The ACP Advocate Blog

by Bob Doherty

Monday, March 29, 2010

How health reform will help Medicare patients

You may have noticed - uncharacteristically for me - that I haven't posted a blog in week. I thought it would be better to allow the readers of this blog to post your own reflections, and you did - with comments ranging for unabashed pride to skepticism to disdain for the law and ACP's role in bringing in about.

I respect the principled arguments made by those who believe that the legislation gives the government too much control, or who fear that it will add to the deficit and public debt, even though the CBO says otherwise. But there is one claim made by some of the critics that sticks in my craw, which is that the legislation will result in "massive cuts" to Medicare.

Here are the facts. Seniors in the traditional Medicare program will get better benefits because of the new law. The Medicare Part D "doughnut hole" will be phased out, starting with a $250 rebate check this year. Later, Medicare will begin covering preventive services, like check-ups and screening tests, with no co-payments or deductibles. The law actually prohibits cuts in Medicare's mandated benefits. Some seniors in Medicare Advantage plans might see a loss of optional benefits, like eye glass coverage, if their health plan decides to trim benefits to offset lower Medicare payments. But the fact is that the overwhelming majority of seniors in the United States will have lower out-of-pocket costs and better coverage.

What about the $500 billion "cuts" in Medicare? Well, for one thing, they aren't cuts, but reductions in the rate of increase paid to some non-physician providers over the next ten years. Hospitals will get smaller annual "market basket" inflation increases. They also will see gradual reductions in their disproportionate share payments, which cover the costs of indigent care, because they will have fewer indigent patients to treat and less uncompensated care. (These cuts were agreed to by the major trade associations representing hospitals.) And the law corrects that long-standing over-payments of Medicare Advantage plans, which up until now were able to charge the federal government more for taking care of seniors than a physician or hospital in traditional Medicare.

And, guess what, the $500 billion in Medicare savings actually extends the life of the Medicare Hospital Insurance Trust Fund. By spending less over the next decade, the Trust Fund won't run out of money in 2017, as previously forecasted by Medicare's actuary. Instead, it is now expected to remain solvent until 2026.

Many physicians will see higher payments under the legislation. General internists and primary care physicians will get a 10% Medicare pay increase for their office and other outpatient visits, beginning in 2011, as long as such visits constitute 60% of their total Medicare allowed charges. And in years 2013 and 2014, Medicaid payments for visits and vaccines by primary care physicians will be increased to no lower than the Medicare rates. ACP fought long and hard to get both provisions included in the final law.

There are a few provisions that could result in reductions in payments to some physicians in future years: payment penalties for not participating in Medicare's Physician Quality Reporting Initiative; a "value index" that beginning in 2014, might lower payments to physicians with higher costs and poorer outcomes; and the possibility that an Independent Payment Advisory Board could recommend additional reductions. ACP has expressed concern about each of these provisions, and we will seek to change them in future legislation. But the fact remains that the legislation will spend billions of dollars more to increase payments for primary care, while physicians were mostly exempted from more cuts.

Yes, physicians are still facing potential cuts from the Medicare's SGR formula. But these cuts were the result of a formula enacted by Congress back in 1997, and that successive Congress - no matter which political party was in control - have failed to correct. President Obama, at least, has proposed to repeal the SGR and to accurately account for the costs of repeal in his budget. Yes, the Senate still needs to act to permanently repeal the SGR, as the House has already voted to do. But the idea that the SGR cuts are the result of the health care reform legislation is silly, when doctors would have been facing the cuts even if health reform had never seen the light of day.

The bottom-line is that health reform law is a good deal for Medicare seniors, because it will lower their out-of-pocket costs, expand coverage for preventive services, close the doughnut hole, extend the life of Medicare Part A, and even pay their primary care physicians a bit more.

Today's question: How do you think the new health reform law will help or hurt Medicare patients?

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?

Sunday, March 21, 2010

Just the facts, ma'am

With the vote on the health reform legislation expected to take place within hours, it would be nice to believe that we can begin moving to the stage where people begin looking at what the legislation will and will not do-- not based on speculation or the political rhetoric--but what is actually in the legislation itself. I realize that this is unlikely, since we all tend to engage in cognitive dissonance when confronted with information that does not square with our own pre-conceived notions, political leanings, and philosophical bent. I know I do it, as much as I try not to, and I am sure this is true of just about all of us. Still, there are trusted and highly credible sources of information that I hope will be of value to anyone who is open to learning more about the legislation and its potential impact:

Today's Washington Post has an excellent interactive tool that shows how the legislation will benefit different categories of people and in different income brackets: insured married with children, small business owner, and Medicare beneficiary, and uninsured middle-age couple, uninsured single father of two, and a recent college graduate.

The Kaiser Family Foundation has an excellent summary of the legislation, which can help you answer questions about what is actually in the bill. You can use that chart to search for key words.

There are two independent fact-checking organizations, www.politifact.com and www.factcheck.org, which provides accurate information to debunk the misinformation being spread by proponents and opponents alike. For instance, they address the claims that the legislation authorizes the federal government to ration care (not true), will result in massive cuts in benefits to Medicare recipients (also not true), or deny women access to mammograms (not true), or impose a government-run health care system like Canada's and the U.K's (not true). Politifact's lead article offers the top ten facts to know about health care reform. These sites don't just take issue with inaccurate information from opponents, but also misinformation from proponents, including President Obama, such as the statement that most people's insurance premiums will go down (not true).

I remind readers to look the information on ACP's own Web site, including FAQs, a two page summary of how the legislation compares to ACP policy, and a more detailed section by section analysis of the bill.

Finally, the Kaiser Family Foundation's March health care tracking poll provides some important insights into the public's views on health reform, showing that the public is divided on the merits of the legislation and the next steps in Congress, but that many don't have a good understanding of some of the key elements in the bill. For instance, the survey found that most respondents were unaware that the Congressional Budget Office has concluded that the legislation will reduce the deficit, not increase it.

Saturday, March 20, 2010

What have ACP members told us in surveys?

As I wrote on Friday, ACP doesn't make policy based on opinion polls, but on an consensus and evidence-based process that, we believe, broadly reflects the views of membership while producing policy that is strongly informed by the best evidence from published research. We have heard from ACP members, though, who have asked whether we have surveyed how our members feel about health reform. In Friday's post, I provided links to two ACP surveys, but discovered that they brought you to restricted pages on our website. So below is a summary of the methdologies and findings, prepared by our research staff:

I realized that the links to the two ACP surveys I mentioned in my post are in a restricted area of the ACP website. I asked our research staff to summarize the methodology and findings, as follows:

2009 ACP Member Survey
ACP's 2009 Member Survey included two separate self-administered paper and Web surveys (Surveys 1 & 2) of two independent random samples of 2,000 U.S., non-student, current ACP members ages 65 and younger. The survey results may be used to describe this population. Data were collected between February and July 2009. Public policy and advocacy questions were included in survey 2. The ACP Research Center received 973 valid responses to Survey 2 (51% response rate). About 67% of responses to Survey 2 came from the paper versions. The final respondent sample for each survey is comparable to the sampling frame in terms of age, specialty, U.S. region, race, sex, IMG status, professional activity and employer.

Member views on public policy issues
Members were asked to rate the degree of priority that several policies should have in ACP's advocacy agenda for reforming the U.S. health care system. A clear majority (over 70%) indicated that the following should be a somewhat high or very high priority for ACP:

* Policies to reduce paperwork and administrative costs of health insurance (90%)
* Policies to increase the number of general internists and other primary care physicians, such as improved reimbursement and loan forgiveness (84%).
* Policies to provide better coverage and incentives for prevention and management of chronic illnesses (82%)
* Policies to reduce the cost of health care and reduce gaps in health care quality (76%)
* Laws guaranteeing that all Americans have access to affordable coverage, with government subsidies for those who cannot afford coverage (71%).


2009 ACP Health Care Reform Survey
The 2009 Health Care Reform Survey was a web survey of a random sample of 2,000 U.S., non-student, non-retired, current ACP members ages 65 and younger. Data were collected between October and November 2009. The ACP Research Center received 290 responses to the survey (15% response rate and a margin of error of plus or minus 8%). The final respondent sample for the survey is comparable to the sampling frame in terms of specialty and U.S. region, but differs from the sampling frame in terms of age, race, sex, IMG status, professional activity and employer. For the most part, responses to the survey questions are not related to the characteristics that are over- or underrepresented in the sample, and, therefore bias appears to be minimal.

Support for Specific Positions on Reform
Respondents were asked whether or not ACP should support twelve different positions for achieving health reform.

A clear majority (over 85% of respondents) indicated support for the following five positions:
* Health reform must include reforms in the medical liability system in order to be effective in controlling costs (94%).
* Individuals and small businesses should be able to have a choice of affordable plans through a purchasing pool (exchange) that gives them the same ability as larger companies to get the best group rates (94%).
* Insurance companies should not be allowed to turn away patients because they have medical conditions (90%).

* All legal residents should have access to affordable health insurance and financial help, when they can't afford it (86%).
* The federal government should create incentives to encourage medical students and young doctors to go into primary care internal medicine (86%).

Over half supported the following five positions:
* Insurance companies should be required to cover evidence-based practices that have been shown to prevent disease, as well as screening tests that detect diseases at no out-of-pocket cost to the patient (79%).
* Larger employers (defined by such factors as number of employees and payroll) should be required to offer health insurance to employees or pay into a fund to help pay for coverage for their employees (73%).
* All Americans should be required to buy health care coverage, as long as there are federal subsidies to make coverage available for those who can't otherwise afford it (65%).
* A public plan option should be available to compete with private health insurance plans on a level playing field as long as it has competitive payment rates and participation isn't mandated (64%).
* Insurance companies should not be allowed to charge patients more because they have medical conditions (62%).

The proportions of respondents who support the final two positions reflect the fact that the proposals are correlates:
* The federal government should increase Medicare payments to primary care physicians even if this would result in lower pay for other specialties (66%).
* The federal government should increase Medicare payments to primary care physicians only if it does not involve reductions to other specialists (31%).

The proportion of members supporting the 12 positions did not differ by age, primary professional activity and practice size.

General internists and internal medicine subspecialists differed significantly in their support for two specific positions:
* A higher proportion of general internists (91%) than subspecialists (51%) feel ACP should advocate for the federal government to increase Medicare payments to primary care physicians even if this would result in lower pay for other subspecialties.
* A higher proportion of subspecialists (62%) than general internists (22%) feel ACP should advocate for the federal government to increase Medicare payments to primary care physicians only if it does not involve reductions to other subspecialties.

Today's question: How would you have answered the same questions?

Friday, March 19, 2010

Why ACP supports a "yes" vote ... the facts

I expected spirited commentary on ACP's position on the final health reform bill, including taking our fair share of lumps. Particularly at a time when emotions are running high, I think the debate needs to be informed by the factual and substantive reasons for ACP's posture.

ACP's website has a new two page summary, a more detailed section by section analysis of how the legislation compares with ACP policies, and responses to Frequently Asked Questions about the legislation.

Anyone who is willing to review the materials with an open mind should find that there is much in the legislation consistent with policies that have long been advocated by ACP's membership.

Our overall approach, as largely mirrored in the legislation itself, is hardly radical - it builds upon and improves the current private employer-based health insurance system, principally relying on tax credit subsidies for individuals and small businesses and group purchasing arrangements to expand coverage, and appropriate and needed regulation of the insurance industry to ensure that it does not engage in practices that help their bottom line by excluding persons with pre-existing conditions. There is no public option or new government run health plan. These are policies that ACP itself advocated at least as far back as 2002, and in some cases much longer, way before this President and Congress took office.

I challenge those of you with a dissenting view to identify the specific policies in the bill that ACP supports - and why you disagree with them? Do you disagree with providing advance refundable tax credits to help people and small businesses buy insurance? To group purchasing arrangements from small businesses and individuals? To giving small businesses, self-employed persons, and others without access to employer-sponsored coverage a wide choice of qualified health plans? To prohibiting insurance companies from turning down or overcharging people with pre-existing conditions? To providing coverage of evidence-based benefits with no cost-sharing? To increasing Medicare and Medicaid payments to primary care physicians? To increasing funding for the National Health Services Corps and Title VII programs? To closing the Medicare Part D doughnut hole? To funding wellness and prevention programs? To standardizing insurance company transactions to reduce administrative costs? To funding research on comparative effectiveness to inform clinical decision-making? To providing coverage, principally through private insurance, to 95% of legal residents in the United States?

On tort reform, yes, we would have liked for the legislation to do more. But caps on non-economic damages, which we continue to support, are not the only alternative to the current trial by jury lottery system. Even when the Republicans controlled the White House, the House of Representatives, and the Senate, they never got tort reform enacted into law. (Caps passed the House on several occasions, but never got a majority of GOP Senators.) I don't make this observation for a partisan reason, only to point out that Washington's inability to enact caps is a bipartisan legacy that both political parties share. Given the long-standing and continued impasse in Washington on caps, it makes sense to explore other solutions on a state level, like funding for health courts.

Some of you have questioned how ACP arrives at its policies. ACP has a very inclusive policy development process that involves review of all policies by our elected Board of Governors and our Council of Student Members, Council of Subspecialists, Council of Young Physicians, Council of Associates, and Council of Student Members, before they are voted on by the Board of Regents. The policies originate in policy committees that are made up of rank and file ACP members. Any ACP member can recommend to their state's chapter governor that a resolution be introduced into the ACP Board of Governors. The resolutions to be discussed at the April Board of Governors meetings are now available for comment by ACP members until April 1. Several of the resolutions are directly relevant to the positions ACP has taken on health reform.

And yes, we have surveyed the membership, although we do not believe surveys - which any researcher will tell you are at best snapshots of opinion at a given time - are a good way to establish policy. The 2009 Membership Survey asked members for their priorities on health reform. On page 96 of the survey, you'll see that there is very broad support among membership for ACP's support for universal coverage, with 70% agreeing that "Guaranteeing by law that all Americans have access to affordable coverage, with government subsidies for those who cannot afford coverage" should be a somewhat high or very high priority. In October through November 2009, a more detailed survey was fielded by ACP's Research Center that also showed strong support from membership for the key policies advocated by ACP - including support for many of the more controversial policies.

Finally, the notion that the volunteer physicians who have dedicated their time to positions of leadership in ACP are a disconnected "elite" is inaccurate and unfair. I know these people, and I have the greatest respect for them. Our current President, Joe Stubbs, is a general internist in small private practice in Albany, Georgia. Our President-elect, Fred Ralston, is in private practice in Fayetteville,Tennessee. The chair of our Medical Service Committee, Yul Ejnes, is in a private internal medicine practice in Cranston, Rhode Island. The chair of our Health and Public Policy Committee, Rich Neubauer, provides care to Alaskan Natives in Anchorage, Alaska. The chair of our Board of Regents, Fred Turton, hails from a long background as a private practice internist in Sarasota, Florida. Yes, we include ACP members who also are in academic practices, as we should - all voices in the ACP membership are represented. But by no means is the ACP leadership detached from the realities of private internal medicine practice, when private internal medicine practice is still the bread and butter of much of our current leadership.

I understand and respect that there is a philosophical and substantive basis for some to disagree with ACP's views. For over a year now, the country has debated such issues as how much the government should be involved in regulating and subsidizing health care. Like the broader public, some ACP members will conclude that the legislation gives the government too much of a role, some too little, and like Goldilocks, some will decide that it gets it just right. But the time has come for Congress to decide one way or another. I believe that ACP has arrived at a strong, factual, evidence-based, and balanced position that serves its members well, by championing improvements that will expand access and coverage to millions of patients in a fiscally responsible way.

Today's questions: (For those who disagree with ACP), what are the specific policies in the bill that ACP supports that you disagree with, and why? (For those who agree with ACP), which specific policies that ACP supports do you agree with, and why? For those who are still unsure, what policies do you think are most important for ACP to continue to advocate?

Thursday, March 18, 2010

It's a wrap

Today, the House leadership released the final "corrections" bill that will modify provisions in the legislation passed by the Senate on December 24, putting it on track to be voted on by the House on Sunday. Politico has a good summary of key changes made by the legislation. Earlier in the day, the Congressional Budget Office released its "score" of the legislation. And President Obama postponed his planned trip to Indonesia and Australia to be present through the voting on the bill.

The CBO report should help innoculate the bill from the charges that it is fiscally irresponsible. Instead, CBO concludes that it will lower the deficit by $130 billion over the next ten years and by more than a trillion dollars over 20 years while covering 32 million more Americans - 95% of all legal residents. And, the CBO shows that the vast majority of Americans - more than 162 million of us - will continue to get coverage from private, employer-based health insurance, not a government-run plan.

What about the charge that the package will harm the Medicare program? Actually, as the House leadership has also pointed out, the Medicare savings in the bill (which are mainly reductions in the rate of increase in payments to hospitals and other non-physician providers - which in the case of the hospitals, was negotiated with their approval) will extend the life of the Medicare Part A trust fund by seven years. That's right - seven more years before Medicare goes broke if this bill is passed than if it isn't.

The final package has an important improvement from the Senate bill that ACP championed. Medicaid payments for all evaluation and management services by primary care physicians in 2013 and 2014 will be increased to no less than the Medicare rates. ACP will work to make this a permanent change so it doesn't expire after 2014. But this change, combined with the 10% Medicare bonus for office and outpatient visits by primary care internists and other primary care clinicians, are important first steps toward addressing long-standing payment disparities.

I'll have more to say about the legislation in tomorrow's blog, but the bottom line is that the changes made from the Senate bill, and the CBO report, confirm ACP's view that the legislation will advance key priorities on coverage, workforce, and payment and delivery system reforms, while reducing the deficit and helping to keep Medicare afloat.

Oh, and as always, I invite your reaction and comments on today's blog and the latest news, but let's try to keep the dialogue free of name-calling or attacks on the integrity and motivations of those you disagree with. Today, I reluctantly allowed a comment to be posted that disparaged those of you who regularly post comments on this blog, which I don't think really helped the argument of the person making the comment. I know that emotions are running strong, and passionate responses can be expected, but can't we all at least try to be respectful of those we disagree with, and assume that they too are motivated by doing what they think is right, even if you or I disagree with them?

Today's question: What is your reaction to the final legislation and the CBO report?

Wednesday, March 17, 2010

"There once was a man named O'Bama ..."

As regular readers of this blog know, Saint Patrick' Day is one of my favorite days of the year. As a first-generation American, I have an appreciation of all things Irish, instilled (or should I stay distilled?) in me by the late Jack Doherty, my Irish-born Dad who ran a neighborhood bar in Woodside, Queens, New York. Following my Dad and his father, I was the third generation of Doherty's to "work behind the stick," as the old-timer would put it, tending bar during my college breaks to help earn some extra dough.

Like any good Irish bar, on Saint Patrick's Day, Doherty's was filled to the brim with celebrants eager to sing a song, down a few, and engage in the traditional Irish sports of story-telling and blustery argument. It's probably because of this that I (usually) enjoy my work as a lobbyist and policy wonk in Washington, a town that more than any other lives on blarney and argument.

One favorite tradition is the Limerick, a five verse poem named after the famous Irish city. Last year, I started the practice of penning a few limericks on health care in honor of Saint Patrick's Day. Now, I don't claim that my poetry will earn kudos, but I hope that they will at least bring you a smile. Tomorrow, we can get back to the more serious stuff of health care reform.

The town halls were something to see,
Voters screaming for their right to be free
"Get government out of health care
But don't dare cut my Medicare"
How they can be so confused, escapes me.

There once was a man named Reid,
On health care, the Senate he'd lead.
But when a man named Brown
Came to D.C. town
Reid doubted they'd finish the deed.

It looked like health care had run out of gas
In Congress, it was at an impasse
The Massachusetts election
The voters' rejection
Can it now be saved by a Hail Mary pass?

Health reform has become a real bummer
Could the arguments get any dumber?
Now it's St. Patrick's Day
And I just gotta say
I wished they had passed it last summer.

Happy Saint Patrick's Day!

Today's question: Care to try your hand at crafting a health reform limerick?

Tuesday, March 16, 2010

How should Congress choose?

By this time next week, we will probably know if health care reform will be signed into law. All indications are that the House will vote on the final legislation on Friday or Saturday. The vote will essentially be on the bill that passed the Senate on December 24, with modifications to be made in a side-car "corrections" bill that can be passed by a simple majority using budget reconciliation.

The process and procedures will be messy, but today, I want to talk about substance. Does ACP believe that the Senate bill, as it will be modified by the corrections bill, deserves a "yes" vote in Congress?

ACP has determined that it does, because in most respects, the legislation is closely aligned with ACP policies developed over many years in a series of position papers.

On coverage, we have long advocated for policies to make affordable coverage available to the vast majority of Americans. We support providing sliding-scale tax credits to help businesses and individuals afford coverage. We support creation of health exchanges to offer one-stop-shopping for qualified health plans and to negotiate affordable premiums with participating plans. We support making all persons up to 133 percent of the Federal Poverty Level eligible for Medicaid. We support increased Medicaid "matching funds" to all states to finance most of the cost associated with such expansion. We support requiring all health plans to provide affordable and non-discriminatory coverage to people with pre-existing conditions. We support requiring all health plans to provide essential and evidence-based benefits including preventive services.

On workforce, we advocate for policies to train more primary care physicians and to reform payment policies to support the value of primary care. We support increased funding for the National Health Service Corps and Title VII health professions training programs. We support creation of a national workforce commission. We support providing eligible primary care physicians with a 10% Medicare bonus on all of their office, nursing home, home health care, and emergency room services, as a first step toward addressing payment disparities.

On delivery system reform, we advocate for accelerated pilot-testing of innovative payment and delivery system reforms, including Patient-Centered Medical Homes. We support funding of more research on comparative effectiveness to inform clinical decision-making.

ACP's support is based solely on how closely the legislation aligns with policy, not the process or politics selected to move it across the finish line.

This doesn't mean we like everything in the legislation. It doesn't go far enough on addressing the crisis in primary care, or in reforming the medical liability tort system. It doesn't give Congress enough control over the recommendations of an expert Medicare payment advisory group. Congress still needs to come up with a permanent solution to the Medicare (SGR) physician payment cuts. These, and other needed improvements, can and should be made in subsequent legislation.

But at this, the final stages of the legislative process, the decision is a pretty simple one. Does the legislation advance the policies that ACP has long championed in our own policy papers? We believe that it does, and tomorrow, ACP will be joining with more than 200 national health organizations to urge that Congress vote "yes" on the final health reform bill.

Should Congress fail to pass health reform, ACP believes that we will be looking at a future - as documented in ACP's recent State of the Nation's health care paper -- where health insurance premiums will double, putting health insurance out of reach of most middle class families, where Medicare will go broke, where one out of five us will have no insurance coverage, and where insurance companies will continue to reject people because they change jobs or get sick.

I know that some of you will see the choice differently. But ACP has made its choice: this legislation, although imperfect, will advance ACP's key policies, and is far better than alternative of once again seeing health reform fail.

Today's question: How do you see the choices facing Congress?

Monday, March 15, 2010

March Madness

While most normal red-blooded Americans are focusing on the NCAA basketball tournament, Washington is paying attention to another "sudden death" tournament going on in the nation's capital.

As early as Thursday, the House of Representatives will cast its votes on whether to approve the December 24 bill passed by the Senate and a side-car "corrections" package, using the "majority rules" reconciliation process.

If the vote fails to get a majority in the House, health reform is dead. Or at least the type of reform that would make a dent in reducing the numbers of uninsured. While Congress might extend some existing health programs that are set to expire, and probably do something to stop the next round of Medicare pay cuts, that's about it. I see no chance that they would "start over" and pass reforms to cover more people or ban insurance companies from turning down people with pre-existing conditions.

Like basketball fans rooting for or against a particular team, I know that some readers of this blog fervently hope that the legislation will fail, while others feel just as strongly that it should pass. (Later this week, I will have more to say about how ACP is approaching the final votes.) Yesterday, Health Affairs published a fascinating new study that helps explain why we Americans are so divided on health reform

The researchers looked at polling from 1999 to today that shows that a person's views on health reform are related to two factors: (1) their partisan and ideological leanings and (2) how much they think the uninsured already get decent care. The first factor - that someone's political views are a major influence on how they view health reform - isn't particularly surprising. One would expect Republicans to be more opposed to using government to expand coverage, and Democrats more in support.

More interesting is that people differ in their perceptions of the care available to the uninsured. Overall, the authors' write, "In 2009 a majority of survey respondents (56 percent) still perceived that the uninsured are able to get necessary medical care." Support for health reform "was significantly more popular among people who perceived that the uninsured are unable to get care (72 percent) or able to get care with great difficulty (75 percent) than it was among those who perceived that it is not too difficult (38 percent) or not at all difficult (31 percent) for the uninsured to get care ... These associations persisted even after political party and demographic characteristics."

And who were the people most, and least, likely to believe the uninsured get needed care? "Democrats are far more likely than Republicans to believe that the uninsured have difficulty gaining access to care. Senior citizens are less aware than others of the problems faced by the uninsured. Even among those Americans who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform."

The fact that large swaths of the American electorate believe that the uninsured are getting the care they need flies in the face of evidence - such as the study that I blogged about on Friday - that people without coverage are more likely to die prematurely than those who have insurance.

Because of this continued divide, the author's state that "even if President Barack Obama signs health reform into law, its future political support could be uncertain. A shift from Democratic to Republican control of either congressional body could mean the reduction or elimination of funding for insurance subsidies. Subsidies are essential to a coverage expansion that these critical constituencies ultimately deem unnecessary." Republicans already are making it clear that they will seek repeal if the bill passes Congress and is signed into law, even though that is not likely to happen as long as President Obama is in the White House.

In this sense, this week's elimination round vote, as crucial as it is, will not settle the long-standing divide in the electorate on the role of government in subsidizing care for the uninsured, or even on the basis question of whether the uninsured already get the care they need.

Today's question: Why do you think most Americans believe that the uninsured can get the care that they need, when studies show otherwise? And why does a person's view on this question tend to track with their partisan leanings?

Wednesday, March 10, 2010

Is lack of coverage an inconvenience? Or matter of life and death?

One of today's great philosophical divides is whether health reform should seek to provide coverage to all Americans. The Democrats (generally) believe that (near) "universal" coverage must be an explicit purpose of health reform, even if this means spending more and raising taxes to pay for it. Most Republicans (generally) do not have as a goal providing coverage to everyone, especially if this means spending more and raising taxes to pay for it. Instead, the GOP wants to offer more choices and reduce regulation of the insurance industry, such as by selling insurance across state lines, even though this would not make much of dent in the number of uninsured.

But what do we really know about the uninsured? Do most of them already get health care, maybe less conveniently than the rest of us? If so, the moral and economic argument for covering everyone, especially if it will cost up to $100 billion a year, isn't too compelling.

Washington Post columnist Robert Samuelson, a persistent critic of the President Obama's proposal, argues that "The uninsured get care now; with insurance they'd get more" but at a cost that will bankrupt the country. He also says that "Many of today's uninsured get health care for free or don't need much because they're young (40 percent are between 18 and 34)."

But what if he is wrong - that lack of health insurance isn't just an inconvenience, but a matter of life and death? A new study that appeared in the December 22, 2009 issue of the Journal of Public Health and that is reprinted in the current issue of ACP's Journal Club finds that the uninsured are much more likely to die prematurely than those with health insurance. Here's what the authors have to say (warning, some of this gets into arcane statistical jargon):

"A 1993 study found a 25% higher risk of death among uninsured compared with privately insured adults. We analyzed the relationship between uninsurance and death with more recent data. . . We conducted a survival analysis with data from the Third National Health and Nutrition Examination Survey. We analyzed participants aged 17 to 64 years to determine whether uninsurance at the time of interview predicted death. . . . Among all participants, 3.1% (95% confidence interval [CI] = 2.5%, 3.7%) died.

"The hazard ratio for mortality among the uninsured compared with the insured, with adjustment for age and gender only, was 1.80 (95% CI = 1.44, 2.26). After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio = 1.40; 95% CI = 1.06, 1.84) than those with insurance.

"Conclusion: Uninsurance is associated with mortality. The strength of that association appears similar to that from a study that evaluated data from the mid-1980s, despite changes in medical therapeutics and the demography of the uninsured since that time."

I doubt that this study - and there are others like it - will dramatically change the public or politicians' views of the current health reform proposal. But in a country that is willing to spend untold billions to prevent other avoidable deaths - think highway, car, aviation, food and prescription drug safety, or for that matter, homeland security - I wonder why there is not the same willingness to invest the money needed to prevent people from dying from lack of insurance?

Today's questions: Do you agree that lack of insurance results in premature death? If so, why do you think there is an unwillingness to treat it like other avoidable deaths? Or is it case where "many of today's uninsured get health care for free or don't need much because they're young?"

Tuesday, March 9, 2010

What does the American public really want?

As part of their closing argument against health reform, Republicans argue that Democrats who vote for the bill will be ignoring the will of the American people, at their own political peril. Senate Minority Leader Mitch McConnell accuses Democrats of wanting "to plow ahead on a partisan bill Americans don't want..."

McConnell is correct that just about every recent poll shows that majorities of Americans dislike the current legislation.

Supporters of the legislation counter that it really has more public support than a simple "for or against it?" poll would yield. The Kaiser Family Foundation tracking poll finds that the country is evenly divided on the legislation, but large majorities support many of the major provisions in the bill. And, when asked about the next steps for health reform, a plurality of 32% said that Congress should, "Move soon to pass the comprehensive legislation that has already been approved by the House and Senate" compared to 22% who want to "Put health care on hold, so Congress can work on other priorities and try to deal with it later in the year," 20% want to "Pull out a few key provisions where there is broad agreement and pass those, even though this won't be comprehensive reform," and 19% want them to "stop working on health care" this year.

Economist Uwe Reinhardt has another interpretation of what the public wants, not from polls, but his own keen observations. He blogs in Health Affairs that "as the policy-making elite stews in its stalemate, the American plebs dreams of a political Messiah willing to build for them a health system that:
1. Lets only patients and their own physicians determine how to respond clinically to a given medical condition, never an insurance clerk or, even worse, government bureaucrats.
2. Limits their families' out-of-pocket payments for health care to make it "affordable."
3. Keeps insurance premiums and taxes for health care low.
4. Does not ever ration health care, because that is un-American and practiced only by un-American alien nations with inferior health systems.
5. Does not allow public or private insurers to let "costs" or "cost-effectiveness" ever enter coverage decisions, because that would implicitly put a price on human life which, in America, unlike elsewhere in the world, is priceless.
6. Does not mandate individuals to purchase health insurance, if they do not wish to do so, if for no other reason than that this would be unconstitutional and, therefore, un-American.
7. On the other hand, grants every American the moral right - backed up by a government mandate called EMTALA - to receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, even if they are uninsured and could not possibly pay for that expensive care with their own resources.
8. Controls Medicare spending, which is widely thought to be completely out of control, as long as it does not reduce payments to hospitals or to doctors or to producers of medical technology, or to any other provider of health care.
9. Provides universal health insurance coverage to all Americans, provided it does not mean raising taxes or cutting Medicare spending or raising premiums on healthy Americans.
10. Keeps government out of health care but somehow makes sure that insurance companies do not exploit patients through incomprehensible fine print, no one engages in price gouging - e.g., charge $10 for an aspirin - and no one in health care earns excessive profits (or any at all).

That's all.

One must wonder why America's policy-making elite has found it so hard to satisfy these simple wishes of the American plebs. And as the American people anxiously wait for that Messiah, I wish them luck. In the meantime, we shall muddle through as usual."

I think Reinhardt is onto something. We tend to blame the politicians for the muddle in Washington, but I wonder if they are just reflecting the muddled views of people they represent. This could be why polls can simultaneously show that the public is against the health reform legislation - except when they say they are for its key elements.

Today's question: Do you think Uwe Reinhardt is correct in how he characterizes the muddled views of the American people?

Monday, March 8, 2010

What's so funny about health care reform?

The only sure thing about the final push for health care reform is that it going to add to the country's collective case of bad temper. How can we not feel down for having to go through at least another few weeks of listening to partisans of all stripes say anything imaginable to attack the other guys' arguments?

For at least one day, then, let's turn down the heat, and look to humor to put smiles back on our faces.

For even-handed skewing of all things Washington, see this link to the "Top Ten Health Care Reform Jokes," selected by Daniel Kurtzman from material provided by Jimmy Fallon, Craig Ferguson, Jimmy Kimmel, Jon Stewart, and others. My favorite: "The health care bill was introduced yesterday. It's 1,990 pages long and costs $894 billion dollars. Or $2.2 million per word. That makes them the most expensive words to come out of Washington since 'Mission Accomplished.'" - Jimmy Fallon

Or check out this article from The Onion. Good satire should be pretty close to the mark, and this one fits the bill. "Congress Deadlocked Over How Not to Provide Health Care" screams the headline. The Onion's "reporter" writes, "The legislative stalemate largely stems from competing ideologies deeply rooted along party lines. Democrats want to create a government-run system for not providing health care, while Republicans say coverage is best denied by allowing private insurers to make it unaffordable for as many citizens as possible."

Who knew that Republicans have a Marxist view of the health reform debate? You don't agree? Then take a look at this You Tube video. That's Groucho - not Karl - leading a rousing chorus of "I don't care what they have to say, it makes no difference anyway, whatever it is, I'm against it!" I found this video after a Google search turned it up on the liberal A Healthy Blog, which says this "nicely sums up" the GOP's approach to health reform.

A cartoon published by Kaiser Health News lambasts Harry (Reid) and Nancy (Pelosi), casting them as the stars in Thelma and Louise 2. Guess where their car is heading!

And my favorite of all is a video from the Tuftscope Health, Ethics and Policy, which shows what it would be like if the airlines were run like U.S. health care!

I hope that today's blog added a little amusement to the day. (Not to worry, though, in the next few days I'll get back to pontificating and riling up people in the process!)

Today's question: Do you have a favorite (but good taste) joke, blog, or video link that pokes fun at health care reform?

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?

Tuesday, March 2, 2010

Should physician anger be directed at denying care to patients?

Congress' failure so far to prevent a Medicare physician payment cut has generated a great deal of anger among physicians. The American Medical Association declares that physicians are "outraged." Alicia Ault blogs that "Doctors are Mad as Hell," citing my post from Friday and its reference to Howard Beale's "I'm mad as hell" rant from 1976"s "Network" movie. Ault also links to a post from the Happy Hospitalist who blogs that "It's time to screw granny and let the government find a way to provide their care for them."

How have we come to the point where a physician would advocate that the medical profession turn away from taking care of elderly patients? Even allowing for the hyperbole that is commonly accepted in the blogosphere, is it right for physicians to allow their righteous indignation at the government's failings to stop a Medicare pay cut (well deserved on this score) descend into threats to deny care to Grandma and Grandpa?

It is one thing to say that continued Medicare pay cuts will force many physicians to limit how many Medicare patients they can see (which I believe to be true), but a very different matter for physicians to advocate that physicians deny care to patients to make a political point. Instead of gaining the support of the public, I believe that the medical profession will lose public support if it seems to be elevating economic self-interest above patient care.

This is that point that "Harrison" made in response to my Friday post: He wrote: "We have to continue to be careful about advocacy. The US economy is precarious. Our patients are increasingly unemployed. It is right for us to advocate for our patients. It is right for us to point out that a 21% cut will lead to an impact on thousands of small businesses and to our employees. But if we start to say that we are going to stop seeing Medicare patients because we are going to get paid $80 per 99214 instead of $100 for a 99214 visit, well ... I don't think that is going to go over so well." Others disagreed.

Last week, an ACP member wrote to me and urged that we organize a "strike" against Medicare patients if the 21% cut goes through, saying he would be "very disappointed" if we did not. I'm not a lawyer, but I know that there are legal reasons why a physician membership organization can't advocate for collective actions by individual members to achieve economic gains for them. But there are ethical reasons as well.

ACP's Ethics, Professionalism and Human Rights Committee published a case study that draws the line between acceptable political advocacy and actions with the intent of denying care to patients to achieve a political purpose. The case study notes that ACP's Ethics Manual, which represents approved ACP policy, states that "... physician efforts to advocate for system change should not include participation in joint actions that adversely affect access to health care or that result in anticompetitive behavior. Physicians should not engage in ... organized actions that are designed implicitly or explicitly to limit or deny services to patients that would otherwise be available." Similarly, in addressing collective actions, the AMA specifically states that "physicians should refrain from strikes because they reduce or delay access to necessary care and interfere with continuity of care, all of which are contrary to professionalism and the physician's ethical obligations."

As I wrote last week, physicians should let their legislators know the continued Medicare pay cuts are unacceptable. They can inform them that they may not be able to afford to continue to see Medicare patients if the cuts continue. But the understandable outrage at government inaction should not turn into calls to organize boycotts or strikes against patients. "Organized actions that are designed implicitly or explicitly to limit or deny services to patients" not only would be bad politics, but according to the ACP and AMA, unethical to boot.

Today's question: Do you think physicians should deny care to their own Medicare patients as means to express their anger at the government?

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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