Health care reform is at the stage where everything will start coming together - or fall apart. Congressional leadership is putting together legislation that it hopes to get through its committee process before the Independence Day recess. President Obama is on the campaign trail again - this time, campaigning for his vision of health care reform. And the stakeholders who can make or break health care reform are moving from the happy talk phase to articulating what they can - and will not - accept.
Although some of the most contentious issues (like how to pay for it) are far from being resolved, it seems to me that we are beginning to see the outlines of potential consensus legislation:
1. People who can't afford coverage, or whose employer does not offer it, will be given sliding scale subsidies (most likely, advance, refundable tax credits based on income) to purchase coverage from one of hundreds of qualified health plans offered by a health exchange.
2. Qualified plans will be required to offer a package of essential benefits, accept anyone without regard to pre-existing conditions, be prohibited from cancelling coverage (guaranteed renewability), and will not be able to vary the premium they charge except for age and gender (modified community rating). Some kind of public plan (more on this later) will likely be offered, in addition to qualified private insurers.
3. The Medicaid program will be expanded to more low-income persons and a uniform standard of eligibility will be adopted.
4. Expanded coverage will be financed in part by hundreds of billions of dollars in savings from the Medicare program - mostly in the form of cuts to different "health care providers" or payment reforms that place providers at financial risk for excess costs. Such payment reforms will be pilot-tested on an accelerated basis, with the federal government having broad authority to expand the most effective models.
5. Despite the Medicare cuts, physicians will fare pretty well. President Obama and Congress are likely to offer to eliminate the hundreds of billions of dollars in accumulated Medicare payment cuts to doctors from the sustainable growth rate (SGR) formula, without requiring that Congress offset the cost by cuts somewhere else - in exchange for doctors getting behind the health care reform legislation. Look to Obama to make some kind of statement about this when he addresses the AMA House of Delegates on Monday. (I'll be there, blogging from the AMA, so will let you know what I think I hear.)
6. Primary care physicians can expect to fare relatively better than other physicians - that is, there likely will higher Medicare payments to primary care doctors and increased funding for primary care training programs and expansion of GME slots for internal medicine and family practice. However, since under Congress' budget rules any increased funding to primary care needs to be paid for with cuts somewhere else, and non-primary care physicians are making it clear that it can't be from them, the initial increases in payments to primary care may be much more modest than primary care physicians had hoped for or might have expected. It remains to be seen if this will be a case of "too little, too late" for primary care.
On the public plan, there are signs that there is movement toward reaching a compromise. The American Medical Association, which was quoted in The New York Times on Wednesday as opposing a public plan, subsequently issued a statement suggesting a willingness to support a public plan provided that it doesn't pay doctors based on Medicare rates and physician participation isn't mandated.
To be sure, a lot of tough issues - like tax increases and employer and individual mandates have to be worked out, and the entire effort could still collapse. But it does seem to me that we are seeing movement to a possible consensus on the key ingredients for health care reform.
Question: What do you think of the outlines for a possible consensus as described above?