Thursday, September 10, 2009

Obama tells the public what "ObamaCare" really means

Even before President Obama uttered the closing words in his health care reform speech to Congress, pundits and politicians alike were tweeting their instant reaction. I am skeptical that hasty opinions can provide an accurate assessment of the impact of the speech on the course of health care reform. This is not to say that the speech didn't have an impact, it is just that we really won't know what the impact is until we see how the public responds over the next days and weeks, and what the politicians do as they figure out how to translate the vision of reform articulated by the president into legislation that can actually pass. Legislation is a slog, and a presidential address - even one as important as this one, delivered at a critical time by a president who demonstrated again his mastery of rhetorical tools of his office - cannot substitute for the nitty-gritting work of finding the legislative "sweet spot" that will unite a fractious Democratic party and deeply divided electorate.

Having just cautioned you about the instant analysis, I am now going to disregard my own advice and provide you my own analysis and what the president's speech might accomplish. Borrowing a phrase from Winston Churchill, though, I also reserve the right to explain afterwards why it didn't happen! (Churchill reportedly once said that, "A politician needs the ability to foretell what is going to happen tomorrow, next week, next month, and next year. And to have the ability afterwards to explain why it didn't happen.")

I think the president's speech potentially accomplished several important things.

First, the president finally answered the call to put his own stamp on health care reform, in much greater specificity than in the past. For all of the talk about "Obamacare" (the catch-all label for critics of the president's efforts), we have not, until now, had a clear idea about what the president really wants. Last night, he made it clear that health care reform, at its most basic level, must regulate the practices of health insurers so that no one can be turned down, have their coverage cancelled, or charged excessive rates because they have a pre-existing condition or health problem. He also said he does not want to put health insurers out of business. He laid out a strong argument for a public plan option as one important piece of comprehensive health reform, but also made it clear that he does not share the views of those on the left or the right who have assigned the public plan with more importance than he thinks it merits. He will fight for a public plan, but only to a point - if he can get what he wants in terms of regulating health insurers and subsidizing coverage, he will not insist that a public plan be included.

Second, he spoke to the need for responsibility for funding health care to be a shared responsibility. The government must provide help to those who can't afford coverage. Employers must provide coverage or pay into a fund to subsidize coverage for their employees. Individuals must buy coverage, with hardship exemptions who still find the cost out of reach.

Third, he forcefully went after critics who have used distortions - he called them lies - to stoke opposition to his proposal. I don't believe that this will stop his critics from doing so, or cause the people who really believe that the president wants to allow government bureaucrats to pull the plug on grandma to change their minds. But his words suggest that there may now be a bigger political cost for doing so. (ACP, for its part, is trying to set the record straight.)

Fourth, he insisted that the legislation will be fully paid for, not adding a "dime" to the deficit. This will create enormous pressure on Congress to either find more savings or scale back the subsidies, but any substantial reduction in the subsidies would go in the face of the president's promise to make coverage affordable to all. I believe that the president missed an opportunity to really be direct with the American people on the sacrifices that real cost control will involve. Instead, he fell on the old argument that most of reform can be paid for by eliminating fraud and waste.

Fifth, he addressed the need for malpractice reform to reduce the costs of defensive medicine. He didn't provide any specifics, other than that he's instructed HHS Secretary Kathleen Sebelius to "immediately" develop a program to provide funding to states to launch demonstration projects to medical liability reform. I don't expect the reforms will include caps on damages. Still, it is an opening on an issue that previously had been ignored by the president and his Democratic allies in Congress.

All of these details were important, but I think the biggest impact of the president's speech may have been in his closing remarks, when he defined health care reform as an issue that will test the moral character of the American people. Referring to the life work of the late Ted Kennedy, Obama said this: "That large-heartedness -- that concern and regard for the plight of others -- is not a partisan feeling. It's not a Republican or a Democratic feeling. It, too, is part of the American character -- our ability to stand in other people's shoes; a recognition that we are all in this together, and when fortune turns against one of us, others are there to lend a helping hand; a belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgment that sometimes government has to step in to help deliver on that promise."

The next few weeks will tell us if he is right in his assessment of the character of the American people.

Today's question: What did you think of the president's speech?


Steve Lucas said...

In reading the summary of the speech from the major wire services I found it to be long on concept and short on concrete answers. The most over riding concern in my area is cost, and additions to the budget deficit. Until solid numbers are in place for savings, I doubt the plan will gain support.

An issue that is growing in importance is tort reform. More and more people are realizing that much of what is done in medicine serves no purpose other than a potential legal defense at an unspecified future date. The financial and time cost are becoming very apparent to patients. While everyone wants to see that rare situation where a doctor over reaches, or otherwise does not meet the current standard of care resolved, there is also the realization that doctors are all too often sued in a simple attempt to extract money.

My understanding is that Penn. requires a signed certificate from a doctor stating that the care a patient received did not meet the current standards. This has reduced malpractice suits by 40%. Certainly a more than reasonable requirement before we launch into a costly legal suit.

My only hope is the debate can continue in a more civil manner and we can get away from all of the political posturing.

Steve Lucas

Unknown said...

The comments by Dr. Doherty reflect the reason I am resigning from ACP. The speech was nothing but Liberal rhetoric with no concrete ideas. Individual mandates, employer mandates, no tort reform, government options, rationing health care all work to destroy our medical system. After 38 years of membership I have had enough!
Kenneth Bergman MD FACP

K. Bates said...

For all my excitement about President Obama's talk, what really matters is the legislation that Congress comes up with. I am less than hopeful they will come up with any reforms that are of actual substance. I'm very much a partisan person who understands that as long as this is an ideological debate, true reform is doomed. If the physician community cannot come to a consensus that the future of our nation is dependent on the health of all (and not just those that can afford it), and that we are supposed to be the stewards of such, what do we expect Congress to do? I'm always proud to see the ACP on the right side of history on this one and we should all ask ourselves,what side of history do we want to be on in the end. Because today, when I talked to yet another insurance company that refused a needed service,spent too many hours jumping through prior auth hoops or wrote scripts and talked to my diabetic patient who lost her insurance when I diagnosed her diabetes, I felt for too many times in my short career that what we have is insufficient at best and amoral at worst.

Dr. Seth said...

I agree entirely with Kenneth. The longwinded 45+ minute speech was merely a vague reiteration of Obama’s past statements. It offered no specifics whatsoever on how he will actually pay for the new socialized system. This is the most fundamental of all questions, and in over forty-five minutes, he could not provide a single substantial answer (I do not count finding $500 billion dollars in waste in the Medicare system an answer – I was almost laughing in its absurdity). He offered no plans for a substantive tort reform (since his administration has been bought out by the trial lawyers for decades). I pray to God that this bill will not pass the House or Senate, because the results will be catastrophic for the country.
The real shame is organizations like the ACP and AMA supporting this ludicrous bill. I thought these organizations were supposed to be looking out for physicians. In fact, that should be their primary reason for existence. You will be hard-pressed to find a physician outside of a university setting that supports this ridiculous bill, and yet these organizations offer Obama their support. This is shameful in my opinion. I too will not be renewing my memberships when the year comes to a close.

Arvind said...

I feel similar to Kenneth, but took a deep breath and decided to give ACP one more opportunity to what is right for its membership.

As far as the speech was concerned, its was another one in a series that basically said "here is what we ant to do and its best for you to understand it. Don't try to suggest any changes because we are not interested". I am not sure which part of that was inspiring or suggested any leadership; all I saw was "my way or the highway".

Can the ACP at least tell the President that medical liability lawsuits have very little to do with "patient safety" and everything to do with lottery system that is currently prevailing in our country? So, Mr. President, please don't bring up "patient safety" when we talk about medical liability reforms.

Rich Neubauer MD said...

I found the President's address inspirational. He is a superb speaker. We have neglected the health care delivery system for far to long and allowed the primary care of patients to slip into decline. It is refreshing to see our President take a strong and courageous position in favor of change.

As an ACP member I am also pleased that ACP has policy in place and continues to develop policy that is being used by legislators in their efforts to find answers to some of the most vexing problems as reform efforts evolve.

Unknown said...

In retrospect, the brilliance of the Clinton administration was its deftness in combining progressive goals with a budget consciousness we haven't seen since. Health care is like education, national defense, and the environment in that it needs to be fixed without wrecking the economy or burying future generations under mountains of debt. It is as unlikely that we will see fiscal restraint under Obama as under Bush, unless we all insist upon real world solutions that we really can afford.

anne scheetz said...

That the American College of Physicians continues to refuse to champion a single-payer health care system as embodied in HR 676, the National Health Care Act, is a source of shame to me as an internist and an ACP member. There is abundant evidence that a single-payer system and only a single-payer system can provide everyone with access to care and also control costs so that health care is affordable. As a member of Physicians for a National Health Program I, along with a growing number of other physicians, will continue to work for that goal, and thus to recover pride in my profession.

BDoherty said...

From the comments posted here on Obama's speech, it is evident that ACP members, like the general public, continue to be divided. As I have written many times before, I write this blog in the spirit of encouraging discussion of the issues, with all sides being heard, informed by my over 30 years of experiencing advocating for internal medicine, and only for internal medicine. (I have never worked for or advocated for any group other than internists, and I may be the only one in Washington who can say that). I choose content for the blog that I believe meets standards of evidence and thoughtful analysis from a wide spectrum of views, and I don't use rhetorical or unsubstantiated opinion pieces and analysis from groups or individuals that have a partisan or ideological axe to grind.

I also think it is better to focus on the issues, rather than assigning some catch-all label to describe someone else's views. As far as ACP's views are concerned, if a label has to be assigned to them, I would describe them as centrist. Which, if you think about it, would be the place any membership organization would likely end up if it has a very large and diverse membership, as the ACP does, and uses a consensus process to determine policy. On substance, ACP's support for health reform that builds upon the current employer-based system, uses targeted sliding scale tax credits to help people who can't afford it buy coverage, provides carrots and sticks to bring everyone into the insurance pool, and gives small employers, the self-employed and individuals the ability to have the group purchasing clout of larger employers and federal employees, places us very much in a "centrist" position and one that polls suggest most Americans support. (Our approach is not that unlike the Massachusetts model, championed at the time by GOP Governor and 2008 presidential candidate Mitt Romney). The problem is that the center today is not an easy place to be, because it invokes the wrath of ideologues from the right and the left. if you either believe that the federal government should have no role in ensuring coverage, or that the government should fund and administer the whole system, then you won't agree with us, but you should at least try to understand how we got to our current middle-ground positions.

Unknown said...

It pains me to think that such "intelligent" people like physicians can be so ignorant when it comes to this issue. This issue for me (aside from being an absolute and utter disaster for physicians/patients/and the country as a whole) is one of rights. Everyone seems to think health care is a right. Where in the Constitution does is say that? Oh, I know there are many things going on in this country that are not in the Constitution, and I am not in favor of them either, but lets stay on topic. Health care cannot be a right, because by definition it must therefore enslave someone else and force them to provide a service. Free speech is a right, but no one is forced to listen. Freedom of religion is a right, but no one is forced to go to a particular church, or church at all. If health care is a right, then I or one of my colleages MUST provide it.
Dr. Doherty, you are clearly enamored with the President and aren't even feigning thinking critically about this health care bill. Explain to me how the President doesn't plan on paying for illegals when there is no provision for verification of there legal status? How in the world can you believe the Pres. when he says it "won't add a dime to the deficit" when the non-partisan Congressional Budget Office says it will double the deficit in 10yrs and triple it in 20? He just flat out refuses to address that fact. Further more, the President continues to talk about competition, but federal regulations continue to be in place that prevent the sale of health insurance policies across state lines, with no mention at all of changing this. Why can I buy car/life/home insurance across state lines but not health insurance? Why is that? What about encouraging Health Savings Accounts so people can actually take some personal responsibilty instead of relying on the government for yet more? Common sense and experience tells everyone that nothing the government runs is run efficiently, cost effectively, or well. Name one thing. Yet, some people like sheep are willing to have the wool pulled over their eyes, bury their heads in the sand, and assume that THIS TIME the governemnt will actually do something right. And, why the hurry to ram this bill down our collective throat when it won't go into effect until 2013, conveniently after the President hopes to be re-elected, so that the people won't see the disaster he has made of the health care system in time to vote against him in the 2012 election. Lets slow down, allow the details of the plan to be sorted out and verified, or be called out for the terrible ideas that they are.
Also, name one time in history, or even in the several states that a national-type/single payer system has been tried(Mass., Oregon, Hawaii), that it has worked well, efficiently, and came in on budget? You can't, because it never has.
Dr. Doherty, this is why I continue to be ashamed of organizations like the ACP, AMA, AMSA, etc., because they are consistently wrong on the health care debate.
It is utterly laughable to say the President's speech had anything substantive in it. He decryed "scare tactics", then proceeded to say some of the scariest things he could think of, like our economy would crumble, we'd all lose our health insurance, etc.
And lastly, one is truely deluding himself if they truely believe that no rationing of care will occur. Seriously? Lets be intillectually honest here. How can you add 30-45 million people to rolls of the insured, cut costs, have the plan be "budget-neutral", and not decrease/ration the services or care provided to the people.
Aside from not working, this plan is unconstitutional, and is one more way the governement steals money from productive members of society to give to unproductive/illegal ones. Lets promote liberty for all, not tyranny.

Ben Compton, MD

heatherh said...

It is very disappointing that the ACP continues to spread Obama's lies, most egregiously the budget neutrality of any legislation that currently exists. If they'll lie about one thing, they're probably lying about everything. Who can trust a word Obama or the ACP puts out? Not I.

William M. Fogarty, Jr., MD said...

Thanks to Bob Doherty for his thoughtful analysis of President Obama's speech and of the ACP's position on health care reform. It should be evident to all that the system under which we operate at present is unsustainable, inefficient and inhumane. The goal of the ACP is and has been for years to help develop a system that will serve all Americans in a comprehensive, humane and cost-effective way. Just saying "No" without offering constructive suggestions serves no one well and will take us further down the road toward collapse of our health care system.

Unknown said...

Since when is stealing from one group of people(in the form of outrageous taxation required to fund this bill) to give to another group humane or fair. And if any one of the close-minded liberals would listen, there are plenty of alternatives being suggested (see my previous post, plus many others). No one is "just saying no", for no's sake. Come on sir, at least be honest.

Unknown said...

Ben that was wonderful. Say it again louder. I don't understand where the support for this comes from in the medical community. Medical care is NOT a right. Free care at the Free Clinic in Virginia is given by MD's because we want to. Not because the Federal gun is to our heads making us. Wake up everyone, the art of medicine will die if this progresses any further. Doctors MUST say NO)!

Unknown said...

I am proud that the ACP, along with many other physician organizations, has taken a stand in support of health care reform, and has provided leadership in defining what is important to achieve effective reform. I cannot imagine how any physician who works in our current system could oppose major reform. Access to health care may not be a constitutional right, but it certainly is a moral issue that defines our nation. Fortunately, multiple surveys show that the large majority of physicians do support the need for reform. The ACP should take comfort from this support and continue to work hard to achieve it.

BDoherty said...

One of the comments posted suggests that ACP is "lying" about the cost of the bills pending in Congress. If I or ACP has provided information that you believe to be inaccurate, please show me specifically where and provide credible and independent data to refute it, and I will make sure that the information is corrected.

To the point of the cost estimates on Obama's plan, first, there is no official cost estimate because there is no single bill or proposal that the President has endorsed. As I noted in my original blog post, President Obama has said that he will not sign a bill that adds a dime to the federal deficit, and it is fine to be skeptical and to hold him accountable for his promise. Whether in the end this will prove to be true is something we will all find out later. I have been critical of the President for not being more direct with the American people on how savings will be achieved and the plan will be paid for.

This is what ACP has said about the cost of the legislation, in our FAQs for members, posted on

"ACP believes that health reform should be funded in a way that is sustainable over the long term and does not contribute to the deficit. Our understanding is that the Congressional Budget Office has determined that H.R. 3200 will not add to the deficit, if the costs associated with replacing the flawed Medicare SGR formula are reflected in Medicare's baseline rather than being subject to pay-go offsets." (Pay-go offsets refer to Congress's rule that all new spending on health reform be offset with revenue increases or savings so the net cost does not add to the deficit.)

The above statement is accurate. In a July 17 letter to the Ways and Means Committee, the CBO's preliminary estimate is that H.R. 3200 would add $239 billion to the federal deficit over ten years (not a trillion dollars as some critics have mistakenly claimed). However, the letter also notes that the legislation would require that the federal government spend $245 billion over ten years to eliminate cuts in physician payments caused by the Medicare Sustainable Growth Rate--in other words, the bill would have a small net positive impact on reducing the deficit, absent the $245 billion expenditure on stopping physician payment cuts. This is why our FAQs said, "H.R. 3200 will not add to the deficit, if the costs associated with replacing the flawed SGR cut are reflected in Medicare's baseline . . . " instead of being subjected to Congress' usual budget rules. Getting rid of the SGR cuts and accounting for all of the costs of providing fair and positive updates going forward as part of projected Medicare spending, has been a long-standing goal of ACP, AMA, and just about every physician group in America. Physicians who criticize H.R. 3200 for adding to the deficit should think about what they are asking for, because the easiest thing for Congress to do would be to eliminate the funding to stop the physician pay cuts, and voila, the bill wouldn't add a dime to the deficit over the next ten years and would still meet all of Congress' other policy goals.

Finally, it is likely that the cost of the bills will be reduced before a final bill is produced. At that time, we will see if the bill will be fully paid for without adding to the deficit. ACP's position is that health reform should be funded without adding to the deficit. We'll see if this is what happens in the end.

Unknown said...

Dr. Doherty,
I quote you: "Physicians who criticize H.R. 3200 for adding to the deficit should think about what they are asking for, because the easiest thing for Congress to do would be to eliminate the funding to stop the physician pay cuts, and voila, the bill wouldn't add a dime to the deficit over the next ten years and would still meet all of Congress' other policy goals."


Oh my gosh, how can people not see that this will ruin the health care industry and all of our jobs! Along with the mass exodus from our vocation, less and less will go into it, making the current physician shortage (esp. primary care) even worse.

Unknown said...

Dr. Doherty,
Futher quoting you:

"Pay-go offsets refer to Congress's rule that all new spending on health reform be offset with REVENUE INCREASES or savings so the net cost does not add to the deficit." (capitalization mine)

"Revenue increases" 1.) is a misnomer in that the government produces nothing so they have no income and 2.)that phrases really refers to TAXES. Therefore, we, productive members of society, are going to be forced to pay for everyone else. I agree, we need to help the poor, and I agree it is a moral imperative to do so. Personally I believe the Bible itself calls us to do this. But the government was not created to do this, nor can or will it do it well. There are always free clinics to work at, and if not, start one like a colleage of mine did. The Walmart $4 list of meds is a beautiful thing for people without a lot of money.

The government is never the solution to problems the free market should be solving. Why is NO ONE taking seriously the idea of opening up interstate selling of insurance policies? Everyone acts like that idea doesn't exist.

Anonymous said...

I believe it imperative that any Health Plan that comes to the Presidents desk for his signature should contain a government insurance option. It is clear that this option is necessary to
give a choice to those who may not be able to afford private insurance.Such an option is viable and is available in virtually every first world country, except this one. It gives the consumer a choice and will act to control insurance premium rates by private companies. I am quite dismayed at the misinformation being disseminated by those opposed to this option. A recent NEJM study suggests that 67% of physicians favor a public option. The opposition is spending enormous sums of money to defeat this on the grounds that it is "socialist", "socialized medicine", and "will give the government control of your health care". Nothing could be further from the truth. The American public needs to be convinced that these are nothing but obfuscations to hide the real reason which is support of big business who donate generously to the Republicans because of their staunch support if big business.

I strongly urge the President not to bow to the pressure of the Republican right wing and persist on demanding a public option to any Health Insurance Bill.

Albert Bodt, M.D.
Southern California Permanente Medical Group
Kaisert Permanente