Monday, March 22, 2010

Reflections on yesterday's vote

The vote in the House of Representatives to adopt the Senate-passed health reform legislation, as modified by a separate corrections bill, has been rightly labeled as "historic" by many observers. On this, there is little disagreement. But the debate in the House of Representatives showed two opposite views of the history being created. For Democrats, it an historical achievement on the par with adoption of Medicare, the Civil Rights Act, and Social Security, writes E.J. Dionne in the Washington Post. For Republicans, it is an historical calamity that will inexorably lead to government-run health care, and "ruin" for the country, according to House minority leader John Boehner (R-OH).

I think we are too close to events - and emotions are running way too high - to determine how historians will rule. What I do know is this. At least since the early 1990s, the American College of Physicians has championed the need for universal health insurance coverage. The "other" internal medicine organization, the American Society of Internal Medicine, which merged with the ACP in 1998, also advocated for health coverage for all Americans, although it differed with the ACP on some specifics on how best to achieve it. (Disclosure: I was the senior government affairs person for ASIM before taking on this role for the combined merged organization, and I remember sparring with the ACP over some cost controls in the Clinton health care plan.) The point, though, is that internists - perhaps more than any other group of physicians - have long been on the side of providing all Americans with health insurance coverage.

I believe that history will show that ACP had a major role in bringing about enactment of the legislation, and that it was able to influence it to incorporate many of its own key policies.

This morning, I received an email from a former Senate staffer, who had worked with ACP several years ago in crafting legislation based on ACP's own "seven year plan" to provide all Americans with access to coverage. This is what he had to say: "Throughout this process, I kept thinking that much of the framework was much like the old ACP bill and that you should be proud of much of that!"

I also believe that history will show that the ACP's Board of Regents and Board of Governors showed tremendous courage in continuing to stand behind reforms to provide Americans with access to affordable coverage, based solely on how the legislation advanced ACP's policies. They did so despite unrelenting partisan and political pressure, and with a keen awareness that a segment of ACP's membership would likely be opposed to the legislation.

And I hope that history will show that I was able to help the organization achieve its vision of coverage for all.

Yet today, my pride in ACP's contribution to yesterday's historic vote is tempered by how polarizing, for the country and for the medical profession itself, the debate has become. Agreeing in abstract that everyone should have coverage is one thing. Achieving consensus on how to accomplish has proven to be a far harder thing. Unfortunately, the debate too often has veered from respectful disagreement about the means to ad hominine attacks on those who see things differently. I hope that we are able to soon get back to a respectful dialogue about how best to provide access to health care, rather than demonizing each other’s views and motivations, but I have my doubts.

And let's be honest. I don't know for sure how the whole thing will turn out. My heart and mind tells me that historians will view it as a tremendous step forward in providing all Americans with access to affordable care, but I am aware that they could decide it was a mistake. I wish that opponents also would be humble enough to acknowledge that they also can't see the future and that they might be wrong when they say it will lead to the "ruin" of our country.

Faced with a choice with uncertain results, ACP supported the legislation for the right reason, to help patients get access to affordable health care.

Today's question: Do you think ACP has been right to advocate for health coverage for all?


Unknown said...

"Do I think ACP has been right to advocate for healthcare for everyone?" NO.

Rich Neubauer MD said...

You've tempted me to post the very first thing that came to mind as I watched the vote count pass the mark yesterday evening: "Now that health care reform has passed, the really hard work begins."

To me, this legislation did two major things: 1) made a commitment that in the modern day world, health care coverage needs to be something everyone has AND 2) broke the logjam that blocked the path to major improvements that need to be made to our delivery system.

On point number two, while this bill starts the process, I think it is clear that workforce issues, fixing primary care, gaining control of burgeoning costs, and tort reform remain issues that will need much more attention.

My hope is that as the dust settles, there can be a coming together to do this work in a more bipartisan fashion than was the case in the past year.

ray said...

I feel confused but and I sure many feel the same way. For many in health care field, the first priority will be "how will it affect my income, work", there is nothing wrong with this but this may lead to loss of objectivity.
Everyone agrees this is not a perfect bill, this is Mitt Romney's bill but only at national level. Medicare will need to start weeding fraud and physicians need to lead play leadership role in making the system efficient which help patients and avoid fragmented care. Hopefully, in this era of internet,twitter maybe health care can finally move into modern times- cannot believe how long it takes to get medical records even in this day and age and no accountability when all tests are repeated even if it means patient gets another 2-3 contrast CT because care was fragmented.

Arvind said...

"They did so despite unrelenting partisan and political pressure, and with a keen awareness that a segment of ACP's membership would likely be opposed to the legislation" - this could also mean that the Regents (just like the present government) think that they know what's best for the organization and don't really care for those with opposing views - sounds like a dictatorship to me!

"Faced with a choice with uncertain results, ACP supported the legislation for the right reason, to help patients get access to affordable health car" - it is time for the ACP to change its name to "American College of Patients" - this suits its mission better than the current name.

And just to sound like a broken record, "access to insurance" does not equal "access to health care". Please stop propagating this myth once and for all...

Steve Lucas said...

I have never seen the debate as one of principle, as everyone supports many of the goals of this bill and the ACP, but one of the mechanisms of achieving those goals. Added to this has been the polarizing rhetoric of both political parties.

On a more practical note I was discussing the challenges facing a private practice in another, more affluent, part of the state and some interesting points were made concerning availability. This practice has been closed for some time. Two specialists are retiring who cared for all of their patient’s medical needs due to the complexity of their care. These patients, mostly elderly, are calling in tears, begging to be added to the practice because there is no doctor available in the area.

Adding to the strain of day to day operations are Medicaid patients who appear and demand immediate attention or an appointment. When told the practice is closed they make any number of threats of legal action because, “they have insurance.” We have just added 16,000,000 new Medicaid patients to the roles.

One cardiologist solution is to have five PA’s. The PA’s have been known to do consults in the ICU.

While we have provided insurance, we have yet to solve the cost and access issue.

Steve Lucas

Jay Larson MD said...

Despite the House vote, the sun rose on Monday. A person died in their sleep. Another person was born. Life moves on.

Even though I was too young to remember, I am sure that the civil rights movement in the 1960s was just as emotionally charged. I am sure that physician opinions at the time were just as divided when Medicare was started. We’ll adapt and get through this time too.

The patient response to the legislation was mixed. One patient was mad because the legislation is a path to Government run health care. The next patient was mad because a single payer system was not put into place. If everyone is mad then the legislation must be just right.

PCP said...

This is nothing but a liberal ram down vote.
Universal coverage under the current US private fee for service system is a disaster waiting to happen.
The history of this country since the 1960s ascent of liberalism and entitlements is one of increasing indebtedness. One which will leave those of my generation with a fiscal disaster the likes of which we have not seen for near 100 yrs.
Sadly until that eventuality when our gov't goes broke and defaults on its debt resulting in a run on our currency and untold suffering, our liberals and politicians will not correct the flaws in our direction as a society for the past half century. Sadly the implication will be one of generational theft or should I say heist.
I say this because none can dispute that this is the most massive expansion of entitlement in half a century. That accepted, who in their gut feel this is the time in our economic history to do this?
Charlie Munger(Warren Buffet's partner at Berkshire Hathaway) recently wrote a parody in Slate magazine titles perhaps morbidly "Basically its over". It speaks of the financial industry excesses and how they built up, and I feel that the woes of our Social entitlement programs is not particularly different.
Those of you who feel this is some pie in the sky would do well to consider that this country had nigh a dime of Debt until 1980. In 30 short years we have near exhausted our demographic dividend(with retiring baby boomers), we have near maxed out our National Debt(witness the hitherto unheard of rumbles of sovereign debt downgrades), we have on top of all that just expanded our entitlement at the biggest rate in 50 yrs.
HIstory will not be kind when the full story is told.

doc777 said...

I agree there are some good things in this bill. However, the question is: Does the good outweigh the bad? How exactly does this bill make health care more affordable and accessible to those without health insurance or those unable to maintain insurance due to the escalating costs?

This bill provides for a mandatory expansion of the state Medicaid programs. This has led roughly 38 states to consider suing the federal government over those mandates. Several of those law suits are already being filed. State budgets already in turmoil would be devastated by the additional costs of these mandates. In addition, years of legal battles will occur testing the constitutionality of these mandates. Our state currently faces a $1 billion deficit in the Medicaid program in the next biennial budget. Assuming (as promised by the Governor) there will be no cuts in services, and taxes are not increased, the only option is to decrease reimbursements. These decreased reimbursements will clearly lead to access issues. Under current reimbursements, we have large hospital systems in our area and their employed physicians refusing to see any additional Medicaid patients. Health insurance without access is essentially no different than having no insurance.

The bill also reportedly reduces the cost of health care premiums through a federal subsidy program. In other words, the bill does little if anything to reduce the cost of health care. Instead it simply provides individuals money to help pay their premiums. This will cost the federal government hundreds of billions of dollars at a time it is running more than a trillion dollar deficit. This country is on the verge of losing its AAA bond status and this legislation will likely not have a positive effect on that decision.

The bill claims to save money, however, it uses 10 years of Medicare cuts and increased taxes to pay for 6 years of benefits. In addition, it does not even include the more than $200 billion it will take to fix the SGR formula. Further, does anyone really think that the cuts to the Medicare Advantage programs will be absorbed by the insurance companies? Once the seniors understand the impact on their benefits, it is uncertain whether these cuts will be allowed to stand.

Although there is a mandate for individuals to purchase health insurance, the penalty is far less than the cost of that health insurance. Given the requirement for insurers to ignore pre-existing conditions, there really is no incentive for a healthy individual to buy insurance until they get sick. Therefore the insurers will be subjected to a higher risk, higher cost group of individuals. These additional costs will be passed on to their members, further increasing premiums for those plans. It is quite clear that increases in premiums will likely accelerate and certainly not be reversed, except in the government programs where price controls will be used to decrease reimbursements to providers.


doc777 said...

I agree that there would theoretically be advantages to a single payer system, which appears to be the direction we are heading. However, that is essentially what we had with the original Medicaid and Medicare programs, yet both have went the path of contracting with private insurers to reduce costs. Given the track record of the government, it would be difficult to conclude that a single payor government run health care system could actually save money while maintaining quality and safety. Instead, a realignment of incentives within the current system (including risk and gain sharing) to encourage cooperation between various health care entities, combined with pressure from payors for those entities to engage in continual quality improvement projects and ongoing tracking of their performance based on accepted quality measures with incentives for achieving high performance levels, seems like a better option to me.

My issues with the College are more related to the process they use to inform their members. I can certainly understand them wanting to support a bill containing many of their key policy items. What bothers me is the unnecessary deception they use when disseminating information to the members. At the time the first House bill was approved, the College issued a memo stating that the bill garnered bipartisan support. In reality it had received 1 Republican vote. When the Senate election in Massachusetts was won by the Republican candidate and health care reform was deemed dead, there was no mention by the College of an imminent catastrophe. However, as health care legislation was resurrected, we heard over the past several days that a lack of passage would be catastrophic. If the College continues to treat its members like a bunch of lemmings, they risk the disengagement of many of the members in the process, and quite likely, a reduction in membership.

I'm not a health policy expert, but I do know that the way this bill was muscled through, makes it unlikely that additional meaningful reforms will occur over the next several years. Unlike this bill. Medicare and Social Security were both passed with strong bipartisan support. In fact, this bill was passed with significant bipartisan opposition.
To summarize, what we have "won" is a massive expansion of the same broke system, no SGR fix, no tort reform, no meaningful cost containment, and the makings of a real (not imaginary) catastrophe.

Harrison said...

I think the bill is a good thing. And ACP's support for the ideal of health care for everyone is well placed and laudable.

I just want to make a comment about the rewriting of history that goes on about the public debt concerns.

The United States has always had a public debt. It has hovered between 20 and 40 percent of our GDP throughout our history.
It spiked to over 100 percent of GDP during WWII. It was still at 60% of GDP in the early 1950's.

The debt fell some through the 60's and 70's, but never below 20% of GDP.

Now with the current recession it is up near 60% of GDP.

The current health care bill will make it slightly worse over the next 10 years according to the CBO.
But the current bill also puts in place elements that may slow some of the entitlement spending that is racing out of control in Medicare.
Yes that will mean that there will be less money per beneficiary in the system if the changes are put into place.
But I worked in Wisconsin which had one of the lowest Medicare spending averages per beneficiary in the country.
We did pretty well with taking care of Medicare patients and we were not frustrated with the system.
Bending the curve toward that level of spending per beneficiary is a good thing.

I'm hopeful that we can continue to make progress.


PCP said...

That is some seriously finicky accounting Harrison.

Might I suggest you visit with the and take another look at your numbers.

at 12.6 trillion and rising as far as the eye can see, with a GDP at 14.3 trillion and having shrunk last year, I somehow don't think that is "up near 60%" as you suggest.
None of this includes off the book liabilities such as Fannie/Freddie which recent history has shown we effectively have no choice but to support.
Lets not even make mention of the unfunded liabilities in the entitlement programs, which have just been massively expanded.

One look at that fiscal picture and it gets you feeling sick as someone of my generation. The current acceleration of our path to financial disaster makes me frankly disgusted with the entitlement expansionary mindset, just as I felt disgusted with the unfunded tax cut mandate.

I don't think fudging the numbers solves the problem.

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

Congratulations to the College and its dedicated leadership and staff on its role in the passage of the health care legislation. This legislation will help millions of our patients to access health care and will relieve them from the fear of financial ruin from illness. While the legislation is not perfect, it is a great first step toward a humane, comprehensive and cost-effective health care system.
It is disappointing to read some of the comments from physicians who seem to deny the problems of the current dysfunctional system and its deleterious effects on our patients and to parrot the often untrue objections of the opponents of reform.
I am proud to be a member of the College and look forward to its continued advocacy for improvements in the system to better serve our patients and our profession.

Unknown said...

Well ASCP (American College of Socialist Physicians) you go ahead and take those long arms and pat yourself on the back. The sheer strategic and tactical brilliance of the socialist democrats must be applauded. They got their super majoraties with an affable leftist POTUS and away they went. And the AMA and ACP went along for the ride to be used as widgets in Obama's new medical autocracy. My wife is a practicing internist of 24 years. She continues survuve private practice while fighting against the growing encroachment of hospital based practice or factory medicine. But her generation of internists will be last to have any resemblence of professionalization and independence. It seems like wherever an internist turns he faces hostility: insurance companies, lawyers, hospitals, malpractice insurers, medicare and now the US government will initiate the final stage of its coup. Fiscal disaster let alone health care delivery disaster is maybe about 10 years way. Tell me one item in this "imperfect" (your claim not mine) legislation that empowers the patient/physician realtionship! Tell me one item in this bill that enhances the independence and automony of primary care physicians and physician patient relationship. Tell me one thing this bill does that demonstrates respect to the skills, talents and integrity of physicians. Medicare is a pathetic immoral, unjust and bankrupt system. Unfortunately, physcians will pay the biggest price for this. They have to maintian private liability coverage while they are forced into socialized system that will determine reimbursements at the same time controling who get's what when. All this talk about health care as a right. My wife's rights to earn a living, provide a service and manage her own talents, skills and training are completely trashed and ignored as she will now become under increasingly government control. Where does anyone get the right to demand the services, skills, talent and training of anyone else and have the delivery of those services then paid by a 3rd party at a discount!

Don Hatton MD said...

To the question "Can the ACP advocate for universal coverage for all?" My response is that it depends on the vote of the Regents. The Regent vote reflects the ACP member vote, as represented from the Governors and Regents. As a medical student, I worked with a physician who was a Greek citizen. I distinctly remember our discussion about health care systems. She stated, that it made no difference to us physicians what sort of system we work in because we will always do what is right for our patients.My recent thought about this is that as part of our "professionalism" as physicians, we must take care of our patients no matter what sort of system we work in.Change does occur. In my father's day in the late 1930's and 40's, "kitchen table" surgery and home deliveries on the farm were common-place. We no longer believe that such practices are quality medicine. The way we will deliver care, will change as it has always changed.As physicians we need to learn to acommodate, so that our patients still get quality medical care.

Yul Ejnes, MD, MACP said...

I have intentionally avoided posting on this blog because I don't believe that those of us involved in College governance need another forum to express ourselves - we need to listen to those voices that we don't usually hear. However, after reading the past few weeks' posts, I will comment. Then I will go back to listening.

My disclosures follow. I am a general internist in private practice working full-time. 98% of my income comes from direct patient care, 100% of my patient care income is on a fee for service basis, and 100% of that income is based on productivity, which many of you refer to as "eat what you kill." I am underpaid, earning in the lowest quartile for IM from all the surveys that I've seen, and I take care of Medicare, privately insured, and self pay patients. Last month I skipped a paycheck to make payroll and it wasn't the first time I had to do that. If that is "out of touch," someone explain to me what "in touch" is.

To answer Bob's question, of course we should advocate for health coverage for all. To respond to one of the posters, nothing can be more disruptive to the patient-physician relationship than the lack of insurance. In many cases, without insurance, there is no patient-physician relationship. When patients cancel appointments because they have no coverage or put off needed care due to the inability to afford it, how does that empower the patient-physician relationship? Granted, given workforce and other issues that we will continue to work on, providing coverage to all does not guarantee that relationship will flourish, but it is a prerequisite.

It is the current payment system that disrespects "the skills, talents and integrity of physicians." The new law pushes CMS to look at and pilot other models of payment, such as the medical home, that restore the respect and autonomy that was threatened long before the current discussion started.

I've been amused by the talk of government bureaucrats getting between the patient and their doctor. If the government bureaucrats want to do that in my practice, they will have to push insurance company bureaucrats, PBM clerks, and several other people out of the way, because there's no room for another person to come between my patients and me. I was trying to think of the last time I had to get on the phone or write a letter for a prior authorization for a test for a Medicare patient, then I realized that it was "never," because Medicare doesn't require prior auth. As far as I know, the new law doesn't change that. As to United, Blue Cross, Aetna, etc., they've been doing it for years. And given that most of the newly insured legal residents of the US will be insured by the private insurers and not by Medicare, that gives me pause.

Without question, there are deficiencies in the new law that we must fight to address, such as medical liability (which is a day to day threat in my life too - being a Regent isn't considered a "safe harbor"), cost control, and SGR, but in my view, it facilitates our future work by getting almost everyone under the umbrella of the uniquely American multi-payer system.

Lastly, I would note that even the Congress, where the debate has been rancorous, has standards of decorum that members of both parties respect and defend, as we saw this weekend. I think that we can do even better than members of Congress. I love irony and sarcasm as much as the next person, but I think that learned professionals such as physicians (especially internists) can disagree without the name calling and aspersions.

Yul Ejnes, Chair MSC

DrJHO7 said...

Do you think ACP has been right to advocate for health coverage for all?
Yes! One of the reasons ACP has been successful as a professional membership organization is its steadfast, ongoing emphasis on advocacy for improving patient care.
I would venture to say that, without ACP's review, advice and guidance at the healthcare reform tables, backed by comprehensive, well-written and well-researched health policy publications, that this healthcare reform bill would not have passed, let alone progressed to the point where it could be voted on.
The governance structure of ACP allows member physicians the opportunity to have their voices heard through the resolutions process, and to become part of that governance structure if they choose to invest the time and energy.
The passage of the reform bill is a place to start. The outcomes of it will need to play out over time. I'm sure we'll learn a few lessons, and I'm sure there will be some pleasant and unpleasant unintended consequences.
Hopefully these will balance out.
It really bothers me that the voting of our legislators was so one-sided. Politics could unravel this whole thing if we let it.
Physicians need to remain engaged if we are to continue to gain traction in the improvement of our health system. ACP provides this opportunity for internists of all walks.
Nobody ever said that practicing medicine or fixing what's wrong with our health system was going to be easy. But, as physicians, it is our responsibility and should be one of our priorities, for our patients and for ourselves.

Harrison said...

I'm happy to look at the real deficit numbers.
But I would ask that anyone worried about the deficit read this article by James Galbraith
The article is entitled "In Defense of Deficits"

I don't think we should be careless with our finances.
But I worry less about giving our children and grandchildren a public debt that has been passed down from generation to generation since the 1800's than I do about passing to our children a broken health care system.
We need to reform and update our health care delivery system.
Health insurance reform and coverage for everyone is a start.
We also need to reform our financial system.
And we need to strengthen our economy in general so our children and grandchildren have a strong job market to look forward to.
Our education system needs help too.

Health care is a good start.
The ACP's advocacy was just right.

Take care

Andy Hedberg said...

The Health Care Reform Bill is a grand step towards finally establishing that health care in America is a right, not just a privilege Congratulations to the membership and staff of the ACP for years of strong advocacy with major contributions towards this stirring accomplishment. The challenge now is to implement reform with the revisions and additions that may be needed over time. It is a privilege to be part of a foresighted organization that recognizes and advances the correction of societal needs, and reflects our professionalism. Andy Hedberg

Rich Neubauer MD said...

It's great to see the positive comments most recently made under this post. My friends Yul Ejnes and Andy Hedberg's comments are particularly heartwarming and well said.

The sick and the needy will be ever present. Even those blessed with wellness need the advice of excellent physicians to interpret the barrage of "health" information that abounds. The internet is not a substitute for a thoughtful physician.

Physicians in private practice do not have a monopoly on establishing excellent physician-patient relationships. There is no question that powerful forces of change are at play in medicine, and those forces are not restricted to "the bill". What the medical practice of the future will look like may not be clear at this time, but we need to evolve while also maintaining the light of knowledge and the discipline of professionalism that are part of our past and the key to our future.

I believe that care needs to be both patient centered and physician led. As systems evolve in the context of our newly enacted reforms we physicians need to advocate to make sure the right principles are maintained. The work of superb organizations like ACP is only beginning.

Jerry M said...

ACP has not been right in supporting the present health care legislation. ACP in it’s characteristically economically naive way has fallen for the greatest ponzy scheme ever forced upon the American people. At least Madoff was put in jail for it. I realize that there is a long list of things ACP supports but at the end of the list is included a reduction in the deficit. It doesn’t compute. To get this bill to balance there is a reduction in medicare spending of 30% . This will result in an increase in denial of care and a reduction in payment to physicians and hospitals. This will result in immense dissatisfaction in those areas. The bill also requires a reduction in physicians’ fee of 21% immediately and more in the years to come. We have already been promised that it would not happen this year but wait till all of the third party payers are controlled by the feds. Then the physicians will have no recourse as they do now by refusing to take medicare patients. Another way they made the bill balance was to make profits on student loans by charging students 6% on money the fed is getting for 2%. I thought the students needed a break..In addition, in order to monitor everyone’s income the IRS needs to spend billions more that is not in the calculation.

This bill doesn’t come any where close to adding up. It’s nice to believe we’re getting our wish list but we should face reality. The American public seems to be willing to face it more than the ACP. Many people in congress had their arms twisted to sign a bill they know is severely faulted and it will come back to haunt them. ACP’s support of this bill will not set well with most practicing physicians especially subspecialist members of ACP.