Wednesday, March 17, 2010

The Fight for Health Reform

My Own Malaise

One would think that with my expertise and profession, I would be listening to the discussions about the President’s health care proposal with tremendous interest.  Instead, I find myself avoiding the news reports about the proposed legislation.  Rather than a discussion of health care, I see an exercise in raw political power that frankly, leaves me cold.  From the left of the political spectrum, I see almost rabid desire to put into place the basis for a government healthcare system based on a universal “right” of health care that is divorced from any cost discussion, being paid by taxes, presumably only on evil rich people who are defined as anyone who does not work directly for the government or in academe.  On the right we hear about the evils of any government assistance for people truly in need as a slippery slope towards communism.  We seem to have lost any middle in this argument.  Thus I feel only depression and malaise at the way the “end game” on health reform is being played.  The Congressional leadership has decided that the left is in charge so they will move ahead steamrolling those who disagree.  Those on the right appear to be accepting the inevitable while also taking political advantage of the issue for the next election cycle.  I just have deep disappointment in our government leaders who seem more intent on winning at any cost than on finding solutions for the country. 

Lowering Health Care Costs as a False Goal

The goals of health reform are supposedly twofold: increasing coverage of those who are uninsured and lowering costs.  The current legislation is totally focused on coverage for those uninsured and is actually likely to increase costs radically above any CBO estimate despite that being trumpeted as a goal.  The CBO, by law, is required to base cost estimates on only those facts and assumptions that the Congress supplies.  The Congress has created false assumptions that Medicare will show decreases in cost without any plan to decrease costs.  In health care, the only way to decrease costs is to lower payment to providers, namely physicians, hospitals, and other health care professionals and organizations, and/or lower the volume of services which is most easily accomplished by eliminating certain services as benefits.  Lowering payments to physicians is not specified in the bill but there is a fee reduction of 21% currently scheduled, however that has already been reversed by a separate bill passed by the Senate.  This separate bill is a companion to health reform that is not in the CBO calculations and it actually guarantees that physician fees will not be lowered.  Since this is separate legislation it avoids inclusion in the calculation of costs related to health reform.  Recently a bill did pass the Senate maintaining physician salaries for the short term at least.  The AMA memo to their members about that bill read as follows:

AMA renews call for permanent reform of Medicare payment formula for America’s seniors and the physicians that care for them

For immediate release:
March 10, 2010

Statement attributable to:
J. James Rohack, MD
President, American Medical Association

“Today, the U.S. Senate voted to again delay this year’s steep 21 percent Medicare physician payment cut to October 1, pushing the problem off into the near future.  If the House adopts this Senate bill, America’s seniors and their physicians will be left in limbo, and access to health care for Medicare patients will continue to be in grave danger.  Physicians cannot keep their practice doors open to all Medicare patients without clear direction from Congress on Medicare payment rates. Already, Medicare payment rates are far below the costs of providing patient care, and physicians are left wondering how they can continue to run a medical practice if Congress does not inject security and stability into the Medicare program.

“Short-term actions are the wrong answer to a long-term problem.  These band-aid fixes have only served to increase the size of the cuts and the cost of reform. The longer Congress delays, the higher the cost to the American taxpayer.  It’s time to fix the formula and ensure that seniors can count on Medicare now and for years to come.”

If the AMA is unsuccessful, we will then be in a position in which physicians will be earning significantly less for serving Medicare patients.  Physicians in response, will either stop accepting Medicare, or shift costs to commercial insurers.  The logical next step would be an outcry by the public to either raise the rates paid to physicians or force physicians to accept lower fees and lower incomes.  If they are forced to accept lower incomes, there may be many who would be happy with that turn of events however it will create a problem of the best and the brightest deciding to go into other fields that are more lucrative.  That could be a loss to all of us.  That is currently a problem in England with the medical profession lacking new young British physicians.  If the AMA is successful, we then face the problem of ever increasing health care costs unless rationing is put in place. 

Rationing means limiting the services rendered, however the current bill actually adds services by mandating certain benefits that are not the norm right now.  Under the bill, a Federal Board will determine which benefits should be mandated.  While many people worry about the rationing of care leading to fewer services, the other side of that coin is the Federal Board increasing coverage for those services that have powerful politics behind them, even if they are not medically helpful.  Thus we will likely see different groups lobbying for coverage of their pet area increasing the volume of services and increasing costs while other services are rationed to lower costs.  We already know that in states that mandate in vitro fertilization for infertility, now only do those costs directly related to in vitro services increase but the number of sick newborns also increase and that increases neonatal intensive care costs dramatically.  Will costs of mandates such as that be offset by rationing of dialysis for the elderly for example?  We just don’t know.

There are answers to this conundrum however those answers, such as health savings accounts and other vehicles which results in informed decisions by patients leading to self rationing are rejected out of hand by this current legislation.

What is the Real Goal?

If the bill is likely to increase costs then what is the real goal and how will it be achieved?  Certainly the social goal of universal coverage is laudatory however it appears to go beyond that.  Two lead opinion pieces in the most recent American Journal of Public Health suggest the long term political goals of this legislation.  In “Selling the Obama Plan: Mistakes, Misunderstanding, and Other Misdemeanors”, Howard Waitzkin of the University of New Mexico waxes eloquent about how everyone loves Medicare and how all that needs to happen is for Medicare to be the only insurer for the entire population.  He does ignore the fact that Medicare is running out of money as it has virtually no controls for cost in place.  The only way the costs would be controlled would again be lower payments to providers and rationing.  While Dr. Waitzkin expresses unhappiness with the current proposal as not going far enough, he also sees the single payer system as being put into place in the long run.  For him, that is a sign of optimism and for me, it is a tremendous fear as it will signficantly decrease medical innovation and our cultural emphasis on care for the individual.  In some ways, Dr. Vincente Navarro of Johns Hopkins University goes even further in his companion article “Consequences of the Privatized Funding of Medical Care and of the Privatized Electoral Process”.  According to Dr. Navarro, Obama’s biggest mistake thus far is that he has not gone far enough in general and has thus “antagonized the left by excluding single-payer”.  Dr. Navarro then goes on to say that this is all a problem created by a privatized electoral system.   Thus it is more government control in health care and even in electoral politics that is the ultimate goal for Dr. Navarro. 

The Audacity of Hope

The audacity of my hope is that even if this bill passes, the effects will be modulated by future legislation by new representatives in coming years.  This bill is phased in over years so I can only hope that any damage done by it can be overturned in the next few years.  This bill does have positive aspects  such as the elimination of pre existing condition provisions and we should in some way focus on the good that can come out of the legislation.  In the meantime, I just stay in my malaise.  It is probably why I could never be in politics.  It just depresses me.