Tuesday, July 31, 2012

The Olympics, Doctors, the NHS, Transformation and Heroes: Why the Difference between the USA and UK, Part III


This blog post originated in my surprise that the Opening Ceremonies of the Olympic Games honored both the National Health Service and Tim Berners-Lee.   Watching the doctors and nurses and patients dancing in the Olympic Stadium made me wonder why health care reform united the United Kingdom and seems to be tearing apart the United States.  I also started to wonder why so many physicians in the United States seem to defend the status quo that has resulted in the “inconceivable” outcomes documented in Part II of the blog.  How can professionals defend a system that is so costly and results in such low quality by any objective measurement? The short answer is that doctors are human beings.

Arrogance and power and social standing make it hard for any professional to exhibit the humility, courage, and existential strength that are needed to continuously improve one’s craft.  In examining journalism’s response to the ongoing News International surveillance, phone hacking, and bribery of police officers scandal in Great Britain, David Carr wonders why the offenders are seen as “outliers;” he wonders why there have not been

“deeply reported investigative articles about how things went so wrong: the failures of leadership, the skewed values and willingness of an industry to treat the public with such contempt. The Guardian correctly suggested that the arrests were unprecedented in the history of newspapers.”

Carr examines the many reasons why 66% of the public no longer trusts newspapers to be accurate, and he zeroes in on why journalism as an industry has lost its way.

“The news media often fail to turn the X-ray machine on themselves because, in part, journalists assign a nobility to the profession that obscures the flaws within it.  We think of ourselves as doing the People’s work, and write off lapses in ethics and practices as potholes on the way to a Greater Truth.” (http://www.nytimes.com/2012/07/30/business/media/holding-up-a-mirror-to-journalism-the-media-equation.html?ref=business)

I started Part I of this blog by discussing one of my heroes, Tim Berners-Lee, but now I have to reflect on one of my heroes who recently passed away:  Joe Paterno.  A sociology professor stated,

“It makes sense that the catastrophic fall of Paterno correlates with the degree of hypocrisy people have identified between Paterno – the moral do-gooder – and this really ugly underbelly of the program he ran that was so morally contemptible.”  (http://blog.pennlive.com/patriotnewssports/2012/07/joe_paterno_provides_a_caution.html)

The Penn State football program and its coach achieved unparalleled success on the field, and Paterno became the most powerful person in the entire university.  Arrogance and an inbreeding where leaders were recruited internally created a culture that valued “protecting” the reputation of the athletic program more than protecting the safety of young men being abused by Jerry Sandusky.

Like journalists serving the Greater Truth and Paterno extolling the Grand Experiment of melding athletics with academics, physicians see themselves as part of a noble profession ably taking care of patients.  Physicians are famous for not appreciating advice or oversight from non-physicians.  When physicians and nurses are found to have done the “inconceivable” things we discussed in Part II, the outlier concept is quickly articulated. 

Dr. Kevin Pho criticizes policy wonks in “The Tension Between Physicians and Health Policy Experts” for not deferring to physicians on how to reform the American health care delivery system.

“Yet, to successfully reform our health system, doctors need to be at the forefront, not policy experts.  And I’m not saying that because I’m a physician myself.” (http://www.kevinmd.com/blog/2011/05/tension-physicians-health-policy-experts.html)

The good doctor doth protest too much. 

This idea that physicians need to always lead any effort to improve health care delivery does not make sense.  Physicians, patients, nurses, hospital administrators, legislators, health plan executives, and employers all have part of the answer to the health care delivery problem.  Robust, long-term solutions to the complicated problems of health care delivery can only be crafted when all of the listed players truly understand how the problem looks and feels to each of the others.  Theory U: Leading from the Future as It Emerges by C. Otto Scharmer (San Francisco:  Berrett-Koehler, 2009) offers a way to gain the wisdom and insight from all concerned when trying to come up with lasting solutions. 

Physicians, like journalists and football coaches, are human beings.  They are no more or less likely than other human beings to act rationally, irrationally, bravely, cowardly, or ethically.  This tension between the idealized view that many physicians have of themselves and reality was nicely captured in a series of letters between Arnold Relman, MD, the former editor of The New England Journal of Medicine and Princeton economist Uwe Reinhardt.  Relman thinks physicians are special and he asks Reinhardt the following question:

“Do you really see no difference between physicians and hospitals on the one hand, and ‘purveyors of other goods and services,’ on the other?”

Reinhardt is ready with a long answer that should be read in its entirety.  The short answer is that doctors act like any other human beings.   A portion of his answer includes the following:

“Surely you will agree that it has been one of American medicine’s more hallowed tenets that piece-rate compensation is the sine qua non of high quality medical care.  Think about this tenet, We have here a profession that openly professes that its members are unlikely to do their best unless they are rewarded in cold cash for every little ministration rendered their patients.  If an economist made that assertion, one might write it off as one more of that profession’s kooky beliefs.  But physicians are saying it.” (http://content.healthaffairs.org/content/5/2/5.full.pdf+html)

Physicians are human beings who try to do their best in a complicated, dysfunctional, rapidly changing health care system that too often results in the bad outcomes documented by Millenson and the ProPublica journalists cited in Part II of this blog.  I agree with Dr. Thomas Smith of Johns Hopkins who was quoted as saying, “Most doctors are sleepwalkers, not evildoers.” (http://www.usatoday.com/news/health/story/health/story/2012-01-30/Doctor-exposes-the-dangers-of-overtreatment/52893278/1)

Human beings, including doctors, are not good judges of their own performance and behaviors.  Self-deception is part of being human and has been called “one of the most puzzling things that humans do.”

“Researchers disagree over what exactly happens in the brain during self-deception.  Social psychologists say people deceive themselves in an unconscious effort to boost self esteem or feel better. Evolutionary psychologists, who say different parts of the brain can harbor conflicting beliefs at the same time, say self-deception is a way of fooling others to our own advantage.” (http://online.wsj.com/article/SB10000872396390443343704577548973568243982.html)

What is not controversial is that human beings deceive themselves and are not good judges of their own behavior. Children as young as three have a “positivity bias” where they see themselves as smart regardless of their abilities. Nobelist  Daniel Kahneman’s Thinking, Fast and Slow (New York: Farrar, Straus and Giroux, 2011) catalogs and analyzes the false beliefs that we humans automatically think are true.  The illusion of validity is the false belief that our own judgment is accurate, and Kahneman admits that even he cannot escape the cognitive illusion that his own judgments are reliable.  Although he won the Nobel Prize in Economics for developing the field of behavioral economics, Kahneman is a still a human being, and human beings harbor cognitive illusions.  Another scholarly book on self-deception worth reading is Robert Trivers’ The Folly of Fools (New York: Basic Books, 2011).

And that is why doctors, being human, need all the help they can get from check lists, social scientists, empowered patients, patient families, employers, spouses, government regulators, individual and group report cards, nurses, and others.  The last word goes to President Ronald Reagan, “Trust, but verify.” 






Monday, July 30, 2012

The Olympics, Doctors, the NHS, Transformation and Heroes: Why the Difference between the USA and UK? Part II


Like many in the United States, I was surprised when the National Health Service (NHS) was honored during the Opening Ceremonies of the London Olympic Games.  The media guide said, “The NHS is the institution which more than any other unites our nation.  It was founded after World War II on Aneurin Bevan’s famous principle, ‘No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.’”  (http://capsules.kaiserhealthnews.org/index.php/2012/07/u-k-national-health-service-gets-gold-medal-mention-at-olympics/)

Should the Bevan principle make Americans think about what makes a society civilized?  Does the American health care delivery system unite our nation?  I could not help thinking back to the Republican Presidential Debate where the audience and Ron Paul seemed to be saying that those without health insurance should be left to die. (http://www.youtube.com/watch?v=8T9fk7NpgIU) (http://www.thedoctorweighsin.com/gop-to-uninsured-feel-free-to-drop-dead/) Health care in the United States divides our country into those who believe health care is a human right and those who think it is not.  Paul Starr summarizes this tension by stating:

“Americans are still at odds over the most basic question about health care: whether it is a requirement for a free life that the community has an obligation to provide or a good that needs to be earned (and if you can’t earn it, too bad for you).” (Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform, New Haven:  Yale University Press, 2011)

Starr traces our dilemma back to the establishment of Medicare as an earned right even though seniors have never paid enough in payroll taxes to cover their insurance costs and Medicaid as an unearned benefit that lacks a moral claim on the community.  This history has created a “protected public” who believe they have earned their medical coverage, and they are largely unwilling to subsidize coverage for the less fortunate.  By creating separate health insurance financing for the elderly, the United States created a political problem that has caused partisan bickering.  It is noteworthy that the Supreme Court decision upholding most of the Patient Protection and Affordable Care Act created a way for governors to elect not to participate in the expansion of the “unearned” benefit of Medicaid. 

Although Senate Minority Leader Mitch McConnell yesterday labeled the American health care delivery system “the finest in the world,” most Americans recognize the status quo as unsustainable, expensive, and unsafe.  Otis Brawley, MD, chief medical officer at the American Cancer Society, has a different take than McConnell:

“Our medical system fails to provide care when care is needed, and fails to stop expensive, often unnecessary and frequently harmful interventions, even in situations when science proves those interventions are the wrong thing to do.”  (How We Do Harm:  A Doctor Breaks Ranks About Being Sick in America, New York:  St. Martin’s Press, 2012)

Michael L. Millenson reviews the depressing statistics about preventable errors causing death in the United States in an article titled “The Toll of Preventable Errors:  How Many Dead Patients?” According to Millenson, the best estimate comes from the Agency for Healthcare Research and Quality; 90,000 hospital patients die each year from preventable, treatment-caused injuries. Millenson also cites a 2010 study of hospital error-reduction programs that concluded “harm remain common, with little evidence of widespread improvements.” (http://www.thedoctorweighsin.com/the-toll-of-preventable-errors-how-many-dead-patients/)

A July 20, 2012 article titled “Why Can’t Medicine Seem to Fix Simple Mistakes?” provides an overview of the ongoing patient safety issue in American medicine. 

“Time and again reporters have uncovered unfathomable lapses at medical facilities, often resulting in patient injuries and death.  Time and again, hospital officials have put in place solutions that seem ridiculously obvious.  And, inconceivably, the fixes are frequently ignored or ineffective.” (http://www.propublica.org/article/why-cant-medicine-seem-to-fix-simple-mistakes)

The article describes five wrong site surgeries at Rhode Island Hospital, nurses at Martin Luther King Jr./Drew Medical Center ignoring monitors in six cases where patients died, and the recent death of a 12-year boy from sepsis where important laboratory results were not reported by NYU’s Langone Medical Center.  The article states:

“That’s what’s so difficult to understand about medical mistakes.  It seems inconceivable that nurses and doctors would reuse a syringe on multiple patients or that they would turn down alarms on cardiac monitors after patients at their hospital had died as a result.” (http://www.propublica.org/article/why-cant-medicine-seem-to-fix-simple-mistakes)

In Part III of this blog we will explore why human doctors and nurses do “inconceivable” things. 

Sunday, July 29, 2012

The Olympics, Doctors, NHS, Transformation, and Heroes: Why the Difference between USA and UK?


I was surprised when the Opening Ceremonies of the Olympics in London honored two of my favorite institutions:  the National Health Service and the World Wide Web.  I was not surprised when LA Times sports writer Diane Pucin posted the following tweet: “For the life of me, though, am still baffled by NHS tribute at opening ceremonies.  Like a tribute to United Health Care or something in US.” @swaldman responded to the sports writer with “Well, maybe, if United Health Care were government-run and a source of national pride.” 

I was not surprised when Meredith Vieira and Matt Lauer of NBC admitted they had no idea why Tim Berners-Lee was being honored by sending out a tweet.  Ever since I read his book Weaving the Web:  The Original Design and Ultimate Destiny of the World Wide Web by Its Inventor (HarperSanFrancisco, 1999), Berners-Lee has been one of my heroes.  Finally locating my hard copy of the book in the guest bedroom where my son Colin used to sleep, I quickly located the marked passage I was looking for:

“People have sometimes asked me whether I am upset that I have not made a lot of money from the Web.  In fact, I made some quite conscious decisions about which way to take my life. These I would not change…. What does distress me, though, is how important a question it seems to be to some.  This happens mostly in America, not Europe. What is maddening is the terrible notion that a person’s value depends on how important and financially successful they are, and that that is measured in terms of money.  That suggests disrespect for the researchers across the globe developing ideas for the next leaps in science and technology.  Core in my upbringing was a value system that put monetary gain well in its place, behind things like doing what I really want to do.  To use net worth as a criterion by which to judge people is to set our children’s sights on cash rather than on things that will actually make them happy.”

I am certainly not alone in admiring Berners-Lee, as this passage from a blog by Daniel Nye Griffiths demonstrates:

With less of a commitment to openness, Berners-Lee could have used the Web to become a very rich man. Instead, he has used every accolade – Fellow of the Royal Society, Knight Commander of the Order of the British Empire, one of only 22 holders of the Order of Merit and recipient of enough honorary doctorates to fill a skip – as a lever, opening doors for his mission to keep the channels of communication open, accessible and affordable.
Looking to the future, he has championed the idea of the Semantic Web – a system of data tagging to help search engines to understand questions as well as find words. Closer to home, he has advised data.gov.uk, and pushed governments past and present to make their data available for free. If you’ve looked at an OS map online recently, you have him to thank.” (http://www.high50.com/archives/life-times/berners-lee-come-on-tim)
The Olympic Opening Ceremonies got me thinking about heroes, health care, doctors, and the struggle to transform the American health care delivery system.  Why is our delivery system such a mess?  Why aren’t Americans proud of their hospitals and doctors and sending out tweets like @MaxwellLeslie’s “The NHS is one Britain’s greatest & most loved institutions, reinforcing the ignorant American stereotype very well with that tweet” by the Southern California sports writer. 
Paul Levy, the former hospital CEO, discussed how Dr. Don Berwick’s praise for the NHS made it impossible for him to ever be confirmed by the United States Senate as the permanent head of CMS.  Levy quoted Berwick’s speech on the occasion of the NHS’ 60th birthday:
“The National Health Service is one of the truly astounding human endeavors of modern times.  Just look at what you are trying to be:  comprehensive, equitable, available to all, free at the point of care, and – more and more – aiming for excellence by world-class standards.  And, because you have chosen to use a nation as the scale and taxation as the funding, the NHS isn’t just technical – it’s political.” (http://runningahospital.blogspot.com/2012/07/will-nhs-medal.html)
And Levy closed his blog post by writing, “In the former colonies (the US), we take on the task in a different way, but we face the same issues.  Indeed, as I have noted, ‘After all, the countries are dealing with the same organisms, both biologically and politically.’” (http://runningahospital.blogspot.com/2012/07/will-nhs-medal.html)
Since the United States and the United Kingdom both have health systems that take care of humans and since both operate under similar democratic political systems, why are the results so different? 
In Part II of this blog post, we will try to answer this question.






Monday, July 16, 2012

Health Insurers & the PPACA: Extinction or Reinvention? Part II




Now that the Supreme Court has upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA), health insurers are scrambling to reinvent themselves for an era of health care reform.  In Part I, we quoted Aetna CEO Mark Bertolini as saying he wants to create a business model that makes sense under the new rules and regulations.  Bertolini in a speech stated, “We need to move the system from underwriting risk to managing populations.  We want to have a different relationship with the providers, physicians and hospitals we do business with.” (http://www.healthdatamanagement.com/news/HIMSS12-Aetna-CEO-insurers-face-extinction-44041-1.html)  Starting with Aetna, Part II will examine the ways that insurance companies are trying to reinvent themselves for a reformed health care delivery system that often wonders why we need health insurers at all.

Early this year, Aetna decided to evolve “’from an insurance carrier to a health solutions company.”” The head of brand and consumer marketing at Aetna stated, “’More and more, the end consumer is who we need to focus on.’” (http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all) Aetna has developed Care Pass Platform, an agnostic tool that all consumers can use to aggregate and organize their fitness, medical, insurance and nutrition data. Aetna is also partnering with Medicity to provide smartphone apps for providers and iTriage to provide apps for consumers. (http://kentbottles.blogspot.com/2012/03/technology-aetna-itriage-and-future-of.html)

Aetna has conducted 57 pilot programs to test ways to decrease per-capita cost and increase the quality of the health care they deliver; the company is participating in 10 accountable care organizations (ACO) and has plans for 17 more ACO experiments.  One successful diabetes pilot in Pennsylvania resulted in acute sick days dropping by 31% with the use of case managers. (http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/22/aetna-ceo-the-supreme-court-decision-doesnt-matter-the-deficit-does/)
   
Aetna also spent $1.6 billion in 2011 to buy health care companies, including Medicity, Prodigy Health Group, Genworth Financial’s Medicare supplement business, and PayFlex Holdings.  (http://articles.courant.com/2011-12-16/business/hc-aetna-acquisitions-1217-20111216_1_prodigy-health-group-aetna-health-insurers)

Aetna’s partnership with Northern Virginia’s Inova Health System to create a health plan where both partners will share costs and profits is perhaps the company’s most innovative experiment.  The partnership will provide incentives to encourage physicians to not over utilize tests and procedures and will also measure and reward quality of care.  Companies will get a rebate if the cost of the care of their employees is lower than expected. (http://www.washingtonpost.com/business/economy/aetna-and-inova-unveil-joint-venture-for-improved-cost-effective-health-care/2012/06/22/gJQAOyoGvV_story.html)

A different innovative approach to responding to health care reform is Highmark’s merger with West Penn Allegheny Health System (WPAHS).  When first announced in June 2011, the idea inspired Hoover’s health care industry team to create the following headline:  “Bizarre Pittsburgh proposal:  will Highmark – West Penn merger work?” (http://bizmology.hoovers.com/2011/06/29/pittsburgh-proposal-will-a-highmark-west-penn-allegheny-health-merger-bring-positive-change-or-is-it-too-weird-to-work/)  A year later in June 2012 Moody’s rating service cited dropping patient volumes and continued operating losses at WPAHS in reaching the conclusion that the $475 million infusion of Highmark funds will not be enough to save the struggling health care system; Moody’s still rates $737 million of WPAHS debt as junk bonds. (http://www.moodys.com/research/Moodys-affirms-West-Penn-Allegheny-Health-Systems-PA-Caa1-bond--PR_248600)

The Highmark WPAHS merger is complicated by Highmark’s unsuccessful attempt to merge with Independence Blue Cross and failed contract negotiations between Highmark and University of Pittsburg Medical Center (UPMC), the major health system in the Western Pennsylvania market that has its own insurance plan that competes with Highmark.  As if dueling advertising campaigns and lawsuits were not enough excitement, the plot thickened when Highmark fired its CEO Dr. Kenneth Melani, the architect of the merger, after he fought with his Highmark employee girl friend’s husband.  Assault charges were dropped against Melani after he successfully completed an anger management program. (http://pittsburgh.cbslocal.com/2012/06/06/assault-charges-dropped-against-former-highmark-ceo/)  One wonders if new Highmark CEO William Winkenwereder, Jr., MD will continue to support the merger plans. (http://www.post-gazette.com/stories/local/region/new-ceo-winkenwerder-targets-trust-in-highmark-639015/)

The Highmark WPAHS merger is an attempt to create “what health-care thought leader, Clayton Christensen, in The Innovator’s Prescription, describes as an integrated, fixed-fee provider system. As such, Highmark and West Penn Allegheny are undertaking a tremendous change agenda.” (http://www.wphospitalnews.com/the-national-significance-of-the-highmark-and-west-penn-allegheny-merger/)  Other observers are watching the merger with interest because such vertical mergers have not been extensively studied or investigated.  The Western Pennsylvania region clearly needs to try something new because the status quo is not working: the largest hospitals and health insurers are engaged in a legal battle; WPAHS, the second largest hospital system, is on the brink of failure; and health care costs in Pittsburgh are substantially higher than in similar markets, relative to the quality of care. (http://www.jdsupra.com/post/documentViewer.aspx?fid=ea6c6a19-8547-4978-bf63-4ea8cf70d1d4)

Wellpoint, which covers about one third of the nearly 100 million Americans who receive their insurance from a Blue Cross plan has been investigated by Congress for canceling policies retroactively in order to achieve at least a $128 million profit. Wellpoint has also been criticized for having 39 executives who each make more $1 million a year and for spending $27 million on staff retreats at resorts in 2007 and 2008. (http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1)  Reform advocates point out that such overhead costs contribute to the $400 billion a year in administrative costs that would largely disappear under a single payer system.  Wellpoint’s response to health care reform has been to spend $100 million on technology upgrades and to buy Medicaid provider Amerigroup for $4.46 billion and CareMore for $800 million.  Angela Braly, Wellpoint’s CEO said, “First and foremost there are significant growth opportunities ahead in the Medicaid marketplace resulting from economics, demographics, budgetary issues, as well as healthcare reform. We expect Medicaid spending under managed care programs to increase by nearly $100 billion by the end of 2014.” (http://www.chicagotribune.com/business/breaking/chi-wellpoint-to-buy-medicaid-provider-amerigroup-for-446b-20120709,0,7644697.story)    At least one critic has wondered about the wisdom of this purchase, based on two future possibilities: 1) if Romney becomes president and the GOP takes control of the Senate, then the Medicaid expansion in the PPACA might be overturned and 2) the Supreme Court ruling left the door open for GOP governors to refuse to participate in the Medicaid expansion. (http://www.forbes.com/sites/aroy/2012/07/11/wellpoint-buys-amerigroup-bets-big-on-medicaid-expansion-but-will-states-and-voters-cooperate/)  Braly, of course, is the health insurance executive who stubbornly defended proposed 2010 premium increases in California that President Obama attacked during the debate over the passage of the PPACA. Anthem Blue Cross, a unit of WellPoint, attempted to increase premiums for individual insurance policies in California by an average of 25 percent, with some rates going up as much as 39 percent. (http://www.nytimes.com/2010/02/25/health/policy/25health.html)

CIGNA has developed a new ad campaign “Go You” that focuses on consumers for the first time. The chief communications officer at CIGNA states, “’It is a shift, it’s an important shift.’”  In the past insurers addressed their advertising campaigns at wholesale business accounts, not individual consumers. (http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all)  To bolster this consumer strategy, CIGNA bought Kronos Optimal Health to obtain their health coaches, health education programs, and lifestyle management systems. (http://www.prnewswire.com/news-releases/cignas-mergers-and-acquisitions-will-help-distinguish-them-from-other-national-carriers-101077224.html).  CIGNA also spent $3.8 billion in cash to buy HealthSpring and its 340,000 Medicare Advantage participants in 11 states and its 800,000 member Medicare prescription division. (http://dealbook.nytimes.com/2011/10/24/cigna-to-buy-healthspring-for-3-7-billion/)  The company is also expanding their Medicare Advantage position in Texas and Arkansas (http://www.streetinsider.com/Mergers+and+Acquisitions/Cigna+(CI)+to+Buy+Arcadian,+Humana+Medicare+Advantage+Plans+in+Texas,+Arkansas/7545734.html).

Humana, like Aetna and CIGNA, is concentrating on the individual health care consumer with television ads showing “a family reunion at a summer home, complete with giggling children, cooing grandparents, bonfires, and swimming at the lake.” (http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all) In addition to the consumer oriented ad campaigns, Humana has a new program that rewards members for losing weight or quitting smoking with points that can be redeemed for hotel reservations, electronics and clothing. 

Humana’s Patient Centered Medical Home Partnership with WellStar Health System has seen decreased inpatient and emergency room expenses by 12% and 17%, respectively, and a decrease in emergency room visits by15% (http://www.ahipcoverage.com/wp-content/uploads/2012/07/MarketHighlights_PaymentDeliveryReform_1-06- 12.pdf) 

On the mergers and acquisitions front, Humana has acquired Concentra, for $790 million in cash. Concentra provides occupational medicine, urgent care, physical therapy and wellness services at more than 300 medical centers in 42 states. (http://dealbook.nytimes.com/2010/11/22/humana-to-buy-concentra/) The insurer has also completed the acquisition of Arcadian Management Services, a Medicare Advantage health maintenance organization (http://www.zacks.com/stock/news/72489/humana-closes-arcadian-purchase)

UnitedHealth Group was one of the earliest converts to evolving from a health insurance company to a health care data mining company.  As early as 2007 their subsidiary Ingenix bought The Lewin Group, a respected health policy think tank in Northern Virginia. A Lewin report in 2009 claimed to show that a public option would force 119 million Americans out of their private health plans and into the government sponsored plan. Although the Lewin report was shown to be faulty, the GOP used it to great advantage in excluding the public option from the final PPACA bill. (http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1)

UnitedHealth Group has also been active in exploring private sector payment and delivery system pilots. Their Patient Centered Medical Home model provides primary care providers a prospective care management fee as well as a performance incentive payment.  Their ACO pilot with Tucson Medical Center includes a spending target based on three years experience by each physician group or hospital and shared savings and bonuses are given to those that meet their goals. United Healthcare is also experimenting with bundled payment programs with oncologists in Georgia, Missouri, Ohio, Tennessee, and Texas. 
Whether these branding and advertising campaigns and payment and delivery system pilots will be successful is an open question.  An Edelman global survey about trust found insurers, banks, and financial service companies at the bottom of a ranking of 16 industries.  They found that corporate reputations were determined by high quality products, transparent and honest business practices, and how companies treat their employees.  They also discovered that when a company is distrusted, 57% of people will believe negative information when they hear it once or twice and only 15% of people will believe positive information. (http://www.edelman.com/trust/2011/)  Of all the players in health care, insurers routinely rank last in terms of consumer trust.
“They are among the most disliked industries in the United States.  The nature of the business is that they really are not that eager to O.K. every expense,” said Professor Regina Herzlinger of Harvard Business School. (http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all)
Another expert, Fred Karutz of Silverlink Communications, thinks that health care insurance companies have a long way to go because they are new to the retail environment. “As people become consumers, they seek out value. In the group space, health plans could never hear the consumer scream, but in the retail space everybody can hear the consumer scream.” (http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all)
The PPACA and the health care reform movement offer tremendous retail opportunities for health insurance companies.  There may be as many 30 million Americans seeking insurance through the exchanges.  There will be about 15 million Baby Boomers who will eligible to sign up for their preferred plan, Medicare Advantage.  The Medicaid expansion could cover as many as 17 million citizens, despite the reservations of many governors. 
Whether health insurance companies can overcome the mistrust that many consumers feel and whether they can truly add value to a reformed system remains to be seen.  They might want to listen to Dr. Elliott S. Fisher, the ACO guru at Dartmouth:
“Their future is going to depend on their ability to demonstrate value to patients and to employers. No one any longer questions the fact that health care is unaffordable and that the current way we are doing business isn’t working.” (http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all)

Health Insurers & the PPACA: Extinction or Reinvention? Part I


With the Supreme Court of the United States upholding the constitutionality of most of the Patient Protection and Affordable Care Act (PPACA), now is a good time to examine the tortured relationship between the health insurers and health care reform.

Key to such an understanding is realizing that the insurance industry often conducts a “deception-based PR strategy [with] two active fronts:” “a ‘charm offensive’ designed to create an image of the industry as an advocate of reform” and “a secret, fearmongering campaign using front groups and business and political allies as shills to disseminate misinformation and lies, with the sole intent of killing any reform that might hinder profits.” (http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1)

The two front PR strategy was certainly in full swing when one compares Karen Ignagni’s White House statement of support for the PPACA with America’s Health Insurance Plans (AHIP) secret funneling of money to the Chamber of Commerce’s efforts to derail health care reform. 

Following the “charm offensive” playbook, Ignagni, the president of AHIP who makes $1.5 million in salary and bonuses as the industry’s chief lobbyist, spoke at President Obama’s health care summit on March 5, 2009:

“Thank you, Mr. President. Thank you for inviting us to participate in this forum.  I think, on behalf of our entire membership, they would want to be able to say to you this afternoon and everyone here that we understand we have to earn a seat at this table. We’ve already offered a comprehensive series of proposals.  We want to work with you. We want to work with the members of Congress on a bipartisan basis here.  You have our commitment.  We hear the American people about what’s not working.  We’ve taken that seriously. You have our commitment to play, to contribute, and to help pass health care reform this year.”(http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1)

Ignagni did not speak about the second front, the fearmongering campaign in which AHIP would play a central role.  Three years after the 2009 White House Summit, the National Journal revealed that AHIP sent the Chamber of Commerce a total of $102.4 million to be used in lobbying against the PPACA.

“The backchannel spending allowed insurers to publicly stake out a pro-reform position while privately funding the leading anti-reform lobbying group in Washington. The chamber spent tens of millions of dollars bankrolling efforts to kill health care reform.” (http://influencealley.nationaljournal.com/2012/06/exclusive-ahip-gave-more-than.php/)

While the Chamber and AHIP efforts to kill the health reform legislation were ultimately unsuccessful, they have certainly contributed to the confusion and division among the American people about the PPACA.  The talking points created by the Strategic Communications Advisory Committee of the AHIP were disseminated to the American public by an array of conservative groups (US Chamber of Commerce, Karl Rove’s Crossroads GPS, and the American Action Network) that spent $235 million on ads attacking the PPACA since its passage in March 2010.  Only $69 million was spent by groups supporting the law. (http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all)  A group of Aetna shareholders is challenging the insurer for donating over $7 million through AHIP to the US Chamber of Commerce and to the American Action Network.  Mercy Investment Services and the Sisters of Charity of Saint Elizabeth claims Aetna “is not in compliance with its corporate political and lobbying disclosure policy.” (http://thinkprogress.org/health/2012/07/14/517291/aetna-shareholders-dismayed-over-insurers-donations-to-anti-obamacare-campaigns/)

An article titled “Distaste for Health Care Law Reflects Spending on Ads” documents how citizens who live near me in the Philadelphia suburbs and would be helped by the PPACA regard it negatively.  They have seen the ads from the fearmongering PR campaign, and the ads work. (http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all)

Today (July 16, 2012) two years after the passage of the law, there is an op-ed in the New York Times titled Five Obamacare Myths.  The piece, subtitled “Cutting through slogans and scare stories,” lists five myths:  PPACA is a job-killer; PPACA is a federal takeover of health insurance; the unfettered marketplace is a better solution; the States will fix health care without federal involvement; running on the PPACA as an achievement is a bad idea. (http://www.nytimes.com/2012/07/16/opinion/keller-five-obamacare-myths.html?ref=opinion)

The Kaiser Family Foundation has done a number of polls and found that the American public is evenly split 41% to 41% between those who favor the PPACA and those who oppose it.  The surveys also demonstrate that many Americans do not really understand what is in the law, but after the Supreme Court ruling a majority (56%) believe the detractors should stop trying to repeal the law and move on to other problems facing the nation (http://healthreform.kff.org/en/public-opinion.aspx)

What does the insurance industry do now that the Supreme Court has largely upheld the PPACA?  Keeping in mind the industry’s history of having a two front PR campaign with a public and secret private face, it seems apparent that the health insurance companies need to reinvent their business model. 

Aetna CEO Mark Bertolini has been the most outspoken industry leader in declaring the old profitable business model dead.  “The system doesn’t work, it’s broke today. The end of insurance companies, the way we’ve run the business in the past, is here.”   Bertolini identifies a convergence of regulatory, demographic, and economic factors including the PPACA ban on medial underwriting and the medical loss ratio rules as resulting in a traditional business model that no longer works.  And Bertolini does not see the results of the presidential election changing what insurance companies need to do to reinvent themselves.  “Reform is not going to stop. It won’t go away.”  At least publicly, Bertolini is embracing the PPACA.  “We got pulled through the crucible against our will and have been reshaped because of it. For most of what has already been implemented, it has been a pretty good thing.”  (http://www.healthdatamanagement.com/news/HIMSS12-Aetna-CEO-insurers-face-extinction-44041-1.html)
           
Part II will examine how health insurers are trying to reinvent themselves and their business model to respond to health care reform.  










Health Insurers & the PPACA: Extinction or Reinvention?


the Supreme Court of the United States upholding the constitutionality of most of the Patient Protection and Affordable Care Act (PPACA), now is a good time to examine the tortured relationship between the health insurers and health care reform.

Key to such an understanding is realizing that the insurance industry often conducts a “deception-based PR strategy [with] two active fronts:” “a ‘charm offensive’ designed to create an image of the industry as an advocate of reform” and “a secret, fearmongering campaign using front groups and business and political allies as shills to disseminate misinformation and lies, with the sole intent of killing any reform that might hinder profits.” (http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1)

The two front PR strategy was certainly in full swing when one compares Karen Ignagni’s White House statement of support for the PPACA with America’s Health Insurance Plans (AHIP) secret funneling of money to the Chamber of Commerce’s efforts to derail health care reform. 

Following the “charm offensive” playbook, Ignagni, the president of AHIP who makes $1.5 million in salary and bonuses as the industry’s chief lobbyist, spoke at President Obama’s health care summit on March 5, 2009:

“Thank you, Mr. President. Thank you for inviting us to participate in this forum.  I think, on behalf of our entire membership, they would want to be able to say to you this afternoon and everyone here that we understand we have to earn a seat at this table. We’ve already offered a comprehensive series of proposals.  We want to work with you. We want to work with the members of Congress on a bipartisan basis here.  You have our commitment.  We hear the American people about what’s not working.  We’ve taken that seriously. You have our commitment to play, to contribute, and to help pass health care reform this year.”(http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1)

Ignagni did not speak about the second front, the fearmongering campaign in which AHIP would play a central role.  Three years after the 2009 White House Summit, the National Journal revealed that AHIP sent the Chamber of Commerce a total of $102.4 million to be used in lobbying against the PPACA.

“The backchannel spending allowed insurers to publicly stake out a pro-reform position while privately funding the leading anti-reform lobbying group in Washington. The chamber spent tens of millions of dollars bankrolling efforts to kill health care reform.” (http://influencealley.nationaljournal.com/2012/06/exclusive-ahip-gave-more-than.php/)

While the Chamber and AHIP efforts to kill the health reform legislation were ultimately unsuccessful, they have certainly contributed to the confusion and division among the American people about the PPACA.  The talking points created by the Strategic Communications Advisory Committee of the AHIP were disseminated to the American public by an array of conservative groups (US Chamber of Commerce, Karl Rove’s Crossroads GPS, and the American Action Network) that spent $235 million on ads attacking the PPACA since its passage in March 2010.  Only $69 million was spent by groups supporting the law. (http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all)  A group of Aetna shareholders is challenging the insurer for donating over $7 million through AHIP to the US Chamber of Commerce and to the American Action Network.  Mercy Investment Services and the Sisters of Charity of Saint Elizabeth claims Aetna “is not in compliance with its corporate political and lobbying disclosure policy.” (http://thinkprogress.org/health/2012/07/14/517291/aetna-shareholders-dismayed-over-insurers-donations-to-anti-obamacare-campaigns/)

An article titled “Distaste for Health Care Law Reflects Spending on Ads” documents how citizens who live near me in the Philadelphia suburbs and would be helped by the PPACA regard it negatively.  They have seen the ads from the fearmongering PR campaign, and the ads work. (http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all)

Today (July 16, 2012) two years after the passage of the law, there is an op-ed in the New York Times titled Five Obamacare Myths.  The piece, subtitled “Cutting through slogans and scare stories,” lists five myths:  PPACA is a job-killer; PPACA is a federal takeover of health insurance; the unfettered marketplace is a better solution; the States will fix health care without federal involvement; running on the PPACA as an achievement is a bad idea. (http://www.nytimes.com/2012/07/16/opinion/keller-five-obamacare-myths.html?ref=opinion)

The Kaiser Family Foundation has done a number of polls and found that the American public is evenly split 41% to 41% between those who favor the PPACA and those who oppose it.  The surveys also demonstrate that many Americans do not really understand what is in the law, but after the Supreme Court ruling a majority (56%) believe the detractors should stop trying to repeal the law and move on to other problems facing the nation (http://healthreform.kff.org/en/public-opinion.aspx)

What does the insurance industry do now that the Supreme Court has largely upheld the PPACA?  Keeping in mind the industry’s history of having a two front PR campaign with a public and secret private face, it seems apparent that the health insurance companies need to reinvent their business model. 

Aetna CEO Mark Bertolini has been the most outspoken industry leader in declaring the old profitable business model dead.  “The system doesn’t work, it’s broke today. The end of insurance companies, the way we’ve run the business in the past, is here.”   Bertolini identifies a convergence of regulatory, demographic, and economic factors including the PPACA ban on medial underwriting and the medical loss ratio rules as resulting in a traditional business model that no longer works.  And Bertolini does not see the results of the presidential election changing what insurance companies need to do to reinvent themselves.  “Reform is not going to stop. It won’t go away.”  At least publicly, Bertolini is embracing the PPACA.  “We got pulled through the crucible against our will and have been reshaped because of it. For most of what has already been implemented, it has been a pretty good thing.”  (http://www.healthdatamanagement.com/news/HIMSS12-Aetna-CEO-insurers-face-extinction-44041-1.html)
           
Part II will examine how health insurers are trying to reinvent themselves and their business model to respond to health care reform.   

Saturday, July 7, 2012

The SCOTUS & the PPACA: The Medicaid Expansion Decision


There were many surprises when the Supreme Court (SCOTUS) issued its long-awaited decision on the Patient Protection and Affordable Care Act (PPACA).  I have written elsewhere why I think Chief Justice John Roberts surprised us all by siding with the four Democratically appointed justices to rule the individual mandate constitutional. (http://www.thedoctorweighsin.com/why-did-chief-justice-roberts-do-it/)  These five justices also surprised us by basing that ruling not on the commerce clause, but on the federal government’s right to tax citizens.  The SCOTUS by a 9 to 7 vote also ruled that the Medicaid expansion was constitutional as long as states would not lose all their existing federal funding if they choose not to expand coverage as called for in the PPACA.  This blog will examine the ramifications of the Medicaid decision, which was also a surprise. 

Much of the debate around the PPACA had concentrated on the individual mandate and not the Medicaid expansion, which as originally approved by Congress would have added up to 17 million Americans to the Medicaid health insurance program.  Health care reform advocates welcomed this expansion because it extended care to poor people, but some state officials, especially Republicans, opposed it because the states have budget deficits and no easy way to pay for the perceived new costs associated with expansion.  Medicaid provides health insurance for low income Americans and is jointly funded by the federal and state governments.  Although states do not have to participate, all states at the present time do take part in the matching program and agree to abide by the rules. 

Prior to passage of the PPACA, Medicaid covered:  pregnant women and children under 6 who had family incomes at or below 133% the Federal Poverty Level, children 6 through 18 with family incomes at or below 100% the Federal Poverty Level, parents and caretaker relatives on the cash assistance program, and elderly and disabled people with Supplemental Security Income benefits.  Beginning in January 2014, The PPACA requires participating states to cover almost all people under 65 earning household incomes at or below 133% the Federal Poverty Level.  The 2012 levels are $14,856 per year per person and $30,657 per year per household of four.  From 2014 to 2016, the federal government will pay all of the costs of the expansion; after 2016 there is a gradual decrease in federal support to 90% in 2020 and thereafter. The single best summary of the entire SCOTUS ruling can be found at the Kaiser Family Foundation here http://www.kff.org/healthreform/8332.cfm.

The SCOTUS ruling on Medicaid expansion is complicated, but the take home message is that the expansion is constitutional as long as the HHS Secretary is not able to take away existing federal support to states that decide not to participate in the expansion.  All other provisions in the PPACA are left intact.
New Medicaid provisions in the PPACA include:

·    Increase in primary care provider payments
·    Options to expand home and community-based services
·    Reductions in disproportionate share hospital payments
·    States maintaining eligibility requirements in place as of March 23, 2010

Health care reform advocates were pleased that the Medicaid expansion was upheld, but they worry that the SCOTUS ruling would allow states to opt out of the expansion.  Mental Health America, an advocacy group, stated, “The expansion of Medicaid also requires those who are newly eligible to receive mental health and substance use services at parity with other benefits.  State participation in the Medicaid expansion is therefore critically important.” (http://www.sacbee.com/2012/06/28/4596221/statement-of-mental-health-america.html)  Other advocates noted that the SCOTUS ruling left the door open for states to make it harder for adults to qualify for Medicaid.  States could throw some low-income adults “into a black hole with nowhere to turn for coverage," said Deborah Bachrach, who was New York’s Medicaid director until 2010.  (http://www.kaiserhealthnews.org/Stories/2012/July/03/states-could-cut-medicaid-rolls-after-ruling.aspx)   Another complicating factor is that under the PPACA most individuals with incomes less than 100% the Federal Poverty Level are not eligible for subsidies to purchase insurance at the newly formed state insurance exchanges and so may end up without access to insurance.  Such worries were confirmed as real when Maine’s Attorney General William Schneider announced plans to strike more than 20,000 Medicaid recipients from the state’s program to save $10 million for the state’s strapped budget.  Not everyone agrees that the Attorney General will be allowed to make this cut.  “‘The court decision was not crystal clear,’ said Alan Weil, a former Medicaid director and head of the nonpartisan National Academy for State Health Policy.  ‘I’ve been telling people [the rules] are still there.’” (http://online.wsj.com/article/SB10001424052702303684004577511103843368654.html) 

The progressive take on the SCOTUS ruling affecting the Medicaid expansion can perhaps be best summarized by Ed Kilgore:

“The sad truth is that Republican governors and state legislators have been claiming ever since ACA was enacted that the expansion, even with the ‘sweet’ super-matches, would bankrupt their budgets. And the even sadder truth is that many of these solons don’t think of this as primarily a fiscal issue, but as an ideological test of their hatred of the ‘welfare state.’ There’s a reason southern Republicans, perhaps even more than their compatriots elsewhere, love Paul Ryan’s Medicaid ‘block grant’ proposal. They want significant reductions in the existing Medicaid program, along with structural changes that would make it unrecognizable as a low-income entitlement. This involves a philosophical objection to giving poor people free health insurance, not just a budgetary concern.” (http://www.tnr.com/blog/plank/104458/why-the-obamacare-ruling-isnt-the-slam-dunk-most-people-think)

The reactions of many GOP governors seemed to confirm Kilgore’s conclusions.  “We’re not going to shove more South Carolinians into a broken system that further ties our hands when we know the best way to find South Carolina solutions for South Carolina health problems is through the flexibility that block grants provide,” said Rob Godfrey, spokesman for Gov. Nikki Haley. (http://www.washingtonpost.com/business/economy/health-care-laws-medicaid-provision-too-good-to-pass-up/2012/07/02/gJQABxkJJW_story.html) ”‘Floridians are interested in jobs and economic growth, a quality education for their children, and keeping the cost of living low,’ Governor Scott said. ‘Neither of these major provisions in ObamaCare will achieve those goals, and since Florida is legally allowed to opt out, that’s the right decision for our citizens.’”(http://hotair.com/archives/2012/07/02/gov-rick-scott-no-medicare-expansion-for-florida-thanks/) Similar defiant pronouncements were issued by Louisiana’s Governor Bobby Jindal and Wisconsin’s Governor Scott Walker. One might assume that a conservative state like Arizona with a controversial governor who is no friend of President Obama would be likely to refuse to participate in the Medicaid expansion.  For a fascinating look at how complicated and not straightforward Arizona’s decision actually is please go to http://www.azcentral.com/arizoannarepublic/opinions/articles/2012/07/05/20120705robert-robb-arizona-has-hard-choice-make.html.

At the end of the day, it may be hard for GOP governors and legislatures to pass up participating in the expansion.  While the GOP has focused on the costs passed onto to the states, some detailed analysis shows that the Medicaid expansion can save money for the states.  Some state and local governments currently help hospitals cope with providing uncompensated care for uninsured patients to the tune of $10.5 billion or 18.5% of uncompensated care nationally.  Having more patients covered by Medicaid would bring these costs down, which is why hospitals are lobbying so hard for their states to participate in the expanded program. (http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/how-the-medicaid-expansion-also-saves-states-money/)   “’Texas hospitals recognize there are concerns with expanding the Medicaid population, but given the state’s high number of uninsured, all options for gaining insurance coverage must be closely considered,” Dan Stultz, executive director of the Texas Hospital Association, said in a statement. ‘Without the Medicaid expansion, many will remain uninsured, shifting costs to the insured and increasing uncompensated care to health-care providers.’”  The Texas Hospital Association has never been known for their progressive views, and yet all hospitals are lobbying for states to participate in the Medicaid expansion (http://www.governing.com/blogs/view/gov-hospitals-likely-to-lobby-states-on-medicaid-expansion.html).

Expansion of Medicaid would also reduce state spending on mental health services for poor and uninsured patients; state and local governments spent $16.3 billion for such services, 42% of the cost of state mental health services in 2009. The Center on Budget and Policy Priorities estimates that state Medicaid spending will ultimately go up by 2.8% by 2022 if states join the expansion. However, that estimate “’actually overstates the net impact on state budgets because it does not reflect the savings that state and local governments will realize in health care costs for the uninsured…In fact states could end up with a net gain.’” (http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/how-the-medicaid-expansion-also-saves-states-money/)     For a state-by-state rundown on the Medicaid expansion please go to this link to a New York Times blog post. http://economix.blogs.nytimes.com/2012/07/02/how-much-would-the-medicaid-expansion-cost-your-state/.

The economic and political realities of the Medicaid expansion have already entered into some gubernatorial races.  Robert Blendon, professor of health policy and political analysis at Harvard, said,  “’Democratic candidates will say we should implement the law and put in exchanges and go after as much funding for coverage as possible, while Republican will say it’s too expensive.’”  “’Medicaid will be an issue anywhere Democrats have a chance to win,’ said Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University. That includes states such as West Virginia, North Carolina, Washington state and possibly Missouri, he said.” (http://www.pennlive.com/newsflash/index.ssf/story/medicaid-expansion-already-an-issue-in-some-gubernatorial-races/68c350064991ce90c070836422118994)  Democratic candidates will probably push for states to participate in the PPACA’s Medicaid expansion because if they do not, their state budgets will end up subsidizing Medicaid coverage for lower income people in other states that do sign up for the program. 

Governors who refuse to participate in the Medicaid expansion may face a backlash from voters like:

“Bunnie Gronborg, 64, of Festus, Mo., [who] said she has two sons in their 30s who are single fathers who lost construction jobs and now lack health insurance. She had hoped they could be covered by the Medicaid expansion, and she doesn't buy the explanation that the state cannot afford it. ‘There's absolutely no reason’ to reject the expansion,’ except being vindictive and playing political games with people's actual health care,’ Gronborg said.” (http://www.huffingtonpost.com/2012/06/29/medicaid-expansion_n_1638720.html)

Ezra Klein thinks that the Medicaid expansion is just too good a deal for states to pass up, even though some GOP governors will be tempted to gain political points with the base by refusing to participate:

“And governors also have to answer to non-Republican voters who don’t want their state missing out on billions in federal dollars, and to the hospitals in their state who have to treat uninsured patients that end up in their emergency rooms, and the insured voters who end up paying for their uninsured brethren.” (http://www.washingtonpost.com/business/economy/health-care-laws-medicaid-provision-too-good-to-pass-up/2012/07/02/gJQABxkJJW_story.html)

Another hard to predict political result of the SCOTUS ruling on both the individual mandate and the Medicaid expansion is the affect it will have on future SCOTUS decisions.  Some conservatives are so mad at Chief Justice Roberts that they are calling him a traitor and saying he should be impeached.  How will the Chief Justice react to the fallout?  Reagan appointee conservative federal judge Richard Posner speculates on how Chief Justice Roberts will respond to his new situation:

“‘These right-wingers who are blasting [Chief Justice John] Roberts are making a very serious mistake. I mean, what would you do if you were Roberts?’ Judge Richard Posner, of the 7th U.S. Circuit Court of Appeals, told NPR. ‘All of a sudden you find out that the people that you thought were your friends have turned against you, they despise you, they mistreat you, they leak to the press, what do you do? Do you become more conservative? Or do you say, ‘What am I doing with this crowd of lunatics?’”(http://www.politico.com/news/stories/0712/78182.html)

Before the SCOTUS decided the case of National Federation of Independent Business v. Sibelius, most of the attention was concentrated on the constitutionality of the individual mandate.  This blog post has examined the reasons why the SCOTUS treatment of the PPACA Medicaid expansion may have more important and more lasting effects on the transformation of the American health care clinical delivery system.