Thursday, November 5, 2009

Will the House reform bill reduce health care costs?

The House of Representatives is poised to vote, as early as Saturday, on H.R. 3962, the Affordable Health Care for America Act. Passage of the bill would be a historic milestone. At no other time in American history, has either the House or Senate passed legislation to extend health insurance coverage to (almost) all Americans.

Of course, like other milestones, there are many more miles to travel before health care reform legislation becomes law. The Senate leadership has yet to figure out how to combine and modify the Senate Finance Committee and Health, Education and Labor and Pensions Committee into a single bill that can get 60 votes. And then the House and Senate would have to reach agreement on what likely will be very major differences between the two versions, and when they do, another vote would have to take place in both chambers before it becomes law.

H.R. 3962 is closely aligned with ACP policies on coverage, workforce, and payment and delivery system. On November 2, ACP sent a letter of support to the House leadership that details the dozens of provisions in the bill that merit ACP's support.

Of course, critics are doing what they can to derail the bill. One unfortunate tactic is the resurfacing of a chain email, about the earlier H.R. 3200, that has been discredited by two independent fact-check organizations. A new partisan critique of the bill repeats several of the same false claims, according to a new analysis from

On a more substantive basis, the bill is getting criticized for not doing enough to control costs.

But as Timothy Jost blogs in Health Affairs, H.R. 3962 actually includes many policies that "will in fact work important changes in the American health care system" to improve health care delivery and lower costs. Among them: accelerated pilot tests of medical homes and accountable care organizations, increased payments for primary care, quality and efficiency incentives for Medicare Advantage plans, comparative effectiveness research, promotion of shared decision-making, gainsharing, reporting on infections acquired in hospitals and ambulatory surgical centers, and workforce initiatives to increase the numbers of primary care physicians

I keep hoping that we can get to the point where there is a substantive debate on whether the bills do too much or too little to control costs; have too much or too little regulation; or spend too much or too little to make coverage affordable. The critics can surely do better than relying on discredited falsehoods, like the one that claims that H.R. 3962 would prohibit people from buying private insurance, to make their case.

Today's question: Do you think the House bill begins to put in place the right policies to expand coverage and control costs?


Rich Neubauer MD said...

Short answer to the expanded coverage question: yes, it represents a beginnng. Short answer to cost contol: clearly not enough to mnake much impact, but at least it is a first step and without a first step there is no reason to believe our current system can reverse a steady upward spiral of cost.

friend said...

I think the current bill eviserates the physician's ability to make a living, make choices based on his/her professional ideals, and destroys the free market ideals of commerce. It will increase costs- mostly it will increase taxes, decrease incentives to go into medicine. it will involve more government dictating how to practice medicine and decrease independent thinking.

amandaandjames said...

I disagree with the entire premise that our government needs to get involved in any aspect of healthcare. As physicians we have already seen with Medicare and Medicaid that government does not control any cost, and that if anything, costs go up once special interests get their government contract. I am very discouraged that the American College of Physicians has been reduced to asking for government handouts in exchange for their support in this misguided effort to take over a huge portion of our economy.

Jay Larson MD said...

The House bill does begin to put in place the right policies to expand coverage.

The cost control issue will be very difficult to predict.

In 1992 Medicare and many private insurers adopted the RBRVS. The RBRVS was designed to lessen the fee disparity between office visits and procedures. We all know how that turned out. What a disaster.

Controlling health care costs is extremely complex and involves predicted human behavior as the environment changes.

Unknown said...

No, the net effect of the bill will be to add millions more patients to a system that has resulted in dramatic escalation of costs in the past ten years, with marginal measurable benefit. In addition, the new bill will result in higher taxes and higher unemployment. Not nearly enough attention is paid to decades of empirical evidence that one of the strongest predictors of poor health outcomes is being poor, unemployed, or underemployed. We are creating public debt that will predictably add millions of folks (mainly our children and grandchildren) to these categories. It is enormously disappointing that neither the Obama administration nor the ACP supported the one intervention that nearly all health care economist agree would help "bend the cost curve" which is taxing health care benefits. Such a tax would raise significant dollars that could be used to support providing care to those who are uninsured, but more importantly it would engage the only group of people truly able to change the current insane trajectory of health care costs - namely patients. I am also very disappointed in the ACP for endorsing what I view as disastrous public policy. Such an endorsement represents the view of I suspect a very isolated segment of the ACP membership (mostly "leaders") who have made very little (no) effort to determine the opinion of the broad ACP membership (how about a survey), nor to acknowledge numerous other professional organizations that have come out in opposition to the current bill (the American College of Surgeons for one). I may choose not to renew my ACP membership as it is becoming clear that it is a "top down" organization that uses the capital of its members to support the will of its out of touch leaders.

PCP said...

Asking this question defies any past historical evidence. It is insane, by Einsteins definition of insanity.

Lets see:

1) Add 30 million people to the insured population.

2) Open the market up to everyone, so those that will need subsidies most will sign up, which without the universal mandate, those that do not will likely take a pass and pay the penalties.

3) Do little to curtail the explosive growth of costs. Allow providers of marginally effective services to continue to peddle their goods at a 3rd party payers dime.

4) Do little seriously to alter the physician manpower trends toward more generalsim, other than a little shuffling.

5) Do nothing to tamper the expectations of people. maintain the everything to everyone medicare mission.

6) Ask no sacrifice of people. Worse ask no personal responsibility of people. Add no incentives or disincentives to insurance products. In fact further flatten the premium distribution.

Why? Why would this not control health care costs?

Will do nothing with this bill but explode the health care costs. Then the next wave of cost containment will emerge.
And, just imagine us physicians. If in this era of largesse, we failed miserably and publicly to get the SGR fix. What chance do we have in the era when costs flip out of control, as most American viscerally know they will.

We will have advocated for policies that worsened our position.
The leadership of Medicine is go gullible it is not funny. In the end we will be used and abused by politicians because we have let them.

Steve Lucas said...

From the nonmedical side I would have to go with PCP's list. The only caution I would add is those in medical leadership positions are fighting an uphill battle against a political system that sees them as pawns. Their ultimate goal is power, not patient care or safety.

Steve Lucas

Arvind said...

Agree with Jay and PCP. This bill has very little reform; mostly increases government stranglehold on medical practice.

Unknown said...

While this bill may address some of the peripheral issues that touch on waste, it does not address the core problem of waste itself. This does not in and of itself undercut the benefits of of the bill such as increasing coverage, and the bill's successes and shortfalls should be addressed in their own right. So long as nobody thinks this bill closes the books on health reform, then it can be seen as a step forward.
The principal problem of waste, however, are the gross under-recognition of its breadth and consequences. As physicians, by issuing orders that waste money on needless tests, treatments, and services, we are undercutting our own authority, placing our patients at risk, and slashing our own salaries (because what is spent on a useless coronary calcium score, or screening chemistry+CBC in a healthy 30-something cannot also be spent to pay us).
It it time for us to change how we practice medicine, and to make 100% clear to patients that that: 1) it is in their interest to support more efficient medicine (lower cost and risk); and 2) we're going to practice more efficient, better medicine with or without their support.