Compromise not Set in Stone
As the sultry days of summer heated up, so did talks about President Barack Obama's push for his signature domestic legislation—meaningful healthcare reform that covers the uninsured and puts a lid on medical costs.
By the time it was evident that Obama's goal of signing healthcare reform legislation during the dog days of August would not be met, the controversial issue had led to a greater gulf between Republicans and Democrats and divisiveness within the Democratic Party, while also spurring dissention among the ranks of the American Medical Association (AMA).
Michael Steele, chairman of the Republican National Committee, called the president's plan for healthcare reform "socialism" and accused him of masterminding a risky experiment that would harm the economy and force millions to drop their current coverage. Sen. Jim DeMint, a Republican from South Carolina, cautioned the overhaul plan could end up being Obama's "Waterloo."
Even though Obama vowed that healthcare reform would drive down costs of medical expenses that represent 17 percent of U.S. gross domestic product, he has struggled to explain how any of the measures under consideration would fulfill that promise. Aspects of digitizing medical records and eliminating waste, for example, are already being addressed by federal mandates and/or incentives. So are other redundancies he recommended eliminating with new legislation.
Obama has spent his summer days campaigning to sway recalcitrant lawmakers and appeal to nervous voters who are still reeling from the economic meltdown and absorbing the reality of the trillions of dollars of debt the nation faces with the passage earlier this year of the American Recovery and Reinvestment Act of 2009 (ARRA).
The president has repeated his mantra not to reduce Medicare benefits, but rather alter how those benefits are delivered. To accomplish this task, he is pushing for an Independent Medicare Advisory Council to set Medicare reimbursementrates based on physician performance rather than the number of procedures performed.
The First Inkling
When Democrats in the U.S. House of Representatives unveiled their bill for healthcare reform in late July via HR 3200, dubbed America's Affordable Health Care Choice of 2009, House Speaker Nancy Pelosi
, a Democrat from California, was confident she would have the votes to pass it, but declined to commit to meeting Obama's timetable. Two House panels had approved the legislation in little more than a day, but action in the Energy and Commerce Committee had stalled when conservative Democrats said they had the votes to defeat it.
"The Speaker was well intentioned because she was hearing optimistic things, but I don't believe there are the votes on the floor as of right now," said Rep. Baron P. Hill
, a Democrat from Indiana.
Sen. Bob Menendez, a Democrat from New Jersey, said even though Sen. Ted Kennedy's Health, Education, Labor & Pensions committee crossed a major hurdle when it passed the healthcare plan, "this is only the first step, and we face a long, drawn-out battle against the special interests that profit from our broken system.
"But meaningful reform is within reach."
Rep. Charles W. Boustany, Jr., MD, a cardiologist and Republican from Louisiana, said Republicans believe healthcare should be reformed, but emphasized that it needs to be done responsibly "and in a very, very thoughtful way, so as not to disrupt the system we currently have. We don't want to see a system completely devastated or disrupted. We want to build off of what works."
Senate Majority Whip Richard Durbin, Democrat from Illinois, predicted the measure would not reach the Senate floor until after Labor Day.
In mid-June, Randy Easterling, MD, president of the Mississippi State Medical Association, was sitting in the fourth row of the Chicago Hyatt Hotel meeting room where Obama rolled out his healthcare reform plan to the AMA. He noted it was the longest speech of Obama's presidency, at 55 minutes.
"I got the distinct impression that this was a man on a mission," said Easterling. "I have no question there's going to be healthcare reform. Will he get everything he wants? No. Will he get most of what he wants? Probably so. How that impacts healthcare, the jury's still out. I can almost guarantee you that if we're having this conversation a year from now, the location and the manner in which people get their healthcare is going to be different. I feel very strongly it's going to be more of a government-run delivery system. I don't think it will be as patient-friendly as it is now, nor as physician-friendly. I don't think it's going to be cheaper. I'm concerned that if it's more government-driven, it will discourage physicians from going to and/or staying in the (rural South)."
At the heart of Obama's healthcare plan is an insurance program funded by taxpayers, administered by Capitol Hill, and open to everyone. Based on the Medicare model, this "public option" would have become the nation's single dominant health plan while also completely restructuring the practice of medicine. But concerns over cost to small businesses led "Blue Dog" Democrats on the House Energy and Commerce Committee to stall the bill for days until a last-minute compromise was worked out just before the August break. Under the agreement, the public option plan was de-coupled from the Medicare program, which will allow providers to negotiate reimbursements with the government in much the same way they do now with the insurance industry. Also, authority was included to allow the government to negotiate drug prices directly with pharmaceutical companies. In a side deal, Pelosi promised the infuriated liberal wing of the House Democrats a vote on a single-payer government run health system, according to sources close to the negotiations.
In a last word on the compromise, The Congressional Progressive Caucus (CPC) sent a letter to Pelosi and the chairmen of key health care committees stating, "Any bill that does not provide, at minimum, for a public option with reimbursement rates based on Medicare rates—not negotiated rates—is unacceptable."
Justin J. Fogg, an account representative with VantageRX in Orlando, Fla., called the plan "deeply flawed," saying Obama's call for a centrally managed government insurance program "worsens Medicare's problems by redistributing even more income away from lower-paid primary care providers and misaligning doctors' financial incentives."
The Lewin Group, a healthcare policy research and consulting firm, estimates that enrollment in the public option could reach 131 million people, if it's open to everyone and pays Medicare rates, as many expect. As a result, two-thirds of the privately insured would move out of or lose coverage. As more patients shift to a lower-paying government plan, doctors' incomes would continue to decline by as much as 20 percent, depending on their specialty.
"To make matters worse, physician income declines will be coupled with regulations that will further increase the cost of practicing medicine, creating a double whammy of lower revenue and higher practice costs," said Fogg. "This will be especially troublesome for primary care doctors who generally operate busy practices on thinner margins."
Mississippi Gov. Haley Barbour, a staunch Republican, called Obamacare little more than "a government-run healthcare system that would result in a federal government takeover of some 18 percent of our economy."
"This healthcare plan calls for enormous cuts in Medicare spending," he said. "One plan cuts Medicare's budget by $489 billion over 10 years. $489 billion. Why? To use the money to create a new healthcare scheme for people without insurance. Medicare works. Why should we cut the services and choices for people on Medicare to create a government-run healthcare system? Why expand the Medicaid program by half as Congress proposes; Mississippi taxpayers already pay nearly $1 billion a year for our share of Medicaid. And, as for the President's daily repeated promise that, if you like your healthcare plan today, you can keep it; I suggest you read Section 102(b)(1)(A) of the House bill that says after five years, no health insurance policy can be sold unless it's approved by the federal government's health commissar."
Based on experience with the 16-year-old TennCare program, the Tennessee Medical Association released a position paper with a cautionary note: "The reforms currently proposed are complex. We must not rush into reform because it has been our experience in Tennessee that it is extremely difficult to implement such broad-sweeping reforms in a short period of time. The haste to 'do something now' will inevitably cause more problems than solutions and create much anxiety among patients and providers alike, ultimately weakening support of, and the desire for, change."
National Community Pharmacists Association (NCPA) CEO Bruce T. Roberts, RPh, said healthcare reform legislation should cover two major points: using medication therapy management and other pharmacist-delivered healthcare services to improve patient outcomes and reduce overall costs, and assuring the American public that there is a viable community pharmacy infrastructure to deliver quality healthcare.
"This is a sweeping legislative proposal that requires additional, careful review," he said. "However, we're pleased that the bill begins to reform the system that will be used to pay pharmacies for generic medications dispensed to Medicaid patients. For Medicaid beneficiaries in underserved rural or urban areas, community pharmacies are often the sole healthcare provider."
Roberts said NCPA members appreciated the inclusion of provisions that exempt community pharmacists who provide durable medical equipment, such as diabetes testing strips, from "duplicative and onerous accreditation and surety bond requirements."
Two Cents More
When news of the House bill's progress hit the streets, the AMA weighed in.
AMA president James Rohack, MD, surprised some doctors when he called HR 3200 "a good start toward health reform."
Rohack pointed out the House bill provisions that AMA considers key to effective, comprehensive health reform: coverage to all Americans through health insurance market reforms; a choice of plans through a health insurance exchange; an end to coverage denials based on pre-existing conditions; fundamental Medicare reform, including repeal of the flawed sustainable growth rate (SGR) formula; additional funding for primary care services, without reductions on specialty care; individual responsibility for health insurance including premium assistance to those who need it; prevention and wellness initiatives to help keep Americans healthy; and initiatives to address physician workforce concerns.
Rohack's comments outraged Elizabeth Lee Vliet, MD, a women's health specialist from Tuscon, Az., who immediately resigned her AMA membership of 30 years in protest, calling the AMA's statement an "unqualified endorsement" of the House bill.
"The AMA has sold out doctors, and most importantly, our patients, in supporting this government takeover of our most private and personal freedom – our choices about when, where, and with whom we will have medical care when we're sick," she said. "In the current widespread concern about the healthcare proposals being pushed through Congress at the rate of a speeding bullet, my patients have said to me over and over, 'Can't the AMA stop this government takeover of our choices in medical services?' Sadly, the AMA isn't on the side of patients, or doctors either, for that matter when it endorses government-run healthcare that outlaws private options. Surprisingly, only about one-third of the physicians in the United States are AMA members."
As a medical school student, Vliet believed the AMA was the "gold standard" of ethical guidelines for the practice of medicine dedicated to the care of patients.
"Turns out the AMA is a gold mine, not a gold standard," she said. "For example, one of its hugely profitable businesses is overseeing and selling the coding manuals doctors use to determine the insurance billing codes for procedures. It's so lucrative because they change the codes each year, and every doctor and hospital in the country has to buy new coding manuals and new computer software to use them or they can't get reimbursements from insurance companies. The AMA wants to retain its revenues from its various businesses and data services, so it gave in and endorsed the House health 'reform' bill."
HR 3200, Vliet said, includes a provision that would outlawindividual private health insurance coverage.
"The House bill has specific language stating that no more new private policies can be written after the government plan 'option' becomes law," she said. "This House bill will destroy excellence in American medical services as it substitutes committee decisions for private decision-making between patients and doctors."
A day after Vliet's outcry, Rohack reiterated AMA's commitment to health reform in 2009.
"Congress must take action to expand coverage to the uninsured through a choice of plans and eliminate denials for pre-existing conditions, include prevention and wellness initiatives, address medical liability reform and repeal the broken Medicare physician payment system that harms seniors' access to care," he said. "Without repeal, physicians face payment cuts of nearly 40 percent over the next five years that will force them to limit the number of seniors they can treat – right as the baby boomers begin aging into Medicare."
Staying in the Loop
The National Conference of State Legislatures (NCSL) recently launched a website via www.ncsl.org
with continuously updated information on the implications for states of this transformative legislation, with links to policy briefs and white papers detailing the various components of the federal healthcare reform legislation.
"State legislatures have led the way on healthcare reform and have a huge stake in how the federal effort plays out," said NCSL executive director William Pound.
The website also provides a breakdown for how the legislation affects states.