Well, the critics of our decision to support the House bill are certainly having their say. My posting from yesterday brought out the predictable howls of protest. Rather than focusing on the issues, though, a few of the comments engaged in over-the-top attacks on the honesty and motivations of their physician colleagues who are in leadership positions in organized medicine. I allowed some of them to be posted (including one that accused us of treachery), because otherwise, I would have been accused of suppressing criticism.
By the same token, though, I view this blog as place for people to have a respectful exchange of views. I don't think most our readers want this to become a place where people can just "flame" other people. Other bloggers may be more interested in fanning outrage rather than an informed discussion of the issues, but this isn't the palace for that. If you submit comments that cross the line from respectful discourse to invective, don't be surprised if they aren't accepted.
Most of the critics, though, were heartfelt in explaining the issues that concerned them. The biggest concern continues to be that the public plan option would lead to government-run (some called it "socialized" medicine). As I reported yesterday, the public plan is set up in a way that this isn't likely to happen. Under the House bill, the public plan option would be limited to only those who are eligible to get coverage through a health exchange (basically, those who don't have employer-sponsored coverage and don't qualify for Medicaid, SCHIP and Medicare). Of those persons, the CBO estimates that only about 8 or 9 million will likely enroll in the public plan, mainly because physician participation in the plan is completely voluntary. What about everyone else? 164 million would be covered by employer-sponsored plans, and the rest in Medicare, Medicaid, and SCHIP, according to CBO. This is two million more people who would be covered by employer-based private insurance than what the CBO expects would be the case under current law. (If the critics have data to show that the CBO is wrong, and everyone will end up in a public plan, I'd like to see it.)
I also expect that the public plan option is likely to go through many, many changes before (or even if) it becomes law. There is that other chamber of Congress - the Senate - and they are looking at things very differently.
Others criticized the tax surcharge on the well-off. To be clear, ACP did not endorse the tax surcharge, because we are guided by policy, and our policies only address tax issues that are directly related to health (like tax credits for the uninsured). Our letter to the House had this to say: "Although we do not have policy on the specific tax surcharge provisions called for by the bill, the College urges Congress to consider a variety of approaches to finance coverage including ones that encourage individuals to make prudent decisions affecting use of health care resources." This is another case where the Senate has other ideas and I would expect the financing to be substantially changed later in the process.
Some expressed concern that the bill will add to the federal deficit and the nation's debt, citing a new statement from the CBO that calls into question whether the House bill will pay for itself without adding to the deficit. Congress' own budget rules require that health care reform be fully paid for, so I expect that adjustments will be made in the legislation to bring down the costs.
Others vent that the House bill makes nurse practitioners equivalent to doctors. It is true that the bill defines NPs as primary care providers in several places, mainly to make them eligible for scholarships and loan forgiveness and to allow them to participate in pilots of the medical home. But nothing in the bill allows them to practice beyond the scope of their state licenses. The bill doesn't change Medicare's rules that pay NPs at a lower rate than physicians. The programs in the bill are directed at increasing the numbers of primary care physicians and NPs, not substituting NPs for physicians.
Finally, some felt that ACP and AMA were settling for too little. As I have said before, H.R. 3200 is by no means perfect. It falls short in several important respects - most notably, the Medicare payment increases for primary care are not enough, by themselves. ACP will continue to work for strengthening the payment reforms for primary care, but we are in a much better position to do this than by being supportive. Legislators help those who help them. The opposite is also true.
H.R. 3200 is just the beginning of the process. I stand by my view that most of the policies in the bill are good for patients and doctors, but we will have plenty of chances to make improvements before a bill is signed into law.
I look forward to continuing this discussion, and have a good weekend.