Monday, August 16, 2010

Part Two, The Future Fifth Anniversary of Health Reform Passage.

Many of health reform's problems of 2015 has been anticipated, but insufficiently addressed.

The Obama administration, perhaps blinded by its zeal for universal coverage as the crown jewel of its political legacy, its arrogance that government could solve any economic or social crisis, and seduced by rosy but unproven scenarios predicting Medicare savings and practice efficiencies, plunged ahead with its divisive, unpopular, costly, and bureaucratic reforms. The public responded by saying - To "L" with left-leaning liberals who lecture us rather than listening to us.

It was not that Congress had completely ignored the prospects of physicians being unable to serve its new constituencies.

Those prospects were always in the background. As John Iglehart, national correspondent for the NEJM, observed in his Health Policy Report in July 2010,

“However, mandated coverage is only one of many challenges facing Democrats as they implement the most sweeping piece of social legislation since the enactment of Medicare and Medicaid. Another challenge that has attracted far less attention is whether newly insured individuals will actually have access to health care once they become insured and whether Medicare should expand its support of graduate medical education (GME) training to increase capacity. The law takes only modest steps to expand the workforce, which is already stretched in some geographic areas and in some specialties.”

Congress took modest steps to address these deficiencies. In its $862 billion stimulus bill and an addendum to that bill, it devoted $300 million to expanding the National Health Service Corps, which relied on recruiting primary care doctors, and it promised another $250 million to train 16,000 more primary care doctors. On a national scale, these amounts were drops in the proverbial bucket of a system that spend $2.5 trillion in 2009.

In the health reform bill itself, starting in 2011, Congress awarded yearly 10% Medicare bonuses over 5 years to primary care doctors to narrow the gap between primary care and specialist incomes; in 2013, it promised to bring Medicaid fees for doctors up to those provided by Medicare; and it launched a series of demonstration projects – medical homes, coordinated care, accountable care organizations, and bundled billing – that emphasized primary care.

The physician community regarded these as modest efforts that paled in the failure to address malpractice reform and Medicare physician payment in the SGR (Sustainable Growth Rate)formula, which called for 21% reductions in physician pay in 2010 and more thereafter.

But at the same time, Congress said it would cut $575 billion out of Medicare over the next 10 years and would reduce support for graduate medical education institutions, which ran the programs that trained new doctors.

The ends, expanding coverage while reducing costs, did not make sense to many, including academic medical centers, hospitals, doctors, and Medicare patients. Besides, Medicare's chief actuary, Richard Foster, said in his annual 2010 report that costs would expand not contract. These contradictions fed doubts and fueled criticisms.

Meanwhile, on the political front, Republicans regained control of the House and Senate and had a 5-4 margin on the Supreme Court.

President Obama narrowly won re-election in 2012. He twice vetoed bills to repeal and reject the health reform law.

But due to unified Republican opposition, and its choking off of funds for reform, President Obama and his team were having a hard time implementing health reform. Funds for health reform implementation were not forthcoming from Congress. Its major provisions for covering the uninsured had begun in earnest in 2014, and Republicans were resisting steps necessary for reform implementation, such as health exchanges and state insurance reforms.

For Big Government, 2015 is not going to be a good year. Politics is the art of the possible, and not everything seemed possible anymore.

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