Friday, July 24, 2009

Singing the health reform blues

The headlines in today's newspapers will give health reformers a bad case of the blues:

"Senate Won't Hit August Deadline" (Wall Street Journal)

"Health Reform Deadline In Doubt Process Could Be Slow and More Contentious" (Washington Post)

"For Public, Obama Didn't Fill in Health Blanks" (New York Times)

There is no question that the prospects for fast action on health care reform took a hit with yesterday's announcement by Senator Majority Leader Harry Reid that the Senate will not schedule a vote until after the August recess. In the House of Representatives, completion of the "mark up" by the House Energy and Commerce Committee has been delayed because of in-fighting between "Blue Dog" fiscally-conservative Democrats and more liberal members of the caucus.

From my standpoint, these setbacks mask the fact that substantial progress is being made. The negotiations in the House of Representatives may be more contentious and taking longer than many had expected, but I believe that the Democrats will reach agreement on ways to trim the cost of the bill that will bring most of the Blue Dogs on board, without losing too many liberal members.

The nature of the Senate is such that it always takes a long, long time to get agreement. Even with the Democrats so-called "filibuster proof" majority of 60, the party leadership can't afford to lose a single Democratic vote - this gives each Senator enormous negotiating power, which inevitably slows down the process. Senator Max Baucus, chair of the Senate Finance Committee, continues to report that "progress is being made" on reaching agreement that could win the support of two or three Republicans. (Although any agreement he reaches with Republicans runs the risk of alienating fellow Democrats whose votes will be needed in the end.) If the Senate Finance Committee reaches agreement on a bill, it will still have to be reconciled over the August recess with legislation reported out of Senator Kennedy's Health, Education, Labor and Pensions Committee.

Then the really tough negotiations will take in the fall. The House and Senate versions will have to be reconciled, and then the final product will need 60 votes in the Senate and a simple majority in the House to pass.

Yet despite all of these obstacles, there actually is pretty solid agreement among the Democrats (and even some Republicans) on the many of the core elements of health reform legislation: expansion of Medicaid to cover the poor with the federal government picking up the tab; sliding scale tax credits to help people buy coverage through a purchasing pool or alliance; an individual insurance mandate; improved coverage for preventive services; insurance market reforms to ban cherry-picking by insurers; workforce and payment policies to increase the numbers of primary care physicians; and payment reforms to link payments to the value of care rendered instead of the volume of services. These policies all are closely aligned with ACP's recommendations.

The remaining issues are tough ones: how to pay for health care reform and reduce the cost of the package (taxes and savings); the role of a public plan; and employer-mandates. Yet, I don't think any of those issues are beyond the capacity of Congress and the President to find common ground.

Despite the gloom and doom headlines, the fact is that health care reform has already advanced further in the legislative process than at any time in history, with two of the three House committees of jurisdiction and one Senate committee approving their respective versions (and in the House, all three committees are working together to produce a single bill). Congress never got anywhere near this close when Bill Clinton was president.

Today's question: Do you think the recent developments are bumps in the road to health care reform, or an indication that the whole effort is heading for collapse?


Jay Larson MD said...

Just a bump in the road.

Senator Chuck Grassley, Senator Mike Enzi, Senator Olympia Snowe, Senator Jeff Bingaman and Senator Kent Conrad have been meeting regularly for hours. This would not occur if the bottom was falling out.

It is good that they are not trying to crank out legislation just to meet a dead line. The amount of work to craft legislation for health care reform and trying to balance all the special interests is enormous. It is amazing how much work has been accomplished already.

Steve Lucas said...

At the most basic level I think everybody would like to see a basic health package available to all Americans. The real issue becomes cost and control.

Traveling to Europe, mostly France, Canada, and spending time speaking with people from the UK I find two very basic differences in our concepts of health care.

First, these folks know they will die. We in America think it is an option and if we spend enough of somebody else's money we will live forever. When this fails we sue. This really does change you outlook on health care and what represents good health. People are much more accepting of the aging process and it's associated problems in these countries.

Secondly, doctors treat the complaint. If you have a sore arm, they treat the sore arm. You will be offered appropriate test, but there is not the financial drive to do a complete physical, blood draw, and what ever else we can convince the insurance company you need to solve your sore arm problem.

Weight, smoking, drinking, etc., are considered personal choices and while the doctor will counsel for a healthy life style there is no such thing as a noncompliant patient. They treat the person in front of them.

This combination, combined with government controls on advertising, drug selection, and so on means that collectively these people live longer and happier lives for half the medical cost we do in the States.

Simply ramping up the system we have is not financially viable. The real issue is: Will the politicians put in place the controls and shift the way we do medicine in this country to achieve this full coverage goal, or will they bend to the lobbyist and put in place something that will eventually make us go broke?

Steve Lucas

bruce said...

Outstanding interviews of Peter Orsag and Denis Contese on Charlie Rose this week.. if only every Senator could could listen to Dr. Contese... Healthcare financing, specifically payments to proceduralists, represents a classic 'tragedy of the commons'. As a general internist with no lab or xray and no PET scanner, I would rather the high rollers be sacrificed now than hobble the nation of my grandchildren.

Unknown said...

I agree with you, Bob. There will be health reform this year and it will have many ACP endorsed principles.

The question remains whether there will also be sorely needed delivery system reforms addressing geographic disparities and pay for value proposals.

With what I've seen thus far, whatever comes out is likely far better than the current status.

jfddoc said...

Probably a bump, but a lot of bumps are still on the horizon. For instance, here is Peter Orszag's response to the CBO scoring of the latest "MedPac-like" proposal:

"With regard to the long-term impact, CBO suggested that the proposal, with several specific tweaks that would strengthen its operations, could generate significant savings. (The potential modifications included items such as providing mandatory funding for the council, rather than having the council rely on the annual appropriations cycle, and requiring independent verification of the expected reductions in program spending rather than relying only on the Medicare actuaries for such verification, along with other suggestions, such as including an across-the-board reduction in payments as a fallback mechanism if the council...."

Did I read that "across the board reduction" of Medicare payments to doctors?

Robert J. Sobel, M.D. said...

From my vantage point, I am pleased with much of the progress but fearful that we may recreate bureaucracies based upon the thinking that perverse incentives reign supreme. There are so many services we provide each day that are not reimbursed. It doesn't bother me when I look at everything as a package deal. Small changes in the landscape can be handled, and the idea that there is a proportionateness to fee for service should not be denied. No alternative has the ability to allow big and small practices to co-exist.

Despite Mr. Lucas observation, there is evidence that per capita physician visits and hospitalizations are not that different between Europeans and Americans. We certainly adapt new technologies are a greater clip, but we heretofore were less for the unproven, alternative approach. It is the persistent financing inequities in our system that have clearly represented the excessive growth that has all of us opining. These reflect unregulated costs to new medications and technologies, advances from which we should be benefiting, but that are unaffordable when we don't prorate their payment. Furthermore, the insurance industry is unable to reign in these costs without direct interference with our prescribing decisions. The President wants to substitute a central bureaucracy for this function, but it will still address the professionals instead of the "tool-makers."

I don't want to begrudge the technologies that make me a better doctor. But, enough already, the prices paid to care for my diabetics today are obscene. The pricing of drugs is not going to respond to all this insurance competition. It will require an Act of Congress. Let's really study the consequences of the Hatch-Waxman law and see if there isn't a better way.

Regulated Royalties remains my best attempt at balancing the new and the old and the big and the small, all of which are important to our health care enterprise.

Of course we are mortal, but we all appreciate the efforts of inspired scientists and want to reward them and ourselves for the tools we now have. If we truly are blessed to continue to have the combination of personal choices, public health infrastructure, and a core of a health care system reward us with longevity increases, we will have to reassess retirement ages and the introduction of our current entitlements. Until then, let's just reign in the extremes and let me get back to my profession.

Unknown said...

Have you read the bill? Neither have Mr. Obama, or, famously, Mr. Conyers (chairman of the House Judiciary Committee) Why Read the Bill

Senator Jim DeMint has formulated these questions for Mr. Obama, who has not replied.

1. If the major provisions of the health care bills will not kick in until 2013, four years from now, why the rush to pass a thousand-page bill before the August recess, a bill you admit that you haven’t fully read yourself?

2. You have said your health care bill will cut costs and not increase the deficit. But, independent analysis by the non-partisan Congressional Budget Office contradicts both claims, saying it will raise costs and increase the deficit by $240 billion in the first ten years. What independent analysis will you provide that supports your claims and refutes CBO’s?

3. You have repeatedly said that your health care bill allows any American who likes their current employer-based plan to keep it. But the most comprehensive independent analysis available, by the Lewin Group, contradicts your claim and found your bill will force over 80 million Americans to lose their current coverage. Will you provide independent analysis to refute this study?

4. Your own record in the Senate reveals you spent years voting against nearly every reform to make health care more affordable and accessible, but this week you said that opponents of your plan are “content to perpetuate the status quo, [and] are, in fact, fighting reform on behalf of powerful special interests.” Which specific elected officials will you cite that have proposed to keep the status quo, and is that how you characterize the opposition of the 52 Blue Dog Democrats in the House and the moderate Democrats in the Senate?

5. Yes or no question: Will you guarantee pro-life Americans that, under your plan, they will not be forced to subsidize elective abortions?

I support sensible health reform, but this terribly flawed legislation will harm doctors, hospitals, and more importantly, our patients.

Unknown said...

I hope the ACP will withdraw their blanket approval of their endorsement of the House Bill. Please read the more conservative approaches to health reform, a good source is the Heritage Foundation. An example here: Domination by the Public Plan

The Obama plan will hurt our patients. Their right to privacy will be jeopardized. Their choice of physicians limited. Hospitals, medical practices, and physicians will be squeezed. This is flawed legislation and warrants open and informed debate, with meaningful input from the members, rather than a blind, premature rubber stamp.

Unknown said...

Have you looked closely at the leadership of President Obama's in-house health team?
Obama's Health Leadership
I hope the College leadership has not been co-opted into supporting a program which will be harmful to our patients.