Is it possible to find bipartisan common ground on improving the Affordable Care Act?
And can the United States have a serious conversion on how to conserve and allocate limited health care resources?
Conventional wisdom says no. Instead of working together to improve the ACA, both parties seem to be locked into a no-win battle over repeal. Discussion of conserving resources and controlling costs seems always to lead to unproductive charges and counter-charges about rationing.
But yesterday, in its annual State of the Nation's Health Care report, the American College of Physicians challenged conventional wisdom.
ACP argued that common ground is possible on sustaining and improving the Affordable Care Act, including incorporating improvements usually associated with Republicans. ACP also expressed its belief that the country must confront the necessity of making hard decisions on conserving and allocating limited health care resources, but in a way that is in accord with distinctly American values.
I had the honor of joining ACP President Fred Ralston, MD, FACP, to present ACP's recommendations at a press conference in Washington, D.C.
We made the case that the United States is facing an unprecedented health care crisis: more uninsured than ever before, the erosion of private employer-based coverage, more people on under-funded public safety net programs, a growing shortage of physicians in critical specialties including primary care, and rising costs that will bankrupt the country. We presented ACP's firm belief that the Affordable Care Act has policies that are essential to addressing these challenges, and should not be repealed.
But we also argued that the law could be improved by giving states more options, earlier, to design their own systems to cover as many people and/or to enter into agreements to sell insurance across state lines; to replace the Medicare SGR formula with one that provides higher updates to all physicians and improved payment for primary care; and to reform the broken medical liability system—an issue traditionally associated with the GOP that President Obama said on Tuesday he is open to addressing. In addition to advocating for caps on non-economic damages, ACP urged Congress to fund a national pilot of health courts, a "no fault" model where claims would be heard by a judge with special training and access to independent medical advice.
We also released a major new ACP position paper, How Can Our Nation Conserve and Distribute Health Care Resources Effectively and Efficiently, which argues that the United States, like all countries, must address the fact of rising health care costs that threaten the economic health of the nation.
"We recognize that discussion of the most effective and appropriate ways to make such decisions, to the benefit of individual patients and the broader population, are undermined when the debate becomes polarized over whether or how care in the United States should be "rationed"—a term that is poorly understood, emotionally driven, and not conducive to reaching consensus. Achieving a national consensus on how best to use health care resources effectively, efficiently, and rationally should instead seek to distinguish between medical rationing, in which decision-makers determine which scarce medical resources are provided and who receives them, and rational medical decision-making, by which judicious choices are made among clinically effective alternatives. We emphasize that choosing among clinically effective alternatives based on medical evidence to provide clinically appropriate and effective care that maximizes value is not the same as rationing, which results in denial of care."
I am a realist, and I don't expect that ACP's recommendations will magically overcome the partisan divide on repeal of the ACA. Nor do I expect that everyone suddenly will join hands, sing kumbaya, and reach agreement on how to allocate limited health care resources, fairly and judiciously.
At some point, though, I hope it will become apparent to all sides that the ACA won't be repealed, but that it can be improved. ACP's recommendations can contribute to finding such bipartisan common ground.
And I hope that responsible people across the ideological spectrum will soon realize that the best way to avoid explicit medical rationing, as exists in many other countries, is to confront the issue now on what the United States can afford. But such decisions must be done through an open, transparent, and participatory process that empowers people to make decisions based on evidence, instead of imposing limits on them.
Today's questions: What is your reaction to ACP's efforts to urge the political parties to seek common ground on improving the ACA? And to our proposal to start a conversation on conserving and allocating resources based on evidence?
Last night's State of the Union didn't have much to say about health care reform. But what was said by President Obama and the GOP response(s) spoke volumes about how far apart the Democrats and Republicans are.
Physicians would welcome a serious, bipartisan effort to reform the medical liability system, although the proof is in the pudding.
The official GOP response from Rep. Paul Ryan (R-WI), didn't show any give – he insisted that the Affordable Care Act had to go "it is driving the explosive growth of our debt." The "unofficial" Tea Party response from Rep. Michelle Bachmann (R-MN) was a caustic attack on "Obamacare" and pretty much all things Obama.
Tomorrow, ACP will be releasing its own State of the Nation's Health Care report, which will include our recommendations on preserving, sustaining, building and improving on the key elements of the Affordable Care Act. We will describe specific changes in the law that we believe would improve its effectiveness and could attract bipartisan common ground—including a new approach to medical liability reform.
But progress on improving the Affordable Care Act will require that the GOP back off on its insistence that repeal is the only acceptable option, and for President Obama and congressional Democrats to really be willing to consider some GOP ideas, including medical liability reform.
The House of Representatives began debate today on its bill to repeal the Affordable Care Act. The GOP has the votes it needs to get it passed, but it will go nowhere in the Senate.
But the vote is more than symbolic, as some press reports have labeled it. There is more than symbolism at work when the House of Representatives decides, as its first order of business, to vote to dismantle the work of its immediate predecessor. Rather, it signals that the Republican-controlled House is serious about mounting a sustained effort to use every tool at its disposal to repeal, halt and defund the law, in pieces if not all at once. Interestingly, the House is taking on this fight at time when the level of strong opposition to the ACA is near an all-time low according to a new AP poll.
Instead of a fight that will be won or lost on a single battlefield, think of it as series of guerilla actions by the GOP to weaken the law, in the hopes of ultimately bringing it down.
Readers of this blog know where I stand on repeal: the Affordable Care Act isn't perfect and can and should be improved, but turning away from its promise of (near) universal health insurance coverage would be a terrible mistake. Repeal would result in at least 32 million more Americans going without health insurance, the continued erosion of private employer-based health insurance coverage, more people ending up in under-funded safety net programs, and elimination of some of the most promising initiatives to begin to bend the cost curve.
Coincidental to tomorrow's vote (since the publication schedule was set months ago), health reform is a major focus of today's edition of the Annals of Internal Medicine. It includes my article (originally published in December as an early web release) on the consequences if the United States allows universal coverage to slip away, and several letters to the editor taking issue with the August 23 article by White House staffers Zeke Emanuel, Bob Kocher, and Nancy-Ann Deparle. The letters, and the authors' response, makes for interesting reading.
Also today, ACP released a statement to urge Congress to "preserve and – as necessary – improve on [the] important reforms created by the Affordable Care Act, not repeal them." The statement lists "essential" policies that need to be preserved, including provisions to provide coverage to nearly all Americans.
This would be good advice as well for President Obama and the Democrats. Wouldn't making the law "work as effectively as possible" by "working together" to fix or modify it be much more constructive, and unifying for the country, than a no-win fight over repeal and replace?
Today's question: What is your reaction: after tomorrow's "symbolic" vote on repeal, should the 112th Congress heed Dr. Frist's advice to take the next two years to work as effectively as possible, or continue to fight to repeal or weaken it?
How would repeal affect coverage and cost of health care?
Next week, the new GOP-controlled House of Representatives will be voting on and is expected to pass a bill to repeal the Affordable Care Act (ACA), lock, stock, and barrel.
There is virtually no chance the repeal bill will get through the Senate, though, which maintains a narrow Democratic majority, and President Obama would veto it if it did.
But let's say that the seemingly impossible happened, and the ACA was repealed. What would the impact be on coverage, costs, and the federal deficit?
- Deficit: repeal of the ACA would increase the deficit by $145 billion from 2012-2019, by another $80 to $90 billion over the 2020-21 period, and by an amount "that is in the broad range of one-half percent of the GDP" in the decade after 2019*--or about a trillion dollars.
- Federal budgetary commitment to health care: repeal would lower the federal budgetary commitment to health care over the next decade but increase it in subsequent years. In other words, if the ACA is repealed, the federal government would pay less now, but more later for health care.
- Coverage: repeal would result in 32 million fewer non-elderly persons having health insurance, leaving about 54 million uninsured. The share of legal non-elderly residents with insurance in 2019 would be 83 percent compared to 94% under the ACA.
- Premiums: premiums for individual insurance would be "somewhat lower" but "on average . . . many people would end up paying more for health insurance coverage -because under [the ACA], the majority of enrollees purchasing coverage in that market would receive subsidies via the insurance exchanges, and [repeal] would eliminate those subsidies." Premiums for employment-based coverage from large employers would be "slightly higher" under repeal than under the ACA. Premiums for employer-based coverage through small employers might be "slightly higher or lower" reflecting uncertainty about the impact of the ACA on premiums in that market.
Repeal, of course, would also eliminate all of the provisions of the ACA, including rules to end discriminatory practices against people with pre-existing condition exclusions, coverage of adult children on their parents' plans, the new 10% increase in Medicare payments to primary care physicians, the new Medicare wellness examination preventive and other screening procedures now available free of charge to beneficiaries, the phase-out of the Medicare Part D doughnut hole, the requirement that insurers spend more on patient care and less on administration, and much, much more.
There is something to be said for politicians trying to deliver on campaign pledges. The GOP promised voters that it would try to repeal the ACA, so it is no surprise and maybe even a bit refreshing that repeal is one of the first things out of the starting gate.
But the evidence is that if the ACA is repealed, the country would have a bigger deficit, more uninsured people, higher out-of-pockets costs and premiums, reduced Medicare benefits, reduced pay to primary care doctors, and elimination of many other popular and beneficial programs created by the ACA. Is this really what the people want?
Today's question: What is your reaction to the CBO's finding that repeal of the ACA will increase the deficit, lead to more uninsured persons, and higher premiums and out-of-pockets costs for many?