I admit that I did not listen to President’s Obama speech before Congress. I wanted to be able to understand his proposal and his arguments without the pomp, circumstance, standing ovations and partisan spins that are integral to such occasions. Instead I waited a couple of days and then sat down to read the text of the speech. To my surprise, I actually say three different speeches incorporated into one speaking session. They were intertwined so it may not have been readily apparent. This is, however, what I saw as I read the speech and confirmed when I read the President’s proposal on the White House web site.
Speech Number 1: The Problem and the Proposal
A major part of the speech was a recitation of the problems that are necessitating action. The fear of bankruptcy for those with catastrophic illness, the problem of being denied coverage for pre-existing conditions, the challenge for those without insurance were all outlined with skill and passion. The President’s high level proposal was largely agreeable to a cross section of Congress and the American people. The president stated, “And there is agreement in this chamber on about 80 percent of what needs to be done.” There is a large part of the President’s proposal which is seen in both Republicans and Democrat proposals. We could pass a law tomorrow if the President and Congress would just take that 80% and pass the legislation and we would have improved the system appreciably with a relatively simple agreement that eliminates pre-existing condition clauses, guarantees insurability and eliminates some of the insurance rules that create barriers to care. Even the insurance carriers support that because they will still have the level playing field and will potentially have more customers. On the White House web site, the President’s proposal is now posted and spells out some of those “significant details” that the President alluded to in the speech that are part of the 20% of which differences remain. Thus he clearly states in the White House proposal “Offers a public health insurance option to provide the uninsured who can’t find affordable coverage with a real choice”. There is little agreement on that public option which seems like it will be modeled on Medicare. Medicare which is now extremely costly to taxpayers, inefficient and largely unpopular with physicians as the payments tend to be lower than they receive from negotiated contracts with private insurers. This is the same Medicare which now offers “waste and inefficiency” which we can somehow mine for the money to pay for the proposal, but more on that in a moment. While there is little sympathy among the public for physician incomes, the fact is that we are not, as a society, able to increase the number of primary care physicians in the United States partly because the Medicare fee schedules for those health professionals falls far short of where they should be.
Speech Number 2: Demonizing the Opposition and the Insurance Companies
President Obama, intermixed his definition of the problems and his solution with a strong targeting of those who disagree with him and with the insurance companies. “Instead of honest debate, we've seen scare tactics. Some have dug into unyielding ideological camps that offer no hope of compromise. Too many have used this as an opportunity to score short-term political points, even if it robs the country of our opportunity to solve a long-term challenge. And out of this blizzard of charges and counter-charges, confusion has reigned.” Actually I have seen a lot of honest debate which the President has chosen to call scare tactics. In a wonderful column in the New York Times, Max Blumenthal quoted Eisenhower as saying, “In a democracy, debate is the breath of life.” We have seen a lot of debate and I still hope that the debate continues. In the end, it will result in a better law being passed. Yet the demonization of those who disagree is troubling. Unfortunately that demonization is strongly emanating from the While House and the Congress.
Speech Number 3: Show Me the Money
The third speech was how to pay for it. I must admit that I did not follow this very well and each time I re-read it, I still don’t understand. It seems like the centerpiece is an independent panel of physicians to suggest ways to eliminate waste and inefficiency. The nature of medical care is very personal and it has always been difficult to lower costs through the simple elimination of waste and inefficiency as one man’s waste is another’s necessity. While I know better than most of the the waste in the system as I have dedicated my professional life to finding ways to decrease cost, improve access and improve care, I also know that having a panel of independent physicians will solve nothing and will not make money appear magically. Covering 30 million people who are now not covered is not free and is not paid for by finding waste. Without comprehensive payment reform of the type that is not seen in any bill, we will just be working around the margins. In a previous blog I discussed the fragmented way physicians are paid and pointed out that the fragmentation leads to higher costs. There is nothing in the proposal to change our payment systems. An Article by Fuchs written back in May (which seems like a lifetime ago in this debate) states “A government insurance company is no substitute for real reform” yet that, and a physician panel, appears to be the drivers of lower costs in this speech and proposal. Forgive me if that just makes no sense to me.
What Happens Next
I do believe that a bill will be passed and that we will be moving into uncharted waters. I only hope it doesn’t cause more harm than good. None of us can know for sure how this will evolve and where we will go. In a future blog, I will discuss my thoughts on lowering costs and improving access while improving care.