Thursday, January 8, 2009

Will the "Blue Dogs" have doctors singing the blues?

Having a big Democratic majority in Congress doesn't guarantee smooth sailing for the Obama administration.

The Washington Post notes that "the last two Democratic presidents, Jimmy Carter and Bill Clinton, saw their party leaders on Capitol Hill turn against them, leading to electoral disasters for the party in 1980 and in 1994. An energy crisis helped to do in Carter, while a failed health-care proposal contributed to a Republican congressional landslide two years into Clinton's first term."

Getting the support of a coalition of fiscally-conservative "Blue Dog" House Democrats may be Obama's biggest challenge. With 47 members, the Blue Dogs have enough votes to block expensive government programs if joined by their GOP colleagues.

What makes a Blue Dog bay all night? The federal budget deficit, which is expected to grow to over $1 trillion in current budget year.

To stop the flow of federal red ink, Blue Dogs want to require that every dollar of new spending be paid for by cuts somewhere else. The Democrats had such a pay-as-you go (pay-go) rule in the last Congress. As an internal operating rule, it wasn't legally binding on them, so they could (and sometimes did) waive it when inconvenient. Writing pay-go into law, as the Blue Dogs propose, would force Congress to make the necessary budget offsets. Think if it as pay-go on steroids.

Jared Allen writes in The Hill that so far, the Blue Dogs are taking Obama's commitment to tackle spending "on faith." Before long, though, I expect that the Blue Dogs will want a lot more than promises from the president's bully pulpit.

Faith might get a believer into heaven, but it won't balance the federal budget.

Doctors may be the ones singing the blues if the Blue Dogs carry the day and pay-go becomes law. Physicians want Congress to eliminate accumulated physician payment cuts caused by Medicare's SGR formula, which will cost upwards of $300 billion, according to the Congressional Budget Office. Congressional leaders are considering "re-basing" Medicare spending so that Congress isn't forced to find $300 billion in offsets. If the Blue Dogs don't go along, it will be very hard to get an agreement on eliminating the SGR.

As fiscal conservatives, Blue Dogs might - and I hope they will - be persuaded by the evidence that primary care doctors deliver better care at lower costs, and therefore should be paid competitively with other specialties. But if they aren't, then higher Medicare pay for primary care might have to be offset by cutting payments to other doctors.

Fiscal discipline is a good thing, but I worry about creating a fiscal straitjacket which will make it harder to for the government to do the things that really need to be done. Like improving pay for primary care, eliminating accumulated Medicare pay cuts, and expanding health insurance coverage.

Today's question: Do you believe that Congress should be required to pay for new spending with dollar-for-dollar cuts in other programs or revenue (tax) increases, even if this makes it harder to get agreement on needed health care reforms?


Steve Lucas said...

Yes, only because we need to confront the medical spending issue on a national level. As long as this debate is postponed we will continue with the same dysfunctional system we currently have, with the same questionable use of money and people.

Steve Lucas

Clifford Dacso, MD said...

Without some discipline on the part of the Obamanauts (which I believe they have) they will be drawn into a "meta-discussion" where the issue of health care becomes a proxy for something else like "fiscal discipline" or "free enterprise." If that becomes the case, health care reform, once again, is doomed. It is the responsibility of the ACP and other organizations who have the ears of the political establishment, to keep the discussion focused right where it needs to be: on providing health care, preventive services, and health educations to the American people. The key leverage point for me is to make the discussion one of *value* not solely cost. In other words, how do we get the greatest return for the money we spend. Should that issue rise to the fore, the tiresome discussions about how much money plastic surgeons make will final disappear.

Jay Larson MD said...

Once the amount spent on health care is fixed, the system will be forced to deal with the difficult issues. Continuing to add more money to health care only allows more parties to continue to consume without limits. It is time for asset allocation to go towards the greatest value to patients and not pile more money into the system.

Arvind said...

First, the statement 'the evidence that primary care doctors deliver better care at lower costs' needs to be better defined.

Second, the long standing willingness of generalists and specialists to get divided by other parties is what has lead us to be in this precarious situation. I can't believe the author would even think of perpetuating such a position. Such tactics are the reason for marginalisation of medical societies and associations in the minds of practicing physicians (of all kinds).

Third, Medicare should only expand up to the limts of its budget, so honestly I hope the blue dogs win their argument. Once a more transparent and true picture of Medicare emerges, we physicians can decide how we want to interact with Medicare in the future - we have been fooled by this illusion for too long. Let there be light!