The ACP Advocate Blog by Bob Doherty

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

noreply@blogger.com (BDoherty) — Fri, 19 Mar 2010 17:08:00 +0000

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?

It's a wrap

noreply@blogger.com (BDoherty) — Thu, 18 Mar 2010 21:47:00 +0000

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?

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

noreply@blogger.com (BDoherty) — Wed, 17 Mar 2010 14:58:00 +0000

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?

How should Congress choose?

noreply@blogger.com (BDoherty) — Tue, 16 Mar 2010 20:02:00 +0000

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?

March Madness

noreply@blogger.com (BDoherty) — Mon, 15 Mar 2010 20:38:00 +0000

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?

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

noreply@blogger.com (BDoherty) — Wed, 10 Mar 2010 21:47:00 +0000

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?"

What does the American public really want?

noreply@blogger.com (BDoherty) — Tue, 09 Mar 2010 21:41:00 +0000

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?

What's so funny about health care reform?

noreply@blogger.com (BDoherty) — Mon, 08 Mar 2010 21:32:00 +0000

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?

Reconciliation (n), rapprochement, the reestablishing of cordial relations

noreply@blogger.com (BDoherty) — Thu, 04 Mar 2010 19:14:00 +0000

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?

Should physician anger be directed at denying care to patients?

noreply@blogger.com (BDoherty) — Tue, 02 Mar 2010 18:52:00 +0000

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?

Jim Bunning throws doctors a curve ball

noreply@blogger.com (BDoherty) — Fri, 26 Feb 2010 17:24:00 +0000

Last night, retiring Senator Jim Bunning (R-KY) single-handedly held up passage of legislation to stop a devastating Medicare payment cut that will go into effect on Sunday. Unless the Senate finds a way to clear the legislation this morning by a unanimous voice vote - considered unlikely because Bunning has stated that he will not withdraw his "hold" on the bill - starting next week, all Medicare claims submitted by physicians will be reduced by 21 percent.

Probably only for a few days, though, because I anticipate that Congress will come back next week and find another route to stop the cut and hold physicians and patients "harmless" (that is, to restore payments for the period when the cut was in effect). CMS may also hold up on processing claims for a few days to give Congress time to act. Still, even if this all comes together, it looks like the result will be another 30 day extension of current rates, meaning that Congress will have to revisit the issue again and do something to stop the next scheduled cut. And at some point, Congress has to figure out what to do about the underlying problem: an unworkable formula (SGR) that triggers cuts in Medicare payments whenever spending on physician and related services grows faster than the overall economy.

It isn't just physicians who are being held hostage to the Senate's dysfunction; the bill also includes an extension of jobless benefits and COBRA coverage for people who otherwise will lose their coverage along with their jobs, and many other popular provisions set to expire at the end of the week. (The House of Representatives has done its part by passing legislation to provide a 30 day extension of the expiring programs. It also has passed legislation to permanently repeal the SGR and replace it with a new formula to provide more stable updates going forward.)

Let me say this as clearly as I can. The continued dysfunction in the Senate is unacceptable. Temporary patches to the SGR are unacceptable. ACP has made it absolutely clear that the only acceptable outcome is permanent repeal of the SGR.

But the current dysfunction in the Senate endangers much more than patients' access to Medicare. It has put health care reform on life support. It has created an unprecedented loss of public confidence in government's capacity to do the right thing. It has led to an increasing degree of anger among the electorate, as more and more of us feel like channeling Howard Beale's "I'm mad as hell, and I'm not going to take it any more ..." rant from 1976's "Network."

Meanwhile, President Obama's bipartisan summit may have produced the ironic result of getting Democrats behind a strategy of enacting the bill without GOP support by using the "majority rules" reconciliation process. Mike Allen blogs in Politico's Playbook that Bloomberg news' headline "Obama Bipartisan Health Summit Clears Path to Party-Line Vote" pretty much says it all. I'll have more to say about the summit next week, but I think one of the President's greatest challenges will be to get the public behind completing the bill on a party-line vote, when confidence in Congress, understandably, is at a historically low point.

Today's question: What do you think physicians and patients should tell their Senators about the SGR?

On blogging . . .

noreply@blogger.com (BDoherty) — Tue, 23 Feb 2010 21:29:00 +0000

Last week, I was honored to learn that the ACP Advocate blog was selected by voters in a national competition as the Best Health Policy/Ethics blog of 2009. Yesterday, ACP issued a news release announcing the award, in which I am quoted as saying that the blog "seeks to inform and entertain readers and to elicit thoughtful commentary from across the political spectrum, not just from ACP members but from others with an interest in health policy."

Awards and recognition are nice, but what I enjoy most is making readers aware of interesting ideas, studies, and commentary that otherwise might not have come to your attention.

I don't try to be impartial, but I try to be fair. I strive to present a range of views, grounded in ACP policies but informed by my own experiences as someone who has been involved in health policy and advocacy for 31 years.

Blogging requires a thick skin. Many of you have told me when you disagree with me - often vehemently. That is okay - I have no interest in this blog being an echo chamber of whatever people think I want to hear. And your commentary gives me an opportunity to explain things better.

For instance, one of the frequent commentators on this blog is "Arvind." He also is one of my toughest critics. He posted this just the other day:

"I find that somehow you are speaking from both sides of your mouth. These two statements could not be any more illustrative - 'the cost of health care is rising faster than families, small businesses, and taxpayers can afford' and 'And because of continued cuts in payments that do not cover their costs, most physicians are not accepting new Medicare and Medicaid patients.' Can anybody explain how 'health care costs' can go out of control when Medicare pays so little that it does not even cover cost of providing care?"

The explanation is that health care costs are rising much faster than growth in the economy and family incomes, and Medicare expenditures also are increasing rapidly because of increases in the volume (numbers) and intensity (resources expended on each person) - even though Medicare payments for each service may not be keeping up with practice costs. Eligibility and enrollment expansions also will increase spending on programs like Medicare and Medicaid. Recessions tend to increase enrollment in and spending by government programs. Pandemics, like H1N1 pandemic, also increase demand for and spending on health care.

Specifically, Chris Fleming blogs in Health Affairs that "Medicare spending is expected to have reached $507.1 billion in 2009, an increase of 8.1 percent from 2008. . .Growth in spending on physician and clinical services is expected to have accelerated to 6.3 percent in 2009, up from 5.0 percent in 2008. Total expenditures are expected to have reached $527.6 billion in 2009. The expected increase is driven primarily by Medicaid spending in this category, which is projected to have grown 10.3 percent in 2009, compared to 8.9 percent in 2008. Projected private spending in this category also accelerated. . .due in part to care associated with the H1N1 virus.

"Total hospital spending is expected to have grown from 4.5 percent in 2008 to 5.9 percent in 2009, reaching $760.6 billion in 2009. This reflects a projected acceleration in hospital spending by public payers - up from 6.2 percent in 2008 to 8.0 percent in 2009 -due to increased enrollment. It also reflects growth in private hospital spending. .

"Prescription drug spending growth is expected to have grown 5.2 percent in 2009, reaching $246.3 billion. This 2.0 percentage point acceleration from 2008 is due to an increase in per person use of drugs, driven by the need for antiviral drugs to treat H1N1, and by higher price growth in brand-name drugs. By 2019, prescription spending is projected to reach $457.8 billion, with spending growth expected to accelerate over the projection period due primarily to increases in drug prices."

I can understand why a practicing physician like "Arvind" would take issue with the idea that health spending is going up when Medicare payments aren't keeping up with his costs. But the fact is that spending is going up because physicians (and hospitals) are treating more people and doing more for them, and more patients are getting ever more costly prescriptions. This is true, even though many doctors, especially primary care physicians, are underpaid for what you do.

Today's question: What does the growth in spending say to you?

"We can work it out"

noreply@blogger.com (BDoherty) — Mon, 22 Feb 2010 21:54:00 +0000

"Life is very short, and there's no time
For fussing and fighting, my friend.
I have always thought that it's a crime,
So I will ask you once again.
Try to see it my way,
Only time will tell if I am right or I am wrong.
While you see it your way
There's a chance that we may fall apart before too long.
We can work it out,
We can work it out."

Lennon/McCartney, 1965

After a year of deferring to Congress, President Obama today released his own health care reform proposal (although it largely borrows from the bills already passed by the House and Senate).

The proposal is part of a coordinated effort by the White House to say to GOP opponents that "we can work it out" . . . but only if they are willing to see it his way. The White House's web site lists 14 Republican ideas that it says are included in the Obama proposal, in the president's budget, and/or in the bills passed by the House and Senate. It also says that "the president remains open to other policies as well. And the purpose of the Bipartisan Summit is to review all ideas and ensure that the best ideas are included in the plan."

The GOP isn't buying it.

Roll Call reports that the President's plan has ignited a partisan backlash. House minority Leader John Boehner (R-OH) and Senate minority leader Mitch McConnell (R-KY) each released statements to make it clear that they will not budge from opposition to Obama's plans. McConnell accuses the president of "completing ignoring what Americans across the country are saying."

Is McConnell right? The "By the Numbers" blog written by Washington Post pollsters suggests that Obama may have stitched together proposals that have "broad, but often malleable, public support." Large majorities, they report, support creation of a new health exchange to give people the same insurance choices that members of Congress have, ending discrimination against persons with pre-existing conditions, enacting reforms to reduce the deficit, closing the Medicare Part D doughnut hole, requiring large employers to provide coverage, financing the changes by raising taxes on higher income persons, and requiring plans to cover adult dependents to age 26 - all features of the President's proposal (and, for that matter, the bills that have already passed the House and Senate).

How does Obama's proposal differ from the bills that passed by the House and Senate? The Kaiser Health News "Blog Watch" has a good summary of the changes he proposes. The proposed changes include increasing the subsidies for people to buy coverage, providing more funding to states to expand Medicaid coverage (applied to all states - no special deals), increased penalties on employers who don't buy coverage, delaying and raising the ceiling for a tax on Cadillac plans, and getting more money out of Medicare Advantage plans. One of the biggest - and controversial - changes is a new proposal to create a new "Health Insurance Rate Authority" to "provide needed oversight at the Federal level [over health insurers' premium increases] and help States determine how rate review will be enforced and monitor insurance market behavior."

In the end, I don't think the changes proposed by President Obama will win over any GOP support. But by embracing changes that have broad "but malleable" support from the public, and daring Republicans to see it his way (or, presumably, get out of the way), he may have charted a way for the Democrats to finish the job, presumably using the "majority rules" reconciliation route.

Today's question: Do you agree with the changes proposed by President Obama? Do you think it will help get health care reform over the finish line?

What my morning commute says about the coming debt crisis

noreply@blogger.com (BDoherty) — Fri, 19 Feb 2010 20:10:00 +0000

The last snowflake fell in Washington 10 days ago, but driving remains an unholy mess. During my morning commute today, gridlock occurred when a car heading in one direction came face to face with a mini-van headed in the other, on a street that was down to one lane. Neither could move forward or back up. (The whole problem could have been prevented if either vehicle had waited to enter the roadway until they were sure there was room to pass. But this is a town of stubborn and competitive people who think that backing down is the cardinal sin.) I sat there for about 15 minutes, and then found an exit strategy - pulling into a nearby parking lot that led to an alley that led to another way out.

The result was not just lost productivity for me and others caught in the gridlock. It also left me (and the other drivers, I expect) frustrated and angry.

This, I think, is an apt metaphor for the growing anger and frustration among voters at the political paralysis in Washington. The latest New York Times CBS poll finds that fewer than one out of ten Americans believe that their member of Congress deserves re-election. A Quinnipiac University poll finds that voters blame both parties equally for the gridlock, yet by "52 - 44 percent they want Congress and the President to keep trying on health care reform rather than giving up and moving on to other matters."

The voters want more bipartisanship, but that doesn't seem likely to happen. The New York Times reports today that despite the bipartisan health reform summit planned for February 25, the White House and Democrats are settling on a strategy of advancing health reform through a "majority rules" budget reconciliation bill that could be passed without GOP support.

Yet as difficult as it is to find a bipartisan way forward on health reform, the stakes for the country of continued gridlock may be even higher when it comes to the looming financial and budget crisis. The New York Times reports that "the unwillingness of the two parties to compromise to control a national debt that is rising to dangerous heights" is triggering fears that this could soon lead to an unprecedented global financial crisis. Yet rarely has the political system seemed more polarized and less able to solve big problems that involve trust, tough choices and little short-term gain NYTimes reporter Jackie Calmes writes.

In a follow up blog posted yesterday, Calmes comments on the President's decision to appoint a bipartisan panel to make recommendations to reduce the debt, "Mr. Obama set no conditions on the commission, including his campaign promise not to raise taxes on households making less than $250,000 a year. Economists across the political spectrum say the debt problem is so great that it demands both long-term revenue increases and reductions in the entitlement programs - Medicare, Medicaid and Social Security - whose escalating costs are the main drivers of long-range projections of unsustainable annual deficits." Yet GOP leaders insisted in response that the commission should focus only on cutting spending instead of raising taxes, and many Democrats are opposed to cuts in Medicare, Medicaid and Social Security.

Calmes writes that former Senator Alan Simpson (R-WY), who agreed to co-chair the panel, "signaled in his statement the real possibility that the commission would not succeed given the politically charged nature of the issue and the polarization in Washington. 'Whatever the results of our work,' he said, 'the American people are going to know about a lot more where we are headed with an honest appraisal of our situation and the courage to do something about it.'"

My morning commute left me irritable, but the partisan gridlock in Washington threatens to deny tens of millions of Americans access to affordable health insurance, and also, quite possibly, could undermine the long-term financial stability of the country.

Today's question: What do you think should be done about the partisan gridlock in Washington?

Its official: the ACP Advocate blog was selected by voters as the Best Health Policy and Ethics Blog of 2009. The announcement called the blog "one of the more influential professional association blogs out there". Thanks to all who support the blog, since any influence it has comes from you!

"An unconscionable abdication of responsibility by our elected leaders"

noreply@blogger.com (BDoherty) — Wed, 17 Feb 2010 21:31:00 +0000

Today, I joined with ACP President Joe Stubbs at a press conference to release a major new ACP report that finds American health care is "facing an unprecedented challenge of affordability and sustainability." Dr. Stubbs observed that "by many measures, the State of America's health care is in decline" with "too many uninsured persons, too few primary care physicians, while the cost of health care is rising faster than families, small businesses, and taxpayers can afford." Yet a "highly-partisan and polarized debate over health care reform legislation regrettably has taken the country's 'eye off the ball' - from the urgency of implementing reforms to make health insurance coverage more affordable, available and secure; to ensure a sufficient supply of primary care physicians and other specialties facing shortages; and to reform payment and delivery systems to achieve better value."

In my remarks, I asked reporters to imagine what health care will look like if reform is not enacted.

"Fast-forward to 2018, a new President is in the White House and ...

"The number of people enrolled in Medicare has increase to almost 60 million, but the ratio of taxpayers paying into the program to support each beneficiary is at its lowest point. Medicare's hospital trust fund is out of money.

"Unrestrained Medicare and Medicaid spending has led to out-of-control deficits and an explosion of public debt, leaving little money for other national priorities.

"At the same time, rising premiums have put health care out of reach for many middle-class families. Small businesses are dropping coverage in droves. 60 million people have no health insurance coverage.

"Because of a shortage of tens of thousands internists and family physicians, it takes many weeks - even months - to get appointments. And because of continued cuts in payments that do not cover their costs, most physicians are not accepting new Medicare and Medicaid patients.

"What's the new President to do? The President might have no choice but to propose huge payroll tax increases, cuts in Medicare benefits and eligibility, and reduced payments to physicians and hospitals. Stringent controls over health care spending are needed, but anything that would make a big and immediate dent - like putting limits on services - would be fiercely resisted by patients and physicians alike."

All of the above is almost certain to happen, unless we change course now.

ACP offered five steps to make health care sustainable and affordable (1) build and improve on the bills. preserving key elements to provide coverage to most Americans, increase the numbers of primary care physicians, and pilot test reforms to improve health care delivery; (2) develop bipartisan proposals to reduce the costs associated with the medical liability tort system; (3) fund programs to expand coverage, train primary care physicians, and encourage testing and dissemination of models to improve health care delivery; (4) end the cycle of Medicare physician payment cuts caused by the Sustainable Growth Rate (SGR) formula; and (5) use the President's executive authority to require that federal agencies and contractors develop policies to increase the numbers of primary care physicians and reduce the time that clinicians and patients spend on health plan administration.

Dr. Stubbs concluded by saying, "The alternative to moving forward on comprehensive health reform is an unconscionable abdication of responsibility by our elected leaders to ensure that high quality health care remains available and affordable for American families today, tomorrow and for years to come."

Today's questions: Do you agree with Dr. Stubbs?

How would the GOP reform health care?

noreply@blogger.com (BDoherty) — Mon, 15 Feb 2010 21:32:00 +0000

It looks as if President Obama's plans for a February 25 bipartisan summit on health care will move forward, even as Republican leaders continue to express reservations.

The kicker is that the President is asking the GOP to show how it would "put a stop to insurance company abuses, extend coverage to millions of Americans, get control of skyrocketing premiums and out-of-pocket costs, and reduce the deficit" (italics added by me). Many Republicans don't view expanding coverage as a principal goal of health care reform.

What kind of alternative might the GOP offer? Newt Gingrich and John Goodman offered "Ten GOP Ideas for Obama" in a February 10 Wall Street Journal op-ed:

They argue that the current tax system, which provides some employees with tax-free Cadillac plans while individuals and self-employed get no tax break, is unfair. Instead, they say that "a step in the right direction would be to give Americans the choice of a generous tax credit or the ability to deduct the value of their health insurance up to a certain amount." They would make health insurance "portable" so that it travels with an employee when they change jobs and also give people the option to buy insurance across state lines.

The Democrats' bills already include sliding scale tax credits for millions of people - those with incomes up to 400% of the Federal Poverty level who do not have access to employer-sponsored insurance - to buy insurance from a purchasing pool. The Gingrich/Goodman proposal is different in that it would give everyone the option of receiving a tax credit or tax deduction. But what they don't explain is how big the credit would need to be to make coverage affordable, or where would the money to pay for it come from? The average premium for a family of four in the large group market is almost $13,000 per year, so the tax credit would have to be pretty big to make coverage affordable for most Americans.

Gingrich and Goodman explain that their ultimate goal is to convert health care into a defined contribution program, just like traditional retirement plans have been replaced by 401-Ks: "Many health economists conclude that tax relief for health insurance should be a fixed-dollar amount, independent of the amount of insurance purchased."

I can see how this would help control health care costs, because individuals would have an incentive to be prudent purchasers (buying coverage that is no higher than the fixed dollar amount). But it could also lead to people buying inadequate coverage, shifting uncovered costs onto everyone else. And, if the fixed dollar amount ("voucher") didn’t keep up with rising premiums, the value of the contribution would erode over time. I could also see major problems of adverse selection if less well-off people found that they could only afford a less costly plan, while the well-off could supplement the voucher and buy more generous insurance out of their own pockets. Regional differences in the costs of buying coverage would also have to be addressed.

I can also see the appeal of allowing people to buy insurance across state lines. What they don't explain is how consumers would be protected from being sold a low quality health plan from another state that sets a very low bar for insurance regulation and consumer protections, since their own state insurance commissioner presumably not have the authority to intervene with an out-of-state plan. The Democrats' Senate bill allows insurance to be sold across state lines, but the states involved would have to enter into an agreement with each other on a regulatory structure.

Gingrich and Goodman have other interesting ideas: designing insurance benefits to improve care for the chronically ill, paying doctors a set amount that takes into account the "quality of care" being delivered but leave the pricing of individual service up to them, and providing more information to consumers. Some of these ideas are included, to one degree or another, in the Democrats' proposals.

And they propose elimination of junk lawsuits - Amen to that!

But they also express opposition to Medicare cuts, when the fact is that savings in the Democrats' bills will help extend the solvency of the Medicare trust fund and help pay for coverage for millions.

I think that the Gingrich and Goodman proposal has some interesting elements. The problem, though, is that they offer no way of paying for things like tax credits, they reject using Medicare savings, don't explain how many people who now don't have coverage would be able to buy it, and how adverse selection would be minimized. It is not clear, then, if their proposal would "put a stop to insurance company abuses, extend coverage to millions of Americans, get control of skyrocketing premiums and out-of-pocket costs, and reduce the deficit" as Obama insists that the GOP alternative should, or if they even agree that these should be the goals of health reform.

Today's question: What do you think of the Gingrich/Goodman alternative?

P.S. Thanks to all of you who voted for the ACP Advocate as the "Best Health Policy/Ethics" blog in the Epocrates 2009 Medical Blogs Award Program. The voting ended yesterday at midnight, and the ACP Advocate was the top vote winner, with 51% of the votes compared to 48% for the very worthy and thought-provoking "Covert Rationing" blog and 1% for the Pharma Marketing blog. I am humbled and honored by your support, but of course, a blog is only as good as those who take the time to read it and post your comments - even, or especially, when you disagree with me!

What happens if the states try to nullify an individual insurance mandate?

noreply@blogger.com (BDoherty) — Fri, 12 Feb 2010 15:37:00 +0000

One issue that divides liberals and conservatives is their views on the respective roles of federal and state governments. Conservatives prefer that the states run things, liberals, the federal government. A growing number of conservatives, including columnist George Will argue that Obama's health care proposals - and in particular, a mandate that individuals buy coverage - would unconstitutionally usurp powers reserved to the states and the people by the constitution's 10th amendment.

The Commonwealth of Virginia, reports the New York Time's Katharine Seelye, is on the verge of enacting a law that would exempt state's residents from complying with an individual insurance mandate. She reports that almost two-thirds of the states have similar legislation in the works. Law professor Timothy Jost argues in the New England Journal of Medicine that such state laws are "constitutionally impossible" and that the "purpose of these laws ... is not legal but rather political" and are "part of a larger campaign to mischaracterize federal legislative efforts and stir up opposition to any federal health care reform."

It is beyond my expertise to predict how federal courts would rule on this issue. From a political standpoint, though, the individual mandate is one of the least popular features of health care reform, according to Kaiser Family Foundation's most recent tracking poll. Conservatives don't like it because they consider it a usurpation of constitutional liberties; and many liberals don't like it because it compels them to buy private health insurance, when they really would like Medicare-for-all.

The logic behind the individual mandate, though, is that if insurance companies are going to be required to accept all comers, without regard to pre-existing conditions, and would be limited in how much more they can charge them, then people need to be compelled to buy coverage when healthy. Otherwise, some would stay out of the insurance pool until they get sick - resulting in higher premiums for everyone else. This then could lead to an insurance pool "death spiral". Faced with higher premiums caused by those who didn't get coverage until they got ill, more insured people would drop coverage, since they too could just "go bare" until they get sick. Rates would go up for the remaining insured population, leading more of them to drop coverage. And so and so on until the entire system collapsed.

One way to get around this problem is to eliminate the insurance mandate altogether, and instead just enroll everyone in a government-run plan like Medicare. I doubt that this is what conservatives want, but it could end up being the simplest way of getting everyone covered, should the present approach of providing subsidies to buy coverage, combined with a ban on pre-existing condition exclusions and a requirement that individuals buy coverage, fail on either constitutional or political grounds.

Today's questions: What do you think about state laws designed to nullify a federal requirement that individuals buy coverage? And about the individual insurance mandate itself?

Washington, D.C. (noun): a place where nothing can move, advance or happen

noreply@blogger.com (BDoherty) — Tue, 09 Feb 2010 21:46:00 +0000

Tom Toles' editorial cartoon in todays Washington Post says it all.

Washington has become a place where nothing can move, advance or happen. Having been paralyzed by a huge snowstorm over the weekend, the federal government has been closed since Monday, our roads are clogged with unplowed snow, our Metrorail system won't run above-ground trains, the schools are closed (until June, it seems)--and to top it off, another 10-20 inches of snowfall is expected in the next 24 hours. (Yes, our trains really don't run when we get more than a few inches of snow. You Chicagoans can stop laughing now.)

Of course, the snow and ice will eventually melt, and Washington will get back to normal. Not so the partisan gridlock that apparently will prevent anything from getting done even when the government reopens for business.

In an effort to break the health care reform stalemate, President Obama invited Republicans to participate in a televised, bipartisan summit, scheduled for February 25. But the House GOP leadership has threatened to boycott the event, writes the Washington Post's Chris Cillizza, unless Obama meets their many demands--including pulling the plug on the current bills and starting over. The Washington Post's Shalaigh Murphy reports that President Obama today told House GOP minority leader John Boehner (R-OH) today that that his core goals -- lowering health-care costs for businesses and individuals and expanding coverage to the uninsured -- remained non-negotiable. But Obama said he would consider GOP alternatives that accomplish the same results. He also said he would sign what he considered to be a "less-than-perfect bill."

Here's the rub. The White House and most Democrats believe a fundamental purpose of health reform must be to provide affordable coverage to all Americans--including the more than 30 million legal U.S. residents who have no health insurance. It is this core belief that caused the House and Senate to produce complex--and costly legislation--designed to ensure that 94-96% of all legal residents would have access to affordable health insurance. By contrast, Laura Meckler writes in the Wall Street Journal that House Republicans reject Obama's standard that the final bill must cover large numbers of uninsured people, quoting Rep. Dave Camp (R., Mich.) as saying: "We didn't portray our bill as being universal coverage . . . We never attempted to do that."

Instead, the House GOP alternative would lower premiums in the small and individual insurance market, with a negligible impact on reducing the numbers of uninsured Americans. According to the Congressional Budget Office, it would "reduce the number of nonelderly people without health insurance by about 3 million in 2019 and leaving about 52 million nonelderly residents uninsured. The share of legal nonelderly residents with insurance coverage in 2019--83 percent--would be roughly in line with the current share." The GOP alternative "would reduce average private health insurance premiums per enrollee in the United States, relative to what they would be under current law-by 7 percent to 10 percent in the small group market, by 5 percent to 8 percent for individually purchased insurance, and by zero to 3 percent in the large group market."

Meanwhile, most voters "want the two sides to keep working to pass comprehensive health-care reform" according to the Washington Post's latest poll. "Nearly two-thirds of Americans say they want Congress to keep working to pass comprehensive health-care reform. Democrats overwhelmingly support continued action on this front, as do 56 percent of independents and 42 percent of Republicans."

The voters may want both parties to work together, but that Democrats and Republicans can't even agree on the ground rules to meet to discuss if they can reach an agreement doesn't bode well for bipartisan progress. Digging Washington out of two blizzards may turn out to be a lot easier than advancing the political prospects for health reform.

Today's questions: Do you believe that covering the uninsured should, or should not, be a principal purpose of health reform? What issues, if any, do you think would be ripe for bipartisan support?

We're #1! We're #1!

noreply@blogger.com (BDoherty) — Thu, 04 Feb 2010 21:29:00 +0000

... in national health care expenditures, that is. This, of course, is nothing new: spending on health care in the U.S. has long out-paced any other industrialized country. What is noteworthy is "the largest one-year increase in [health care's] GDP share since the federal government began keeping track in 1960" blogs Chris Fleming, of Health Affairs. He writes that a new study shows that health care spending increased by an estimated 5.7 percent since 2008 despite a projected decline in the gross domestic product (GDP) in the same period.

The recession is having a big impact on respective roles of the public and private sectors. "Health spending by public payers is expected to have grown much faster in 2009 (8.7 percent growth, to $1.2 trillion) than that of private payers (3.0 percent growth, to $1.3 trillion)" Fleming writes, which is attributable to an increase in "projected growth in Medicaid enrollment (6.5 percent) and spending (9.9 percent) as a result of increasing unemployment related to the recession. Conversely, enrollment in private insurance is expected to have declined 1.2 percent in 2009, despite federal subsidies for Americans who have lost their jobs to extend their private insurance coverage via the Consolidated Omnibus Budget Reconciliation Act (COBRA) that increased participation in these plans."

"For the first time, government programs next year will account for more than half of all U.S. health-care spending, federal actuaries predict, as the weak economy sends more people into Medicaid and slows growth of private insurance", writes Peter Landers in the Wall Street Journal.

Free-market advocates would be loath to admit it, but in an employer-based private insurance system, when people lose their jobs, they also lose their coverage, unless the government steps in to provide it. If it wasn't for Medicaid and the government subsidies for COBRA coverage, far more Americans would have been without health insurance during this recession.

And for all of the anti-government sentiment among much of the electorate, I don't see people demanding that Congress repeal Medicaid or eliminate COBRA subsidies, or get rid of Medicare or the VA, for that matter. People dislike government, except when they need it.

What the health reform bills propose to do is replace the current patchwork system with an improved safety net - expanded Medicaid for the poor and near-poor, tax credit subsidies for people up to 400 percent of the federal poverty level, limits on pre-existing condition exclusions, and subsidies and purchasing pools to make coverage more available and affordable for small businesses. They would build upon what the government already does - provide people with affordable coverage when the private, employer-based system fails them - but in a more organized and coherent way.

Today's question: What is your reaction to the new estimates on government and private sectors spending on health care?

Health reform and the Obama budget

noreply@blogger.com (BDoherty) — Tue, 02 Feb 2010 19:53:00 +0000

Does the President's new budget mean that the White House is shifting toward smaller-scale health reforms in lieu of comprehensive legislation?

Time magazine's Katie Pickert blogs that "the HHS budget doesn't do what massive health reform legislation was supposed to do." She notes that an AP reporter asked HHS Secretary Kathleen Sebelius "to clarify what was obvious already - that the 2011 HHS budget doesn't make any real headway toward solving the country's health care crisis." Sebelius responded that the "budget 'in no way replicates the efforts in the health reform legislation to reach out to the 30 some million Americans who have no health insurance at all and those who are woefully underinsured, … This budget - absent health reform - will still leave a major gap.'"

The National Journal writes that the budget "focuses more on the economy than on health reform." ABC's Jake Tapper explains that "the budget assumes $150 billion in deficit reduction from enactment of the health reform legislation," while the Wall Street Journal's Janet Adamy blogs that the budget offers a "back up" plan should the "embattled" health reform legislation fail. Jacob Goldstein reminds readers of the WSJ's health blog that "the big [cost] drivers are mandatory spending on Medicare and Medicaid - huge, rapidly growing costs that are outside the purview of Obama's (or any president's) annual recommendations for discretionary spending."

My take is that the President's budget doesn't itself signal a retreat health reform, but tries to have it both ways - pledging fealty to enactment of a comprehensive bill, while suggesting ways to advance smaller-scale reforms should the broader effort fail. Among the President's health funding priorities are:

-- Primary care training: $2.5 billion for community health centers, enough to fund current centers and create 25 new ones; $169 million to the National Health Service Corps, to train up to 400 more primary care physicians, nurse practitioners, and dentists to serve in underserved areas, bringing the total to 8,500 clinicians. $54 million for Title VII primary care training programs, the same as FY2010, but the current preference for family medicine programs (over internal medicine) would be eliminated.

-- Health information technology: $110 million for "continuing efforts to improve health IT policy, coordination and research activities."

-- Comparative effectiveness: $286 million for the Agency for Healthcare Research and Quality to study the effectiveness of different medical options.

-- Coverage: $25.5 billion to support State Medicaid programs by temporarily increasing Federal Medicaid funding for six months through June 2011.

-- Delivery system reforms: "new Medicare and Medicaid demonstration projects that evaluate reforms to provide higher quality care at lower costs, improve beneficiary education and understanding of benefits offered, and better align provider payments with costs and outcomes. Special emphasis will be placed on demonstrations that improve care coordination for beneficiaries with chronic conditions, that better integrate Medicare and Medicaid benefits, and that provide higher value for dollars spent."

-- Medicare physician payment: the budget includes an increase in Medicare baseline spending of more than $200 billion to accommodate enactment of legislation to end the annual cycle of SGR cuts. (Congress, though, appears to be leaning toward setting aside enough money to prevent cuts for the next five years but not enough to permanently repeal the SGR.)

For the past year, President Obama has pursued a "Big Bang" approach to health reform, centered on getting Congress to pass sweeping expansions of coverage coupled with other reforms to make insurance more affordable and available - yet the effort remains (hopelessly?) stalled in Congress. The new budget doesn't necessarily mean that he is walking away from big changes. But the budget does suggest to me a grudging awareness, if not acceptance, by the White House, that smaller, incremental steps could be all that he will get.

Today's question: What is your reaction to the President's budget?

Did Obama's SOTU address give enough of a lift to health reform?

noreply@blogger.com (BDoherty) — Thu, 28 Jan 2010 21:23:00 +0000

In my mind, President Obama's State of the Union speech settled, at least for now, the question of whether he remains committed to health reform:

"So, as temperatures cool, I want everyone to take another look at the plan we've proposed. There's a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo. But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. Let me know. Let me know. I'm eager to see it. Here's what I ask Congress, though: Don't walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people. Let's get it done. Let's get it done."

But will Obama back up his words by putting the full weight of his office behind the effort? Roll Call reports that Democrats are looking to the President to help them find a "clear path" to break the gridlock, and some remain doubtful about its chances.

Perhaps the most important development, other than Obama's speech, is a declaration today by Speaker Nancy Pelosi (D-CA) that she has the votes to pass health reform if the Senate agrees to adjust the bill through the budget reconciliation process, which requires only a simple majority. Channeling Winston Churchill, Pelosi is quoted as saying, "We'll go through the gate. If the gate is closed, we'll go over the fence. If the fence is too high, we'll pole vault in. If that doesn't work, we'll parachute in. But we're going to get health care reform passed for the American people." Senator Majority Leader Harry Reid (D-NV) also is "looking very closely" at the reconciliation option, according to Roll Call.

There are big differences between the House and Senate bills, though, so it will require President Obama's direct involvement and leadership to get agreement on the changes to be made through reconciliation and persuade a majority of Democrats to go along.

What about the GOP? I would like to believe that there could be agreement on an approach that would attract bipartisan support, but I doubt it. Republicans uniformly will oppose use of reconciliation to "force" enactment of health care. The Democrats will counter that reconciliation is justified to overcome Republican "obstructionism" in the Senate, which prevents legislation from being passed by a simple majority vote, and they will remind people that reconciliation was used to pass the Medicare Part D prescription drug program and the Bush tax cuts when the GOP controlled Congress.

The one area that could have been a fertile ground for bipartisanship is medical liability reform, but it is probably too late for that. The President asked for "better approaches" from either party to reduce the deficit and lower premiums. The CBO estimates that tort reform would "lower costs for health care both directly, by reducing medical malpractice costs - which consist of malpractice insurance premiums and settlements, awards, and legal and administrative costs not covered by insurance - and indirectly, by reducing the use of health care services through changes in the practice patterns of providers" and "reduce federal budget deficits by about $54 billion during the 2010-2019 period." Unfortunately, I don't see the President doing the heavy lifting within his own party to enact tort reform, and I don't see Republicans agreeing to support the broader health reform bill even if he did.

Finally, the wild card in all of this is whether the President's speech and subsequent actions will slow the erosion of public support. Last night, the President acknowledged the problem:

"Still, this is a complex issue, and the longer it was debated, the more skeptical people became. I take my share of the blame for not explaining it more clearly to the American people. And I know that with all the lobbying and horse-trading, the process left most Americans wondering, What's in it for me?"

The Kaiser Family Foundation's latest health tracking poll, fielded earlier this month but before the Massachusetts special election, found the public evenly divided overall about the health reform bills, but that, "Majorities reported feeling more favorable toward the proposed legislation after learning about many of the key elements, with the notable exceptions of the individual mandate and the overall price tag."

President Obama's speech provided a lift to health reform, but he will need to do more to persuade a skeptical public about what's in it for them.

Today's question: Do you think Obama's the State of the Union address lifted the prospects for health reform?

Which countries have the longest waits for medical care?

noreply@blogger.com (BDoherty) — Wed, 27 Jan 2010 21:25:00 +0000

Yesterday, I borrowed liberally from Dr. Seuss' "Oh, the Places You Will Go" to describe the "weirdish, wild space" - The Waiting Place - in which we now find health reform.

This got me thinking about The Waiting Place in a different context: the time it takes to get an appointment with a physician. Anyone one of us who has had to wait weeks, or even months, for an appointment would agree that The Waiting Place is, as Dr. Seuss described it, a "most useless place" to be.

Critics of the pending health reform bills, like Conservatives for Patient Rights argue that they will lead to longer wait times for appointments. Their argument being that "government-run" health care, as exists in Canada or the United Kingdom, has been demonstrated to result in long waits for medical appointments.

I would dispute the premise that the reforms being considered by Congress are akin to the systems in place in Canada or the United Kingdom. Like it or not, the House and Senate bills would maintain private, employer-based health coverage as the principal source of insurance coverage. Still, I began to wonder about what the data show about wait times in different countries.

In 2007, the Commonwealth Fund released a report that compared U.S. health care against several other countries based on a variety of benchmarks. The data were principally derived from statistically random surveys of adult residents and primary care physicians from 2004 to 2006, in the following countries: United States, Canada, New Zealand, United Kingdom, Germany, and the Netherlands. This is what the researchers found:

* Canada had the highest percentage of patients (36%) who had to wait six days or more for an appointment with a doctor, but the United States had the second highest percentage (23%) who reported that they had to wait at least this long. New Zealand, Australia, Germany, and the U.K. all had substantially smaller numbers of people reporting waits of 6 days or longer. Canada and the United States, in that order, also had the lowest percentage of persons who said they could get an appointment with a doctor the same or next day.
* The United States had the largest percentage of persons (61%) who said that getting care on nights, weekends, or holidays, without going to the emergency room, was "very" or "somewhat" difficult. In Canada, it was 54%, and in the U.K, 38%. Germany did the best, with only 22% saying that it was difficult to get after-hours care.
* The United States, though, scored well on physicians' perceptions of how many patients experience long waits for diagnostic tests. 57% of physicians in the U.K, and 51% of Canadian physicians reported that their patients experienced long waits for diagnostic tests, compared to only 9% of U.S. physicians who reported the same.
* The U.K (60%) and Canada (57%) had the highest numbers of persons who had to wait four weeks or more to get to see a specialist physician. In the U.S., only 23% reported a wait of four weeks or more for specialty care.
* The U.S. also did very well on measures of wait times for non-emergency or elective surgery. Only 8% of surveyed patients in the United States reported a wait time of four months or more for elective surgery, compared to 33% in Canada and 41% in the U.K. Germany scored the best, with only 6% reporting a long wait for elective surgery.

The take-away message is that both the United States and Canada do pretty poorly, compared to most other industrialized countries, on how long patients have to wait to get a regular appointment with a primary care physician or after-hours care, but the U.S. does better than most on having shorter wait times for diagnostic procedures, elective surgery, and specialty care. Each of these countries, though, with the exception of the United States, has universal health insurance coverage, funded and regulated in large part by the government, so it doesn't seem likely that government-subsidized health care, in itself, is the sole factor in determining how long patients are stuck in The Waiting Place. Other factors, like the numbers of primary care physicians and specialists in each country, may be more important.

Today's question: What is your reaction to the data on each country's experience with wait times for medical care?

Dr. Seuss' Rx for Obama's health reform slump

noreply@blogger.com (BDoherty) — Tue, 26 Jan 2010 18:21:00 +0000

"Oh!
The places you'll go!

You'll be on your way up!
You'll be seeing great sights!
You'll join the high fliers
Who soar to high heights.

You won't lag behind, because you'll have the speed.
You'll pass the whole gang and you'll soon take the lead.
Wherever you fly, you'll be the best of the best.
Wherever you go, you will top all the rest.

Except when you don't.
Because sometimes you won't.

You can get all hung up
In a prickle-ly perch.
And your gang will fly on.
You'll be left in a Lurch.

You'll come down from the Lurch
With an unpleasant bump.
And the chances are, then,
that you'll be in a Slump.
And when you are in a Slump,
You're not in for much fun.
Un-slumping yourself
Is not easily done.

You can get so confused
that you'll start in to race
down long wiggled roads at a break-necking pace
and grind for miles across weirdish wild space,
headed, I fear, toward a most useless place.

The Waiting Place ...
... for people just waiting.
Waiting for a bus to come, or a plane to go
or the mail to come, or the rain to go
or the phone to ring, or the snow to snow
or waiting around for a Yes or NO
or waiting for their hair to grow.
Everyone is just waiting."

The above excerpts come from Dr. Seuss' final, masterful book, "Oh, The Places You'll Go!," a motivational tale of overcoming life's challenges to arrive at great places.

I can't think of a better description of the present health reform slump, and of the weirdish, wild, space - the Waiting Place - in which members of Congress now find themselves. Waiting for President Obama to signal his intentions. Waiting for Speaker Pelosi and Majority Leader Reid to come up with a plan. Waiting for another chance to get health reform done, right.

(Meanwhile. Kristen Gerencher blogs in Market Watch about efforts by various stakeholders to ramp up pressure on Congress and the president to move forward on reform, including a joint letter sent yesterday to Congress and President Obama by the American Academy of Family Physicians, American College of Physicians, and American Osteopathic Association, advocating that a pathway be found to move forward on "essential" reforms to expand coverage, ensure a sufficient primary care workforce, reform payment and delivery systems, and support alternatives to the medical liability tort system.)

Dr. Suess wraps up by saying:

"On and on you will hike.
And I know you'll hike far
And face up to your problems
Whatever they are ...

And will you succeed?
Yes, You will, indeed!
(98 and 3/4 percent guaranteed)

KID, YOU'LL MOVE MOUNTAINS!"

President Obama's State of the Union address tomorrow will tell us much about whether he can face up to his problems, regain the initiative, and move mountains to achieve comprehensive health care reform for all Americans.

Today's question: What do you think President Obama should say about health reform in his State of the Union address?

P.S. The ACP Advocate Blog is a finalist in the sixth annual Medical Weblog Awards for the Best Health Policies/Ethics Weblog. Voting begins on January 27 and will close at 12 midnight on February 14. Please take a moment to vote for the ACP Advocate Blog.

Will Congress throw the uninsured under the bus?

noreply@blogger.com (BDoherty) — Mon, 25 Jan 2010 21:16:00 +0000

The Wall Street Journal reports that the Democrats may put aside the party's goal of providing health insurance coverage to (almost all) legal residents. Instead, they might push for more scaled-back reforms including, "modest coverage for the uninsured, perhaps aid for small businesses, new rules for insurance companies and some policy changes to control federal health spending." To be clear, as the WSJ points out, no decisions have been made, and likely won't be, until after President Obama's state of the union address Wednesday.

I understand the political reasons why some members of Congress may want to put aside the goal of achieving near-universal coverage. Most voters have health insurance, and polls show that voters with health insurance increasingly are concerned that the health reform bills will increase their costs and reduce the quality of care they receive. So the political calculation appears to be: why pass something that is disfavored by a good proportion of the 85% of your constituents that have health insurance, so as to provide coverage to the 15% who don't, many of whom don't vote? Especially since most of the almost trillion dollar cost of the proposed bills is to fund programs to expand coverage.

We've seen this before. In 1995, when President Bill Clinton's efforts to reform health care collapsed, 40.6 million people in the United States, or 15.4% of the population, were without health insurance coverage during the entire year, according to the Census Bureau. In 2008, the exact same proportion of the population -15.4% - went without health insurance, but because of population growth, the total number of uninsured persons reached 46.3 million. The uninsured rate would be much higher, if it were not for enactment and reauthorization of the State Children's Health Insurance Program, which in 2008 provided coverage to 7.4 million low-income kids. The best one can say is 15 years after Clinton's health reform initiative collapsed, we have made absolutely no progress in reducing the percentage of the population without health insurance.

One big difference now is that both the House of Representatives and the Senate have passed bills that would cover between 94-96% of legal U.S. residents - the farthest this has ever advanced in the legislative process. Yet Congress and maybe President Obama may be on verge of deciding that the politics make it too hard to get the bills over the finish line.

I understand that the bills are controversial, and that people are troubled by the deal-making that went into getting the necessary votes. I appreciate that people are concerned that the U.S. can't afford to take this on now, even though the CBO says that the legislation will reduce the federal budget deficit. I "get it" that many people don't trust the government to deliver on the promise of better care at lower cost. I know that changes will need to be made in the bills to increase public support, such as elimination of some of the special deals made in the Senate. What I don't get is the apparent willingness of politicians to again throw the uninsured under the bus.

I don't know if providing everyone access to health coverage is a right, but I do believe that it is the right thing to do. I continue to have some hope that President Obama and Congress will find a way to ensure that "the U.S. health care delivery system provides access, best quality care and health insurance coverage for 100%" of Americans, as called for by ACP's vision of a desired future for U.S. health care. Tomorrow's state of the union address should at least tell us where the President stands.

Today's question: Do you think Congress and the President should throw in the towel in providing affordable health insurance coverage to all?

"Dazed and Confused"

noreply@blogger.com (BDoherty) — Thu, 21 Jan 2010 18:39:00 +0000

... is how Chris Frate aptly characterizes the Democrats' state of mind on how to proceed with health care reform. It doesn't help that President Obama and his White House staff are sending mixed signals.

It seems as if there are only a few options left:

- The House passes the Senate bill "as is" but with a commitment to modify parts of it through a separate budget reconciliation bill. This has the advantage of not requiring 60 votes because a filibuster is not in order in the Senate for a bill that has already passed and is awaiting action by the other chamber. Any changes made through budget reconciliation can also be passed by a simple majority. But as the Washington Post reports today Speaker Pelosi has rejected this option, at least for now.

- The House and Senate could drop the current bills and start anew with drafting a new bill to be passed strictly through budget reconciliation on a strict majority vote. This though creates all kinds of political and procedural hurdles - including the need for the committees of authorization to have to "mark up" a new bill. The reconciliation bill could only include provisions with a direct effect on federal spending and revenue, so popular regulatory provisions, like banning pre-existing conditions exclusions, likely would have to be left out. And, with the Democrats eager to get health reform behind them, I don't see them wanting to start anew.

- Reid and the White House could reach out to a small handful of Republicans, like Olympia Snowe (R-ME) and Susan Collins (R-ME), to get them to support a compromise that gets them to 60 votes. Not impossible, but difficult, because the Democratic leadership may have burned bridges with them, and the few Republicans who might be "in play" will be under tremendous pressure from their party not to play ball. Compromises to get GOP votes will run the risk of losing votes from Democrats, and I would not be surprised to see some of the Senators who voted for the current bill having second thoughts. The back-and-forth negotiations that would be required would drag the process out longer and lead to more deal-making, the last thing the Democrats want.

- Or the Democrats could themselves break the bills up into individual parts and force Republicans to vote for or against provisions that may be popular. The likely result would be a far less expensive bill that would make modest changes (like banning pre-existing conditions and voluntary pooling arrangements, maybe with Medicaid expansion and some limited subsidies targeted to the poor). This too, though, would require new committee "mark up" and drag the process out for months, with no certainty of success. And disaggregating the bills could lead to an unworkable result: for instance, requiring that insurance companies accept people with pre-existing conditions (popular with voters) likely will require a mandate that individuals buy insurance (less popular) and subsidies (very expensive) to make coverage affordable.

- The White House and Congressional leadership could just walk away from the process of trying to get health reform passed and try to blame it on Republican obstructionism, making the midterms a referendum where both sides would point figures on why health reform failed.

Where does this leave ACP and its public policy agenda? We don't control the politics, process or procedures of health care reform. Our agenda is determined by our own policies - not the politics of the moment. As such, we will continue to advocate that Congress enact legislation to advance our four priority areas: coverage for all, workforce and primary care, payment and delivery system reform, and medical liability reform. We have been pushing this agenda long before the latest political developments, and will continue to do so until progress is achieved.

There is no easy way forward. But if health reform fails, the best opportunity we've had to advance fundamental reforms to achieve key policy objectives - like reforming Medicare payments to support primary care, training more primary care internists, funding research on comparative effectiveness, and of course, affordable coverage for all - will be set back. And if health reform fails, health care spending will rise at a rate that that the country simply can't afford.

Kevin Pho, MD, may have said it best, in his admonition to his colleagues on the Right:

"With the potential defeat of ObamaCare, you may have won the battle, but will lose the war. The current health reform efforts, in the grand scheme of things, were very incremental in nature. Without it, the number of uninsured will rise, and health costs will continue to spiral upwards. That will eventually bring America's economy to its knees, and, as I said a few months ago, 'once that happens, more draconian measures will be forced upon us. Measures that assuredly will not be friendly to doctors.'"

Today's question: Do you agree with Kevin Pho that defeat of Obama's health care reform will lead to more draconian measures being forced upon physicians?

P.S. - The ACP Advocate Blog with Bob Doherty has been nominated for consideration in the Best Health Policy/Ethics category in the 2009 Medical Webblogs Award Program sponsored by epocrates. (It may not yet show up yet in the list of nominees, since it usually takes a day or so for the latest nominees to show up.) If you would like to support the nomination, you can do so by following the instructions "to place a nomination." The editors ask that when nominating, you indicate the blog's name and URL, as well as your thoughts why this particular blog deserves recognition.