Thursday, January 28, 2010

Did Obama's SOTU address give enough of a lift to health reform?

In my mind, President Obama's State of the Union speech settled, at least for now, the question of whether he remains committed to health reform:

"So, as temperatures cool, I want everyone to take another look at the plan we've proposed. There's a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo. But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. Let me know. Let me know. I'm eager to see it. Here's what I ask Congress, though: Don't walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people. Let's get it done. Let's get it done."

But will Obama back up his words by putting the full weight of his office behind the effort? Roll Call reports that Democrats are looking to the President to help them find a "clear path" to break the gridlock, and some remain doubtful about its chances.

Perhaps the most important development, other than Obama's speech, is a declaration today by Speaker Nancy Pelosi (D-CA) that she has the votes to pass health reform if the Senate agrees to adjust the bill through the budget reconciliation process, which requires only a simple majority. Channeling Winston Churchill, Pelosi is quoted as saying, "We'll go through the gate. If the gate is closed, we'll go over the fence. If the fence is too high, we'll pole vault in. If that doesn't work, we'll parachute in. But we're going to get health care reform passed for the American people." Senator Majority Leader Harry Reid (D-NV) also is "looking very closely" at the reconciliation option, according to Roll Call.

There are big differences between the House and Senate bills, though, so it will require President Obama's direct involvement and leadership to get agreement on the changes to be made through reconciliation and persuade a majority of Democrats to go along.

What about the GOP? I would like to believe that there could be agreement on an approach that would attract bipartisan support, but I doubt it. Republicans uniformly will oppose use of reconciliation to "force" enactment of health care. The Democrats will counter that reconciliation is justified to overcome Republican "obstructionism" in the Senate, which prevents legislation from being passed by a simple majority vote, and they will remind people that reconciliation was used to pass the Medicare Part D prescription drug program and the Bush tax cuts when the GOP controlled Congress.

The one area that could have been a fertile ground for bipartisanship is medical liability reform, but it is probably too late for that. The President asked for "better approaches" from either party to reduce the deficit and lower premiums. The CBO estimates that tort reform would "lower costs for health care both directly, by reducing medical malpractice costs - which consist of malpractice insurance premiums and settlements, awards, and legal and administrative costs not covered by insurance - and indirectly, by reducing the use of health care services through changes in the practice patterns of providers" and "reduce federal budget deficits by about $54 billion during the 2010-2019 period." Unfortunately, I don't see the President doing the heavy lifting within his own party to enact tort reform, and I don't see Republicans agreeing to support the broader health reform bill even if he did.

Finally, the wild card in all of this is whether the President's speech and subsequent actions will slow the erosion of public support. Last night, the President acknowledged the problem:

"Still, this is a complex issue, and the longer it was debated, the more skeptical people became. I take my share of the blame for not explaining it more clearly to the American people. And I know that with all the lobbying and horse-trading, the process left most Americans wondering, What's in it for me?"

The Kaiser Family Foundation's latest health tracking poll, fielded earlier this month but before the Massachusetts special election, found the public evenly divided overall about the health reform bills, but that, "Majorities reported feeling more favorable toward the proposed legislation after learning about many of the key elements, with the notable exceptions of the individual mandate and the overall price tag."

President Obama's speech provided a lift to health reform, but he will need to do more to persuade a skeptical public about what's in it for them.

Today's question: Do you think Obama's the State of the Union address lifted the prospects for health reform?


Fred Smith, MD, FACP said...

As a physician supporter of the current Health Care Reform legislation - which I believe meets many of ACP's goals - I had become pretty dispirited over developments over the last month, including the Massachusetts Senate election results.
However, Obama's optimism and call to perseverance gave me a personal lift. It may be too much to expect, but perhaps his undiscouraged quest for bipartisan cooperation will appeal to a Senator or two in the Party of No.
At the least, he may have given new enthusiasm and backbone to congressonal Democrats to 'get this thing done", instead of running for the hills. If reconciliation is what's needed, I am for it. I only ask that he put his entire energy into LEADING the Congress through the obstacles, as well as continuing his explanation to the American people.

Arvind said...

I think the President came out like a lame duck yesterday. Either he fails to understand the public's dislike of the proposals in the Senate and House bills or he is simply to stubborn to acknowledge the fact that it is not the messenger but the message that does not appeal to most average folks, especially those that are currently insured.

He would have been far better served if his advisers had asked him to acknowledge that the majority of his policy proposals were greatly miscalculated, and that he would take a fresh approach and involve "the people" in formulating the policies. Just like the ACP Board formulates its own policies without consultation with its dues-paying members, so does the Obama administration create policies without adequately consulting tax-paying citizens. I hate to bring this up again, but the public will only embrace a policy that it has a stake it, not something rushed through Congress via horse-trading and back-room deal-making.

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

There is nothing wrong with his speaking skills and he is right that the new 59-41 split means the Republicans have to accept the burden of some of the responsibility for the outcome. It did not appear that there was much friendliness from the right, though Senator McConnell seemed appreciative of the invitation to "let me know."

On this blog, we have certainly shared a few opinions on this matter in the last year and I agree with Dr. Neubauer on this being a seminal moment. Leadership would entail creating a plan that levels the playing field without disrupting its core activities: The provision of care, the development and distribution of medical products, and the support of infrastructure. What must be done to reduce costs is a streamlining of the process and a rational financing approach that could build on the Medicare fee schedule. While we all have complaints here, it might be possible for our voices to be heard if a coherent system were to evolve.

If we have to move incrementally, let us prioritize the essentials:

1) return marketing limits of the past that protect us from the distasteful hyping of medical care (a bigger cost driver than defensive medicine)

2) force private insurance to divest of shareholder interests and empower states to regulate without the current ERISA shelters and with streamlined federal guidelines. Construct the mandate and subsidies as insightfully as possible and build in a flexible updating process. Let Medicare be a model, by having all covered services, tests, and drugs entered into an updated fee schedule that does not punish physician services while other costs grow disproportionately (SGR fix would be implicit in this).

3) Reform Hatch-Waxman so prescription authority can return to physicians, so financial coercion can be restrained, and so that our fund of knowledge can grow in a way that compares the old and the new without gimicry. We need not pharmacy-benefit hassles, formulary limits, approval loops, and third-party interference in the guise of education. There is no way for physicians to maintain a coherent approach to disease when prescribing the new is punished, and prescribing the old allows excess profits to those who provide no incremental service. Regulated Royalties could be administered by the FDA in concert with private and public payors and would not require undue interference with patient and physician autonomy.

4) Avoid the lure of mandating quality bureaucracies or integrated records. All this will do is further erode the independence of the small practices that continue to provide the bulk of care in this country. As well, it will raise costs, feed creative malpractice suits, and enforce a stifling hegemony.

Despite the impressive ability of politics to forge 50/50 divisions, most problems can be framed in a way where 90/10 splits would be more common. If we can frame the problem correctly, we could have true bipartisan support (like when push comes to shove and the 21% SGR cut is at our door).

Steve Lucas said...

I feel the President’s address did not recognize that no matter how dysfunctional, 85% of Americans are covered by some type of insurance. What the government was asking is that we upend our current system for one that would greatly change this landscape and then cover the remaining 15% of us.

What I feel we truly need is a more streamline bill and program that would be more easily understood and implemented. Many of the ideas and concepts found on this blog would go a long way to improving medical care while reducing cost.

Clarity and brevity are what is needed now, along with a good dose of bipartisan realism of doing what is best for the country.

Steve Lucas

Rich Neubauer MD said...

Just as physicians are experts in the science and art of healing, politicians need to be the experts in the political process. There is no doubt that in the present era and circumstance, this job is particularly difficult.

Mr. Obama is a master of the spoken word, and his State of the Union address was masterful.

Now, his words need to be translated into deeds and results. Just as a seriously ill ICU patient tries the skills and wisdom of a master physician, the current situation is challenging the skills and wisdom of our political leaders. When such a patient survives, it is a sublime thing. I hope the analogy carries forth for health care reform legislation.

Anonymous said...

Since, according to ABC's Jake Tapper, "the budget assumes $150 billion in deficit reduction from enactment of the health reform legislation," it follows that a result of reform not being enacted would be an increase in the deficit in that amount. This is diametrically opposed to the argument of many of the naysayers, i.e., that reform will increase federal deficits.