John Carroll

John Carroll

As a seasoned political observer of Oregon politics, Christy Quirk thought Measure 23 had just about everything going against it. It called for a single-payer insurance system that brazenly highlighted the higher income and payroll taxes that would be used to pay for it. The organizers had few allies who could muscle support. They had little money to get their message out.

"It wasn't very well written," says Quirk, a Democratic pollster, "and it was put on the ballot by people who believed in the issue without paying attention to political considerations."

And then there was the opposition: The "No" group easily put together a $1.4 million war chest, quickly enlisted a broad array of business groups to join the antichorus, and found a ready ear on the editorial boards of the most influential publications in the state.

The Oregonian summed up the one-sided discourse the day before the vote: "This is nothing less than a bizarre prescription for financial ruin."

Even some of the most sympathetic groups thought it was a prescription for electoral failure.

"This couldn't have been more poorly structured," says Kristina Wilfore, executive director of the Ballot Initiative Strategy Center, which backs progressive efforts around the country. On Election Day, voters turned against the measure, 4 to 1.

Poisoned atmosphere

In politics, there's losing and then there's getting crushed. As Bill Clinton found out in the early '90s, getting crushed on health care reform leaves you with few friendly faces looking to renew the battle.

"When a measure goes down by such an enormous margin," says Quirk, "it provides political cover for anyone who opposes any change in the system." Now, the idea of health care reform could seem so toxic that state legislators will be unlikely to embrace any big changes. And when the single-payer system goes down to defeat in Oregon — which has been sympathetic to a wide variety of liberal political notions — the idea may never play in Peoria.

The overwhelming results in Oregon, says "No" campaign chief Dave Fiskum, "ought to at least give proponents second thoughts" about any measure tied to huge tax increases.

Stick a finger in the air of local politics these days, and you'll probably detect a strong wind pushing against new health care reform efforts like Measure 23. Right now, there isn't enough money to keep paying for current programs, let alone new or expanded ones.

From New York to California, state legislatures have awakened from the intoxicating tax windfalls of the '90s to the grueling hangover brought on by multibillion-dollar deficits. Far from expanding benefits, many states are looking for ways to shrink Medicaid rolls by tightening eligibility rules. In Maryland, a once-popular health care reform package designed to increase Medicaid rolls and offer tax incentives to spur private businesses to offer benefits now appears to be on the ropes, a likely victim of the $1.8 billion shortfall the state faces over the next two years. And so it goes around the nation, as progressive health care measures are swamped by a tidal wave of red ink.

But don't write an epitaph for single-payer systems — or other bold reform efforts — yet.

Far from slipping away in humiliation into political oblivion, supporters of health care reform say they may have been dealt a setback but can scale back and start looking for more modest ways to expand coverage. The grass-roots strategy of pushing reform one state at a time isn't going to stop now, supporters say. Time, a dysfunctional health care system, and soaring costs can turn the tables yet again come the next election.

They have cause for hope.

Even as voters in Oregon were trouncing reformers, John Baldacci was cruising to a victory as governor of Maine riding the popular support he got for backing universal access to health care. A reinvigorated Al Gore is touring the nation, talking up nothing other than single payer as a cure for what ails a sick health-care system. A new study commissioned by Rhode Island's General Assembly claims a single-payer system would be less expensive, drastically reducing overall administration costs. And Massachusetts Sen. Ted Kennedy raised business groups' hackles with a speech advocating a federal requirement that all businesses with five or more employees provide health insurance and pay at least 75 percent of the premium.

Meanwhile, the number of uninsured Americans keeps creeping upward, with some 1.4 million added to the ranks last year, according to the Census Bureau. And there is evidence that many of these newly uninsured are politically active white-collar workers who have been laid off in the slowdown.

"I do not think [the reform movement] will be tempered," says Laura Pemberton, manager of Senate legislative affairs for the National Federation of Independent Business. She points to a flurry of new state and federal initiatives that back government-mandated health care, a sore point with many members who would be forced to shoulder the burden. The NFIB hopes that the new, more conservative freshman class in Congress will be able to steer reform in the direction of association health plans, a controversial Republican-backed plan that would let businesses buy health insurance from national groups not beholden to state mandates.

Incremental changes

Just days after the vote, members of Universal Health Care Access Network (UHCAN) organized a network meeting in Baltimore to discuss strategy. Far from retreating, they plan to learn from Oregon, form broader coalitions, and tackle a new set of initiatives.

"While most states will cut back and make situations worse, there will be a handful of states that turn danger into opportunity, finding ways to expand coverage and integrate systems," says Ken Frisof, a practicing physician and national chair of UHCAN. "But they'll be in a definite minority."

Don't read too much into the Oregon defeat, says Mark Lindgren, head of Health Care for All Oregon. The early groundwork that was needed to build a coalition of Oregon supporters well in advance of an election wasn't done. A handful of volunteers working with "bailing twine and duct tape" — and $40,000 — were up against a well-organized opposition funded by allies with very deep pockets.

But at least some of that equation can be changed in future contests.

For at least the near future, some reformers are forgoing some big initiatives like single-payer and targeting more marginal progress. In Oregon, that may lead to a link-up with labor for an initiative to fund universal access for children under the age of 18, funded with a 2-percent payroll tax.

"Just because this went down by such a large margin doesn't mean that voters aren't interested in health care," observes Quirk. Wholesale reform may be a hard sell right now, but measures that offer coverage for the uninsured or underinsured — particularly children — stand a much better chance at the polls or in the legislature.

"I believe that voters are most likely to pass a measure when there are changes at the margin," says Quirk.

If, as the old saying goes, two weeks is a long time in politics, two years borders on an eternity. And for now, reformers are betting that a setback like the one they experienced in Oregon is no cause for panic.

"We'll be back," says Lindgren. His fiercest opponents are betting on it.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.