September 16, 2019

Health Care Is Inexorably Changing, Despite Legal Uncertainty

For the nation’s health care system, there may be no going back.

No matter what the Supreme Court decides about the constitutionality of the federal law adopted last year, health care in America has changed in ways that will not be easily undone. Provisions already put in place, like tougher oversight of health insurers, the expansion of coverage to one million young adults and more protections for workers with pre-existing conditions are already well cemented and popular.

And a combination of the law and economic pressures has forced major institutions to wrestle with the relentless rise in health care costs.

From Colorado to Maryland, hospitals are scrambling to buy hospitals. Doctors are leaving small private practices. Large insurance companies are becoming more dominant as smaller ones disappear because they cannot stay competitive. States are simplifying decades of Medicaid rules and planning new ways for poor and rich alike to buy policies more easily.

But how to pay for these changes, and what will happen to the 30 million uninsured Americans the law intends to cover, will be up in the air if the mandate at the heart of the law — the requirement that individuals buy health insurance or face a penalty — is struck down.

The election results of 2010 and stiff state opposition to the mandate also complicate the picture. Hospital administrators, insurers and doctors are counting on federal subsidies and coverage expansion that would result in a surge of patients with insurance to offset cuts in government programs that many fear could soon become draconian. Large health systems could then use their newfound clout to demand higher prices from private insurers even as federal and state governments pay less.

Other changes influenced by the legislation may leave some patients and doctors lost in the new land of giants. As medicine moves from a cottage industry to one dominated by large organizations, some patients with insurance will probably find their choices more limited. But their care may be better coordinated, as hospitals, doctors and even insurers join to streamline services.

“The system is transforming itself,” said Charles N. Kahn III, president of the Federation of American Hospitals. “But the success of these changes depends a lot on whether there is sufficient funding.”

Hospital systems are anticipating a major influx of federal funds and patients as a result of the law. In Maryland, for instance, the Johns Hopkins Hospital and Health System recently bought two suburban hospitals and is spending several hundred million dollars on computer systems to link its clinics and hospitals across the state. It has hired hundreds of primary care doctors and nurses, forged partnerships with urgent care clinics and expanded home health service to serve an expected flood of new patients.

“If the law is struck down, health care reform will have to continue one way or another,” said Patricia Brown, president of Johns Hopkins HealthCare.

Across town, Baltimore Medical System, a community health center, expects to expand its medical staff by 50 percent over the next three years to accommodate an anticipated increase in patients to 70,000 from 47,000.

“We are looking for new clinicians on a constant basis,” said Jay Wolvovsky, the system’s chief executive, who said that hiring would stop if the law were overturned and federal funding were in doubt. “We wouldn’t be able to expand and we’d be stuck where we are.”

In states like Texas, the law is deeply unpopular, and the medical association has a “Calendar of Doom” listing the timeline for important provisions of the law and other government rules. Still, changes in delivering medical care are taking hold, including a move away from small doctor practices that were predominant for more than a century.

Texas medicine will never be the same no matter what happens with the law, said Louis J. Goodman, the association’s chief executive, and older doctors blame a cascade of new rules and changes well beyond the new health law. “There’s a feeling among doctors here that government is crushing them,” Mr. Goodman said.

And even though critics say the law does little to reduce the costs of care, its passage touched off myriad efforts to pare widespread waste.

“The interest from the doctor and hospital community has accelerated,” Tom Richards, a senior executive at Cigna, said of efforts to exact savings and improve care.

Article source: http://feeds.nytimes.com/click.phdo?i=40a8075a5adfa1bc2dc61dd259c0f9ba

In Solyndra Loan Guarantees, White House Intervention Is Questioned

But at a subcommittee hearing, officials of the Energy Department’s loan office and the White House budget office defended their decisions, which they said were carefully reviewed and not politically inspired.

The collapse of the deal has turned what was once portrayed by some as a shining example of the promise of federal subsidies to stimulate economic growth through green jobs into a grim lesson in what others call the futility of federal meddling in the marketplace.

The subcommittee’s Republican staff members, in a memorandum issued at the hearing, said that e-mails among White House staff “raise questions as to whether the Solyndra loan guarantee was pushed to approval before it was ready in order for the Administration to highlight the stimulus, and whether additional time might have resulted in stronger mitigation of the risks presented by the deal.” The e-mails were first disclosed in The Washington Post and on the Web site of ABC News.

While President Obama has made fostering the green energy sector a hallmark of his policies since coming into office, his Energy Department has repeatedly asserted that Solyndra, based in Fremont, Calif., was well on its way to getting a loan guarantee during the closing years of President George W. Bush’s administration.

“In fact, by the time the Obama administration took office in late January 2009, the loan programs staff had already established a goal of, and timeline for, issuing the company a conditional loan guarantee commitment in March 2009,” Jonathan Silver, executive director of energy loan programs, said in prepared testimony. Financed through the stimulus package that had just passed Congress, it was the first loan guarantee issued by the Energy Department under a program created by a 2005 energy law.

But Representative Cliff Stearns, a Florida Republican who is the chairman of the Energy and Commerce subcommittee on oversight and investigations, said Mr. Silver was wrong to claim “that Solyndra was a train ready to leave the station when Mr. Obama took office.” He said that in the last days of the Bush administration, an Energy Department committee unanimously rejected the request for a loan guarantee, calling it premature.

“Only after the Obama administration took control, and the stimulus passed, was the Solyndra deal pushed through,” Mr. Stearns said.

The Energy Department, in an e-mail with the subject “facts vs. fiction,” immediately disputed that account. Its review committee “did not reject the application,” wrote Dan Leistikow, the agency spokesman. “It noted that the project ‘appears to have merit’ and simply remanded the application without prejudice so that work could continue.”

Much of the early minutes of the hearing was taken up with assigning political blame. Mr. Stearns chastised the Democratic minority for having voted against having the committee subpoena documents concerning the deal.

“It should not take a financial restructuring, bankruptcy and an F.B.I. raid for my colleagues on the other side of the aisle to put politics aside and join us in our efforts,” he said. The F.B.I. seized documents at the company several days ago.

But the ranking Democratic member, Representative Diana DeGette of Colorado, said, “It should be clear to everyone in this room that solar energy development is not a Democratic or Republican issue — it is an issue of security American energy innovation for decades to come.”

The Solyndra loan guarantee was the Obama administration’s first. The administration, seeking to forge a “clean energy” economy and provide jobs in the face of a growing recession, picked the project partly because it was what government officials were then fond of calling “shovel ready.”

But Representative Michael C. Burgess, a Republican of Texas, said in an opening statement, “It appears the shovel that this project was ready for was to bury it somewhere.”

Jeffrey D. Zients, deputy director for management at the White House budget office, said that before the loan was finally approved in September 2009, its terms and the risks involved were carefully reviewed, with the energy loan office answering detailed queries from the budget office, and with advice from a credit rating agency, engineers and market analysts.

Jay Carney, the White House spokesman, said that the e-mails that the committee disclosed had “nothing to do with anything besides the need to get an answer to make a scheduling decision.” The company’s groundbreaking event, for its second solar panel manufacturing plant, was held on Sept. 4, 2009, with Energy Secretary Steven Chu attending and Mr. Biden speaking via satellite hookup.

At the hearing on Wednesday, skeptical Republicans pointed out that the Energy Department was likely to award billions more in loan guarantees soon, and questioned its ability to pick winners.

Mr. Zients said that under the Bush and Obama administrations, the energy loan program has closed 18 loan guarantees and made conditional commitments for another 18, including not only many solar projects, but also others for wind and geothermal energy. “We have reason to be optimistic that the portfolio as a whole will perform,” he said of the other loans.

Article source: http://feeds.nytimes.com/click.phdo?i=f54511982feeb3d2963122882be134f6