain I will not make a lesson but I
didn’t like to stay around it can do it pretty well because my son was covered I
did check it and they provided medical care at about a 2/3 the cost that the
rest of the country was providing it now if they could do it for 60 years in
Rochester why can’t we do it now that question there are many systems in this
country that are delivering high quality care at very reasonable prices you may
have heard about a system called a co-op a cooperative there’s a cooperative in
Seattle and it’s called the Puget Sound cooperative it’s a not-for-profit
organization it’s prepaid system in other words it’s a health maintenance
organization the people there are very happy with their care they get excellent
care Kaiser Permanente has a number of hospitals and doctors all over the
country on the East Coast on the west coast where higher quality care is given
at very reasonable prices many of the people in California go to that system
because they’re having difficulty with their care otherwise so the the way that
those systems do better with their care is they are an organized and integrated
delivery system that does not have the wrong incentives for healthcare we
incent our doctors to do the most expensive treatment we don’t incent
our doctors to do the right treatment so if you have the right incentives you
will do much better with care I can talk about this a little bit more this is one
of my favorite topics is paying for value but I’ll see if there are some
other questions okay next question my question is for any of the panelists who
care to take a stab at it just assume for a moment that you were
starting from scratch with the basic premise that you wanted everyone to have
insurance what would your system look like I think
if I started first thing I’d want is I’d want to make sure that everybody had
basic care without any problems second thing I’d want to make sure of is at
some point in time there was a marginal cost involved otherwise people will not
ration their own care and at some point in time the population
needs to ration its own care but beyond that marginal cost that was involved you
would want to have something that took care of catastrophic illness right you
don’t want people to fall off the margin and and fall way off the barrowed and
without you know saying the numbers are magical or the right or something you
could imagine having a system where the first thousand dollars in health care
for an individual in a year was covered maybe the second thousand dollars in
health care in a year was out-of-pocket and beyond that you did a 90/10 or an
80/20 or whatever underneath that you put I hate called public option because that
has connotations here but you put an insurance or an assistance plan under it
so people that could not pay that second thousand dollars would not stop their
health care at the first thousand now you’d have to do that in a way that that
gave them still gave them an incentive to ration their care
you could for example put a thousand dollar account in each of their name if
they were on the assistance program and they could use that to pay for that
second thousand dollars worth of care and at the end of the year whatever was
left was theirs that way you provided them assistance but you also provided
them some incentive to rush and they don’t care okay you could do something
like that you could set that up either as an employer-based insurance program
like we do things now or you could set that up where it was individual based
insurance at this level it doesn’t matter there are implications beyond the
question at hand that might be impacted by that but I think the main thing is is
you want to make sure people don’t fall through the cracks but you want to make
sure people have an incentive at some level to make personal decisions about
their health care and have a personal investment in that without having people
go bankrupt because they couldn’t afford the care they needed or without having
them go dead because they didn’t get the care at all one comment if you read the
details than this thousand page of the House and the Senate Finance Committee
with Senator Baucus you will see that some of those ideas that you mentioned
which are very good ideas are going to be taking place with this new product
this new health care plan again it’s not a public option this new health care
plan it’s a health exchange you can choose from insurance products they will
have standardized products with standardized rates maximum out-of-pocket
costs they have rain of the co-pays so again it will give
people some incentive to not want that cat scan or that MRI scan just because
they have a headache and they want to make sure they don’t have a brain tumor
so that is a way that’s a good suggestion and actually some of these
suggestions are in this healthcare bill this healthcare bill has a lot of good
ideas in it and we need to get it passed I’d like to say one thing that I think’s
interesting we we hear a lot of talk about providing insurance for everyone
but I think most of the people that are proponents of that or what they’re
really saying is we want to provide healthcare for everyone there’s
basically two classes of people that don’t have insurance that would like it
there’s two reasons they don’t one is they don’t have the income to pay the
premiums or number two they have a pre-existing condition in both cases if
you just think about the role insurance plays in a financial system in me their
case is insurance the profit or the proper solution for them number one if
you have very few assets you have no risk to insure therefore the insurance
is not is not the right Avenue if you have a pre-existing condition let’s say
you have a condition that requires requires $40,000 worth of medications
per year well no one is going to insure you for any value less than $40,000 per
year because that cost is going to happen for sure
for there to be risk to be insured there has to be uncertainty in the cash flows
a cure occurring so what we need to think about for the uninsured
particularly the ones would that would like to be insured insurance is not the
answer it makes no sense it’s just really who is going to pay for their
healthcare and how is it going to be paid for because both of those groups
are unable to do it can I make another comment you know when you think about
who’s gonna pay for health care only 1% of the population is wealthy enough to
cover their own health care bills so we have to have someone else pay for the
care of those people who fall ill none of us is unlikely to have some health
care problem until we drop dead we are like
have some healthcare problems and we are likely to have very expensive health
care problems so if we don’t have other than 1% of the population able to pay
for their own health care we’ve got to pool our resources we they have to pool
that through our taxes or we have to pool that through our insurance we have
to pay for insurance and again this health care bill is going to keep the
insurance companies from having exclusions or higher prices for
pre-existing conditions but the insurance companies are only going to do
that in other words they’re only gonna not restrict people from buying
insurance because of their pre-existing conditions the only way the insurance
companies are going to allow that is to have everyone buy health insurance so
please don’t be shocked if we are required to buy health insurance either
through the government or through an insurance company okay we’ll have our
next question please okay you talked about how there are great ideas in this
health care bill and I want to just focus on two of them and the amount of
money that could be safe from them and the first is recently added and as
President Obama said last night and it is tort reform on the amount of money
that we could save from people’s potentially suing their doctors and
maybe how much is their the availability of a cap and how much do you think you
would actually save on that and the second question I have is with
preventive care how much can we save from those later problems do you think
and how much would that affect the problem as opposed to a public option
okay tort reform and preventive care any thoughts on those topics perfectly happy
to answer these questions let’s talk about the liability or defense of
medicine I don’t think you’ll find one doctor in this country who doesn’t think
we can’t save a lot of money if we can stop the practice of defensive medicine
every doctor in this country is afraid of getting sued every doctor is doing
unless sorry tests and treatment now you may
argue about how much that is some experts say it’s eighty billion dollars
some trial attorneys say it’s only 1% of the costs of health care and it is true
in Iowa we have actually very low premiums for my malpractice insurance
I’m not paying a lot of money here in Iowa for malpractice premiums that’s not
the expense of liability and malpractice attorneys it is the practice of doing
more tests and treatment because the doctor doesn’t want to get sued we have
to do tests and and procedures to keep from getting sued and so people need to
understand that we could save a lot of money on health care if the doctors
weren’t so frightened about being sued now the question was about caps I’m
sorry I don’t think caps are going to succeed we do want liability reform
through a couple of things number one is the certificate of merit that will stop
the frivolous lawsuits we have to stop junk lawsuits secondly there’s what’s
called early information if the doctor admits to a patient that they made a
mistake or area had a problem that will keep the the paid that will make the
patient less likely to sue the doctor so we do have some ways to help so I don’t
think tort reform right now is really going to work through caps obviously
some states have done that Texas has done that they think it’s really
successful I don’t think even though my doctor colleagues want caps I don’t know
that that’s going to succeed the second question she had was about preventive
medicine or preventive care no question we need to have more preventive care the
problem is it’s going to take a long time to pay off but if we don’t start
now with preventive care we are going to have even more of an epidemic of
diabetes and complications from vascular disease we spend two hundred fifty
billion on cardiovascular care in this country
and if we just had people who would watch their blood pressure exercise more
watch their diet don’t get diabetes because they’re overweight we do need to
make changes in preventive care and the issue of preventive care potential
savings extend well beyond just the healthcare issue given that that is one
of the primary causes for bankruptcy is a catastrophic or chronic illness that
people can’t pay for their care they can slide into homelessness they can not be
able to work anymore all of these things have costs and so if
we can improve the preventive care I think we will begin to see savings in
other areas of government service provision if we can prevent some of the
outcomes that are a result of these kinds of illnesses one last point I
think it’s it needs to be pointed out the preventative care isn’t something
that we necessarily need healthcare reform to get the biggest benefits out
of because the most important parts of preventive care are self-administered
all right if we are really going to get what we could get out of preventing
disease and discomfort in this country that’s something that we all have to
start doing for ourselves okay the obesity the lack of exercise we could
get religion even if Congress never does anything okay
but that’s something we have to do ourselves and if we don’t do that anyway
we will never gain nearly the advantages that we could have a preventive care at
McFarland clinic for Mary Greeley hospital mark I have a kind of follow up
on that what about some of the companies that are putting things into play now
that if you don’t smoke and if you are you do exercise they’re basically giving
them benefits or premiums maybe at cash benefit do you believe that something
like that would be a good incentive for companies
I think incentives for living healthy are good I also think that
we can carry those too far at times there are some differences and one of
the reasons that I can’t sit and say everybody here it’s got to go out and
run five miles and get healthy is because really we have a certain freedom
for lifestyles in this country so I think they are good I’m not sure we can
mandate them all I think it’s something that that is got to be self-administered
one of the things that I see in most of the options I see in the health care
plan is that we are looking at qualified plans and we are looking at Community
Rating which takes a lot of the incentives for getting religion on on
preventative care particularly self administered preventive care off the
table so I’m not sure what a company’s ability to maintain those benefits
particularly in terms of their health care their health care benefits into the
future will be if we have the healthcare reform proposals that are on the table
okay let’s go to our next question okay no really a lot of times I think
when we think about it we think about very inexpensive procedures but my
wife’s an optometrist does everybody at age 50 need a visual field or just those
that are at risk of glaucoma not a cheap procedure does everybody need a
colonoscopy at age 50 or just those at risk for the diseases that may be could
can find so we’re not necessarily always talking about cheap inexpensive things
or preventive care sometimes it’s expensive diagnostic testing that can
that can stop something very expensive down the road but baby can’t do it
forever okay thanks okay our next question I guess I have two points one
is in talking about people taking personal responsibility for rationing
their care I’m not sure how that would work if you I mean I’ve worked in
nutrition education for years with the public and there are a lot of people
there’s a lot of misinformation and there is a lot that people don’t
understand about just basic good good health nutrition how can somebody if I
don’t understand my disease if I don’t understand the research if I
don’t understand the options that are available how can I effectively ration
my care for a quality outcome I don’t believe that when we look at
self-administered care we ask people to do a better job take care of their own
health that we just close the door and say go do it
certainly there’s people that have conditions that are complicated enough
that it is hard to understand or it’s beyond what they’re going to pick out of
reading medical texts providing services to help people understand what they need
to do would be a lot cheaper in most cases than dealing with consequences of
not letting them know so I don’t I don’t think the suggestion is is that we just
close the door and say heal yourself and there is room for for guidance on those
sorts of times yes there is certainly more information
readily available to the public but I also agree with mark unfortunately we
have a problem with health literacy in this country many of our adults are not
able to understand a lot of instructions they’ve done some studies on people who
leave the doctor’s office or relieve the emergency department and unfortunately a
lot of people don’t understand the instructions so it is difficult but I
think we just need to continue with an educational program I think the other
thing that you need to do is change the payment system for doctors because our
primary care doctors the doctors who actually talk to you and help you help
guide you through the healthcare system help coordinate your care those doctors
are underpaid and if you think that your doctor doesn’t spend enough time with
you it’s because that doctor in Iowa has to see so many patients he has to keep
here she has to keep running on a treadmill all day and so again we need
to change the payment system for our health care professionals we need to
have doctors work in teams with nurses with nurse practitioners with physicians
assistants and those teams of professionals can help to educate people
the doctor doesn’t have time to do all of the education we need to have a
healthcare system that actually has what we call health coaches or people that
can actually help people they’ve done Studies on chronic disease for example
diabetics congestive heart failure chronic obstructive pulmonary disease
those are very expensive diseases if you can keep those people healthy and keep
them out of the hospital you can save a lot of money in the healthcare system
they’ve done studies using teams of professionals health coaches doctors
nurses working together in patients who had congestive heart failure and chronic
obstructive lung disease they reduced the admission and
readmission rate to the hospital by 50% so were the patients happy that they
weren’t in the hospital so often yes were the insurance companies happy that
they didn’t have to pay for the hospitalization yes so why don’t we
incent doctors to work in teams with health
coaches to keep people healthy and keep them out of the hospital where they
spend so much money per day so again my answer for you is we need to have a
better healthcare system and it doesn’t revolve just around doctors it revolves
around teams of professionals that are actually rewarded for keeping people
healthy instead of just treating them to sending for a helicopter to get them to
a tertiary care center so we need to invest in what we call primary care
coordination of care and the health care system has to change our delivery system
you screwed up and we’ve got to have some reform this health care bill will
take a few steps toward that it’s not enough but will hopefully make some
progress okay I heard I suppose on public radio they were talking about a
population of uninsured people and said that they found that a third of those
were actually eligible for some kind of a program and I just wondered what you
found in Iowa thank you and my research I don’t know the reasons
that people are uninsured but my colleague here Kim who I just spoke to
yesterday on this issue actually has looked at this with specific population
groups and one of the things that she said they’re particularly interested in
is the relationship between housing food security and health insurance and this
is particularly an issue among groups like the immigrant population or
low-income people one of the things that we see though with these groups
is they’re not always aware of the services and the programs that are
available to them for a number of reasons and so it I wouldn’t be
surprised if there are a large number of people who could get into programs or
who could get care who just simply are not aware and they’re juggling so many
other issues that they really don’t have the luxury of sitting on the internet
and learning about these things there may be language barriers there may be
education issues so it’s an outreach issue I believe an education I think
there was a forty six point six million figure we always hear as a census and
that all it says you either have insurance or you don’t it doesn’t say if
you’re you could if you apply it it doesn’t say if you want it or not I’ve
seen estimates all the way from 8 to the 46 of those but one insurance and can’t
get it so it’s somewhere between eight and forty okay
Hoffman okay I’m gonna ask a question that I could answer myself but I’m not
going to I’m going to ask you to answer it you’re all talking around the issue
of what we in economics call adverse selection so I think it would be really
important for the audience who many of whom may not understand adverse
selection to explain why is it important from a cost perspective to have everyone
in short please do these are yeah I think the the primary thing is if you
have a pre-existing conditions the premiums to actually cover your cost or
prohibitive therefore to include those in the system
they will have to pay less than than the present value of their of their expected
care therefore there has to be somebody paying more than the expected value of
their expected care in it their adverse selection means this let’s have a plan
it’s a it’s this much it’s this much each and you have the path the
population that that value is lower than their expected value of their insurance
and the other half or that value is higher than their expected
value their insurance those with the lower are in those with the higher are
out and and that’s exactly what you’re talking about
here’s the thing that bothers me about it is is when you have these two groups
neither of which are paying an amount that is correlated with the amount of
health care they’re going to can go in to consume what you have lost when that
happens is the financial motivation to maintain good health now there’s all
other kinds of reasons for good health but think about it this way I like to
smoke I don’t smoke by the way there’s a smoker they enjoy smoking they see all
these reasons that I should smoke I know it’s bad for me I might have health
problems down there down the road but I’m weighing these things out I’m gonna
smoke but if you’ve now put on I’m financially responsible for my
healthcare problems down the road maybe that’s enough to tip the balance to
moderate their behavior if you don’t have that financial incentive now we
have to go in and try to change people’s behavior via laws and taxes back
cigarettes makes them a little that life less
likely to want to smoke or wear seatbelts because if I get in the wreck
to get injured other people are gonna have to pay for it so she’s exactly
right you got this balancing act but it’s a little concerning to me when you
disconnect the value you pay did expected a value that health care that
you’re going to consume could could I talk about that you know we have a
couple of nephrologist kidney specialists at our clinic and the
percentage of Medicare patients that they see is about 98% because when
people have kidney failure and they go on dialysis the insurance companies will
drop them like a hot potato so if you wonder why Medicare has such high costs
it’s because as we all get older we’re going to cost more because as we turn 50
we’re gonna have heart disease we may have more cancer so as the age goes up
the cost of care so to to make the insurance companies
accept those people with diabetes or chronic disease and not kick them out or
keep them from coming in to their insurance we have to have healthy people
buying health insurance to balance that high cost of care and like I said
earlier the insurance companies are willing to do that they’re willing to
take on these people with pre-existing conditions and not kick out people who
get sick as long as there’s a mandate that everyone healthy people included
the young Invincibles as they’re called they have to buy insurance now the new
law that the new bill is going to still have age related premiums in other words
younger people will have cheaper premiums older folks will have more
expensive premiums but for someone who is already sick and gets laid off from
their job an insurance company won’t touch them unless they want to pay
hundred thousand dollars for their insurance the only way they’re gonna get
insurance is to become disabled and then they can apply for Social Security and
Medicare so those are the people that fall through the cracks in our system
right now and the only way we’re going to get the insurance companies to cover
the people that are sicker the adverse selection is to allow the insurance
companies to rate their premiums by putting healthy people into the mix so
it’s it’s pretty simple you they’re all like I say there who can afford to buy
their own health care only 1% of the population the rest of us have to pool
our resources and we’ve got to have healthy people people who who are not
gonna cost money system well Pat’s signaling that we have time for two more
questions and they’re up here now and would you like to ask a question please
yes Thank You Diane um I’ve had the dubious
pleasure of being involved in healthcare policy law and reform for over 20 years
and so I’d like to direct this question to dr. immerman this current reform
effort seems to be particularly acrimonious and you mentioned earlier
that having things couched in such personal terms was a detriment and I’m
curious as to what advice you would give politicians in terms of couching it in
another way first off I’ll start out maybe it’s the
wrong answer but I’m not sure it’s a politician problem the old say is that
we live in a democracy and in a democracy you get the government you
deserve at some point in time when we talk about incentives for doing the
right thing in health care we have to realize that our politicians follow the
incentives we give them okay as long as we are willing as a society to decide
that rather than finding middle ground it is in our best interest to see if we
can stake out a position so far from middle ground that we can move the
middle to where we really want to be we are going to stake out our problems in
personal terms and it’s not just politicians if you read the editorials
in the Des Moines Register or the M’s Tribune if if you listen to most any
debate you will find that for some reason in this country changing our mind
or we’re being swayed that has become a
sign of weakness rather than a sign of flexibility or maturity and I think our
politicians reflect us in them and not the other way around so maybe that’s the
wrong answer it’s probably not the answer you were looking at but I think
our politicians just like our doctors and and our insurance companies follow
the incentives that that are placed in front of them and I think the tone of
the debate in Washington reflects the tone of debate in Ames our final
question I’ve been aware of the inequity and Medicare reimbursements dr. Kitchell
referred to and I’ve thought about it for some time that’s certainly very
troubling thing I am I believe I’m correct in saying in Iowa isn’t the only
one there are a number of areas of the country and I don’t know how they decide
these things or what the deal is but it strikes me that there should be legal
grounds I mean for suing under the Equal Protection Clause I mean I could see you
know medical associations and attorneys general and banding together and and and
why haven’t those of us who are being beaten down haven’t we sued under you
know equal protection claim you’ve just touched upon my favorite topic is
geographic inequity and I’ll try to keep this short because I could probably talk
for a couple hours on it but yes I was not the only state that has very low
payments if you look at the Medicare payments per patient the Medicare
payments per patient not per doctor not per hospital the Medicare pay payments
per patient in Miami Florida they are sixteen thousand three hundred
dollars per patient per year right here in Ames
they are six thousand two hundred dollars per patient per year in other
words we are saved the federal government $10,000 for every
Medicare patient that we have here in Iowa
yes we’re angry about this and the Iowa Medical Society and I have had this is
one of our primary concerns for many years I’ve spoken out against this for
this is about my seventh year the Iowa Medical Society has now got enough money
to proceed with a lawsuit against Center for Medicare services and in fact we’ve
without some legislation that has not gone very far because unfortunately in
the house those states like California New York Florida Massachusetts they have
higher payments and so their congressmen do not want to equalize those Geographic
payments the Miami congressmen are getting together with Florida with the
other Florida congressman in California and unfortunately there are more of
those than there are rural legislators so that’s why we have not been
successful and that’s why I think unless senator Grassley senator Harkin and
Bruce Braley a congressman from northeast Iowa if they are successful we
will not go ahead with the lawsuit but basically we will if they’re not
successful this year yes not only are we paying taxes to the
federal government and the money is not coming back to Iowa it’s going to
Florida in California New York all of us in Iowa are paying higher medical
insurance premiums because the hospitals and the doctors need to get paid and so
the private insurance companies are generous here and they actually make
people who buy insurance in Iowa pay more to make up for what Medicare
doesn’t pay now you may say why can’t we get the attorneys general in these other
states to help us and it’s been very frustrating I don’t really have an
answer I just want to give everyone else something else to be angry about
we have other Geographic inequities in Iowa the average Iowa wage and salary
worker does earn just 80 percent of the US average and for our non-farm
proprietors these are our sole business owners or entrepreneurs it’s actually
more like well in our non-metro areas it’s 52 percent of the national average
so we do have lower earnings here the cost of health care even provided by our
employers is a little bit more equalized in terms of what we pay for insurance so
what we pay is a much larger chunk of our earnings in this state than in other
states and that is something that Iowa’s even the ones who have health insurance
should be concerned about it’s eating up a bigger and bigger portion of our
paychecks here and it’s especially an issue for small business people and
sulphur fighters to give to give an idea of what the value is or what the size of
the gap is in terms of what insurance companies pay we’re going above
what Medicare pays in Iowa an insurance company pays about a hundred and fifty
percent of the Medicare rate for procedures in the hospitals and if you
think back to the rates that that were given to you earlier the differential
between what private insurance pays to a doctor or hospital and and what they pay
a Medicare pays to a doctor Hospital those numbers run-run true the estimate
is that health insurance premiums in Iowa are between eleven and thirteen
percent higher because of that and it’s not necessarily just that insurance
companies are generous in doing now insurance companies depend on two things
they depend on patients and insurance to pay premiums and they depend on some
place to send those insurance for service and if they don’t pay the extra
in Iowa as we heard before the hospitals and the clinics close their doors and if
that happens you don’t have insurance you don’t have proper insurance coverage
so it’s not necessarily altruistic it’s it’s a question of survivor and that’s
what the payment differential does but for everybody that has insurance it’s
about eleven to thirteen percent extra that is basically an indirect tax on
employment in our Medicare system okay I’m actually going to end with the last
question but I meant I’m asking for simple yes and no answers you know I’m
from there at political science we love polls and things like that so I’m going
to pull the panel and the question is there’s a simple yes or no will health
care reform be passed by the US Congress before the end of this year mark no
Liesl yes yes yes okay dr. Kitchell I was in
Washington yesterday and I hardly say yes
okay well three two one write that down okay oh okay yes that we extend our time
frame tonight by consensus yeah is that what you want to do I close it then you
can say around for some questions to have okay we’ll do that I want to thank
you all for coming tonight thank you especially to President Joe free Provost
Hoffman our panelists and the committee on lectures for sponsoring tonight’s
forum as dr. Joffrey said when he opened this this is a series of faculty forum
sponsored by the office of the senior vice president and provost our next
faculty forum will be on economic recovery we’ll also have some economists
on that panel as well including Peter Rossum who’s in the front row here and
if I’ve neglected someone else on the panel I apologize by no peers on it
it’ll be held at eight o’clock on Tuesday October 13th right here in this
room in the Great Hall and I hope that you can come to that again thank you so
much for coming thank you to our panelists and thank you for your
civility and I’ll be calling this in to CNN later or put it on YouTube okay and
feel free to come up to our panelist and ask your questions

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