To hear the current GOP presidential candidates describe it, former Gov. Mitt Romney’s support for the 2006 Massachusetts health care reform initiative was the worst thing since the Spanish Flu.
We can chalk a lot of the hyperbole up to campaigning, but the critics raise some good points.
First, costs have gone up. That’s not surprising as more people are covered, many of whom didn’t have coverage before and therefore likely had medical issues that, once they were insured, they addressed. Moreover, Mass’ per-capita health care costs have been higher than the national average for a long time – this is a structural issue as much – if not more – than a result of reform.
Second, the individual mandate turned out to be a rather unsatisfactory ‘solution’. I’d argue that the problem with the mandate’s design was two-fold – the penalty for failing to obtain health insurance wasn’t stiff enough to drive high enrollment and the individual market was hammered by adverse selection. Some may argue that actual participation results may indicate my pessimism re the low penalty was misplaced.
In the individual market, people could enroll in, and then drop coverage at any time, resulting in some pretty serious adverse selection issues. Someone would need care, sign up for insurance, get the treatment, then stop paying premiums. This was a big problem in the individual market (and I’d argue supports my point about the inadequacy of the penalty).
There’s no question that the big problem is the cost issue – especially in today’s tough economic environment. (I’ll leave aside the ‘should government be this activist’ argument for now)
There are some pretty interesting solutions to the cost problem emerging in Massachusetts, solutions with broader implications for the country.
A couple years back the Mass Blues set up a program basing reimbursement in their HMOs in part on quality; this plan covered over a half-million members and looks to be expanding. Known as an Alternative Quality Contract, the program involves:
“A global, risk-adjusted, fixed payment per patient, with annual increases in line with inflation; and
Performance-based incentives linked to nationally-recognized measures of quality, efficiency and patient experience.”
There’s a pretty thorough description of the program in the link and it’s well worth reading.
With several years’ experience on which to build, Massachusetts’ politicians, health plans, and providers are gradually adopting new business practices, pricing models, and reimbursement methodologies designed to address long-term system costs. The legislation under consideration would put global payments in place for about a quarter of Massachusetts residents covered by Medicaid and state-subsidized insurance and state employees.
One of the more promising steps is a legislative initiative to enable/encourage global payments to provider organizations instead of the current fee-for-service reimbursement system. The concept, which is associated with Accountable Care Organizations, is based on the idea that incentivizing physicians and other providers to maintain and improve the health of members is more cost effective than paying them for each visit and procedure.
While relations between the dominant health care systems and insurers have been pretty combative, there appears to be a thaw in the air. Partners Healthcare, the largest system in eastern Massachusetts, just signed on to the program in a deal that appears to be a major win for cost cutters.
Lest we forget, the Massachusetts reform plan has achieved remarkable success in expanding coverage – a mere two percent of residents are uninsured along with less than one percent of kids.
What does this mean?
Mass’ legislators decided to pass reform first and tackle costs later. There’s no question costs have gone up, in part driven by expanded coverage. There’s also no question that providers and insurers are working together to “bend the cost curve” and their efforts look promising for both lower trend and better care.
Are there lessons we can take for the country as a whole?
Yes. Unsurprisingly, expanding coverage increases costs. But over time, stakeholders, prodded by intelligent legislation and forced to compete not on the basis of risk selection but quality and cost, can and will figure out how to control costs.

The latest meteor crossing thru the GOP presidential race firmament is Herman Cain, the Godfather of pizza.
Only in America.
As difficult as it may be, I’m actually going to attempt to take Cain seriously. Leaving aside his bizarre tax plan, one that would actually dramatically increase taxes on consumption smack dab in the middle of an economic recovery, (that’s been adequately eviscerated by others far more knowledgeable than I in the implications of tax policy) I’ll examine Cain’s rather thin health care resume and policy plans.
That said, one should note that the 9-9-9 is just an interim step in Cain’s three-step process, which concludes with a flat 30% tax on all goods and services – and no other taxes of any kind.
Cain does have a long track record on health care issues – he led the National Restaurant Association back in the early nineties and was a vocal opponent of the Clinton reform efforts. That said, his website and other public statements are long on sound bites and short on substance.
He advocates:
– treating employer and individual contributions for health insurance the same for tax purposes
– repealing the Accountable Care Act and replacing it with expanded tax credits for personal savings accounts for health care
– tort reform
– switch from the current Medicare system to some type of voucher for Medicare – how this works is uncertain as there are precious few details, but when you end payroll taxes, you end Medicare…
So what would happen with Cain as President?
Well, health care services and products and procedures and treatments would be taxed at nine percent. Yep, everything from appendectomies to pills, proctological exams, psychological counseling, and PET scans.
Next, Medicare would disappear to be replaced by some form of voucher, where people would try to by coverage from private insurers on the free market. How this would work is…uncertain. I’m not sure how many private insurers would jump at the chance to provide coverage to senior citizens with Alzheimer’s, cancer, heart disease, or osteoporosis…
What did I just write?
I should have said NO private insurers…
That’s about all we can conclude at this point. Until – or rather unless – we get more detail from the Godfather of Pizza, there’s just not enough substance to his soundbites.

The announcements this week that the United States Preventive Services Task Force has decided healthy men shouldn’t get the P.S.A. blood test is long overdue, but nonetheless very welcome news.
The test, which ostensibly screens for prostate cancer, is notoriously inaccurate, delivering a high rate of false positives and false negatives. And, men who get these tests have no greater chance of surviving the test than men who don’t.
Seventy percent of positive PSA tests are false positives; the patient does not have prostate cancer. Worse, these false positive tests often result in more tests and treatments that then result in impotence and incontinence and in some cases, premature death. According to the chair of the Task Force, “This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does.”
Over a twenty year period, about a million men got prostate surgery, radiation, or a combination as a result of a PSA test. Of those, about 5000 died soon after surgery, and from 10,000 to 70,000 suffered serious complications, and 200,000 to 300,000 were incontinent, impotent, or both. The dimension of the problem was starkly illustrated when the test’s developer called its widespread use “a public health disaster.”
There are passionate and dedicated folks who will argue vehemently that PSA tests are necessary and save lives. Unfortunately, many have become part of a campaign financed almost entirely by the pharmaceutical industry. I engaged in a dialogue for some time with one of them, and despite my best efforts, his conclusion is that the test saved his life and therefore others should get it as well.
It’s one thing to talk population health and an entirely different thing when one is talking about the health of one’s family or self. Unfortunately, well-meaning people often confuse the two – and this is what has led them to advocate for a test that is:
– costly (PSA tests range in cost from $70 – $200, plus the office visits, or about $3 billion a year just for the tests in the US);
– results in surgery that kills about five thousand men over a twenty year period and
– causes impotence and/or incontinence in 20% to 30% of patients
Some will argue that more recent developments in surgery have delivered better results – I’d say it’s too early to tell, which is why the Task Force used a database that would allow them to see effects over the long term.
What’s the net?
PSA testing is a great example of business masquerading as good medicine, funded by businesses who profit from the test, who arguably, are partially responsible for the deaths and suffering of thousands of men.
It’s also a great lesson on why we need more science education in our schools, so so many of us would actually understand what a disaster the PSA test has become.