Yesterday, the chairmen of the three House committees with jurisdiction over health released America's Affordable Health Choices Act of 2009, H.R. 3200, a comprehensive bill to reform U.S. health care. With release of the bill, we can expect to see an intensification of the battle that is underway already to sway physician opinion.
ACP has concluded that the bill goes a long way in addressing the College's priorities for health reform.
On coverage, it creates a pluralistic framework so that all Americans will have access to affordable health insurance coverage. It reforms the insurance industry so that coverage no longer is out of reach for people who have pre-existing conditions or who develop an illness while insured. It provides for sliding scale tax credits, coverage of evidence-based preventive services with no cost-sharing, and expansion of Medicaid to cover the poor.
On workforce, it would create an advisory process to set goals and policies to achieve a sufficient and optimal number and distribution of physicians and other clinicians, and includes polices to increase the numbers of physicians in primary care internal medicine, family medicine and geriatrics, including increased funding and creation of new pathways to provide scholarships and loan forgiveness to primary care physicians who agree to practice in areas of need.
On payment and delivery system reform, the bill would eliminate the accumulated Medicare SGR payment cuts, provide a new framework for future updates that allow for spending on physician services to increase at a rate greater than GDP, and create a higher spending baseline target for evaluation and management and preventive services, including those associated with primary care. It increases Medicare payments for designated services provided by primary care physicians - not as much as we would like, but it is a start. It raises Medicaid payments for primary care until they are equivalent to Medicare. It provides funding that is provided to pilot-test, on a national scale, the idea of paying physicians for care coordination in a qualified Patient-Centered Medical Home.
H.R. 3200 also would fund independent, transparent and evidence-based research on the comparative effectiveness of different treatments to inform physician-patient decision-making, as called for by ACP. It also include provisions in the bill to simplify and reduce the costs associated with interactions with health plans.
So what's not to like? These are the principal arguments that critics are using to sway doctors to oppose the bill:
The say that the "public plan option" included in H.R. 3200 would lead to the destruction of private insurance and government-run health care.
The idea that the public plan would destroy private insurance is not supported by expert analysis. The Congressional Budget Office notes that because physician participation in the public plan is voluntary, and payments are likely to be lower than payments under private insurance plans, it is difficult to estimate how many people would enroll in the public plan. The CBO suggests that enrollment in a public plan, at full implementation, could be as many of 8 or 9 million people out of the estimated 30 million who would get coverage through the exchange, many of whom though are currently uninsured, but even so, this would mean that most people in the exchange would be covered under private insurance. CBO also estimates that the vast majority of persons - 164 million, an increase of two million persons compared to current law - would be covered by employers.
Opponents also argue that Comparative Effectiveness Research would lead to rationing of care by government bureaucrats. Actually, there is nothing in the bill that allows costs to be used to deny care. The research would be conducted by physicians and other scientists in agencies, like the National Institutes of Health and the Agency for Health Care Research and Quality, not government bureaucrats. Coverage decisions would still be made as they are today, but instead would be informed by the best available clinical evidence instead of by criteria that often is not guided by science.
I understand that died-in-the-wool conservatives aren't likely to support H.R. 3200, because of the cost and the expanded role for government. Just as I wouldn't expect support from died-in-the-denim liberals who believes that Canadian-style health care is the only answer. But on the policies that matter most to ACP, I believe that the bill moves things in the right direction and deserves internists' support.
Today's questions: Who do you think will win the battle for physicians' hearts and minds? Health reform advocates who support expanded government regulation of insurance and subsidies to help people buy it - and a strong public plan? Or critics who argue that Congress' approach to health reform will lead to a government take-over of medicine and rationing of care?