Can Health Care Reform Succeed This Time? Health care reform officially began in Washington this week, and lawmakers have been hashing out the painful trade-offs of a bipartisan plan. Guest host Paul Raeburn talks with experts about the economic and medical realities of improving care and coverage at lower costs.
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Can Health Care Reform Succeed This Time?

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Can Health Care Reform Succeed This Time?

Can Health Care Reform Succeed This Time?

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This is SCIENCE FRIDAY from NPR News, and I'm Paul Raeburn. Ira Flatow will be back next week. Earlier this week, health care reform officially began in Washington. Almost everyone across party lines agrees that American health care needs an overhaul, but now lawmakers are getting down to the details, the sometimes painful details, of a truly bipartisan health care plan.

It's the phase of health reform when grand visions of better care and universal coverage can get lost in a mire of lobbying, tough compromises and unresolvable deadlocks, as they have many times in the past.

President Obama himself has said reform is not inevitable, so if we're going to get there, how are we going to do it? That's what we'll be talking about this hour. If you have a question or comment to share, give us a call. Our number is 1-800-989-8255. That's 1-800-989-TALK. Or if you are on Twitter, you can tweet us your questions by writing the @ sign followed scifri. If you want more information about what we'll be talking about this hour, check out our Web site at, where you will find links to our topics.

Joining me now to get us started with an update on the health-care debate in Washington this week is my guest, Mara Liasson, a national political correspondent for National Public Radio in Washington. She joins us over the phone. Welcome to SCIENCE FRIDAY.

MARA LIASSON: Nice to be here.

RAEBURN: Well, we need your help here before we can talk about the some of the issues to find out what exactly is going on, which seems to be changing by the minute. Can you start, Mara, by giving us just a sense of what bills are around, how many there are, and you know, what are the similarities and the important differences.

LIASSON: Well, there are five committees in Congress who are working on health care, and I think where we are is a really pivotal moment in the health-care drama.

I mean, you've had President Obama setting the stage for months. He's done a very good job of building up a head of steam behind health care reform, kind of convincing people that now is the time to do it, now or never. We have to do it because the costs are out of control. It's not just a moral imperative, it's a fiscal imperative, and that's been easy to get consensus on.

Even Republicans think it's time to reform health care. Now we're at the point where they're actually trying to craft a bill that is bipartisan, paid for, in other words it doesn't add to the deficit, that expands coverage to everyone over time and improves quality.

Those are very hard things to do, and what happened this week is that the two Senate committees, the Senate Finance Committee and the Senate Health and Education Committee, sent their draft plans to the Congressional Budget Office, who is the single most important player right now in the whole health-care debate because they score these plans.

They get on their green eye shades and their pencils and they - or whatever they use now, computers - and they tell you if, in fact, the savings that you think you're going to get by doing some things will really do that.

RAEBURN: That's an independent, non-partisan group.

LIASSON: Yeah, it's independent, non-partisan, and it's famous for giving congressional leaders headaches because it said this week, well, the Senate Finance Committee's bill is going to cost $1.6 trillion. Max Baucus, as the chairman of the committee, had hoped his bill would cost $1 trillion or less.

Now the higher the cost, the harder it's going to be to pay for it because you have to find more cuts, more taxes to raise. You know, you have to - and those things are extremely painful. So the Senate Finance Committee went back to the drawing board.

They're considering deeper cuts, they're considering a kind of automatic trigger. If things do get too expensive, automatically cuts would be made. They're considering raising taxes on health-care benefits. That's something Democrats hate. They're considering an employer mandate.

RAEBURN: And Obama, I think - didn't Obama promise not to do that during his campaign?

LIASSON: He, well this is a little complicated. He attacked McCain for a plan that would have eliminated the tax deduction for employer benefits, and he did run ads saying that tax health benefits was a terrible thing.

Now, McCain wanted to eliminate them completely. What the Senate Finance Committee is talking about is capping them, not eliminating them completely, but in other words, if your health-care plan that you get from your employer is worth over $17,000, then you'll have to pay taxes on the amount above that. That's what they're talking about.

Yes, the president would have to walk back from a campaign pledge, but even more serious politically, he promised explicitly, over and over again, as early as, as recently as April 15, not to raise taxes on people who made less than $250,000 by a single dime.

Now if you tax employer-provided health benefits, you are raising taxes on the middle class, and that's what Democrats, I think, will have to swallow if they're going to get a plan through.

Republicans are going to have to swallow things they don't like, such as this employer mandate, a pay-or-play requirement on businesses that either you cover your employers or you pay into some kind of fund. So that's, in other words...

RAEBURN: Yeah, let's go back to the CBO report for a minute because that was such a bombshell this week with the huge cost figures. Did the CBO also attempt to estimate any savings that might arise from reform?

LIASSON: Well yes, but they only estimate savings if they think they can score them. In other words, one of the big areas that the White House thinks you can get savings from is by making - taking best practices, in other words going to places that have high quality but lower-cost health care, and there are places, in Pennsylvania and the Rocky Mountains and the Mayo Clinic, and trying to replicate them all over the country.

There are places elsewhere in the country, McAllen, Texas, is the famous example, where they pay a lot of money for health care, and they get poorer quality, poorer outcomes. So this is called comparative effectiveness or enforcing best practices.

The problem is that the CBO can't score that. In other words, there's nothing tangible there. Nobody quite knows how to enforce innovation, and you know, maybe after 10 years they could figures it out, but the CBO only looks at a 10-year window, and they don't find those kinds of reforms or innovations scorable. In other words, they can't put a number on them.

RAEBURN: It's in part because we've never tried to do anything quite like this before, so it's hard to...

LIASSON: Yeah, that's right. Nobody's ever done it before.


LIASSON: But they also think that if you have a public - if you squeeze Medicare, for instance, that's a savings, but if it means that hospitals are going to raise prices elsewhere to make up for the cuts from Medicare, well then that doesn't save you any money net.

RAEBURN: Right. There are a lot of moving pieces here to consider.

LIASSON: So CBO tries to look at the whole thing, yeah.

RAEBURN: Now give us, if you can, a little bit of a preview before you have to go. What can we expect to see today, next week, in the short term and over the longer term?

LIASSON: I think the big thing we're waiting for is the Senate Finance Committee. They are the key committee. They're trying to produce a bipartisan plan. Now the other committees, the Senate Health Committee and the House committees, they don't care.

They're willing to pass something with Democratic votes only, and in the Senate, they could muscle something through with 51 votes, but that is generally considered not a good idea when you're looking at legislation of this importance, reforming, you know, one-20th or 20 percent of the percent of the American economy, whatever health care accounts for.

So Max Baucus is trying to produce a bill that could actually get moderate Republican votes and Democratic votes to pass it with a 60-plus majority. So he's gone back to the drawing board. He's not going to come back with anything until July. July is key. After July 4th, when Congress is back from its break, he will have a, probably a much more modest plan rolled out more slowly, and just one point about that.

You can make this thing come in under $1 trillion if you don't get to universal coverage quickly, if you roll it out very slowly, have lower subsidies at the beginning. The problem with that politically is you're putting all the pain up front, the tax hikes, the spending cuts, you know, the restrictions, and the goodies, which is universal coverage, you're waiting.

So people might revolt. In other words, if you have to pay higher taxes, but you still don't have universal coverage, that could cause a backlash against the bill. They are trying to get the pain and the promise, the dessert, all at once, and that's very hard to do.

RAEBURN: Well, thanks for taking the time to give us an update. My guest has been Mara Liasson, national political correspondent for NPR in Washington. Thanks for being with us.

LIASSON: Thank you.

RAEBURN: For the rest of the hour, we're going to talk about some of these issues, and we'll talk with some of the people who are involved in understanding them and resolving them.

We'll talk with one of the architects of the new Massachusetts health-care plan, we'll address some tough questions surrounding the cost of medical care and the quality of that care. More money does not always produce better care.

In some ways, we seem to be spending vast amounts of money on things that don't make anybody feel better, and we will zero in on Grand Junction, Colorado. Mara mentioned McAllen, Texas, which has become notorious for spending a lot of money on health care. Grand Junction seems to be one of the places where they can deliver good care at low cost. How do they do it? We'll find out.

Joining me now to talk about these issues are my guests: Michael Pramenko, family physician and member of the Colorado Medical Society's Health Care Congress. He joins us from the studios of KNZZ in Grand Junction, Colorado. Welcome to SCIENCE FRIDAY, Dr. Pramenko.

Dr. MICHAEL PRAMENKO (Colorado Medical Society): Good afternoon, Paul. It's a delight to be with you this afternoon.

RAEBURN: And we also have Jonathan Gruber, board member of the Massachusetts Commonwealth Health Insurance Connector - I hope he'll explain what exactly that beast is. He's also professor of economics at the Massachusetts Institute of Technology in Cambridge, Massachusetts. He joins us by phone. Welcome to SCIENCE FRIDAY, Dr. Gruber.

Professor JONATHAN GRUBER (Massachusetts Institute of Technology): Thanks, Paul, good to be here.

RAEBURN: And Dr. James Rohack, president of the American Medical Association, a cardiologist at Scott and White Healthcare in Temple, Texas. He joins us from the studios of KAMU in College Park, Texas. Welcome to SCIENCE FRIDAY, Dr. Rohack.

Dr. JAMES ROHACK (President, American Medical Association): Great to be here, Paul.

RAEBURN: So Dr. Pramenko, let's start with you. Grand Junction is suddenly. Maybe it was always famous, but now it's famous for being a place where people deliver good health care at reasonable cost, even low cost. How do you guys do it?

Dr. PRAMENKO: Well, this has been an effort of collaboration. It started away back in the 1970s, after the HMO Act of 1973, and local doctors with some foresight and altruism put together a local, non-profit health-insurance company to try to keep costs down, premiums down so more people could buy insurance.

RAEBURN: And so tell me a little bit about how that worked and what the mechanism is. A particular question of mine is whether you do this because you have a group of particularly selfless and dedicated doctors who are willing to work for less than they might otherwise make, or whether this is a system that, you know, might be easily replicable even in places where you don't have a bunch of close colleagues getting together.

Dr. PRAMENKO: Yeah, well, I do think it can be replicated. You know, you go back, and the holy grail to providing universal care and to health-care reform really is cost control. I mean, you can have, you know, suddenly tomorrow have a public plan, but unless you solve the cost problem, it's not going to make it over the years. The inflation rates just won't make it.

So whatever type of paying system you have or payer system you have, you've got manage the cost and contain that cost. And the way that's happened here in Grand Junction is, again, through collaboration, through this non-profit insurance company and physicians, physicians willing to look at each other and to do peer review; physicians willing to look at the cost of hospitalization, looking at how much specialists cost and the comparison from one specialist to the next; and you know, providing incentives for the use of generic drugs.

RAEBURN: Let me stop for just a moment. We have to take a pause. We'll be right back after this short break.

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RAEBURN: From NPR News, this is SCIENCE FRIDAY, and I'm Paul Raeburn. We're talking this hour about overhauling the nation's health care. My guests are Michael Pramenko, family physician in Grand Junction, Colorado; Professor Jonathan Gruber, a professor of economics at the Massachusetts Institute of Technology; and Dr. James Rohack, president of the American Medical Association.

Dr. Rohack, let me go to you for a moment if we may. Dr. Pramenko was talking about a group of physicians and colleagues in Grand Junction who got together to try to control costs, and the obvious question is, is cost control going to be done on the backs of physicians? However we reform health care, is the result going to be that physicians make less money? Does it have to be that way?

Dr. ROHACK: Well, Paul, the American Medical Association is absolutely committed to all Americans having affordable, high-quality health coverage, and one way we can do that is to reduce the unnecessary costs in the health care system.

The unnecessary costs are partially administrative burden, but also variation in care, and we recognize that, and so the AMA actually brings together national specialty societies to create what are the best practices to be able to provide care for different medical conditions.

But we know in our current environment that unless there's liability protections against not ordering that additional test, physicians may still be pressured to order that additional CAT scan or MRI unless we can come up with these practice guidelines and not have to worry about being sued in a courtroom because you didn't order it, even though it wasn't needed.

RAEBURN: So some studies I know have shown that the medical liability question which you're raising would save some money but perhaps not a lot of money in the health care system. I'm sure there are other studies that disagree. But are you suggesting that that could be a major piece of how we're able to save money and pay for health care reform?

Dr. ROHACK: Well, certainly we believe that defensive medicine is a real cost and a significant cost because it contributes to the variation in care. You can take a look across the United States between environments like Grand Junction, that doesn't have a high liability problem because of tort reforms passed by the Colorado Medical Society many years ago.

But in other areas, many tests are ordered because of a fear of a lawsuit. So we believe that this has to be dealt with by using science, and the science is such that comparative effectiveness can allow us to compare different devices and drugs to say what's really best for the patient and then using technology to be able to adopt it quicker, so when the patient sits down with the physician, you basically have the best practice for that patient at the time the care needs to be delivered, and that way we can start to eliminate the unnecessary cost so we can provide affordable health insurance coverage for all Americans.

RAEBURN: Professor Gruber, you have had to address some of these questions or think about them with the health reform in Massachusetts. Tell us a little bit about how long you've been at it there and what the results are turning out to be so far.

Prof. GRUBER: Well, Massachusetts has been at health reform for a long time. Governor Dukakis made a major health reform that was a basis for his run at the presidency a number of years ago, but this last round really began with Governor Romney in around 2004, 2005 and a recognition that we could get to universal coverage in an affordable way in our state, and it culminated in a law in April, 2006 that passed our legislature virtually unanimously that provides health insurance, universal health insurance coverage for our state, and the results have been impressive.

We've covered over 400,000 people with health insurance. Our uninsurance rate is down to about 2.7 percent, by far the lowest in the nation. We've done so within budget. We've come in within our budget projections, and we've done so in a way which is built on a system that works. Employer-provided insurance has actually risen, not fallen as many had feared, and the reform is popular, about 75 percent public approval of the reform itself. So, so far it's going pretty well.

RAEBURN: Now, you apparently managed to achieve the bipartisan consensus that people are working so hard for in Washington. You also made health insurance mandatory in Massachusetts. Has that worked? Has that -there's a lot of controversy about that in Washington now. What's your experience been?

Prof. GRUBER: I think the experience has been very positive on that on a couple of ways. One is I think it's been - I think it's widely recognized that's what you need to do to get to universal coverage, and we've gotten fairly close. The second is that administratively it's gone well.

This was a pretty new experiment. People got a new tax form they had to fill out, the Form 1099-HC, proving they had health insurance. Ninety-eight percent of taxpayers got that right the very first year, and it's remained - as I say, it's remained popular. So, so far I think the mandate's working pretty well.

RAEBURN: Well, you're sounding awfully optimistic, so let me try to throw some cold water on that for the sake of discussion. Are you going broke? How is it come out cost-wise?

Prof. GRUBER: No, actually, we're not going broke. I mean, this bill - the best estimate is this year we'll spend about $800 million as a state to cover over 400,000 people. If you project that to the nation, that would be consistent with a cost of about $100 billion for the nation as a whole, which is basically the kind of range they're talking about at the federal level.

One person who was very important here in Massachusetts once said that working at the national is like working in Massachusetts. You just add three more zeroes. And I think we can see it work within budget. It's not cheap. You're providing health insurance for new people, and that's not a free - that's not free. But I think it's a worthwhile investment for society.

RAEBURN: I'd like to take a call from Adam in San Mateo. Adam, are you with us?

ADAM (Caller): Yes, I am.

RAEBURN: Go ahead.

ADAM: Yes, hi. You know, I've been following this health care insurance thing since the campaign in 2008, and from what I can see, the biggest problem is the government is trying to pay for everything.

I mean, I believe the problem is lack of competition, and more importantly, I don't believe that we should be leaving health care with employment. I have health care from my employer, and you know what? Most of my colleagues, like me, do not know how much we're paying for it.

If you don't know how much you're paying for your health care, how are you going to compete? How are you going to shop for it? I couldn't shop for it.

RAEBURN: Okay. How could we get a little more competition into the system, Professor Gruber?

Prof. GRUBER: Oh, I think the listener makes an excellent point, which is the fundamental cause of the high and rising costs in health care in America is that most of us get it through our employer. Not only do we not know what it costs, but we're buying it with tax-subsidized dollars. If your employer pays you in wages, you pay taxes on that. If your employer gives you generous health insurance, you don't pay taxes on that.

As a result, our employment-based system is not portable, and it's led to excessively generous insurance, and I think that an important part of reform that's being discussed seriously in the Senate Finance Committee would be to actually have employers report on people's pay stubs what their insurance costs and actually tax them on any excess of that cost above, say, the national average.

RAEBURN: Adam, does that address your question?

ADAM: Actually, to a certain degree, but I think there should be a totally - I mean, why are we taking money, you know, from the benefit and then we pay it back to others? Why can't we just not tax health care and just make people buy their own health care that in some way that, you know, I mean - actually I came up with an idea, but I don't know how do I submit something like that, because I think it should just be a personal responsibility to provide for health care. Why is government doing all this for you when health care should be something like taxes, that's something you must by?

RAEBURN: All right, at least we got that message out to our listeners. Thanks for calling, Adam. Let me go for a minute to Jack in Naperville, Illinois. Are you there, Jack?

JACK (Caller): Yes, I am. Thank you for taking my call.

RAEBURN: Yeah, so you're going to tell us how we're going to pay for it all.

JACK: Well actually, yeah. One of the things that people don't talk about is the medical industrial complex that exists here in the United States and across the country, as well as international, and why not a windfall-profits tax on the pharmaceutical and medical-device companies that do profit from Americans and people from around the world getting sick?

Another thing that we don't talk about is taxing hospitals. Everybody wants to beat up the physicians, but the vast majority of hospitals here in the United States are not for profit and do get a substantial tax credit from the federal government. Especially here in Naperville, Illinois, Chicagoland area, it's kind of a running joke that the hospital systems here are real-estate development companies who just happen to provide health care as a side business, because what they do with all their profits, they just reinvest into new facilities, outpatient facilities, when there may not actually be the need for those additional facilities.

RAEBURN: Dr. Rohack, any of this compute to you? What do you think?

Dr. ROHACK: Well, clearly both people that talked about the problems of a fixed dollar amount that the federal government pays for health care, both to physicians, as well as to hospitals, means that the private sector winds up subsidizing even more.

We know that choice and competition are two very strong principals of America that the American Medical Association believes that has to be part of fundamental reform. Having the ability to privately contract for health care between a doctor and a patient, very important. And the other recognition is that our current system, because the federal government through price controls doesn't make it able to have the patient really know what the cost of care is.

We do need to have a change in how people get information on what the cost of care is and really what is best for them. And we believe that information technology can be one tool to help the doctor and the patient know what it costs, what the benefit is, and so that they can make that personal choice what's best for them.

RAEBURN: Dr. Pramenko, I'm very interested in what you did in Grand Junction and also your perspectives based on that experience. There's a lot of discussion now about a public plan, a public insurance plan that would be funded by the government. Would that fit in to the kinds of things you're doing in Grand Junction? Do you think it's a good idea?

Dr. PRAMENKO: Well, you know, if private for-profit insurance companies went away tomorrow, I probably wouldn't lose any sleep over it. What I'm concerned is, is that we're playing too much attention right now to the debate regarding a public plan versus a private plan, because I really think that really misses where the debate needs to be and that's on the cost and controlling the cost. Because whether you have private or public payers, that's what's going to allow you to function as a medical system down the road.

I do think we have to be careful with this competition point. You know, if you have four gas stations on the corner, you're going to drive the price of the gas down. If you have four hospitals on the corner, the cost of medicine and the cost of overall care will go up. It doesn't quite fit the model that we use for widgets or gasoline.

And so in Grand Junction, yeah, we've looked at that, and we hope that the plan we have and the program we have does not get hurt by any reform that takes place. But if we go back and we focus on cost, and we really focus on trying to control those costs with changing behavior of patients and physicians, I think we'll focus a bit better on where to go after a solution to the problem.

RAEBURN: Now, are the savings coming from physicians from hospitals from all the places where money is spent on healthcare?

Dr. PRAMENKO: Yes, it is. It's a culture that's different than in other areas and shared in other areas of the country as well. You mentioned Mayo and in Pennsylvania under the Geisinger System. But it's a culture that's a bit different. You know, there's a level of collaboration here between a non-profit local insurance company that really cares more about investing in the community than any shareholder. And those are - that's a real critical element there, because if you want physicians to change their behavior and look at quality and cost, you have to have a level of trust and collaboration.

Now, do you think a physician's going to have trust and collaborate with a pair that's maybe a thousand miles away that's sending rules down the pike? Or do you think they're going to listen to their colleagues - that have helped set up this system, that put quality and cost controls in place - do you think you're going to get a little bit more agreement on that? I think so too.

RAEBURN: I'm Paul Raeburn and this is SCIENCE FRIDAY from NPR News. Dr. Rohack, to just have you respond to Dr. Pramenko, do you think doctors and insurance companies elsewhere in the country would be able to work out a similar arrangement?

Mr. ROHACK: Well, the hugest barrier that we have right now for physicians to come together are anti-trust laws, so that if physicians in communities start to come together to focus on quality and then start talking about value - and part of value is price - the federal government anti-trust lawyers start to come down and become problematic for us to evolve into a system.

I think that what Dr. Pramenko has highlighted, though - we have to align incentives. And the incentives that has to be aligned are between those who received the care, that is our patients; those who are providing the care, that is physicians and hospitals; and those that are paying for care, which can be a pooling of insurers or a pooling of taxes through a government system. When the incentives are not aligned, that's when health care becomes problematic.

So the AMA we're - we believe that, anti-trust reform to allow physicians to come together is very important. And those who have the data, who have the information that physicians need about their practice needs to be able to provide that feedback back to physicians in a collegial way, not in a current way that many insurers provide it back with telling the doctors, you're a good doctor or you're a bad doctor and we're not going to tell you exactly which patients don't have their mammograms done or colonoscopies, we're just going to tell you that you're bad. And that's not a way to evolve our health care system.

Dr. PRAMENKO: Well, can I comment on the FTC issue?


Dr. PRAMENKO: That's--

RAEBURN: That's the monopoly issue you're talking about.

Dr. PRAMENKO: Right. And out here in Grand Junction, the FTC did look at us about 10 years ago or plus 10 years ago and there was a lawsuit that was brought. And, you know, they looked at the complaint and saw what we were doing, mixing in and giving such great access to the Medicaid folks, which we do have a special arrangement, whereas things get pooled so some doctors get paid a bit more to see Medicaid patients to increase access and other doctors have to actually make a little bit less. Again, a level of collaboration that you hardly see anywhere else in the country.

Well, the FTC looked at that and they said, no, we're not going to, you know, bring a lawsuit against this community that's obviously doing some very altruistic things and trying to make the system better. And so, we actually won that round with the FTC.

RAEBURN: Is there - does Congress need to do something or the FTC need to do something to change that, though, so others won't have that same threat?

Dr. PRAMENKO: Yeah. There are some changes that need to be made now. And - but there has to be also good leadership so that, you know, that system doesn't get abused. And that, you know, we're rewarding altruism and not greed.

RAEBURN: Would you make more money if you moved somewhere else and set up shop than you're making under this arrangement in Grand Junction?

Dr. PRAMENKO: As a primary care physician, probably not. There's not a big, wide range of what I'm capable of making.

(Soundbite of laughter)

Dr. PRAMENKO: Specialists that I work with will definitely say yes to that question. There's no question about that.

RAEBURN: That seems to me to be a bit of a problem because we can't really ask people to make less money than they were able to make. We can ask them, but we - certainly, not all of them will agree.

Dr. PRAMENKO: There's no - it's a recruitment problem. Now, we're fortunate that we live in a beautiful part of the country here. And so there's other reasons why doctors come and practice here. And fortunately for us that's been part of the success story is because, you know, we live in a place where other doctors want to come and live, too.

But there's no question that some of our specialties are suffering because doctors can make more elsewhere.

RAEBURN: Stay with us. We'll have lots more on the nation's health care. And we'll be right back after this short break.

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We're talking this hour about patching together a national plan for health care with my guests Dr. Michael Pramenko, a family physician in Grand Junction, Colorado; Professor Jonathan Gruber, a professor of economics at the Massachusetts Institute of Technology; and Dr. James Rohack, president of the American Medical Association.

Now, Dr. Rohack, you - somewhat resembling what Dr. Pramenko's situation is in Grand Junction, you have a sort of arrangement with your local health insurance companies, do you not?

Dr. ROHACK: Yes. At Scott and White Healthcare, we've been around for 110 years with initially a physician group, multi-specialty, then later added a hospital, and 25 years ago a community-based health plan, a nonprofit, again, working together to try and make the community better.

But we also interact with national payers, and as a result of that we kind of see the differences in attitude and interactions, as well as the administrative burdens that the different entities put on the actual physician's practice.

RAEBURN: And that has helped control costs there? Have you had similar success controlling costs?

Dr. ROHACK: Well, when you take a look at what Scott and White has on national Medicare data, certainly we are one of the most conservative and effective places in the country. And part of that is because we have a very strong belief in primary care.

All our patients that enter Scott and White get a personal physician in primary care that helps to coordinate that care. And I think that is a very important lesson as we deal with health system reform that a patient-centered medical home can help deal with some of this care coordination transition problems that help to drive up unnecessary costs.

One of the things the AMA is devoted to this year is to try and help so that as patients leave the hospital, the physician who's going to care for them at the other end knows what medications they're taking.

So medication reconciliation is an important way to try and prevent patients from having unnecessary drug interactions that winds up them back in the hospital, thus driving up health care costs.

And I think that's where the incentives need to be aligned. We want to keep patients healthy. We want to keep them out of the hospital if they don't need it. And the way to do that is good communication and information sharing between the specialty physicians and those who specialize in primary care.

RAEBURN: That's a hallmark of what's called a medical home, that coordination.

Dr. ROHACK: Absolutely. And right now, the medical home - when a physician like Dr. Pramenko spends a lot of time on the phone trying to coordinate that patient care, that's not paid for. And so when you look at some of the frustration that many primary care colleagues have it's because they're spending an hour and a half a day dealing with administrative burdens and, again, not getting it paid for.

So we believe as part of comprehensive health reform, we have to get that change so that patients and physicians, as they're interacting with each other, have appropriate communication, payment for that, as well as not having any sort of Medicare payment formula that right now penalizes doctors when you're providing more care for the patient that's needed it, by keeping them out of a hospital.

We need to change our system so that we align all the incentives - the Medicare incentives, the outpatient incentives, the communication incentives - so that patients can get the best care possible and physicians have the time to spend with patients, which is what we both want.

RAEBURN: Professor Gruber, we talked about some surprises in the Massachusetts experience. One of those had to do with the number of people getting insurance through their employers. Can you tell us what you expected and what has happened?

Prof. GRUBER: Yeah. This is really a striking finding. I think a big concern with the reform system, which involves a lot of new government money is that it would lead people to leave their employers and get insurance on the public programs instead.

But in fact, the opposite's happened here. Employer response in insurance is actually up 150,000 in the state. And the best explanation is really the effect, once again, of the individual mandate.

If you watched every Red Sox game during the summer of 2007, there was an ad between the first and second inning, saying you had to have health insurance in Massachusetts by the end of the year. I think a lot of people went to their employers and said, hey, I've got to have health insurance, I hear you're the place to get it. And the employers gave it to them.

So it's really been a striking development, I think - bodes well for the notion that we've pressed here in Massachusetts of building on the existing system rather than tearing it down and starting over.

RAEBURN: Does the Massachusetts experience say anything about the virtues of a public health insurance plan of the type that's being discussed in Washington?

Prof. GRUBER: No. It doesn't really. I think there has been a lot of confusion about this. While I think it's important to separate two roles the government can play - one role is as a financer, basically making health insurance affordable for people.

The earlier caller talked about why don't we just mandate people have health insurance? Well, we can't just do that. Health insurance is too expensive for low income people. A typical family policy would be 50 percent of the income of someone at the poverty line - or twice the poverty line. You just can't do that.

So the first role is the financial health insurance. That's what we've done here in Massachusetts. We paid subsidies for individuals to get their health insurance but through private health insurance companies. The state is not providing insurance.

The public option is a separate issue. That's not about the government as financer, that's about the government as insurer - literally saying, we, instead of Aetna, are going to provide your insurance.

So instead of you getting a government subsidy or insurance through Aetna, we're going to say you're going to get your insurance through Gov-Care or whatever our new plan is.

That is a separate issue and raises separate questions. But it's important to recognize that a public option by itself doesn't cost money. What costs money is the government as a financer.

RAEBURN: We have a caller from Boston. Hi, you're on SCIENCE FRIDAY.

ANNELE (Caller): Hello.

RAEBURN: Hi. You're in the air. Go ahead.

ANNELEE: Hi. My name is Annele(ph).

RAEBURN: Hi, Annele.

ANNELE: And I have to say, well, first of all, I know this is a very unfair format because people like me, the callers, have limited time to answer all these BS that I'm hearing, plus I'm only the second one. And I would like to say, first of all - because the more I listen to Jonathan Gruber, the more incensed I am. He's painting such a rosy picture. It's surreal.

RAEBURN: You've had problems, I take it.

ANNELE: Okay. So Jonathan Gruber is lying by omission. And I'll give you some figures.

RAEBURN: Just - well, give me a little bit about your experience why do you...

ANNELE: Yeah. My experience is that, okay - and I have the memo from the office here. My husband and I have to buy our health insurance through the office. And I just actually fired my long letter to Kerry, Kennedy, Bernie Sanders, the White House and so on, explaining that a year ago in May, our premium, for my husband and myself with Blue Cross Blue Shield of Massachusetts, was 811. And the renewal rate was 1,117. So it was, you know, over 37 something percent increase. So...

RAEBURN: 800 to 1,100 more or less?

ANNELE: Yeah. So, we dropped that. We went on to a lower one. And, of course, this year again, that lower one to - that allowed us to keep 812 per month premium with higher co-pay and $1,000 deductible. Well, this year we just got the memo that one is also going up about 31.5 percent...

RAEBURN: Okay. Let me stop you, Annele, if I may, because I want to make sure we get Professor Gruber a chance to respond.

ANNELE: Sure. But let met just say one thing.


ANNELE: That the plan we had two years ago - because this is really significant. I can do math. Okay? The plan we had until June 31, 2008, which was, as I repeat, 811 per month, should we renew now, a year later, it is $1,492.98. That's an 84 percent increase.

RAEBURN: Okay. Thanks for calling. Let's - Professor Gruber, what about that? That doesn't - she's right. That paints a very different picture from what you're painting.

Prof. GRUBER: Well, I think there's two points of response to that. The first is that, you know, individuals can have different experiences. All we can look at is what's happened overall. And overall, health care costs in Massachusetts have risen about at the national average, about six to seven percent a year since we've passed this reform. So sorry to hear about the listeners' experience, that's rather unusual relative to what we're seeing overall on average.

The other response is that what we've done here in Massachusetts, which nowhere else has, is to make sure that listeners like the one that called, if they have incomes - say, family income is at $60,000 or less, we're going to heavily subsidize those premiums.

So while it's true that premiums are going up in Massachusetts, just like everywhere else, by about six to seven percent a year, the difference in Massachusetts versus living in any other state, is if that listener's and the family with income less than $60,000 a year, the government couldn't give them a lot of help.

That said, I think, you know, the listener's question raised a general point. The Massachusetts reform is not about cost control. That was not our goal. Our goal is to cover our citizens, make sure the citizens didn't have to go to bed a night worry about waking up being bankrupted by their medical expenditures.

Cost control is a separate issue that has been addressed by - you know, by the other speakers and is a major new battle we have to face at the national level.

RAEBURN: Tell me just briefly, while I have you, the - you're in the board of Massachusetts Health Insurance Connector. What is that thing? It's an odd name.

Prof. GRUBER: So basically, the Connector is the new authority that runs our health reform. So - but the reason it's called the Connector is because our health reform really has three fundamental pieces.

The first is that we provided this heavily subsidized insurance for those with incomes below $60,000, as I mentioned. The second is the individual mandate which says that you do have to buy health insurance in return for the fact we're subsidizing it. The third is we've reformed the way our health insurance market works, and that's where the connector piece comes in, which is we've set up a new organized market place for buying health insurance - you can see it by going to And it's basically an amazing new Web site where you can go and choose from variety of health insurance products in organized shopping framework that didn't really exist before. So that's what the connector piece is. At the national level, it's often referred to as an exchange.

But it's basically the notion that we are going to get rid of our very dysfunctional and hard to navigate insurance market for individuals with small businesses and loose to a more reasonable Web-based portal.

RAEBURN: Dr. Rohack, the - a lot of these plans of all sorts seem to involve more government involvement whether it's the connector in Massachusetts, it's kind of government involvement, whether it's a public plan in Washington, more regulation, et cetera. I don't think the AMA and maybe your personal experience with the government has been all that good, and I'm talking about Medicare.

Dr. ROHACK: Well, clearly Medicare, when it was started many years ago, was not supposed to interfere with the practice of medicine, and of course, that has changed. And I think one of the highlights of the Medicare program is that it's still a silo. Part A pays for the hospital. Part B pays for the doctors. Part D pays for drugs.

And so, in the part B, there is a formula that's been around now for almost 20 - I mean, sorry, almost 10 years or longer that basically has whatever procedures, whatever tests are done, whatever volume of services are done in one particular calendar year, the next year the physician payment is cut to maintain budget mutuality. And as a result of that, January 1st, physicians faced a 21 percent cut in Medicare payment to care for patients.

So what happens with the government system, because of its monopoly powers and its huge size, if they want to control a budget, they basically start to slash away at reimbursement. And unfortunately, the patient winds up being at risk of trying to find someone who is going to care for them.

We believe that that's - that needs to be changed right now, that fundamental health system reform. People are now talking very much about changing this formula that's flawed. And we believe very importantly that, especially those in rural and underserved areas where physicians are at age 68, 69, 70 thinking about, well, do I still want to stay in practice if you're faced with a 21 percent decrease in the income coming in knowing that you yourself are having to spend higher premiums in insurance coverage for your workers...

RAEBURN: Let me pause for a moment to say - just to remind everybody, I'm Paul Raeburn. This is SCIENCE FRIDAY from NPR News.

Go ahead.

Dr. ROHACK: Then it becomes a real problem to get all that and keep your office open. So we're - we believe in the discussion that's - that will occur that pluralism(ph) is important. We need to have a private market so that we have innovation and choice. And then the role of the government is to provide the safety net for those that can't afford.

And again, we believe, as Jonathan mentioned, having subsidies from the federal side to allow the individual to purchase insurance for themselves and their family and then allow the private market to be the one to innovate to allow the changes needed so we have an American system of health care for every one that's affordable and has high quality.

RAEBURN: The AMA and the government can now find a way to get together on this, do you think?

Dr. ROHACK: Well, we were excited when President Obama came to speak to our house of delegates on Monday. He signaled that physicians are going to be central to making health reform. We, as physicians, we got into this profession because we want to serve our patients. And so we want to make sure the patients' voice are taken care of.

We want a system so that patients will have the ability to choose their physician, decide what care they need along with their physician based on science, and then having a payment mechanism that's fair so that the patient doesn't have to decide, do I buy my medicines or do I pay for my electricity.

RAEBURN: Dr. Pramenko, we're talking a lot about costs and keeping cost down and getting rid of unneeded treatments and so forth. Do you think that the arrangement you worked out in Grand Junction has also done the flip side of that, which is to provide better treatment for people who weren't getting enough of it?

Dr. PRAMENKO: Oh, yeah. You know, there's two sides of the coin. There's people that are aren't getting enough care and there's people that are getting too much care


Dr. PRAMENKO: And that's obviously seen in the Dartmouth Atlas study. There's no question our arrangement here increased access with the Medicaid folks to a greater degree than most areas in the country, unparalleled. And because of that, you know - you know that gap. And then, there are arrangements on the other side, you know, looking at cost and quality, kind of reigned in too much. Can I comment on a moment on the - on this issue with the caller from Massachusetts?

RAEBURN: Just very briefly. Sure.

Dr. PRAMENKO: Okay. You know, there's a need for a mandate to get insurance if you're going to get universality. I think there's a broad agreement for that. But, you know, and - but that's going to require a subsidy. And the issue I see there is if you're going to require a subsidy and make people get insurance, why should the insurance companies be profiting from that.

And, you know, that's where I think you can have private entities like we have here in Grand Junction, Rocky Mountain Health Plans. It's non-profit. You can mandate insurance. But they're not profiting off of that mandate if you made it that way. Our CEOs here make about as much as the doctors. They're not pulling in millions of dollars or billions like some of these private insurance companies are.

RAEBURN: All right. That will be the last word. Thanks very much. I'd like to thank all my guests for a fascinating discussion.

That was Dr. Michael Pramenko, family physician and member of the Colorado Medical Society's Health Care Congress. We also talked with Professor Jonathan Gruber, a board member of the Massachusetts Commonwealth Health Insurance Connector and professor of economics at MIT in Cambridge, and Dr. James Rohack, president of the American Medical Association and a cardiologist at Scott and White Healthcare in Temple, Texas.

Thanks to all of you for joining me today.

Prof. GRUBER: Thanks, Paul.

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