Thursday, November 4, 2010

To repeal or not to repeal, that is the question

Did the mid-term elections produce a mandate to repeal the Affordable Care Act?

Yes, says John Boehner (R-OH), Speaker of the House in waiting. Within hours of learning that the GOP had picked up at least 60 House seats, he pledged to "do everything we can to try to repeal this bill and replace it with common sense reforms to bring down the cost of health care." Senate Minority Leader Mitch McConnell (R-KY) chimed in by promising to push for outright repeal, and if that doesn't work, to try to undo it "piece by piece."

Meanwhile, Senator Harry Reid (D-NV), who presumably will remain as Majority Leader in the new 112th Congress, albeit with a much smaller majority, offered to consider "tweaking" the legislation but not to "denigrate the great work we did." A chastened President Obama also indicated a willingness to consider "reasonable changes" in the law but said that it was the "right thing to do." He also acknowledged that the process that produced the legislation was an "ugly mess" but that the "outcome was a good one."

The truth is that the voter's gave a split decision - literally. According to exit polling of a random sample of more than 18,000 voters conducted for the Washington Post, almost half of the voters said that the law should be repealed. But "almost the same number" felt it should be kept or expanded. Moreover, health care lagged well below the economy as an issue, with over 90% expressing concern about the economy while only 18% mentioned health care as a top voting concern. Many Democrats who voted for the Affordable Care Act were voted out of office, but so were many who voted against it.

The results from state referenda also were mixed. Colorado voters voted down a "symbolic" referendum to exempt the state's residents from some of the law's mandates, but voters in Oklahoma and Arizona gave approval to similar measures.

An article that appeared in the New England Journal of Medicine a few days before the election predicted the voters' split decision. Robert Blendon and John Benson analyzed 17 independent polls and found that "more than 7 months after the health care reform law was enacted, a majority of Americans neither favor nor oppose it." Many provisions of the law are popular, they report, but Americans also are concerned that the law will damage the economy and add to the federal debt. On the question of whether the law should be repealed, "18% of registered voters believed that Congress should implement the bill as it currently stands, 31% thought Congress should make additional changes to increase the government's involvement in the country's health care system, and 41% believed that Congress should repeal most of the major provisions of the bill and replace them with a completely different set of proposals."

The bottom-line is that the evidence - from numerous polls taken before the election and from the exit poll of those who actually cast their votes - does not show a mandate for repeal. Rep. Boehner and Senator McConnell, though, are accurately reflecting the views of most registered Republicans, who overwhelming disapprove of the law. Democrats, on the other hand, mostly support it, and independents are divided.

This is not to suggest that President Obama has been successful in selling the country on health care reform. Quite the opposite: the fact that seven months after it passed, most voters still don't know how they feel about it, suggests that the White House has not persuaded a skeptical public that it will be good for the country. But the GOP also has not persuaded a skeptical public that it should be repealed.

Instead, over the next weeks and months - and quite likely, through the 2012 Presidential election - the battle to influence public opinion will continue. But right now, the public's views are unsettled enough that neither the politicians who advocate for repeal, nor the politicians who advocate for staying the course (maybe with some "tweaks"), can have all that much confidence that they have the public on their side.

Today's question: What do you think the voters were saying about repeal of the health reform law?


Steve Lucas said...

All of this will play out against the backdrop of the $276 billion that will be needed to fix doctor payments.

Most people have something they like about health care reform. Kid’s issue rank high with the people I speak with, other issues such as the insurance mandate rank low.

Much of the political posturing is playing to the various bases as anything the House does will be stopped in the Senate.

The polls are telling the politicians there are issues we can agree on, but people want this bill broken down into parts, and the cost of each issue examined. The Tea Party has brought a new emphasis on spending, not expanding government.

Steve Lucas

ryanjo said...

The Republicans are cocky, the Democrats are defiant; not a formula for revising the ACA enough to "save it". When half the voters want it gone, and less than one of 5 even care, no one will shed a tear as this turkey is gutted.

Many state governments, bolstered by conservative majorities, will resist mandates at the local level. The House will undermine implementation, but leave the shards visible so that "Obamacare" can be a rallying point for the next 2 years.

The moment for healthcare reform has passed. There is still an opportunity to reflect on the reasons for failure. First point: what was the hurry? Do we introduce new drugs or treatments without limited trial, review and consensus? Politicians are hopelessly addicted to "legislative momentum", but how could the AMA & ACP applaud such a far-reaching change with no data?

What do our physicians' organizations do now? We build alliances with policymakers that understand that payment reform, rebuilding primary care & reduced admin burdens are needed to save our profession. We work to replace those who don't. If we merely "lend our expertise" again, just forget the PCMH and all the other initiatives.

Harrison said...

Can we not drop the horse race focus?
Who cares what 'message' the 'voters' were trying to send.
We should not be encouraging our politicians to do what they think they were elected to do.
We should be encouraging our elected leaders to do what they think is right for the country.
Then, if we don't like what they did we should consider whether they deserve another term.
We should not consider one issue. We should consider patterns and a body of work.

The health care reform bill is law.
The right thing to do is to enact it and stengthen it as we learn more about it.
It would be wrong to again engage in a national debate about the whole thing.

We should encourage our representatives to enact and interpret and amend as appropriate.

Otherwise we are just giving in to poll watching and mindless and meaningless bickering.


Arvind said...

There are some aspects of the law (please let's not call it "health care reform") that most folks agree about. There are others that simply should be the government's decisions - such as telling us how to practice or what insurance plans should cover, etc.

The best message the electorate has sent is "don't tell us what is goo and bad for us". Now the Republicans must muster the courage to allow transparency and market forces to decide the cost of care in each locality, and dismantle the "health care industry" of price fixing and CPT codes. Once we get the AMA and the government out of the decision-making process, and allow consumers (patient, ideally) and providers to work out the true "value" of services provided, there will be better quality and more selective use of services, i.e. cost savings. It is time for the government to get out of the health insurance business, but work to keep those providing insurance honest. It is also imperative that the public fully understand the exact cost of health care services they are receiving and the cost of their lifestyles and behaviors.

Jay Larson MD said...

It will be interested to see what the Republicans consider "common sense reforms to bring down the cost of health care". As Olser has said...Common sense is not common.

W. Bond said...

Let’s see, the largest mid-term gains since either the late 30’s or late 40’s depending on the close races combined with historical changes in state houses. This was not a normal mid-term swing. The Republicans have likely gained back 10 more seats than the Democrats took in ’06 and ’08.

The health care bill was – contrary to all normal political prudence – passed on strict party line votes despite signals from the electorate (most noticeably the election of a Senator from Mass. Running opposed to it) that it was opposed. Michael Barone referred to the legislation prior the election as “[the most] unpopular major measure passed by Congress since the Kansas-Nebraska Act of 1854!”

It would be a singular error to rely on exit polling and not on ballots cast. The election was a repudiation of legislative overreach and a clear rejection of progressive big government proposals. The biggest of them was the ACP supported health care bill.

Now that it is past, what efforts is the ACP making to court Republican lawmakers? Will the ACP consider dusting off it’s (I believe still current) recommendations to repeal Medicare price controls and allow physicians to set prices, if done transparently, above Medicare reimbursement levels? Price competition is a key feature of all working economies. No good has ever in history of the world been produced, nor any service delivered, in an increasingly efficient and productive manner without it. Let patients vote with their feet – it’s the truest measure of quality and value.