From town hall meetings to tea party gatherings, citizens all over Nevada have jumped into the debate on healthcare reform with a vigor seldom seen in the political landscape. As a frantic Congress attempts to draft and pass some kind of reform legislation from a number of bills that have been put forward, many Nevadans have taken to the Internet and to the streets to make their voices heard. Hundreds from Nevada joined the estimated hundreds of thousands of Americans who marched in Washington, D.C. on September 12 to send a message to lawmakers. Regardless of their political philosophy, Nevadans continue to assiduously follow the discussion that can potentially result in significant changes in their lives.
While nearly everyone says that the country needs some type of healthcare reform, agreement as to its specifics has been illusive at best. “I think we do need reform,” explains Dr. Fred Maryanski, president of Nevada State College (NSC) in Henderson. “We seem to have an inefficient and expensive healthcare system. Many pieces work, but the costs are high and some people don’t have care.” Dr. Carolyn Yucha, dean of the Schools of Nursing and Allied Health Sciences at the University of Nevada, Las Vegas (UNLV), also emphasizes the need for reform partly because the current system doesn’t cover the uninsured in an efficient or humane way. “We certainly need healthcare reform because we cannot refuse care to people,” she says. “If people don’t have insurance somebody still has to pay for it.”
The concerns about reform seem to depend, at least to some degree, upon individual situations and preferences. After all, our health is indeed a personal and private matter. Young and healthy uninsured and underinsured people worry that requiring everyone to have insurance will force them to buy something they believe they don’t need at this time. The Congressional Budget Office projects that it could force some middle-income uninsured adults to pay around 15 percent of their income if they earn too much money to qualify for a government subsidy. On the other hand, 60 percent of older people oppose some aspects of healthcare reform because they are worried the proposed $500 billion cuts from Medicare could lead to lower quality care and rationing, according to a recent Rassmussen poll. At the same time, a surprising number of people are pleased with what insurance they already have. Rassmussen also found that 68 percent of American voters have health insurance that they rate as good or excellent. “I’d like my insurance to remain the same,” Maryanski says. “I’d like to extend coverage to as many people as feasible, but we have to be aware of budget realities.”
Show Me the Money
Although most people would like everyone to have the same gold plated insurance that Congress has, ultimately it comes down to the money. “We can’t afford the system we have now,” explains Dr. Ole J. Thienhaus, dean of the University of Nevada School of Medicine (UNSOM). In its broadest terms, debate has swirled around how to fund care for everyone while cost, quality and access are cited as the major components. One of the most contested portions of the debate is the public or government option versus the private option for providing insurance. Proponents of the government option system say it could provide universal care to everyone in a more efficient manner because it would be centralized and employ a simplification of forms. “I’m personally in favor of a single payer system,” Yucha says.
However, citing failures of the federal government to run existing institutions efficiently, such as Medicare and the U.S. Postal Service, opponents to the public option say they have no confidence in the government being able to deliver quality care at a reasonable price from a system as large as what universal healthcare would be. “We believe that the private sector is the best place to vet out inefficiencies,” says Mike Murphy, president of Anthem Blue Cross Blue Shield of Nevada. “Competition comes with 1,300 insurance companies in the country.” Opponents also worry that the public option would eventually eliminate choice and competition by completely swallowing private insurance companies. “The government will get to make all the rules,” explains Jim Miller, president and CEO of Renown Health in Reno. “It would drive them [private insurance companies] out of business because subsidized public plans will be able to offer plans for less money.”
Still others have suggested a combination of public and private options, which is similar to what exists today with Medicare, Medicaid, Indian Healthcare and the Veterans Administration (VA) operating alongside the hundreds of private insurance companies. Rather than serving the masses, however, the four government programs are focused on specific segments of the population. Critics of this combination point to the failure of Medicare and Medicaid to remain solvent over the years as evidence of the inability of the federal government to be in business, however. “I can’t think of any government program where they do a better job than private enterprise,” says Gary Bartlett, who has 30 years of experience selling healthcare insurance to small businesses from his namesake agency in Reno. Critics of increasing the government influence in a public/private combination also say that it would simply provide a longer lead time into what would eventually be primarily a public option.
Although it hasn’t been included in any meaningful way in legislation proposed so far, tort reform has become a part of many conversations dealing with the cost of healthcare. With as much as 25% of the total cost of healthcare being spent on what could be considered unnecessary tests, proponents of tort reform say hundreds of millions of dollars could be saved by limiting damage awards. “We need to get past our nation’s rapid growth in lawsuits,” Miller says. “It’s causing physicians to get diagnostic tests that they may not need. They’re totally afraid they’ll get sued.” Bartlett agrees that any discussion of cost savings should include tort reform. “There’s tremendous amounts of dollars that could be recovered by tort reform. It would be a major issue to lower premiums,” he says. The potential of lawsuits can also affect the type of medical career a physician chooses, where he or she practices and how long, according to Maryanski. Because doctors must pay the high cost of malpractice premiums regardless of how much they work, many completely retire early since it wouldn’t be cost effective to practice anything other than full-time medicine.
With many people eager to tell their favorite horror story regarding private healthcare coverage, insurance companies have been the recipients of complaints and blame for much of what is perceived to be wrong with the healthcare system in general. Insurance executives insist they are eager for meaningful reform, however, and have stepped up to the plate with pithy suggestions on what changes can be made. “We are in favor of healthcare reform,” Murphy emphasizes. “It has to contain a reduction in cost and improvement in quality.” Prevailing opinions at this time seem to favor the demise of the unpopular pre-existing condition clause which is contained in many policies. “Nobody in our country should go uninsured because of their health condition,” Bartlett insists. “This is devastating on people. They can’t go get coverage and they can go broke.”
Although many young people are resistant to mandatory coverage, most insurance companies support it because it spreads the risk among a wider pool of people, most especially healthy ones. “We believe if you’re going to have true reform you have to have a tough mandate that everybody has to be insured,” Murphy says. “Our healthcare system is unsustainable without a mix of people.” Bartlett disagrees, saying that forcing everybody to get insurance isn’t a good idea. “It’s taking advantage of younger healthy people,” he explains. He suggests that costs could be better controlled by using high risk pools and a system of re-insurance companies that could spread the risk around. At the same time, some scholars of the U.S. Constitution are questioning whether this proposed individual mandate is even constitutional. Giving the federal government the power to require everyone to have health insurance is not mentioned anywhere in that historic document unless one loosely interprets the Commerce Clause to cover it, which allows for the regulation of economic activities.
Insurance companies have also come under fire for having what some people perceive to be monopolies or, at the very least, shallow competition because healthcare insurance cannot be sold across state lines. For the most part, healthcare is a local decision with oversight at the state level, according to Murphy. Because costs and levels of care differ widely from one section of the country to the other, selling insurance products across state lines could be extremely challenging. The mandate covering autism, recently passed by the Nevada State Legislature, may or may not be mandated coverage in other states, for example. In Nevada, however, it adds approximately one and one-half percent to the cost of policy premiums. Bartlett has a more optimistic view of statewide sales, saying it might be possible to tweak the system to enable reciprocity of products and services and thus create more competition. “I don’t think it’s totally undoable,” he says.
Insurance companies and businesses have enormous stakes in whatever decisions are made along with the 170 million Americans who receive insurance through their employers. On average, business spends 15 to 20 percent of its total budget on healthcare insurance. “Most employers are happy to furnish health insurance until it becomes cost prohibitive,” Bartlett explains. He says a public option would probably take business out of the business of healthcare, however. “Employers will look for the least expensive plan and will eventually move their people to it,” he explains. Although they would be relieved of the burden of dealing with employee insurance under that scenario, many business owners do not look kindly upon the potential of a public option because it represents government interference. “A lot of business entrepreneurs don’t like government control,” Bartlett says. “It’s the beginning of the government making inroads into their businesses.”
With healthcare taxes and fees pumping $250 million into the state’s general fund every year, the State of Nevada also has a large vested interest in the outcome of reform. Rather than immediately climbing on the public option bandwagon (which they believe could eventually lead to their demise), however, insurance companies have suggested a variety of changes to the current system that could lead to meaningful reform. Along with tort reform, these include promoting healthy behaviors, standardizing cost and quality information, expanding on healthy savings accounts and offering high deductible plans, to name a few.
Physicians Weigh In
Although the American Medical Association (AMA) has stated it supports many of the suggested healthcare reforms, other physician groups have pointed out that the association is a lobbying group that only represents about 18 percent of the country’s practicing physicians. Faced with acute shortages of physicians and other healthcare personnel already, many people fear that some reforms could make a bad situation even worse. A recent poll by Investors Business Daily (IBD/TIPP) found that 72 percent of doctors don’t believe that the government can add 47 million uninsured people to the healthcare system and still deliver better quality care at a lower cost. The poll also found that 45 percent of doctors would consider taking an early retirement if reforms, such as the public option, were passed. If that were true, 360,000 physicians out of around 800,000 who currently practice in this country would consider quitting. “I hear everyday from physicians who say, ‘It isn’t worth it anymore. I should retire,’” Miller says. Doctors are especially concerned about the absence of tort reform.
The shortage of medical personnel in Nevada, especially in rural areas, has been a continuing challenge over the years, prompting the late entrepreneur, Howard Hughes, to initially fund UNSOM in 1969 at the University of Nevada, Reno (UNR). The mission was to locally educate physicians who would then stay in Nevada to practice. Since that time around 2,000 physicians have been hooded with around half of them staying in state. As dean of the school, Thienhaus deals with the complicated task of educating physicians for the future under the confines of today’s budgetary constraints. Because the majority of money comes from clinical income (largely from treating under-insured and uninsured patients), he always has concerns about the levels of reimbursement. From that standpoint, he believes the school might be reimbursed more adequately if more people were insured.
In a sea of red ink that seems to cover most budgets these days, UNR is celebrating the $10-million gift from the William N. Pennington Foundation to help build a $49-million health sciences building that will allow the Orvis School of Nursing to double its enrollment to 300 students and for the University of Nevada School of Medicine to expand from 62 students per class to a total of 400 students. Construction will begin early next year with completion scheduled for 2011. The new facility will not only enable Nevada to help address the shortage of healthcare personnel, but it will allow future nurses and doctors to learn and train together in an interdisciplinary fashion.
Meanwhile, in Southern Nevada, Dr. Shirlee Snyder, interim dean and professor of the School of Nursing at NSC, faces similar challenges as Thienhaus. “The college and its foundation board continue to work on achieving one of its priorities, the construction of a nursing and science building,” she says. The facility will enable the school to gradually increase its number of students. “We need to prepare for the prediction that over the next 15 years, the nation’s nursing shortage will grow twice as large as any nursing shortage previously experienced. This will also impact the supply of nursing faculty,” she explains. NSC also offers a grant-supported part-time pilot tract to encourage students who have financial and family needs, according to Snyder and Maryanski. With about 750 students currently in various phases of the program, NSC has graduated 437 students with nursing degrees since its inception in 2003.
At UNLV, Yucha says she worries about getting enough qualified students to fill the slots in the nursing program. Several decades ago many of the brightest women chose nursing careers. Today, many of those potential nurses become engineers, doctors or architects. At the same time, however, the percentage of male nurses has increased to around 15 percent of the total. Yucha also says the image of nursing as presented by the media gives a false picture of what the profession is all about. “If you watch TV and you’ve never been in a hospital you don’t know what a nurse does. The whole image issue affects us,” she explains.
Both Snyder and Yucha believe that nursing organizations should be more vocal and take a larger part in the discussion of healthcare reform. “Recommendations from the nursing professional organizations call for strengthening support for Advanced Practice RNs, for example, the need to recognize and reimburse Nurse Practitioners and Certified Nurse Midwives as primary healthcare providers,” Snyder says. With the shortage of doctors predicted to become worse, nurses and other trained medical personnel will likely see their roles expanded in the larger picture of healthcare.” As we go forward nurses will assume a larger share of patients’ care,” Maryanski says.
Follow the Money
As an administrator who has been in the healthcare business for more than 30 years, Miller views the overall issue from the standpoint of dollars and cents. “I think our healthcare is not broken, but our payment system is,” he says. Far from a user-friendly system that can compare apples to apples, it encompasses a vast amount of services and payments that just don’t match up. Some services, such as same day surgery, are high profit with payments well in excess of the cost. Women’s and children’s services, however, are compensated at a much lower rate and often are in the red. “Most all of the costs are driven by Medicare’s fee schedule,” he says. Reimbursement to doctors for Medicare is notoriously low as well as the compensation hospitals receive for treating uninsured patients under a government mandate. In the case of the hospitals, the cost is passed down to insured patients thus driving the overall costs of healthcare up. An obvious reform to the system would be to bring costs and payments more in line. “None of the government programs pay for the cost of their cares,” Miller says.
Another problem with managing healthcare costs is the lack of oversight by those who receive the services. “People don’t even know the costs,” Miller says. The few who might try to figure out the cost of treatment are forced to decipher confusing statements that usually arrive months after the service was provided. Miller advocates increasing the responsibility on the part of patients for knowing the costs, understanding the treatments and participating to some degree in the payment. “Everybody should always pay something,” he explains.
Although Renown always manages to fill its positions, even if it means hiring from out of state, Miller worries about having adequate staff in the future. “There are shortages almost everywhere,” he says. “We are headed for a healthcare services availability crisis.” The wrong kind of healthcare reform coupled with increased demand on the system by more aging baby boomers could cause even greater shortages. “We are facing a shortage of doctors in certain areas, such as primary care,” Thienhaus says. “If reform increases the number of eligible patients, the shortage will be far worse.”
As the incredibly complex debate continues, nobody knows at this point what changes will actually take place. We can only follow the action, hope to remain informed and voice our opinions when we are able. Some people worry that the discussion will go nowhere. “My greatest concern is that nothing will happen,” Snyder says. “My hope is that all of the discussions occurring on Capital Hill will result in an improved healthcare system because the current system fails to meet the medical needs of many Americans.” Others worry that the end result will be worse care for many people. “My concern is to not lower the standard to provide something for everybody,” Maryanski says. Still others emphasize the need to do the job right. “My greatest fear is that we would move in a direction without knowing what we’re doing,” Murphy says. “We’re trying to cut through the junk. It needs to be done in a responsible way.”