Thursday, March 4, 2010

Reconciliation (n), rapprochement, the reestablishing of cordial relations

This is one definition of reconciliation, but yesterday's announcement by President Obama that he will pursue final enactment of health reform on a simple majority vote, likely using a parliamentary procedure called reconciliation, will have the opposite effect on relations between Republicans and Democrats.

Yesterday, ACP was invited to the East Room of the White House to hear President Obama's remarks on a way forward on health care reform. Dr. Fred Ralston, ACP's president-elect, was invited to sit in the first row, facing President Obama. (You can see Dr. Ralston and President Obama together and shaking hands in video clips from the White House and C-SPAN. Dr. Ralston is the one wearing a lab coat with the ACP logo. He was accompanied by Dr. Fred Turton, the chair of the Board of Regents; Dr. John Tooker, Chief Executive Officer and Executive Vice President; and me.)

Here is how the President explained the key elements of his proposal:

"First, it would end the worst practices of insurance companies. No longer would they be able to deny your coverage because of a preexisting condition ... to drop your coverage because you got sick ... to force you to pay unlimited amounts of money out of your own pocket ... to arbitrarily and massively raise premiums ...

"Second, [it] ... would give uninsured individuals and small business owners the same kind of choice of private health insurance that members of Congress get for themselves ... The reason federal employees get a good deal on health insurance is that we all participate in an insurance market where insurance companies give better coverage and better rates, because they get more customers ... if you still can't afford the insurance in this new marketplace ... then we'll offer you tax credits to do so - tax credits that add up to the largest middle-class tax cut for health care in history.

"Finally, my proposal would bring down the cost of health care for millions -- families, businesses, and the federal government. We have now incorporated most of the serious ideas from across the political spectrum about how to contain the rising cost of health care ..."

The above policies generally are consistent with ACP's own proposal to expand access to care, and most already are included in the bills passed by the House and Senate.

In a separate letter the President offered to consider four ideas popular in Republican circles: increased emphasis on eliminating fraud, expansion of health savings accounts, increased funding of state programs to test alternatives to the current tort system including health courts, and increased Medicaid payments to physicians.

The big news of the day - but not really unexpected - was that President Obama called for Congress to take the final steps using a complicated and controversial procedure, called reconciliation, which would allow for changes in the Senate-passed bill to be made on a simple majority vote:

"Reform has already passed the House with a majority. It has already passed the Senate with a supermajority of 60 votes. And now it deserves the same kind of up or down vote that was cast on welfare reform, that was cast on the Children's Health Insurance Program, that was used for COBRA health coverage for the unemployed, and, by the way, for both Bush tax cuts --- all of which had to pass Congress with nothing more than a simple majority. I, therefore, ask leaders in both houses of Congress to finish their work and schedule a vote in the next few weeks."

Republicans responded by expressing outrage and vowing to do everything possible to block a reconciliation vote.

The reconciliation process will be ugly and polarizing, although it is hard to see the country being any more divided than it is right now. ACP has no control over the process used to pass legislation, but what we can do is to continue to work to achieve enactment of legislation that includes our key priorities on coverage, workforce, physician payment, and medical liability reform.

The next few weeks will be the endgame for health reform. It will either pass, with the final changes made on a partisan basis using a simple majority vote. Or it will be defeated, and health care reform likely will be dead for years to come. The outcome remains in doubt, but Marc Ambinder, an experienced Washington observer, now believes that events have shifted in reform's favor. We'll see.

Today's question: What do you think about yesterday's remarks by the President and his plan to push Congress to make the final changes using a simple majority vote?


Phil 314 said...

Can you say "co-opted"!

Harrison said...

I caught a comment by Senator McConnell that was interesting. He vowed to make the Democrats pay at the polls in November for the decision to push ahead with health care reform.
As one of the leaders of the Republican party isn't it his job to do exactly that in November anyway.
Was the 2008 result due to the Republican leadership making a decision to go easy on Democratic party opponents?

Public statements are so often hollow and intended to provoke thoughtless anger.
And we too often give in without considering the substance behind it.

The Republicans, theoretically, would be willing to accept mandated purchase of health care insurance if it was offered at the level of individuals.
Of course in order for this to work it would require federal government assistance programs to help individuals who can't afford to be in the market.
The bill under consideration is not too far from this.
The President offered proposals that include even a few more Republican proposals.
The President still has not moved enough on tort reform but he suggested in remarks that he could be persuaded.
It seems unlikely that that alone is all that keeps Republicans from supporting the current bill.

It would be nice to hear substance in the rhetoric coming from the Republican leadership.
Harping on the one note of scrapping the current bill does not make sense.
It is not constructive.

And not finding a single Republican vote given all of the concessions to Republican ideas that have been made causes a great deal of cynicism from many who watch this debate.

Reconciliation makes sense.
Doing nothing after coming this far does not make sense.


Steve Lucas said...

I found the President’s comments to be less about motivation and more about partisan politics. Reconciliation is about the use of force to achieve a goal, not about overcoming a political road block.

All my life I have fought against “smart guys.” If I only understood. I f I would let the process play out. I need to step aside and let the smart people make the decisions.

So now we have a large bill that will remake 1/6th of the US economy, with claims of savings from elimination of fraud and abuse. So why are we not taking those steps now to eliminate fraud and abuse?

Everyone will be covered, but we are going to cut payments to doctors. Where are the people coming from to treat these new patients with these diminished financial incentives?

We have 10 years of new taxes to pay for 6 years of coverage. What happens in year 11?

The questions go on and on.

The President’s remarks were political and rooted in a 1960’s dream of a European modeled US. I have been fortunate enough to travel to France every year for the last 20 years.

There is much to admire about the country. One point is made to me on every trip; they wish to become more like the US. Their social services were born out of the need to handle thousands of displaced people as the result of WW II. As I was told by one person; we bombed Europe back to the dark ages.

High taxes on the working, government control of almost every working position, and a social net that makes failure almost impossible has left the country at a competitive disadvantage. A disadvantage recognized by the political leadership and those working to excel, but ignored by those who benefit by the current government subsidies.

I personally feel we need to reform out health care system. We have many issues that could be solved by the inclusion of many ideas found in Europe. We also need to deal with the uniqueness that defines the US.

I feel that the current health care reform bill does not control cost or resolve some basic issues regarding availability. This bill is a grand political gesture being pushed by a small group with at least one foot firmly planted in the past.

Steve Lucas

PCP said...

The outcome of this reform process remains in doubt, however, I think the odds now are in favor of something passing, since the Democrats who have the majority find themselves in a position of being criticized for their initial yes vote irrespective of their final vote. IF they vote yes a second time, then they atleast have the option of standing their ground and trying to defend it, even if they are standing on very thin ice. American voters especially dislike a flip-flopper leader. So for nothing to do with the merits or demerits of the legislation, nothing to do with the general public sentiment, nothing to do with the fiscal crisis looming etc. and everything to do with political calculations, I suspect something will be rammed through.

A more pertinent question then is what impact will all this then have on organised medicine. ACP in my opinion has misread a significant portion of its membership in many of its policy positions recently. Their unabashed embrace of the current legislation sans provisions being demanded by private practice physicians which I believe still make up the majority of memebers(Bob can correct me if I am incorrect here) puts them in a precarious position.
In my view the results of this reform are unlikely to be kind to Doctors. Most of us did not expect a financial windfall out of this reform, but surely we expected other things that would greatly improve our practice environment, like the ability to plan our small businesses with some surety ie SGR fix, professional autonomy ie Doctors alone leading Advanced medical homes, litigation reform, rationalization of medical spending on value provided, introduction of personal responsibility into health care etc. There are many such items which we ought to have secured in so called "reform". However for ideological reasons amongst leadership, we have chosen a different path.
The result of all this I suspect will be a bleed of membership out of the organization. The AMA has witnessed this largely out of their disregard for cognitive specialties, and now I suspect the ACP will find the same trend develop over the coming years as the results of its misdiagnosis of what ails the private practitioner.

Rich Neubauer MD said...

What do you think about yesterday's remarks by the President and his plan to push Congress to make the final changes using a simple majority vote?

His remarks were all appropriate and welcome. It needs to happen.

Jerry M said...

Frankly I was embarrassed that physicians were used as props for the President’s infomercial. I hope ACP realizes that a high percentage of it’s constituency appose most of what is in the monstrous legislation before congress. Of the physicians I work with in the hospital I know no one who favors it. Lack of true tort reform, reduction in medicare spending by 30%, imposing rules derived from so called comparative effectiveness research and control of private insurers (price controls) are some of the deal breakers for me. The fact that it gives lip service to supporting primary care does not make up for the fact that it will result in lower payment to all physicians and reduction in what they will be allowed to do for their patients.

It is obvious that the public is against this legislation by about 75% by the last CNN poll. Even using reconciliation, not enough Democrats will be willing to commit political suicide to pass it. I only wish ACP would see the light but then they are only continuing their liberal ideas first aired in the early 80s with the support of a global healthcare budget that they used to attempt to woo Hillary Clinton.

Unknown said...

I agree with PCP. The ACP leadership is on the issue of health care reform out of touch with its members. I am unaware of any effort by the ACP to formally survey members on their views on proposed health care reform measures. I will await the one ACP survey which I can count on receiving which is my next membership dues statements.

Jay Larson MD said...

The health care reform debate has gone on long enough. It is now all about policital maneuvering.

Time to fish or cut bait.

Arvind said...

Steve, PCP and Jerry have said all the things I would have liked to say. The President showed how he could charm those same physicians standing around him to smile and agree, knowing how this current plan schemes to dismantle their profession and convert all them into employees of the walmart of medicine that this government wants to build. As I have said many times, it is time for the ACP to wake up and see reality; or face the irrelevancy that the AMA now faces.

Harrison said...

I find it interesting that the doctors who know this web site well enough to post on this blog feel that the ACP is unrepresentative.
Policy statements are passed through the board of governors and then the regents.
Resolutions can be submitted by any member at any time for consideration by the board of governors.
If members want ACP policy to be different, then write it clearly and advocate for it.
If members feel that the ACP is not representing them they can become more active in state councils and perhaps even run for governor.
ACP policy can be changed in much the same way that AMA policy can be changed.
The process and the policies that exist can be accessed through this web site.
I'm pretty technologically challenged and I was able to figure it out.

As far as public opinion polls go, I guess I'm not convinced that health care reform as it is currently being debated is as unpopular as the polls suggest. The process has been unsavory, and people react to that when asked.
But the various component ideas of the Senate plan that the House is being asked to pass enjoy a fair amount of popular support.
Even among physicians.


Michael D. Miller, MD said...

Your characterization of reconciliation is not accurate. It is somewhat complicated, but not really controversial. It has been used many times to implement Congressional budget provisions. Using it to amend a single bill would be a first, but once the reconciliation process starts, it will likely include many other things. Also, reconciliation is a term of art within the Federal legislative process, much like putting a bill "in the hopper," or the medical term "to assess a patient" - which hopefully is used to mean "to evaluate," rather than "to charge a fee or tax."

jfddoc said...

The Reconciliation debate seems to be just a political ploy to get 218 votes in the House to pass the Senate version without changes. Once that happens, then the point is moot, as Mr. Obama can sign the Bill into Law.

On a somewhat different subject, check out Thomas Sowell's latest column entitled "Getting Out of Medicine":