BREAKFAST WITH THE CHIEFS
Friday, October 18, 2013
Introductions and welcome by Moderator Anton Hart, Chair,
the HealthcareBoard and Publisher, Longwoods Publishing. Mr. Hart thanked the
event’s sponsors, the Health Council of Canada and Accenture, then introduced
today’s chiefs:
Trudy Lieberman is a past president of the Association of
Health Care Journalists in the U.S. and currently covers health for the Columbia Journalism Review. Lieberman is
visiting four cities across Canada as a Fulbright Scholar and guest
of the Evidence Network of Canadian Health Policy, commonly known as
EvidenceNetwork.ca.
André Picard is a health reporter and columnist at The Globe and Mail, with a new book
launching through The Conference Board of Canada on October 30.
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TRUDY LIEBERMAN began by indicating what she believed to be
the main question people have, which is “what is Obamacare?” She then provided
a brief overview while mentioning that André Picard would discuss the areas of
convergence between the two country’s health care systems.
What is the “Affordable Care Act”? First off, says
Lieberman, it does not provide health insurance to all Americans. It affects
the individual market, where people go for healthcare when they do not have
coverage. Even so, pre-existing
conditions, such as asthma are often not covered by insurance companies in this
market. Obamacare makes it easier for people to shop in that market.
Lieberman has been writing about U.S. health care for more than twenty years and knows that people in the U.S. have trouble navigating that
system.
Approximately 25 million people in the U.S. shop in the
individual market, and that’s who Obamacare is aimed at helping. Some may have
had healthcare coverage, while others are new to buying coverage. In order to
coax people to buy in to the system, the government is offering subsidies .
However, 40% of the individual market will not qualify for subsidies and yet,
there are penalties for not purchasing insurance, even when a good policy could
cost upwards of $16,000.
People are worried and do not know if the subsidies will be
sufficient enough to buy an adequate healthcare policy, or if the subsidies
will last over time. Those in the middle class are especially concerned.
The reform law called for an expansion of Medicaid, the
federal-state program for the poor. But 27 states chose not to expand, leaving
those with incomes below the poverty line with no options. They are barred from
shopping in the exchanges and are too poor to buy coverage ion their own.
In her opinion, the Achilles heel of Obamacare is the lack
of expansion of Medicaid.
The confusion about Obamacare also lies in the fact that the
press and media not always explained it properly to the American public.
OTHER MAIN POINTS:
Obamacare does not build in equity. There will be four types of plans sold in the
exchanges. Most will/are expected to opt for the bronze plan which covers 60%
of costs. Then there’s silver at 70%, gold at 80% and platinum at 90%. However, many states won’t
be able to offer a platinum plan because it will be too expensive for most
shoppers.
Out of pocket spending is high. Deductables will be around
$4,000 or $6,000 for a family policy but might be as high as $10,000 or $20,000.
Co-insurance consists of the percentage of insurance a patient has to pay for,
such as diagnostic imaging, which is not covered by plans.
There have been multiple cost-cutting moves, including
moving services from the hospital to outpatient settings. Insurance companies are asking people to pay
for high cost sharing for he most commonly-used services. This is something
that has not yet sunk in with the American public.
Obamacare also does not include a cost containment clause
Lieberman does not know if Obamacare will work and expects it
will take at least two or three insurance cycles to see what companies are
doing with the premiums and whether people actually buy and have insurance.
While the goal is affordable health care, she predicts
Americans may not get it.
The administration and the media could have done a better
job in promoting the new law, says Lieberman. As a result there’s been somewhat
of a backlash against Obamacare. But there hasn’t been a sustained discussion
as to what it can and will do. The individual mandate was never made clear;
which was probably a deliberate act by the administration to prevent backlash.
The irony is, this type of plan was first introduced by the Republicans in the
nineties to counter the Clinton Administration’s plan.
Lieberman finds the press could have tied the threads
together better for the public to make things more clear because most Americans
are quite confused.
ANDRÉ PICARD thanked Trudy and indicated her talk better
informs him every time.
His discussion centred around the common challenges existing
between Canada and the U.S.
He stated that in many ways, we do many of the same things
in Canada as in the U.S. but without the debate, so we should guard against
self-righteousness. There is no “Affordable Care Act” in Canada. There are a
lot of disparities between the provinces, Picard found, but we just don’t talk
about them.
We also have many of the same financial challenges that
exist in the U.S. but again, there’s no discussion. Health care in Canada
covers only 70 per cent of the costs. Canadians pay about 30% of the medical
costs because more things like drugs may not be covered.
COMMON CHALLENGES:
1. MOVING CARE TO THE COMMUNITY: Hospital-based
models need to be turned into community-based models. There isn’t a plan or the
organization to meet the demands and needs for homecare and nursing homecare.
2. PRIMARY CARE: Better primary care services are
needed. A central coordinating point for healthcare is needed – one that
provides support throughout the patient journey. We know all the bad things
happen in transition through a lack of coordination, says Picard. So who is
going to coordinate care and guide us through the complexity of care, he asks?
3. Need to move to a CHRONIC CARE MODEL from an
ACUTE CARE MODEL.
4. DRUGS: Costs are high and this is a big void in
the Canadian system. Only 45% of drugs are covered by public plans. Private plans
are also tightening their strings. As a result, almost 600,000 Canadians do not
have catastrophic drug coverage, which is a gaping hole in Medicare.
5. SOCIAL DETERMINANTS: Inequality is having a
major impact on people’s welfare.
6. QUALITY: This is paramount. Medical errors or
adverse events due to a lack of quality are some of the leading causes of
avoidable death. People want affordable healthcare, but not at the sacrifice of
quality.
7. RATIONING: The U.S. rations care economically.
If you can’t afford it, you don’t get it.
In Canada, services bottleneck, create wait lists and people have to
wait for certain kinds of care. Rationing is a reality, but the trick is to
find the best way to do it.
8. PATIENTS WHO USE TOO MUCH HEALTHCARE: In Canada,
1% of the patients use 25% of care, while another 5% consume 50%. Costs can be
controlled by better management of difficult patients. We need to be more
innovative and smarter, says Picard. For instance, there was a man who had all
sorts of health issues and visited Emergency 238 times a year, costing the
system an estimated $1.5 million per year. So it was decided to assign him a
full-time nurse at a cost of $60,000 per year.
This nurse even found the man an apartment. She was a guiding light of
sorts. The following year the man reduced his ER visits to 60. This was a
pragmatic solution that saved the system close to one million dollars.
9. PUBLIC VS. PRIVATE: Canada has both, whether we
know it or not. The U.S. has both. We need to discuss the right mix of public
and private healthcare. Currently it’s about 70-30.
Both countries need to have real conversations about
healthcare. But what is the proper forum for such a debate. There is too much
extremism. So how are we to have this much-needed discussion?, asks Picard.
TRUDY LIEBERMAN: Long term care is a real issue in the U.S..
It’s interesting to see what has been done in the U.S. The Affordable Care Act
included a Class Act that was championed by the late Senator Ted Kennedy. Originally it wasn’t very popular. The idea
behind this was to pay a bit into the federal system then tap into that when
older. But the provision was repealed because it wasn’t going to work. As a
voluntary program, people weren’t going to pay into it.
Since the Class Act was repealed, there’s been virtually no
discussion of homecare in the U.S.
But we do have something that has worked somewhat called the
“Older Americans Act” which dates back to the Johnson administration. This
provides services to keep elders at home. Unfortunately, it hasn’t received
adequate funding for the last few decades. Now there’s a long wait list for
homecare services in almost every jurisdiction. Some people wait months just to
get a hot meal from “Meals on Wheels.” PEOPLE DO THE BEST THEY CAN, BUT THE
BEST ON MANY DAYS ISN’T ENOUGH, one man said.
QUESTIONS/COMMENTS from the audience:
1. DR. CHARLES WRIGHT, Council Member, Health
Council of Canada: That was enlightening
for me. You used the word “rationing” which is a highly allergenic word. If we
could only capture a portion of unnecessary care, some sort of rationing might
be needed but at least the system would be more sustainable.
ANDRE PICARD: 25-30 % of healthcare is
overdone. We need to ration care on what works and what is effective. Evidence-based
rationed care.
TRUDY LIEBERMAN: We’ve been talking about
this for many years but nothing is being done about it. There are powerful
interests who like doing extra tests, and it’s hard to deal with those forces.
2. SHOLOM GLOUBERMAN, President, Patients Canada: We don’t have healthcare services in the
community. We don’t partner with patients on chronic care. Bloated hospital care,
very few community services -- we spend here in Canada a fraction of what is
spent on community services in Britain. Insurance doesn’t cover it but covers
hospital stays for example. We have an aging population, and chronic diseases
become a part of life. We don’t deal or care for it properly. Patients aren’t
partners in their care. What we need is to start to build up community services
because they’re not covered by insurance.
ANDRÉ PICARD: There are definitely
administration issues. Medicare was created in the fifties for a population
demographic for that era. Now demographics have changed -- needs have changed.
But the system has not been adjusted to account for the change in demographics.
3. QUESTION: Who
gets to define when care is necessary or futile? What will happen based on the
upcoming Supreme Court of Canada decision?
ANDRÉ PICARD: It’s unfortunate this has to
be settled by the courts, and there isn’t the political courage in this country
to deal with it. The larger question in my opinion is “what is in Medicare, and
what is not?” It’s a tough issue. How should public services be rationed? In
Canada, we do this by sidestepping the discussion. We’re moving towards a
populist system, like in the U.S.
4. JOHN G. ABBOTT, CEO, Health Council of Canada: How does Obamacare tie into the American
deficit and any comparisons to Canada?
TRUDY LIEBERMAN: Obamacare won’t break the
bank, per se. Ultimately, opponents
of Obamacare want to deal with entitlement and the privatization of Medicare –
like drug benefits. People are okay with richer citizens paying more for
healthcare, but what is the definition of “rich”? That’s a concern for those
who support Medicare and that’s a big issue. The other is entitlement and
Social Security. Many want to privatize it. But the cost of living formula may
be changed in order to reduce the amount that government needs to spend, which
will hurt low-income households, especially women. Long-term subsidies under Obamacare
will then come into play. They are financed for ten years, but we don’t know
whether subsidies will be secure in the long-term. Ultimately they could meet
the same fate as Medicare, whatever that will be.
5. COMMENT ABOUT HOSPITAL COSTS:
TRUDY LIEBERMAN: In the “Affordable Care
Act,” there is nothing calling for negotiating prices or services. Hospitals publish “retail” prices which are
usually quite high. But they are wildly different from hospital to hospital
even within the same community. But
these prices are essentially phony. [someone in audience: “They’re for the
people who come from Canada for treatment.” – laughter]. In practice, the
hospitals negotiate with insurance companies and bargain for much less than the
published costs. Many hospital systems though are growing larger and are
becoming conglomerates that compete against each other. They advertise who has
the better equipment or the best cardiac care but not price. There’s a real
fear that these conglomerates will have the power to set prices without much
competition or push back from the government.
ANDRÉ PICARD: Canadians are ignorant about
the real costs of healthcare. We overpay. We have a similar system to the U.S.
TRUDY LIEBERMAN: Steve Brill’s “Time
Magazine” article about healthcare was really well done.
More transparency is needed.
Breakfast with the Chiefs concludes.
