The Health Reform Law: A Favor You Can’t Understand

The January 20 and January 27 editions of the New England Journal of Medicine arrived today. The two editions contained 5 articles on health reform.

1. “Assessing the ACO Prototype – Medicare’s Physician Group Practice Prototype”

2. “Can Congress Make You Buy Broccoli? And Why That’s a Hard Question”

3. “The Importance of the Individual Mandate – Evidence from Massachusetts”

4. “Health Care Reform – What Went Wrong on the Way to the Court House”

5. “Implementing Health Care Reform – An Interview with HHS Secretary Kathleen Sibelius”

The 5 articles were intellectually-presented , intelligently-argued, inconclusive, and hard to understand, save perhaps for the Sibelius piece.

She said, “We have a law, and we will continue to implement it. With President Obama in the White House, efforts to repeal the ACA will not succeed.”

Fair enough, and fairly obvious, something I could understand.

As I sought vainly to digest what we being said, I kept thinking of Ira Magaziner, Ivy League graduate (Brown), Rhodes Scholar, consultant, and Hillary Clinton’s former chief advisor on health care policy.

Magaziner was a master of arcane, intellectual, policy double-speak. One critic said Magaziner was like a member of the Mafia. The Mafia's most memorable code promise is, of course, “To do you a favor you can’t refuse.

But of Magaziner, the critic said with a twist, “ He is going to do us a favor we can’t understand.”

That lack of understanding is the health reform law’s most fundamental flaw. The law is too fiendishly complicated for anybody to understand. Nobody seems to understand the debates over the law’s actual costs, constitutionality of the individual mandate, resistance of the states to travails of implementation, or viability of accountable care organizations.

The latest mystery is why 729 organizations covering 2.3 million people have been granted waivers from participating in the law. Sibelius has given waivers to a wide swath of entities, including the Robert Wood Johnson Foundation, businesses, large and small, labor unions, big and little, and to a variety of enterprises that offer health and prescription drug coverage with limited benefits, and to four states – Massachusetts, New Jersey, Ohio, and Tennessee. One can only conclude, if you don’t like the law and you have White House connections, you don’t have to play.

The only thing certain about the ultimate fate of the law are its uncertainties. In the meantime, on the physician front, it is certain that the law favors large group practices as prototypes for accountable care organizations.

Since 2005, Medicare has engaged in a demonstration project with 10 large groups - Billings Clinic in Billings, Montana; Dartmouth-Hitchcock Clinic, in Lebanon, New Hampshire; Everett Clinic in Everett, Washington; Forsyth Medical Group in Winston-Salem, North Carolina; the Geisinger Clinic, in Danville, Virginia; the Marshfield Clinic, in Marshfield, Wisconsin, the MIddlesex Health System in Middletown, Connecticut, the Park Nicollet Clinic, in St. Louis Park, Minnesota; St. John’s Clinic in Springfield, Missouri; and the University of Michigan Faculty Group Practice, in Ann Arbor, Michigan - to prove beyond reasonable certainty that ACOs will save Medicare money.

The only thing certain about ACOs saving Medicare money are their uncertainties in doing so. To date, in 5 of the 10 clinics, Medicare money has been saved at one time or another, but in only 2 of the 10 have these ACO prototypes saved money every year.

Because so few of America’s doctors belong to these big clinics and because of the length of time it takes for these clinics to achieve results, one article conclude of ACOs “Congress may need to take more sweeping steps to slow the growth of Medicare spending long before the ACO model can prove whether it is up to meeting these challenges.”

ACOs may be another example of a favor we can’t refuse because we don’t understand what it will achieve.