Pennsylvania and Hawaii are the only two states in the country that do not have a mechanism in place for the regulation of premium rates set forth by insurers as it applies to their small businesses — a demographic courted heavily by both Republicans and Democrats as players in the final direction of pivotal health reform. The Pandora’s Box cast wide open by the recent Anthem BC scandal is adding a new critical layer of scrutiny not only to Barack Obama’s reform trajectory, but also to the ways in which Insurance market fluctuations influence the overall cost of healthcare delivery and access.

Implications for the these two states are obvious, as government regulatory oversight could go a long way in keeping the relationship between small business and the insurance they purchase an open, transparent, and freely accessible system for consumers of healthcare (patients), giving states’ insurance commissioners added muscle. Alternatively, control of regulatory processes by the federal government could add just another layer of bureaucracy (read: increased administrative healthcare costs to the taxpayer and shifting rising costs to other entities — like Pharma) to an already overburdened HHS Dept. Over the next few days, the unfolding issue of federal gov’t Insurance regulation over state’s private insurance markets will become a hot-button one, adding some eleventh-hour drama to the health reform debate. | LINK

Legislative grilling in California begins today for Anthem Blue Cross, the insurer whose efforts to increase some average premiums by almost 40% did not go unnoticed by the White House. Wellpoint, the payer’s parent company, will begin its time being questioned before a special state House committee tomorrow. Although the most likely effect of such questioning will be the negative national PR that has accompanied it, the excessive scrutiny of the company’s books will almost certainly provide the impetus for local reform in this area at the hands of state legislatures as it applies to other insurers — eventually leveling the playing field in the Insurance marketplace.

In other Anthem Blue Cross news, a California man’s breach-of-contract trial with the insurer has just begun.

Hot on the heels of Insurance hiking premiums among policyholders in California comes a warning of sorts from HHS Sec’y Sebelius: California is not immune. In fact, the spectre of recent burgeoning rates seen at the hands of a Blue Cross/Shield plan subsidiary in the Golden Gate State is only the tip of a rapidly moving iceberg in a healthcare marketplace within which Big Insurance says it must remain competitive.

RI, CT, and OR were three other states cited in Sebelius’s remarks. As healthcare reform moves at a more restrained pace in the run-up to an eventual bill, there is no denying the market is seeing the effects of an economy far from recovery. As millions jettison more expensive coverage for the bare minimum, costs for care delivery are beginning to reflect payouts to plans for the sicker and older portion of the risk pools, creating even more urgency for Obama and company for reform as he has seemingly moved on to his other top domestic priority — jobs. | LINK

• The Wellpoint saga continues…as well as the blame game for significant premium hikes.
• Study: alcohol + energy drinks (like Red Bull) = recipe for disaster.
• Has the H1N1 pandemic peaked?
• The first study of the anti-CSF prototypes for treatment/reversal of Alzheimer dementia is underway.

The trial will measure in the cerebrospinal fluid (CSF) and blood plasma of amnestic mild cognitively impaired (MCI) patients the biochemical changes that are associated with AD and correlate them with the pharmacokinetics of the drug and its metabolites.

• For California, the bleeding never ends. Today, Gov. Schwarzenegger releases his spending plan for 2010-11 which details even deeper cuts to its Dept. of Human Services.

In the Massachusetts healthcare economy, the balance between employer, employee (policyholder, beneficiary), and health plan (insurer) is getting new scrutiny. Its chief executive, Gov. Patrick, filed a bill calling for the broadening of powers of the state’s insurance commissioner in capping rates for care delivery services by hospitals, doctor groups, imaging centers, and insurers. He cites the crippling effect of higher rates on employers and employees of small businesses.

Of course, in a state rocked by lowered reimbursement schedules, a diaspora of primary care physicians to other practice locales with a secondary shortage in those primary care services — the news of capped payments to docs is not generating a lot of support in that camp for Patrick’s plan. And what do the small businesses think? Cautious optimism rules the day. Smaller acute hospitals (who already are at the mercy of government whims with respect to Medicare and Medicaid payments) fear for their bottom lines amid the potential for layoffs and cuts in healthcare delivery services.

Insurance companies have no problem supporting the governor’s proposal, just as long as negotiations of rates with the other parties don’t cut into their bottom lines. | LINK

Fraud leading to waste and cost increases in the delivery of healthcare also has its origins in the Insurance free market.

Two Texas-based companies were sued by the state [Minnesota] Attorney General’s office Wednesday for allegedly defrauding Minnesotans who purchased so-called health discount plans from the firms.

The “discounts” were actually limited to a small number of providers, with coverage far below that which would be called comprehensive, according to the MN’s atty gen’s office. | LINK

A year ago, this blog cited a study which detailed the difficulties cancer patients faced when navigating the byzantine nature of health plans which essentially made it difficult, if not impossible, to receive life-saving treatments. The paper [PDF] went on to describe the problems these patients would still face even when eligibility requirements for government assistance via Medicare or Medicaid were at least partially met.

Either through ignorance of policyholders’ plans limitations or via the inability for their out-of-pocket costs to cover the difference, cancer patients have continued to face significant challenges in accessing crucial care. The verdict may still be out on the finer points of President Obama’s goals for reform, but Insurance does not really seem to be waiting for his signature on legislation to react.

With respect to one insurer, news comes of a cancer patient’s current fight to obtain treatment oncologists thought could save his life. Relapsing neuroblastoma has sidelined a five year-old’s life right now; his insurer has refused a new treatment option it deems as expiremental — in spite of covering a cheaper treatment in 2007 that was also called such, resulting in a full remission. The child’s parents are suing the carrier.

Advocates for insurance reform have taken a backseat in the reform debate, which is not surprising. Although, Obama has described his reform plans are not a referendum on reform of Insurance in a strict sense, it is apparent that sound arguments based upon solutions in the way coverage is paid and delivered need to transcend the rather simple promise of non-discrimination based upon claims denials.

If Obama ever wished he could tell Insurance to just go and “take a hike”, I’m sure he wouldn’t mean it in a literal sense. A California-based insurance company’s decision to raise policyholders’ premium rates by as much as near 40% has prompted a state inquiry and the ire of HHS Sec’y Kathleen Sebelius. The attention the White House is giving this case at a time when reform efforts are rocky is somewhat of a balm for the president’s increasingly wounded pride on the effort to promise wider healthcare access and affordability as dictated during his campaign for the nation’s highest office. Why would an insurance company, even if it is for-profit, create such a negative PR issue for itself at a time when unemployment — and by extension, healthcare inaccessibility — in California and nationwide are at such cripplingly high levels?

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All it took was an inch — as the GOP is going the whole mile, and then some. I’m talking about the stalemate in getting Obama’s reform bill passed. The election of Scott Brown to fill the seat once held by the legendary health reform stalwart Ted Kennedy seems to be only the beginning of an effort by the GOP to take over the parameters of what “reform” really means at this point.

The WaPo has an interesting analysis into the Democrats’ missteps leading to where the party finds itself today: a wounded warrior with very little to show in the way of valor in upholding Obama’s original plans for an overhaul.

Looking back, Obama and his congressional allies failed to appreciate the depth of frustration with Washington – people’s desire for health care legislation that would respond to their anxieties, not the clamor of interest groups.

There’s more. Some GOP lawmakers are upping the anti-reform rhetoric with fiesty language meant to energize its base and incite debate for their benefit. Invoking states’ rights arguments, a VA congressman calls reform measures at the hands of Democrats “mobster mandates”, and such issues “cross the line” as far as he’s concerned.

Del. Robert G. Marshall (R-13th District) has filed the “Virginia Health Care Freedom Act” (HB 10), which would “protect an individual’s right and power to participate or decline to participate in a health care system or plan,” according to a summary of the bill.

Mobsters and missteps. February is getting off to a rollicking start for the party that was supposed to have had a bill on Obama’s desk by now.

You just have to hand it to Minnesota and its spirit of rugged self-determination. Its citizen individualism and desire to pioneer are just a couple of the qualities that are part of the state’s storied history as innovator and trendsetter. The concept of managed care as a healthcare delivery ideal had some of its roots in Minnesota, a concept going back over 35 years. Designed as a way to create a balance between providers and payments for services rendered, it has evolved — for better or worse — into a system upon which today’s healthcare marketplace has codified current business practices. That is, the very dynamic which has given the current President of the United States such a strong (though somewhat misguided) desire to overhaul the way healthcare is delivered in this country.

Pharma, Insurance, and the physician are the core triptych at which so much in the debate to reform healthcare is directed. Many primary care physicians feel as though they are at the epicenter of this reform morass, and many are left feeling dismayed over why they chose medicine as a profession at all. For many family docs, for example, navigating the complexities of day-to-day practice; feeling the pressure of seeing enough patients to justify employment in many manage care systems; and dealing with Insurance and public payers in order to simply get paid are essentially too much for them to deal with. Attrition from the profession usually results.

Imagine the self-determination of one Minnesota family physician — an employee of a primary care group in the Twin Cities for decades — when he simply could not “take it any more”. With actions that can at once be described as both narcissistic and noble, this doc decided to go it alone and get Insurance out of the mix altogether. Armed with $80 000 and a desire to accept only cash, he’s jumping into uncharted territory in 21st century healthcare delivery and going back to the pre-managed care days of Dr. Marcus Welby — and he’s doing it in one of the most heavily-penetrated managed care states in the country. The spirit of Minnesota innovation shines again, at least for one physician. | LINK

The funny thing about 20/20 vision in politics besides its keen ability to note history as it unfolds in the political process…is the ease with which it gives pundits in any genre a basis to pontificate^[1] or, rather…create, new issues and stories.  A recycling of information, if you will — the lifeblood of the blogosphere.

For Doctor Pundit’s inaugural accounting of its yearlong then-and-now pontifications on healthcare policy, we begin with an issue whose posting on this blog became its #1 blog entry for all of 2009 (according to Google Analytics statistics). Obama’s ascendancy to the the highest elected seat in the land carried along with it the hopes and dreams of the disenfranchised in this country who were hungry for change — any change — from the stranglehold that (they thought) was the Bush administration’s clamp on any meaningful attention to domestic policy in favor of its affinity for foreign policy and the War in Iraq. Healthcare was just one of those domestic policy points Obama supporters were clutching as possible rallying points for galvanizing their candidate’s ability to win the nation’s highest office — one which, for the first time, seemed a real possibility for an African-American candidate.

Enter Barack Obama, who not only won the 44th presidency, but also answered his party’s mandate in doing so. As part of his commitment to the people who placed him there (or to himself, as healthcare policy reform was as self-serving a legacy accomplishment for Obama as was any other domestic issue), Obama would finally make healthcare accessible to all. And he would get the Republicans and Democrats — and Pharma and Insurance — to work together to make it possible. Lofty? To Obama, at the time, not especially.

Apparently, expansion of the federal government’s role in financing Medicaid is a priority. According to the WaPo, Obama plans on allowing states temporarily to sign up jobless residents for Medicaid, with the federal government for the first time paying the entire cost of doing so. Even more boldly, the new president will also provide “unprecedented” federal subsidies to increase the affordability of COBRA, a temporary coverage mechanism for laid-off workers that, for many, remains unaffordable.

Fast forward 12 months later, and Obama is fighting for not only a candidate’s political life but also his own legacy as it applies to the reform of healthcare on a national level. A year ago, Obama had high hopes on expanding both Medicare and Medicaid to deliver high quality healthcare to those who needed it the most. At the time, it appeared to Obama, at least, that cost was no object. A year later, multiple iterations of CBO analyses have shed light on what lawmakers, Obama, and now the American people know only too well: Obama’s promises to increase healthcare access to the almost 50M uninsured have broken down on a massive level, its overarching meaning reduced at this moment to a vote this Tuesday in the state of Massachusetts on an open U.S. Senate seat. Twelve months and thousands of contentious healthcare townhalls later, Obama’s dreams of the affordability, bipartisan entreaties, and corporate cooperation of Pharma and Insurance with respect to healthcare reform are turning into a cruel reality on how he just seemed to lose all control of the debate.

1. …or rant, although I’ll try to stay away from heavy-handed verbal drama [↩]

At the outset of the recession that began over two years ago, an unfortunate by-product of joblessness — loss of insurance coverage and subsequent inability for many to afford sky-high COBRA benefits — was becoming an all-too common phenomenon.

Enter President Obama’s ability to subsidize those payments for millions as part of his economic stimulus package. That was the good news. The bad? Those first with receiving aid in February 2008 are now faced with the prospect of having those subsidies end. Well, not so fast. House lawmakers voted to extend the benefits as part of the defense spending measure (H.R. 3326) on December 16, 2009. The Senate then cleared the measure for the President’s signature. | LINK

[The following editorial is crossposted at HealthcareWealthcare.com]

I’ve written much on my health policy blog … of the microscope under which the state of Massachusetts is operating its own brand of healthcare delivery in the wake of universal healthcare coverage. The ambitious undertaking by the state’s lawmakers to introduce the concept of universal coverage to its citizens over two years ago attempts to answer the question — can healthcare delivery costs be reined in while mandating care for everyone? The answer is, to the surprise of no one, a resounding “no”. As a matter of fact, the cost of covering an additional 430,000 people has thrown the state’s healthcare economy into a tailspin.

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