Thursday, November 11, 2010

Is there an alternative to re-fighting health care reform?

Everything seems to be pointing toward two years of partisan and ideological confrontations over health reform. The leadership of an emboldened Republican party has made it clear that it will use its newfound House majority to seek to "repeal and replace" the Affordable Care Act (ACA), and if that doesn't work, to "defund" it. Huge GOP gains in statehouses make it likely that more states will resist implementation. Meanwhile, President Obama has stated that he is open to "tweaking" the law but not "re-litigating" the health reform debate.

This is a debate that neither side is likely to win.

Let's start with the Republicans. They believe that they have a mandate to seek repeal of the ACA, but they won't be able to deliver. The House GOP will run smack dab into a Senate that will do what the Senate does best, which is to bury legislation that comes out of the House. Senate Democrats will use their majority - and the filibuster, if needed - to block efforts by the House to repeal or reverse key provisions, and President Obama will use his veto pen if necessary.

Plus, when it comes to specific changes, the GOP may find that they don’t have the public's support. Do voters really want the new Congress to repeal the prohibitions against insurance companies charging more to people with pre-existing conditions? Do they want to give up their "free" preventive services and annual Medicare wellness exam? Will they want to give up the promise made by the law that if they lose their jobs starting in 2014, they won't lose their health benefits?

What about physicians? Do they really want Congress to take away the 10% increase in Medicare payments for primary care to be in effect for the next five years? Do they want Congress to withdraw funding to raise Medicaid primary care payments to the Medicare rates? Do physicians want Congress to defund programs intended to reverse a growing shortage of primary care physicians? Do they want Congress to halt the redistribution of unused residency positions to general internal medicine and family medicine residency programs? Do they want Congress to stop the federal government from enforcing rules to require insurance companies to standardize, simplify and reduce paperwork on physicians and patients?

What about the programs created to lower costs and improve outcomes? Will the new GOP House, which has complained that the Affordable Care Act doesn’t do enough to control costs, want to eliminate funding for comparative effectiveness research and the new Center on Medicare and Medicaid Innovation - two of the most promising avenues to lower costs and improve outcomes? And if the GOP were to repeal the savings in Medicare from reducing payments to hospitals and Medicare Advantage plans without finding offsets, the result would be a whopping $500 billion increase in the budget deficit, according to the CBO.

By committing itself to a "repeal and replace" agenda, the GOP risks alienating many voters for trying to dismantle popular parts of the law, disappointing its base for failing to get rid of it, and upending its promise of deficit reduction.

This doesn't mean that President Obama or the Democrats necessarily will have the upper-hand. The fact is that the President has been unable to persuade a huge chunk of the electorate that the Affordable Care Act will make health care more affordable. Instead, many believe it will lead to higher premiums, more government spending, and more debt. As long as this is so, the Affordable Care Act will continue to be politically vulnerable, and many Democrats who support it will continue to be at electoral risk.

There is another option than for both parties to engage in a no-win fight over repeal. They could look for ways to make improvements that preserve the key elements of the ACA - including the promise to provide coverage to most Americans - but allow for testing by states of free-market approaches to delivering such coverage.

They could start by allowing states a great deal of flexibility in setting up the health exchanges. The Washington Post reported on Tuesday that with GOP gains at the state level, "two models are likely to appear: Democratic governors and legislatures are likely to emphasize vigorous regulation and government oversight, while Republican state leaders are likely to put greater stock in privatization and other free-market approaches." States could experiment, for example, by offering health savings accounts on an equal playing field with other insurance products. HHS Secretary Sebelius has already signaled a willingness to consider states' requests for waivers from certain ACA requirements.

President Obama and Congress could also agree to expand upon and accelerate the authority granted by the ACA to allow insurance to be sold across state lines. They could agree to a serious effort to make real reforms in the medical liability system, such as authorizing and funding a national demonstration project of health courts. They could even commit to a bipartisan effort to reform Medicaid to make it a more effective and affordable program. And while they are at it, they could get a bipartisan deal on reforming physician payments and repealing the Medicare SGR.

For all of this to happen, though the GOP would need to back down from repeal being the only acceptable option and accept the law's commitment to provide most Americans with affordable coverage. President Obama and his congressional allies would have to be willing to give the states more options to implement market-based reforms, to recognize that not every program created by the ACA is of equal importance for funding, and to show courage in making medical liability reform a priority.

The political dynamics are such that none of this is likely to happen, but I think the country would be better off if they tried.

Today's question: Do you think President Obama and the GOP can agree on improvements to the ACA, or is the polarized debate on "repeal and replace" our inevitable future?


Steve Lucas said...

I would give the Republicans a little more credit for political awareness. They may put forth a bill to repeal health care reform knowing it will not make its way through the Senate. This will then allow them to attack parts of the bill, leaving those issues where there is strong public support to remain in effect.

The Congress may also have it’s work accomplished as the last election put 28 Republican AG’s in place, and all are expected to join in the suit to have this statute declared unconstitutional. This will really set back the whole process and any chance of positive reform may be lost.

I am a business person, not a doctor, and my most immediate concern would be the cuts in payments due Dec. and Jan. 1. The combination would, in my opinion, make it almost impossible to see government insured patients. While I have a problem with doctors crying poverty, there is the very real need to make a buck. Doctors will find it very enticing to go to work for someone else, eschewing private practice for the reliability of hospital employment.

The real issue is time. If the politicians do not act quickly, preferring to posture, then many, many small practices will be put at financial risk.

Steve Lucas

Jay Larson MD said...

This is a no brainer, especially since John Boehner wants to "do everything we can to try to repeal this bill".

Arvind said...

This Bill was passed along party lines, so repeal will be the first option. If there had been genuine negotiations prior to passing this on a Saturday night, perhaps there would be possibility of bipartisanship. Just as the President kept saying "election have consequences". Its best to accept that this was a poorly crafted, partisan Bill, unacceptable to a majority of the population.

PCP said...

There is currently no financial viability to a General Internist private practice.
I very seldom see a young internist open up a private practice anymore. I see them either sub-specialise, become hospitalists, join larger multi-specialty groups or some such variation. A few go to CHCs or FQHCs for either J1 waiver jobs or NHSC loan repayment but generally move on after that commitment period because of the poor and frustrating working conditions there.
So General IM is already on a death spiral, with or without the 25% projected cut over the next 2 months, most readers of this blog I think acknowledge this.
What this cut might do is cause the hardy older PCPs like one or two frequent posters on this board to throw in the towel earlier, and therefore further accelerate the demise of this field.
The gov't will say, oh don't sweat it, the NPs will do it if there are access issues, that is then up to the public to decide upon. I clearly have my views on that.
On the specialty side is where we will start to see big changes, specialty practices will start to slip into the same hole that private primary care practices have been swallowed into over the past decade. That too (like it did for primary care) will take some time to play out. What we are seeing is the gradual erosion of medicare into what medicaid is in most states. Private insurers are riding on the back of these gov't programs effectively creating virtual oligopolies, crushing private practices and dictating onerous terms that are threatening the autonomy of the profession and hence its ability to give patients the most objective advise.
With that as the backdrop, the Gov't is pushing ACOs, EHRs and other such ways to further control and manage the profession. Ultimately Doctors will get crushed and turned into mere employees, but the worst losers will be patients who will have lost a motivated, fearless and powerful advocate. That will then rapidly erode trust and bring about a whole new set of issues we have not considered.
None of these are welcome developments.
If only people would understand and respect the value Private Practice brings to their health care. A few people do but the vast majority do not.

Unknown said...

wow is all that I can say i don't think i have been on a site yet that put as much detail into their blog as you have so thank you for putting it in such a way that someone like me can understand. also there is more information at Health Care Reform

Harrison said...

Polarized debate is our inevitable future.
This is not just on health care reform.
It will start with the tax cut debate.
It will include the budget debate.
It will probably include our continued involvement in Afghanistan and Iraq and even in the Israeli-Palestinian conflict.

The ratings of Fox News and MSNBC will increase as more people give in to the notion that politics is necessarily adversarial.

And it will be ignored that things held up in the Senate by a minority of Senators and by ideological differences will gain passage by margins of 90 - 10 or 80 - 20 many times.

It will be ignored that there is plenty of common ground between the parties.

It will be ignored that there in fact is a lot of common ground even on health care reform right now between the parties and even between the discussants on this site.

The argument is just too interesting and too entertaining, and we love to be entertained.


Toni Brayer, MD said...

I appreciate this thoughtful post with the potential scenarios that could actually work for the American people.

Because the Republican's main goal (self stated) is to win back the white house, I fear there will be no compromises and gridlock will be the outcome. They will not be able to "repeal and replace" for the reasons you stated, so "delay and confusion" will prevail.

I doubt that you could find too many Americans that would list the advantages of ACA. Your list is huge, but unknown by the public.

They know something happened, but they don't know what. Insurance premiums continue to rise (30-40% increases in California), even though the medical loss ratio is going down and people are not using health services because of the recession. The public has not seen the benefits of reform and the Dems have done a terrible job of messaging.

The first baby boomers are reaching Medicare age. I know of many who are just breathing a sigh of relief that they are almost there. What does that tell us about the mess we are in? No-one is dreading government sponsored Medicare, they are embracing it with both arms. ACA didn't really tinker with Medicare, except to expand some benefits and attempt to improve the plight of primary care. Alas, I agree with PCP that it is too little, too late for primary care. That train has already left the station and crashed.