Tuesday, January 18, 2011

After tomorrow’s vote, what then?

The House of Representatives began debate today on its bill to repeal the Affordable Care Act. The GOP has the votes it needs to get it passed, but it will go nowhere in the Senate.

But the vote is more than symbolic, as some press reports have labeled it. There is more than symbolism at work when the House of Representatives decides, as its first order of business, to vote to dismantle the work of its immediate predecessor. Rather, it signals that the Republican-controlled House is serious about mounting a sustained effort to use every tool at its disposal to repeal, halt and defund the law, in pieces if not all at once. Interestingly, the House is taking on this fight at time when the level of strong opposition to the ACA is near an all-time low according to a new AP poll.

Instead of a fight that will be won or lost on a single battlefield, think of it as series of guerilla actions by the GOP to weaken the law, in the hopes of ultimately bringing it down.

Readers of this blog know where I stand on repeal: the Affordable Care Act isn’t perfect and can and should be improved, but turning away from its promise of (near) universal health insurance coverage would be a terrible mistake. Repeal would result in at least 32 million more Americans going without health insurance, the continued erosion of private employer-based health insurance coverage, more people ending up in under-funded safety net programs, and elimination of some of the most promising initiatives to begin to bend the cost curve.

Coincidental to tomorrow’s vote (since the publication schedule was set months ago), health reform is a major focus of today’s edition of the Annals of Internal Medicine. It includes my article (originally published in December as an early web release) on the consequences if the United States allows universal coverage to slip away, and several letters to the editor taking issue with the August 23 article by White House staffers Zeke Emanuel, Bob Kocher, and Nancy-Ann Deparle. The letters, and the authors’ response, makes for interesting reading.

Also today, ACP released a statement to urge Congress to "preserve and – as necessary – improve on [the] important reforms created by the Affordable Care Act, not repeal them.” The statement lists “essential” policies that need to be preserved, including provisions to provide coverage to nearly all Americans.

But ACP also advocates that “Congress and the White House . . . work together to find effective ways to restrain cost growth and ensure effective implementation of the law [including] . . . enacting more effective medical liability reforms, ensuring that states are granted the flexibility and resources they need to effectively expand coverage, giving Congress more decision-making authority over recommendations from an independent payment advisory board, and replacing the cycle of Medicare physician payment cuts caused by the Sustainable Growth Rate (SGR) with a permanent solution. Other improvements should include removing or modifying the burdensome 1099 reporting requirement for small businesses and the requirement that physicians provide written authorization for over-the-counter medications reimbursed by a flexible spending account. Such improvements, though, should not compromise necessary funding for other essential policies in the ACA.”

My fervent hope is that Congress will move away from framing the issue as being a yes or no choice between repeal or keeping the law unchanged. The GOP might listen to the sage advice of one of its own, former Senate majority leader Dr. Bill Frist, a heat surgeon from Tennessee:

“The reality is that the law will remain largely intact. . . That being the case, is it is important that it be made to work as effectively as possible . . . there are lots of things that can be fixed or modified by working together.”

This would be good advice as well for President Obama and the Democrats. Wouldn’t making the law “work as effectively as possible” by “working together” to fix or modify it be much more constructive, and unifying for the country, than a no-win fight over repeal and replace?

Today’s question: What is your reaction: after tomorrow’s “symbolic” vote on repeal, should the 112th Congress heed Dr. Frist’s advice to take the next two years to work as effectively as possible, or continue to fight to repeal or weaken it?


ryanjo said...

President Obama and the Democrats are reaping the fruits of ramming through an unpopular law without a single vote from the opposite side of the aisle. Now they face the politics of payback. Too bad they couldn't wait and craft a compromise, or a demonstration project. But their timetable was the election cycle, so now their hasty blunder is allowing their opponents to take the stage to act out the ACA's repudiation.

Not a climate to expect much bipartisan progress.

As far as ACP's role, it is time for some absolutes. We need payment reform, paperwork reduction and improving the lot of primary care. If its not in your healthcare bill -- not only doesn't ACP support it, we actively oppose it.

Rich Neubauer MD said...

The ACA was clearly a first step toward all the things that need to be done to create a truly functional health care system for our country. By expanding coverage to almost all Americans, along with the other key reforms of the insurance system, it was an essential first step that had to be taken in order to address the other bull in the china closet which is overall health care costs.

Listening to some talking heads on the news, it seems that the GOP repeal effort may actually backfire it providing democrats a platform to better sell reform to the public which has now had a taste of some of the improvements provided by the ACA. I certainly hope so.

I do fear the GOP effort to disassemble some key features of the ACA via funding mechanisms. Hopefully this effort will not affect too much the overall trajectory of the ACA.

What should happen next is a careful prospective assessment of the ongoing impacts of ACA and a willingness to make adjustments, revisions, and even major changes to achieve the ultimate goal of universality of health care for the American people combined with effective allocation of health care resources, and grabbing control of overall health care costs. Republicans would be wise to use their control of the house to make contributions to a bipartisan effort of improving ACA rather than their current tactic.

Steve Lucas said...

This is political theater. The result will be the expected vote and then the expected stopping of the bill in the Senate.

There are some very real issues with this bill:

10 years of revenue with only 6 years of services.

The “doc fix” is a separate piece of legislation and not included in the cost.

$750B in new taxes v $500B in new spending.

The EMR requirement is creating all types of unintended consequences: See the Jan. 17, 2011 Akron Beacon Journal Pained by hospital fees article relating how a purchased medical practice now is able to charge hospital fees for in office procedures.

We are also seeing the expansion of the Executive branch of government by the creation of various boards that will act to put in place rules and regulations without Congress’s approval.

While I certainly understand the attractiveness of this bill, I am also aware of the short comings and cost. The House’s vote will send the message that there is need for major reform and I hope bi-partisan debate on what will become a wholesale replacement of this legislation. Remember, this piece of legislation was passed on a strictly party line bases and there were no Republicans included in the behind closed door discussion.

Troubling to me is the statements by the Democratic leadership that this bill is cost effective and that Social Security is financially sound. Nothing could be farther from the truth.

We have several problems in this country that are all coming together at the same time. Health care, government retirement funding, and our competitive position in the world economy are major issues that must be dealt with as a group.

We need an adult conversation, and nobody is going to get everything they want.

Steve Lucas

Robert J. Sobel, M.D. said...

Thanks Bob. I had not seen the letters section as I had been dealing with not liking Nathan's editorial against my friend John Buse. Lots of comments that flowed nicely and reiterated the concerns we've been expressing here. We do need reform and I support the simple principles that will stabilize costs:

1) no new bureacratic tangles

2) finance outpatient care fairly ASAP

3) no incentives that punish independent practices

4) regulate drug costs and eliminate the pharmacy-benefit industry

Lots of billions in the latter. Leave the rest of us alone.

I would ask Congress to do whatever it takes to really fix our health care system. They've given private insurance a lifeline; make sure the playing field stays level and stable. Don't let new technology and administrative distractions swallow up our dollars and our time.

Pat S. said...

I find it incomprehensible that the ACP was supportive of the Obama Healthcare law. As my professional association it is unreal that it would advocate for a law that describes physician primary care providers as equivalent to nurse practitioners and PAs. It was economic suicide for internists, family practice, and pediatricians. The outcome of that legislation is millions of dollars being appropriated to increase PAs, and nurse practitioners to take over the primary care position.

So my hope is that the entire law be repealed, that the ACP actually advocate for real doctors taking care of real patients instead of academicians who work in a make believe world and are paid a salary no matter how little work they do. Wake up!! Real doctors are slugging away every day just to make their overhead, much less pay for their kids college education.

What is needed is real policies that allow competitive companies from all over the country to offer policies to all segments of the population, tort reform, and the ability of an individual to get insurance at a competitive rate. Medicaid and Medicare already provide coverage for indigent populations-if they take the time to get it (medicaid).

Harrison said...

I think sometimes that doctors are a little too hung up on the role of government -- even with the ACA.
Change is in the air.
The ACA put money behind innovations like a patient centered medical home and Accountable Care Organizations -- but without the money the industry was headed in that direction anyway.
Insurance products are looking for ways to cut costs with ever more expensive technologies available. They also need to grow in their markets.
So they are trying to find ways to get doctors and hospitals to share in risk.
Then they can promise to steer some of the saved money back to the doctors.
Primary care is one strategy for doing this -- and perhaps the most promising. But specialists were always going to be part of it.

The ACA's main thrust was to expand the pool of covered lives.
More covered lives equals more money for the industry.
Some of that will come from individuals through premiums, and some will come from businesses and some will come from taxpayers.
It wasn't ever going to come from any other source.

The only issue really is who gets the money and what is it spent on.

We have an advocacy group that is looking towards the inevitable future and trying to position us to do well with that, and it so happens that at this point in history, advocating for us also means that we can effectively advocate for improvements in the health care system. We can advocate for better communication tools, for research to help determine which treatments really work, for better coverage of groups of people who are disadvantaged by the current system but who would benefit from primary care and our health care system if they could gain access.

Why does this generate controversy?


ryanjo said...

I admit I am speechless at some of the comments above. Well, almost.

"Why does this generate controversy?"

Has any prior initiative by either our government or the insurance industry improved physician's or patient's lives, or care quality? For what the ACA will surely cause, please re-read both the the August 23 article by Emanuel, Kocher and Deparle, and the letters to the editor. I was stunned at the conclusions of the article, relegating physicians to cogs in the corporate wheel. And even more deeply disappointed that ACP was leading the way.

"The ACA's main thrust was to expand the pool of covered lives. More covered lives equals more money for the industry."

Oh, so like Medicaid. Plenty of covered lives. No funds. Dismal quality of care.

"We have an advocacy group that is looking towards the inevitable future and trying to position us to do well with that"

Would that this be true! With rare exceptions, most of the writers to AIM and commenters on this blog, I presume practicing MDs, find much wanting in the ACPs leadership's course.

Arvind said...

Agree with Steve Lucas, Dr. Sobel and Pat S. Unfortunately the ACA does not accomplish any of the points that these doctors make, thereby any substantial change in it means uprooting it from its foundations. Essentially, the ACA cannot be "fixed". Just like lipstick on a pig....

Clearly the ACA was passed (shoved down our throats) without input of practicing physicians, and our representative organizations relinquished their obligations in order to curry favor with the administration.

All of us know that this repeal might just be symbolic, but we can hope that the 112th Congress can chip away at the unwelcome intrusion of govt control into clinical practice by way of defunding all the departments that have been created by the ACA. You can read my Letter to the Editor in the current Annals also.

Robert J. Sobel, M.D. said...


The controversy is not the goals you relate in your final paragraph. It is your assumption that "the industry was headed in that direction anyways." Why should I be penalized for not e-prescribing? Why should I have to negotiate with the hospital for reimbursement? Why in God's name would consolidation be preached by anyone as a way to preserve the best in American medicine?

There is a role for consolidation (the most liberal who promote a single payor certainly seem to accept that principle). I would think a state-based, BC/BS, few independents, few exchange based, limited public insurance landscape would be potentially workable. Keeping the physician base productive and well compensated would not be a bad investment (especially in the cognitive domain). Controlling the duplicative, distracting, and dangeorous games brought about by the high price of drugs and scans and borderline procedures would reap loads of good premium dollars to spend more effectively.

Leave independent physicians alone and quit dictating new terms while holding a 30% cut over our heads. This remains a shameful stance that D.C. can't overcome (i.e., the SGR). Let's rebalance the playing field by controlling costs on the new technologies and streamlining bureaucracy.

HMO=ACO=Demise of Independence

Good riddance to the new bureaucratic moves? How about a real reform?

Unknown said...

The ACP is right on.
One thing that needs to be added to the bill that seems to have been overlooked is putting a cap on how much the insurance companies can charge for insurance. Even if the government gives a tax break for the insurance, that doesn't come until way after the insurance has been purchased. Also, it would be wrong for the companies to overcharge thinking that the government would just make up for it. The last thing our government needs is another unnecessary monetary drain. There may be some benefit from competition with the government-sponsored health plan, but it's not a good permanent solution. What should be done is a cap on insurance companies' percent profit. Of course, I don't expect that to go over very well in the House.

Harrison said...

I respect everyone's opinions. The passion generated by the ACA is undeniable. Vocal and thoughtful physicians strongly disagree with it.
That is clear.

But I don't disagree with it.

I think that our health care system would look very different today if Medicare and Medicaid had not been enacted.
But Medicare and Medicaid were life changing positive forces for millions of people.
Yes, even Medicaid.
And it continues to be.
It is underfunded. The reimbursement rates are horrible.
And I am working full time with a group that cannot accept it in California because we could not survive with the low pay and the number of patients it would bring us.
In fact in California they sometimes just pay with IOU's. Those aren't worth much.

Still, it isn't fair to characterize the impact of the program just in those terms. Both Medicare and Medicaid gave access to health care to millions.
By doing this these programs allowed health care procedures to expand, and clinical research followed this because money was there.

To argue that the private insurance market would have stepped in to offer access to the majority of our elderly is to ignore the history that allowed for the successful argument that led to enacting the program in the first place.

Without Medicare and Medicaid we would have fewer doctors, fewer patients, and much higher morbidity and mortality in our elderly populations. We would also have much higher poverty rates in general.

So now we have the ACA.
The initiative was aimed at both access and cost control.
It was an action taken by Congress to deal with the world as it is. To deal with the market as it is.

It offers benefits to patients.
Our patients.
It imposes a mandatory health insurance purchase requirement -- which may or may not be constitutional. But the outlay of money will be there either way. We either ask for the money from people up front in an effort to deal with potential crises in a controlled manner, or we continue to do what we have been which is to let people access the system when they are really sick in an inefficient way and find the money from state and local goverments or from hospitals and health insurance plans charging more to everyone else to pay for those who don't pay.

The SGR is ridiculous.
It is not part of the ACA.
I don't think we want to be seen taking a public stance against such initiatives as eprescribing. On what basis? Do we feel that it is impossible to improve on our poorly written and often mistakenly interpretted scrawlings on prescription pads.

We really shouldn't take a vocal obstructionist position.

I still support the ACP's positions.


W. Bond said...


The difference between you and those with the opposite opinion likely comes down to this: you think that incredibly complex goods and services can be efficiently and productively centrally-planned. Others do not.

Think how difficult it would be to provide something relatively simple like free shoes to the entire population efficiently. Could it be done? Yet here we all are with high-quality, affordable footwear, and no one goes barefoot! (Sure, some can afford better shoes than others, or choose to allocate a greater percent of their resources to their shoes than others, etc.). How does this happen? How is that the problem of shoelessness is solved without a commission, a director, a national czar?

It is not the goal, you see, it is the means. Those who disagree with you argue that such central planning is in fact impossible due to an intransigent problem stemming from incomplete knowledge.

Do you think that this problem is solvable if we just do the planning better, smarter? Or are we to be commended just for having good goals, even though it is impossible to meet them? Do the easy-to-foresee unintended consequences not matter as long as we mean well?

Arvind said...

Totally agree with Dr. Sobel. Harrison, you are sadly mistaken. But its obvious that nobody can convince you. So I won't try. Try and read Rep. Paul Ryan's recent article that explained why it is necessary to repeal and replace the ACA.

Harrison said...

I will read Paul Ryan's article. I don't expect however that it will convince me that the best course of action is repeal.
I lived in Wisconsin for a long time. I met with Paul Ryan in his office in Washington DC on a couple of occasions and I spoke even more with his health care issues aide. Mr. Ryan is a very fast talking politician. He doesn't let others in the room speak when he is present and he doesn't listen. His aide is a reflection of him. His aide loves the political games that are played in Washington.
You don't leave his office with a feeling that he understands you or the issue.
You leave knowing for sure that he has his mind made up and he knows what he wants the public to think of him -- that he is fiscally conservative and a defender of American values.

The problem I have with the theory behind what you suggest is that those who espouse it believe that the rest of us haven't read Friedman and Hayek, and that if we did we would understand and agree.
But I have read the Road to Serfdom, and I don't agree. I think it is possible to have a degree of central planning, and I think that our current debate is taking place in an economy that has built in a lot of expectations based on socialist structures that have to be part of the solution -- because we have come too far down that path.


W. Bond said...

“I think that our current debate is taking place in an economy that has built in a lot of expectations based on socialist structures that have to be part of the solution -- because we have come too far down that path.”


You are to be truly commended for your honesty and for clearly thinking through your arguments and in understanding your assumptions.

I disagree (in ways that are too lengthy for a blog comment), naturally, but admire your self-understanding, nonetheless.

Cheers, Wbond