Wednesday, July 28, 2010

Foreword to Book on Health Reform

This is the foreword to Health Care Reform Perspective, my new book on health reform. Basically I describe physicians’ initial reaction to the newly passed health reform law.


The date was March 23, 2010. After a year-long partisan political struggle, pay-offs to wavering Democratic Senators, and doubts about long-term costs, Obama’s health reform bill passed.

For Democrats, it should have been the best of times. Obama supporters proclaimed a “historic achievement.” President Obama was heralded as the most “consequential “of Democratic Presidents, more so than FDR or LBJ.


His party had finally passed a sweeping, unprecedented health reform bill, thanks to a single minded commitment by the President, and the legislative skills of Nancy Pelosi, leader of the House, and Harry Reid, leader of the Senate.

Democrats all voted for the bill. Republicans were unanimously against it. For a bill of this magnitude affecting every American to pass without a single opposition vote was indeed unprecedented. It may have been its greatest political flaw.

For Republicans, it was a bitter pill to swallow. They felt Democratic had snookered them. Under cover of darkness, Senate Democrats persuaded the House to approve the Senate version. And it was done amidst public opposition to the bill, mounting skepticism about a faltering economy, soaring national debt, and gathering gloom over government growth and skyrocketing national debt.

To add insult to injury, in a July recess appointment, Obama named Doctor Donald Berwick, staunch admirer of Britain’s National Health Service and advocate of rationing, as head of CMS (Centers for Medicare and Medicaid Services). Berwick said he had seen the errors of some of his socialistic ways, but Republicans were not convinced.


Republicans called for Repeal and Replacement of the health law. The Tea Party movement grew. Obama approval ratings sank. Democrats lost millions of white male, elderly, and independent voters. Calls for “take our country back” were heard. In a July 26 Rasmussen poll, Most voters (58%) still favor repeal of the health care law. By a 44%-28% margin, voters believe repeal of the health care law would be good for the economy.

Among physicians, there is broad opposition to the health reform law, as exemplified by multiple surveys indicating one-third to one-half of physicians say they will cease seeing Medicare or Medicaid patients if the health law passed and implemented as written. If carried out, lack of physician access would create a political crisis of unimaginable scope.

For many Democrats legislative triumph may have been a Pyrrhic victory. There were ominous polls indicating Democrats might lose the House, even the Senate, in the November mid-term elections.

The Trophy

Still, in the heat of it all, Democrats still had their trophy, the health bill. It was now the law of the land. The law was called the Patient Protection and Affordability Act (PPACA). For short, it became known as the Affordability Care Act (ACA). But to most critics, it was simply Obamacare. The law’s proponents claimed, perhaps rightfully, that the term “Obamacare” was a perjorative term, code indicating opposition to health reform.

In 2010, the new law quickly covered those with preexisting illness, all children, and “children” up to 26 and closed the “donut hole” for Medicare medications.

Beyond the cherished few million who received immediate benefits, most of the rest of the populace failed to grasp whom the bill “protected,” outside the 32 million waiting to be covered on 2014. Certainly, Medicare beneficiaries did not feel protected, nor did taxpayers, American businesses, or physicians, for that matter. Meanwhile, after passage, the number of uninsured grew steadily to 47 million by the summer of 2010.

No one, not even its supporters, seriously believed the bill was “affordable,” not even the office of Management and Budget. The cost was variously estimated at $1 trillion over ten years (Obama estimate) to $2.6 trillion by Republicans over 15 years.


Besides, the Democratic estimate rested on the assumption that “savings” would be achieved by gutting Medicare of $575 billion, ending fraud and abuse, rationalizing care by doctors and hospitals, and cutting care utilization through comparative research analysis. Skepticism about these “savings” was understandable. Never in the history of the Republic had Congress cut spending while expanding entitlement programs.

The final irony was: nobody really understood what was in the over 3000 page health bill or what its consequences might be. Very few even read it. Yet the law applied to every American citizen.

Basic Assumption

Furthermore, it was based on this assumption: a small trained, technocratic, professional elite knew what they were doing, spoke for the people, and were smarter than the masses, who did not know what good for them. Their approach and ethos sprang from their belief that studies of statistical analysis of data outcomes of masses of people, rather than on individual concerns, held the clues and was the secret for improving the system.

The Best of Times, The Worst of Times

Politically, for Democrats, enactment of the health law was at first the best of times. But it soured, as the economy continued to falter, and joblessness and as casting the blame on President Bush receded as a credible political tactic.

For Republicans it was at first bad, then the best of times. But they had no credible leader and no credible message. Perhaps both would come before midterm elections in November.

What was lacking was perspective of what Health reform really meant for Americans - and for physicians who cared for them.

That is what this book is about. It rests on the thesis that a little perspective goes a long way.

Richard L. Reece, MD
Old Saybrook, Connecticut

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