The ACP Advocate Blog

by Bob Doherty

Wednesday, December 22, 2010

The Twelve Days of Health Reform

Today's blog will be my last for 2010, as I will be taking a break to spend the Christmas and New Year’s holidays with family and friends.

In keeping with a tradition I started two years ago, I again have taken the liberty of mangling a beloved holiday song, story, or rhyme to give a humorous (I hope!) perspective on current politics. In December, 2008, I adapted “Twas the Night Before Christmas” to convey President-elect Obama as being a not-so-jolly old elf besieged by lobbyists demanding stimulus gifts. Last year, I depicted the GOP as the Grinch trying to stop “ObamaCare” from coming.

Today, I’ve re-written the “Twelve Days of Christmas” carol so that it is the government bestowing “gifts” (based on actual provisions of the Affordable Care Act) that the new Congress may later take away. (Of course, in the real world, the ACA’s changes won’t take place over 12 days, but over many years.) Here goes:

“On the first day of health reform, the government gave to me,
A promise of health care, available universally.

On the second day of health reform, the government gave to me,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the third day of health reform, the government gave to me,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the fourth day of health reform, the government gave to me,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the fifth day of health reform, the government gave to me,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the sixth day of health reform, the government gave to me,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the seventh day of health reform, the government gave to me,
Higher Medicare payroll taxes,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the eighth day of health reform, the government gave to me,
Better benefits in my company’s plan,
Higher Medicare payroll taxes,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the ninth day of health reform, the government gave to me,
Medicaid for my self-employed cousin,
Better benefits in my company’s plan,
Higher Medicare payroll taxes,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the tenth day of health reform, the government gave to me,
Low cost insurance through an exchange,
Medicaid for my self-employed cousin,
Better benefits in my company’s plan,
Higher Medicare payroll taxes,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the eleventh day of health reform, the government gave to me,
A fine if I don’t buy coverage,
Low cost insurance through an exchange,
Medicaid for my self-employed cousin,
Better benefits in my company’s plan,
Higher Medicare payroll taxes,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the Twelfth day of health reform, John Boehner gave to me,
No funding for the Affordable Care Act,
No fine if I don’t buy coverage,
No low cost insurance through an exchange,
No Medicaid for my self-employed cousin,
No better benefits in my company’s plan,
No higher Medicare payroll taxes,
No more money to my primary care doctor,
No free Medicare visits for my mom,
No tax credits for my small business,
No insurance for my adult kids,
No coverage of my pre-existing conditions,
And a “Hell no!” * to health care, available universally!"

*On March 22, the day health reform passed the House, Rep. John Boehner (R-OH), who in January will become majority leader, famously invoked the “Hell No” mantra in expressing his opposition.

Today’s question: No question today, just my hope that you have a happy, prosperous holiday season and new year with family and friends!

Thursday, December 16, 2010

Irony

If you appreciate irony, it doesn’t get much sweeter than this:

A GOP-appointed judge rules that a GOP idea, recently embraced by a Democratic president who a few years ago campaigned against it, is unconstitutional, possibly paving the way for a government-run program.

Strange, but true. A Republican-appointed judge in Virginia has ruled that the ACA’s individual mandate is unconstitutional (although two other federal judges appointed by Democrats have upheld it, and the Supreme Court will ultimately decide). The irony is that the roots of the individual mandate can be found in conservative proposals from the early 1990s.

In 1990, the conservative Heritage Foundation developed a plan for universal coverage that described the individual mandate as a “social contract” between the government and individuals:

“Under this social contract, the federal government would agree to make it financially possible, through refund able tax benefits or in some cases by providing access to public-sector health programs, for every American family to purchase at least a basic package of, including catastrophic insurance. In return, government would require, by law every head of household to acquire at least a basic health plan for his or her family.”

The individual mandate was then incorporated into bills proposed by GOP stalwarts Orrin Hatch (R-UT) and Chuck Grassley (R-IO) as an alternative to “Hillary Care.” It later became a lynchpin of the Massachusetts health reform plan championed by then governor (and likely 2012 presidential candidate) Mitt Romney (R-MA).

That was then, this is now.

The Heritage Foundation now argues that the individual mandate is “unprecedented” and “unconstitutional”- conveniently ignoring its own past ownership of the idea. A few days ago, Senator Hatch hailed the Virginia judge’s decision to overturn the individual mandate as “a great day for liberty. Congress must obey the Constitution rather than make it up as we go along. Liberty limits on government, and today those limits have been upheld.”

The irony isn’t limited to Republicans. During the Democratic primary, candidate Barack Obama not only opposed an individual mandate, he used it in attack ads against Hillary Clinton:

"What's [Clinton] not telling you about her health care plan?" an announcer asks. "It forces everyone to buy insurance, even if you can't afford it."

That was then, this is now.

Following the Virginia ruling, the White House had this to say:

“Opponents of reform claim that the individual responsibility requirement – the requirement that all Americans carry a minimum level insurance by 2014 – exceeds Congress’ power to regulate interstate commerce because it penalizes economic ‘inactivity.’ Make no mistake -- individuals who choose to go without health insurance are actively engaged in economic decision making – the decision to pay for health care out-of-pocket or to seek uncompensated care. Every year millions of those who have chosen to go without health insurance actively seek medical care, which is evident in the billions of dollars spent on uncompensated care every year.”

(I wonder what Obama’s Secretary of State would have to say about this now, but of course, she can’t.)

The above is fact – you can look it up. More speculative is the part about the Virginia ruling possibly leading to a single payer plan. But the Washington Post’s Ezra Klein plausibly writes:

“The individual mandate was created by conservatives who realized that it was the only way to get universal coverage into the private market. Otherwise, insurers turn away the sick, public anger rises, and, eventually, you get some kind of government-run, single-payer system, much as they did in Europe, and much as we have with Medicare.”

If Ezra Klein is correct, could anything be more ironic?

Today’s question: What do you think about the irony involved in today’s debate on the individual mandate?

Monday, December 13, 2010

Your comments, my responses

I started responding to specific comments from readers on two of my recent blogs, but have decided that they raise issues important enough to make up today’s entire post.

On “What happens if universal coverage is allowed to slip away” commenter ryanjo writes that there “is rapidly evaporating support for the ACA.” I think we pay too much attention to polls, but I took a look at recent survey data to see if she is right. Instead, I found that polls taken since the November elections do not show declining support; rather, public opinion remains pretty well split in half between those favoring repeal and those who want to keep or expand the Affordable Care Act; as it has been for months. A McClatchy-Marist of all registered voters found that 16% want to “let it stand” and 35% want to “change it so it does more” compared with 11% who said “change it so does less’ and 33% who said “repeal it completely. CNN/Opinion Research poll found that 24% want to leave the new law as is, 24% want to expand it, 49% want to “repeal and replace” and 4% were unsure. A Quinnipiac University poll found that 30% want to expand it, 18% want to leave it as is, 47% want to repeal it, and 6% were unsure. While it is true that a lot of Americans don’t like the ACA, there are as many or more who want to keep or expand it.

Her observation that the ACA will leave [more than] 20 million without health insurance is correct but doesn’t tell the whole story, because a big portion of them would be people who are not legal residents. The Congressional Budget Office estimates that the ACA will “reduce the number of nonelderly people who are uninsured by about 32 million, leaving about 23 million nonelderly residents uninsured (about one-third of whom would be unauthorized immigrants). Under the legislation, the share of legal nonelderly residents with insurance coverage would rise from about 83 percent currently to about 94 percent”-- a huge and historic step toward universal coverage.

I’ve addressed the issue of Medicare “cuts” in past blogs, but the bottom-line is that the reductions in payments to hospitals and Medicare Advantage plans extends the long-term solvency of the program (because the Trust fund will spend less, and therefore the funds will last longer).

I share the concern that ryanjo expresses about Medicaid’s “shaky” finances. But if the ACA was repealed, the continued decline of employer-sponsored health insurance would result in millions more Americans ending up on Medicaid anyway, but without an influx of federal dollars to help states afford it. (Last year, almost 4 million people ended up on Medicaid, the biggest increase since the program was created.) A new report by the Urban Institute think tank finds that the ACA will put Medicaid on a much more solid funding foundation with “potential savings for state Medicaid budgets which, even in a worse-case scenario, would outweigh costs associated with the health reform law.” The analysis shows that “savings could range between $40.6 billion to as high as $131.6 billion during 2014-2019.” The ACA also increases Medicaid payments to primary care physicians in 2013 and 2014 so they are no less than the Medicare rate, at no cost to the states.

As far as the link between employment and coverage is concerned, once the ACA is fully implemented in 2014, people who lose their jobs or can’t get coverage from an employer will have access to subsidized coverage through the state health exchanges or from Medicaid if eligible. In the short-term, employers like McDonald’s that offer so called “mini-med” plans are seeking waivers from the ACA’s requirements, but such plans have been criticized as providing bare-bones, inadequate coverage to low-wage employees. Once 2014 comes around, these companies and their employees will have more options to choose from but they won’t be able to stick their employees in plans that don’t cover the medical care they need.

The above improvements will happen, of course, only if Congress doesn’t pull back from the ACA’s promise of providing affordable coverage to (nearly) all Americans.

In response to my post “Looking out for internists . . . and patients”, ryanjo thanked ACP for its efforts but she rightly pointed out that many ACP members called their own legislators. I agree that any successes that ACP has in its advocacy efforts is directly related to the willingness of its members to engage in the political process, so my hats-off to ryanjo and the many others who took the time to call Congress.

PCP and Arvind posted comments suggesting that “not losing” or “playing defense” isn’t the same as winning, but any successful football coach, battlefield general, or political strategist would tell you that defense and offense are equally important in achieving victory. Jay Larson is right that the 10% Medicare increase and relief from the SGR cut is “welcome” but not enough to “stop war weary general internists from leaving practice or infuse internal medicine” but it’s a start.

The members of ACP’s Council of Subspecialty Societies who wrote ACP’s “medical home neighbor” position paper would likely disagree with Arvind that ACP has left subspecialists out to dry. Also, the Medicare and Medicaid payment increases to general internists and other primary care physicians that are mandated by the ACA do not come from reducing payments to other specialists, but are completely paid for by the federal government.

I appreciate the comments made by ryanjo, Arvind, PCP, Jay Larson and the many others who take the time to read my commentary and add their own. We clearly don’t agree on some of the issues, and I don’t expect to change many minds. But this blog is all about providing a forum for respectful dialogue. and although I can’t respond directly to every comment, I read them all and am genuinely interested in your views.

Today’s question: Are there other issues that have been raised here, or elsewhere, that you would like to see addressed in future ACP Advocate blogs?

Thursday, December 9, 2010

Looking out for internists . . . and their patients

A defining characteristic of the American College of Physicians is that it has a very broad public policy/advocacy agenda that emphasizes what it believes to be best for the public. In the past 15 months alone, ACP has published position papers on such topics as health care transparency, racial and ethnic disparities, EHR quality based measurement and reporting, tobacco control and prevention, accountable care organizations, FDA regulation of prescription drugs, and controlling the costs of health care.

The downside of having such a broad agenda is that some ACP members question if the organization also is looking out for their interests. They want to know if the ACP understands the daily frustrations faced by practicing internists – the drip, drip, drip of dissatisfaction created by unrelenting paperwork and unfair and inadequate pay.

The answer is yes. While ACP prides itself on addressing broad societal issues that affect access to care, much of ACP’s advocacy is directed at reversing, preventing, or altering policies that threaten to make members lives miserable, and getting policies adopted to make things better.

Yesterday, Congress cleared legislation for President Obama’s signature to exempt physicians from the FTC’s “red flags” rule. The FTC rule would have defined physicians as “creditors” and as creditors, physicians would have been required to implement burdensome procedures to prevent and detect identity theft. ACP joined in a lawsuit to challenge the rule and was part of a coalition of professional organizations to persuade Congress to get involved. Now that Congress has expressly exempted physicians from the Red Flags rule, judicial intervention should no longer be necessary to prevent the FTC from imposing more hassles on doctors.

Also, today the House of Representatives joined the Senate in passing bipartisan legislation to prevent a 23% Medicare pay cut that would have gone into effect on January 1 and extend current rates through 2011. President Obama has promised to sign it into law. For many years now, putting an end to the cuts caused by the Medicare SGR formula has been a top ACP priority. Most recently, ACP distributed to Capitol Hill a video of internists making a heartfelt plea for Congress to “just fix” the SGR. Although the bill passed by Congress doesn’t provide the permanent solution to the SGR sought by ACP, physicians can at least be ensured of stable updates through the end of next year. For most physicians, this means a continuation of their current Medicare rates for another year, but as a result of ACP advocacy, primary care internists stand to get a big Medicare raise on January 1.

The Affordable Care Act directs Medicare to provide a 10% bonus payment to primary care physicians for designated “primary care services” – office, nursing home, home and custodial care visits. To qualify, the ACA requires that a physician be in a recognized primary care specialty (internal medicine, pediatrics, family medicine, and geriatrics) and that 60% of their total Medicare billings must come from the designated primary care visits.

Originally, CMS interpreted the ACA as requiring that Medicare count hospital visits and ancillary procedures against the 60% billing requirement. ACP pointed out to CMS that this would exclude many office-based internists who see patients in the hospital or operate an in-office lab from the bonus. Now, in response to ACP’s comments, CMS has decided that hospital visits and ancillary procedures no longer will count against a primary care physician in determining eligibility for the bonus. With this change, the vast majority of general office-based internists will get the 10% increase in pay for their primary care services. For an office-based general internist with a typical number of Medicare patients and primary care services, the result will be a $12,000 increase in total Medicare payments, starting on January 1 and continuing each year through 2015, or an average total gain of $60,000 over next five years for each eligible internist. (Internists with an above average mix of Medicare patients and primary care visits will do even better.)

ACP is unapologetic about caring deeply about broad societal issues that affect the public, including ensuring that all Americans have access to affordable health insurance coverage, but advocacy on such issues does not come at the expense of looking out for the interests of members. The fact is that in recent weeks ACP has achieved several substantial victories for its members: preventing a federal agency from imposing another unnecessary administrative burden, ensuring stable Medicare payments for 12 more months, and ensuring that most primary care internists get a raise. More needs to be done to slow the drip, drip, drip of dissatisfaction created by unrelenting paperwork and unfair and inadequate pay, but these wins will certainly make things better for most ACP members.

Today’s question: What is your reaction to ACP’s successful advocacy on exempting doctors from the FTC’s red flags rule, stopping the SGR cuts, and ensuring that most general internists will qualify for increased Medicare payments?

Tuesday, December 7, 2010

What happens if universal coverage is allowed to slip away?

One of the things about the health care reform debate that has bothered me the most is how little of it has been about the uninsured. The Republicans have not offered a plausible plan to cover the uninsured, and the Democrats have mostly emphasized the benefits for people who already have insurance (while assuring them that they can keep their doctor and their health plan). But the Affordable Care Act makes only modest improvements (like better coverage of preventive services) for people with insurance. Instead, most of its benefits will go to subsidize coverage for people who otherwise couldn’t afford health insurance.

This makes the law a harder sell for the 80% of U.S. residents with health insurance, and may help explain why support for the law seems stuck in the mid-to-high 40s in most polls. (Seniors, for instance, are the least supportive of the ACA. Could this be because they already have universal government-run health coverage – Medicare – and don’t see much to gain by extending coverage to others?)

But I think it is critically important that the debate over the future of the ACA focus on the uninsured – and the enormous consequences for our country if Congress turns its back on the promise of ensuring that nearly all Americans have access to coverage.

As I wrote in an article that appears today in the web version of the Annals of Internal Medicine, the United States is facing an unprecedented crisis in access to affordable health insurance coverage. Last year, a record 50.7 million residents had no health insurance and the percentage of Americans with private, employer-based coverage decreased for the ninth consecutive year. Many of them had chronic illnesses, and more were from middle-class families than in previous years.

A new study in Health Affairs finds that, “Throughout the past decade, even in good economic times, the number of Americans with employer-sponsored insurance has fallen, and the number of uninsured Americans has increased. . .”

This might not matter too much if the uninsured receive the same care and had as good of an outcome as the rest of us. But they don’t: the IOM found that each year, lack of health insurance leads to unnecessary suffering and premature, preventable death for tens of thousands of Americans.

The good news is that Affordable Care Act will “largely end the link between employment loss and insurance coverage”, meaning that Americans will have guaranteed access to affordable health insurance, not only in good times but especially in the bad times when millions can no longer count on a job, or if employed, can no longer count on their employer to provide them with affordable health insurance.

The Great Recession has taught us that being uninsured isn’t someone else’s problem, but a crisis that can touch each and everyone one of us. There are a lot of elements of the ACA that should be debated, and if there are ideas on how to improve it, all the better. But as I wrote in Annals, “providing all Americans with affordable health care coverage is a moral and medical imperative to prevent needless suffering and death, and must not be allowed to go ‘slip slidin' away.’”

Today’s Question: What is your reaction to my Annals article, and my premise that it is imperative that Congress not turn its back on providing all Americans with access to affordable coverage?

Friday, December 3, 2010

“Death Panels” redux

One of the canards slung at the Affordable Care Act is that it creates “death panels” that would allow the government to deny patients life-saving treatments, even though two independent and non-partisan fact-checking organizations found it would do no such thing.

I don’t bring this up now to rehash the debate, but because the New York Times has a story today on Arizona’s decision to deny certain transplants to Medicaid enrollees - “death by budget cuts” in the words of reporter Marc Lacey. His story profiles several patients who died when they were unable to raise money on their own to fund a transplant. Lacey quotes a physician expert on transplants who flatly states, “There’s no doubt that people aren’t going to make it because of this decision.”

Arizona Medicaid officials told the Times that they “recommended discontinuing some transplants only after assessing the success rates for previous patients. Among the discontinued procedures are lung transplants, liver transplants for hepatitis C patients and some bone marrow and pancreas transplants, which altogether would save the state about $4.5 million a year.”

Lacey writes that the state based its decision on “analysis . . . of the transplants that were cut, which many health experts now say was seriously flawed. For instance, the state said that 13 of 14 patients under the state’s health system who received bone marrow transplants from nonrelatives over a two-year period died within six months. But outside specialists said the success rates were considerably higher, particularly for leukemia patients in their first remission.”

As a non-clinician myself, I don’t feel qualified to express an opinion on whether the evidence supports the efficacy of transplants for patients with these conditions. But if you take Arizona Medicaid officials at their word, Arizona is making decisions based on the expected quality and longevity of life that may result from a given intervention and the cost of that intervention. Isn’t this the kind of “rationing” that critics of “government-run” health care rail against, only in this case it is a conservative-run state governor and legislature that is implementing such restrictions to save the state’s taxpayers some money?

Transplants, because the demand will always exceed the supply, have always been rationed based on medical criteria, although Arizona is taking it to a different level by explicitly taking cost into account.

The problem with Arizona’s approach is that the impact will fall disproportionately hard on the state’s poor. They don’t have access to private health insurance coverage that includes transplants and they don’t have the resources to fund transplants on their own.

The larger point is that the United States already limits access to health care, as all countries must do - because it isn’t possible for everyone to get everything they want or need. There is a superb discussion of this point in the November 24 issue of JAMA. Drs. Meltzer and Detsky write:

“Rationing already takes place [in the United States] in many ways in health care. Managed care is exactly a form of rationing in which a private insurer determines whether patients should or should not receive services. In addition, private sector rationing injects profit motives into the calculations. . . It is critical that Americans learn that rationing currently exists and is inevitable and focus their thinking on how its vagaries are best minimized, rather than use the word to instill fear.”

Tossing around words like “death panels” and “death by budget cuts” instills fear, when what we need is a reasoned discussion of how finite health care resources should be allocated equitably and rationally, and by whom - not just in Arizona, but throughout the United States.

Today’s questions: What is your reaction to Arizona’s decision to deny coverage for some transplants? Do you agree that all countries, including the U.S., ration care in some manner, and if so, is there a better way?

Wednesday, December 1, 2010

“Cowardice”—or bravery--on health care costs?

In assessing the “best and worst” of the recommendations from the National Commission on Fiscal Responsibility, Washington Post blogger Ezra Klein accuses the Commission of “cowardice” in addressing health care spending:

“The plan's health-care savings largely consist of hoping the cost controls . . . and various demonstration projects in the new health-care law work and expanding their power and reach. . . In the event that more savings are needed, they throw out a grab bag of liberal and conservative policies . . . but don't really put their weight behind any. . .[their] decision to hide from the big questions here is quite disappointing . . . ”

Pretty harsh words, considering that in other respects Klein gives the Commission high marks. But I think there is a lot more to the Commission’s recommendations on health spending than meet’s (Klein’s) eyes, even though I have my own doubts about the advisability and political acceptability of many of them:

Medicare SGR cuts: Give the Commission credit for acknowledging the truth: the Medicare SGR cuts to doctors are “phantom savings . . . from . . . cuts that will never materialize.” The Commission proposes to eliminate the SGR and its deep scheduled cuts; instead, payments to physicians would be frozen at the current (2010) level through 2013 and cut by one percent in 2014.

I don’t think physicians will welcome a multi-year freeze followed by a “small” cut that will result in Medicare payments not keeping pace with their costs. Non-primary care physicians in particular are likely to balk. Although not mentioned by the Commission, most primary care physicians would implicitly be protected from having their Medicare payments fall below overhead costs because of the Primary Care Incentive Program created by the Affordable Care Act (ACA). Under this program, most primary care physicians will see their Medicare payments for office visits and other designated visits increased by 10%, starting in 2011, and continuing each year for the next five years--through 2015.

New physician payment system: The Commission would require that CMS “develop an improved physician payment formula that encourages care coordination across multiple providers and settings and pays doctors based on quality instead of quantity of services.” The proposal “would reinstate the SGR formula in 2015 . . . until CMS develops a revised physician payment system” that would cost less than spending under the SGR. In other words, fee-for-service would be replaced with payment for quality and care coordination, or the SGR (and its deep cuts) would come back.

Expanded pilot-programs: The basis for the new payment system would likely come out of accelerated adoption of pilots created by the ACA “to test delivery system reforms which have the potential to reduce costs without harming quality of care” like accountable care organizations, patient-centered medical homes, and bundled payments. Medicare would be directed to “implement any pilot projects that have shown success in controlling costs without harming the quality of care by 2015.”

Cuts to teaching hospitals: The federal government would save $60 billion over the next ten years by bringing GME and IME payments “in line with the costs of medical education by limiting hospitals’ direct GME payments to 120 percent of the national average salary paid to residents in 2010 and updated annually thereafter by chained CPI and by reducing the IME adjustment from 5.5 percent to 2.2 percent.” I find it interesting that the Commission not only doesn’t allow for any increased funding for residency programs facing shortages (like general internal medicine) but would cut spending across-the-board.

Medical liability: The Commission recommends adoption of reforms to reduce the costs of defensive medicine, including creation of “specialized ‘health courts’ for medical malpractice lawsuits, an approach that ACP believes has promise. It stops short of recommending caps on awards; instead calling on Congress to “consider” and “evaluate” caps.

Other cost controls: The Commission would limit the amount of an employer’s contribution to health insurance that is treated as tax free-income, establish a “global” health care budget that would limit spending increases to the GDP plus one percent with an automatic enforcement mechanism if spending exceeds the budget (starting in 2020 and subsequent years); cut hundreds of billions out of “discretionary spending” including health programs funded out of appropriations; give more power to the Independent Payment Advisory Board established by the ACA; and pilot-test converting Medicare to a premium support program.

Whether you agree with the Commission’s recommendations or not, I think they are a serious—and bold—effort to put on the table ideas to reduce health care spending. The likelihood is that the Commission’s report won’t go anywhere—for now. It may not even get the required of 14 out of 18 members for Congress to take it up. I expect, though, that many of its ideas may get serious attention later, because the U.S. will have no choice but to tackle the challenge of rising deficits and debt, with health care spending being the single largest threat to fiscal solvency.

Today’s question: What is your reaction to the Commission’s recommendations on health care spending?

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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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