by Dr.Rob of Musings of a Distractible Mind
I have been asked by patients, readers, family members, and by fellow bloggers what I think about the bill passed by the House of Regurgitants Representatives yesterday. I resent this. I have tried hard to remain neutral as possible, finding equal cause to point and sneer at both conservatives and liberals. It’s much more fun to watch the kids fight than it is to figure out which one is to blame.
But given the enormous pressure put on me by these people, as well as threatening phone calls from Oprah and Dr. Oz, I will give my “radical moderate” view of the HC bill. My perspective is, of course, that of a primary care physician who will deal with the aftermath of this in a way very few talking heads on TV can understand. The business of HC is my business, literally. So, reluctantly, I take leave of the critic’s chair and take on the position where I will be a target for any rotten fruit thrown.
1. It’s not Armageddon.
We are all still alive and breathing, and will continue to do so after this law is passed and signed. The bill does not change things as radically as the shrill voices on the right suggest. It does not constitute a government takeover of HC, nor does it seem to extend any government programs by a whole lot. It is really not about HC at all, but instead about health insurance.
The goal of getting more people insured is a good one. Our system clearly (from my perspective) makes my services unaffordable – especially if you consider what people pay for procedures and medications I order. The lack of affordable insurance does harm people; I see it every day. The system is broken and needs fixing. Anyone who says otherwise needs to get a urine drug screen ASAP and then seek professional help.
Beware of the fear-mongers who make this out to be the “pro-death panel” legislation. It’s really not that bad.
2. It’s not Nirvana.
It’s actually more like the Foo Fighters…no wait, that’s another blog post.
There are folks on the Left who think that we are entering a golden age because of this. Some suggest this is the “Waterloo for the Republicans.” No, this bill is simply a rearrangement of how money is being spent, not a fount of blessings to those in need. Some people will benefit from this – especially those with no insurance – but most people won’t see a whole bunch of change from it.
This bill addresses the problem of the uninsured, but does not deal with the much more important issue of cost. If anything, it may worsen the problem that is actually at the core of the troubles: out of control spending. Figuring out how things are going to be paid without controlling what is being paid for is like rearranging chairs on the Titanic. The reason people cannot afford insurance is not because there are enough insurance options, it is because of the incredible amount of waste in the system. Agreeing to cover more with insurance without controlling cost will make the situation worse, not better.
3. The process was a national embarrassment.
The debate in DC did not seem to be about people getting the care they need; it seemed to be about which side would win. The lack of bipartisanship is a condemnation of both sides, an indication that power is more important to our representatives than is representation. Why didn’t the Democrats agree to tort reform (which nearly everyone supports)? Why couldn’t the Republicans concede that having people with no insurance is a problem the government should address?
We have a terrible situation in our country: a HC system that is out of control in its cost and that will bankrupt us if nothing is done. Yet what this difficulty has won us is not a national resolve to fix this problem, it is an increase in the partisan screaming and a worsened environment to effect real and beneficial change.
To me, the debate turned debacle is a very good argument for term-limits for members of congress.
4. It missed the point.
The real problem in healthcare, again, is not who is paying. The real problem is that it costs far too much. We are not in a crisis because of insurance; we are in a crisis because of what is being paid for by insurance. For legislation to have a real chance for fixing this problem, it must find a way to control spending.
The problem of health insurance is far easier than that of cost. Here’s why I think cost-control is going to be an even harder thing to tackle:
- There are industries making billions of dollars off of the inefficiency and waste in HC (see my post about the Sea Creatures). Devices that don’t really help people, and specialty procedures that are unproven are paid for while primary care gets the shaft. People like shiny technology and legislators have a hard time saying “no” to it – especially with the lobbyist dollars that will protect this waste-eating industry. It’s boring to promote primary care and doesn’t play well to the constituents.
- We don’t have the IT to do it. Any attempt at cost control will fail without good health IT. Doctors control a huge percentage of HC costs, yet most are operating blindly. We rely on the word of the patient for what happens in other HC settings. If you are going to expect physicians to make prudent medical decisions and eliminate waste, you must give them adequate information. Unfortunately, the current push for EMR is not about delivering information to physicians, but instead about letting doctors document more efficiently. Use IT to inform, not conform. Use IT to enable docs instead of burdening them more.
- “Rationing.” Any control of cost will be about denying care. I believe that denying care that harms patients is a good thing to do, as is suggesting cheaper alternatives if they are equal in benefit. Patients are angry when they can’t get Nexium covered by the insurance company, but OTC Prilosec is just as good for them. Patients are angry when they can’t get an MRI for their back pain when it is really not appropriate for 98% of back pain sufferers. People don’t want to be denied. Americans want an all-you-can-eat buffet of medical care. Unfortunately, any change for the positive will inevitably involve some sacrifice.
So, what do I think about the legislation? I honestly don’t think it’s that big of a deal. I think it’s good that something is being done about those without insurance, but I worry that nobody is checking the balance on the credit card. I like the arrangement of chairs on the deck, but perhaps the hole in the boat merits a little consideration.
One of the political liabilities of the HCR bill is that the most important elements -- the insurance exchanges, subsidized plans, and the expansion of Medicaid -- do not go into effect for several years, indeed until after the next presidential election. This was, lamentably, a gimmick Congress used to stay beneath an arbitrary cost ceiling imposed by President Obama. But it is what it is. So what is in the short-term horizon for health care? What effects will be seen immediately?
Shamelessly borrowing from a note that Speaker Pelosi (a close personal friend) sent me last night, here are some of the key provisions that go into effect within the next 90 days, 6 months, or year:
- SMALL BUSINESS TAX CREDITS— Tax credits of up to 35 percent of premiums will be immediately available to firms that choose to offer coverage. (Beginning in 2014, the small business tax credits will cover 50 percent of premiums.)
- BEGINS TO CLOSE THE MEDICARE PART D DONUT HOLE—Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010. Completely closes the donut hole by 2020.
- COMMUNITY HEALTH CENTERS—Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years. Effective beginning in fiscal year 2010.
- INCREASING NUMBER OF PRIMARY CARE DOCTORS—Provides new investment in training programs to increase the number of primary care doctors, nurses, and public health professionals. Effective beginning in fiscal year 2010.
- INCREASING REIMBURSEMENT FOR PRIMARY CARE SERVICES—Creates a 10% bonus for primary care services provided under medicare.
- ENDS RESCISSIONS—Bans health plans from dropping people from coverage when they get sick.
- NO DISCRIMINATON AGAINST CHILDREN WITH PRE‐EXISTING CONDITIONS—Prohibits health plans from denying coverage to children with pre‐existing conditions. Beginning in 2014, this prohibition would apply to all persons.
- BANS LIFETIME LIMITS ON COVERAGE—Prohibits health plans from placing lifetime caps on coverage.
- BANS RESTRICTIVE ANNUAL LIMITS ON COVERAGE—Tightly restricts new plans’ use of annual limits to ensure access to needed care.
- FREE PREVENTIVE CARE UNDER NEW PRIVATE PLANS—Requires new private plans to cover preventive services with no co‐payments and with preventive services being exempt from deductibles.
- NEW, INDEPENDENT APPEALS PROCESS—Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan.
- ENSURING VALUE FOR PREMIUM PAYMENTS—Requires plans in the individual and small group market to spend 80 percent of premium dollars on medical services, and plans in the large group market to spend 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders.
- IMMEDIATE HELP FOR THE UNINSURED UNTIL EXCHANGE IS AVAILABLE (INTERIM HIGH‐RISK POOL)— Provides immediate access to insurance for Americans who are uninsured because of a pre‐existing condition ‐ through a temporary high‐risk pool.
- EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS’ INSURANCE – Requires health plans to allow young people up to their 26th birthday to remain on their parents’ insurance policy, at the parents’ choice.
- PROHIBITING DISCRIMINATION BASED ON SALARY—Prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher wage employees.
Overall, this is pretty good bang for the buck in the initial years. I'd still like to see the exchanges start up immediately, but the interim high-risk pools are a nice start (are they subsidized? I'm not sure). It will definitely give the Dems some good talking points leading up to November, and hopefully will start giving consumers some needed relief.