Tuesday, March 23, 2010

Critically Ill Congress Takes Turn for the Better...

Sunday night the United States House of Representatives passed the most ambitious and far-reaching piece of health care legislation since Medicare and possibly ever.  The bill, which was approved on a 219-212 largely party line vote, will expand access to health care to approximately 32 million Americans.  Partly mirroring Massachusetts own health care reform passed in 2006, the federal effort will require that most Americans have health insurance and assist those that cannot afford it by enrolling them in Medicare or offering subsidies to purchase private plans.  Insurers will be barred from dropping or denying coverage to those who become sick.

The passage of the bill is a monumental legislative achievement for both President Barack Obama and the Democrat controlled House of Representatives.  Although the passed bill carries great political risk, its passage and Obama's planned nationwide tour promoting the bill, realization of national health care reform in Washington offers beleaguered Democrats their first real opportunity to blunt Republican momentum going into the November midterms.

The bill that officially became law upon receiving Obama's signature is actually the first of two parts of the same reform package.  The House technically passed the bill the US Senate passed on a party-line filibuster proof vote last Christmas eve.  However, that bill was very different from the one that the House had itself earlier passed.  After Scott Brown was elected to complete the late Ted Kennedy term, the Democrats lost their filibuster-proof majority and would then be unable to pass a final health care bill after a Senate-House worked out differences.  Because the Senate bill contained/lacked a number of measures the House Democratic caucus hated/demanded, the process of reconciliation came into being.

Reconciliation is a budget-related procedural vote ensconced in Senate rules.  Essentially it permits changes to current laws that affect the budget, as a great deal of the health care bill does, without the need to overcome a filibuster.  Created in the 1970s, its intent is to permit passage of the budget, without a filibuster fight.  Changes using reconciliation are technically temporary, but because the heart of health care reform exists in the Senate bill, this will unlikely be a problem.  Republicans claimed that the rule ran afoul of the Constitutions forgetting that the filibuster, itself, is mentioned nowhere in the nation's founding document.  Nor is the use of reconciliation unprecedented.  Republicans used the maneuver to pass the Medicare Part D prescription drug coverage under former President Bush.

Many have heralded the bill as one of the great achievements of the Democrat's social agenda, one that includes Social Security, Medicare, and Civil Rights.  Republicans, meanwhile, stand in a much weakened posiiton.  Although still poised to make gains in the November elections, their all-or-nothing approach has exposed their politically motivated absolutism and excluded them from having any say on this once-in-a-generation reform bill.  Republicans are now shifting gears and turning campaigns into an effort to repeal the reform, a unlikely prospect that would require twelve seats to change parties in the Senate and more than three times as many in the House.  Plus, it would need to overcome a presidential veto.  Although 34 Democrats voted against the bill most of those seats are the ones most likely to change hands.

The successful passage of the bill has been largely attributed to a last minute deal made with the Democrats' pro-life wing headed by Michigan Congressman Bart Stupak.  Stupak, who successfully pushed for a strongly worded abortion amendment to the House's original health bill, had pledged to vote against the reform bill if it failed to prohibit federal funding or subsidies for health care policies that pay for the procedure.  The Senate bill lacked this amendment and its inclusion within the reconciliation bill would be outside the narrow parameters allowed under Senate rules.  Instead, President Obama issued an executive order intended to clarify that federal funds will not be used to pay for abortions via subsidized insurance.  Politico wrote about how Pittsburgh's Congressman and Stupak's roommate Mike Doyle played a role in the effort.

Stupak and American Roman Catholic bishops really wanted a total legislative ban, but Stupak, at heart, wanted to vote for the bill and saw the executive order as a fair compromise.  Obama is probably the most pro-choice president this country has seen or will see in some time and so the likelihood the executive order will be rescinded by a future president is low.  Groups on both sides of the abortion debate bemoaned the compromise.  Pro-lifers complained it did not go far enough and abortion rights groups lamented that poor women and even some more affluent ones may be denied coverage for abortion.  What die-hard pro-lifers would have wanted could run-afoul of Roe v. Wade and had they, particularly its Roman Catholic wing, been insistent, it would have killed health care reform.  Roman Catholic groups, the abortion issue aside, were wildly in favor of health care reform.  As for abortion rights groups, their argument falls flat.  Many abortions are not paid by insurance.  Even women who have insurance opt to pay out of pocket to minimize the evidence of their decision.  Few women have abortions with the desire to have it be a known fact.  Nobody, including pro-choice advocates, consider it a badge of honor.  Many poor women are less likely to have abortions to begin with and when they do, many legitimate options already exist that involve little or no cost.

Although 34 Democrats voted against the bill, most were from the caucus' Blue Dog Democrat organization.  The Blue Dogs are often fiscal and sometimes social conservatives that find commonality with the Democrats on other issues.  Most of its members who voted no came from Southern states, fearing both losses at the polls and perhaps a genuine concern about the bill's scope.  Some Democrats, however, voted no for quite different reasons.  Stephen Lynch of Massachusetts claimed that the bill failed to keep premiums down while Dan Lipinski took issue with the bills failure to keep the government out of the abortion business.  Lynch's vote is particularly disappointing because although it espouses a legitimate concern, it seems to suggest that that alone is worth keeping millions of Americans uninsured.  Lipinski's nay vote reflects a courage of convictions, but one that like the pro-life movement, suggests that millions of unborn children will be aborted once health care reform is passed.  Neither Lipinski's Chicago based district, nor Lynch's Boston centered district are considered targets for GOP wins and therefore their reason can be taken at face value and not out of fear of losing office.

Although Lynch's concerns were misplaced in the context of the health care bill's passage, they do point to a huge problem in health care costs.  Insurance premium do rise in part because of insurance companies' greed.  However, as a business, they must respond to rising costs.  Even if the United States was able to transition to a single-payer system, something that some say would have been likely had reform failed this time around, it would have to deal with the same rising costs (A single payer system has some terrific advantages, but its major downside is that it would leave the countless Americans employed by the health insurance business unemployed).

Those rising costs arise from many problems, but we'll examine four.  Overuse of prescription drugs, overuse of specialists, a refusal to engage in healthier living, and dramatically and increasingly expensive care during the last three months of life.  All of them are an outgrowth of an American attitude toward medicine, which quite simply views there being a solution for everything.  I think the overuse of prescriptions speaks for itself, especially when many, though not all medications do what diet, exercise, and generally healthy living can accomplish.  Oh and let's not forget the plethora of drugs for mood and behavior disorders...  Moving on, although there are legitimate needs for specialists, many work to address some of the most simple problems that Americans simply do not have the patience to deal with.  An orthopedic specialist may spend their time working with knee replacement patients.  However, they may also charge hundreds of dollars for several or even an infinite number of visits to relieve a pain in the arm with a series of exercises.  A wrist splint and aspirin could be just as effective long term.

The third problem is particularly problematic.  Among those with employer-provided insurance, this is probably the single most direct cost of increasing premiums.  Employees feel that since they have the coverage, why not use it.  Correcting this behavior as well as encouraging healthier lifestyle is extremely difficult.  For example, government efforts have in the past focused on either taxing items like candy and soda or requiring, as New York City has done, that all eateries place calorie information on their menus.  The former is a smack in the face to those that are responsible with their food purchases and otherwise extremely intrusive.  Additionally, it is often a fig leaf for legislators cravenly searching for meager funds.  Posting calorie information is not really onerous either for the patron or the eating establishment, but is it really effective?  The answer is no.  The best solutions for this would be a concerted effort by the government, through education and enlisting the aid of doctors to staunchly advocate healthy living, when it is most effective, before the medicating or surgical alternatives.  More on that in a minute.

The cost of providing care during the last three months of life is a major burden as well, but one that has no easy answers.  One cannot simply say to family or patients themselves, "don't bother."  At the same time, the use of expensive, experimental, and often times unsuccessful procedures to cure the un-curable leaves millions of dollars of costs.  Between insurers, Medicaid, Medicare, out of pocket payments, and unpaid bills born by hospitals, billions are spent to hold back the inevitable.  What may work here may connect to some pilot programs included in the health care bill.  One program would pay doctors and medical facilities based on the quality and not quantity of care.  Its intent, in addition to holding down medical costs, would be to encourage doctors and hospitals to advocate treatments that work and not might/could work.

This proposal could also be channeled into changing Americans attitudes about how they view their health and medicine.  If the government pays doctors based on the best care, it may lead them to encourage their patients to adopt healthier lifestyles rather than with dozens of procedures.

However, doctors themselves needs to change as well.  The American Medical Association supported the bill as long as its members face no tangible changes.  The effect of this leaves one of the most important elements of health care, doctors themselves, untouched by any significant changes.  If anything it will be a boon to them and to hospitals as they will find more patients, newly enrolled in insurance, able to pay.  However, enrolling more people in insurance requires more primary care doctors, a field that fewer and fewer medical resident enter.  Most newly minted doctors transition to specialist care as soon as possible(insert high dollar value here), which pays much better than primary care does ($100,000-200,000).  This has been a continual problem in Massachusetts since reform was enacted and is partly responsible for the unacceptably low drop in emergency room visits that many use in place of preventative care.  Although doctors' licensing and prescription-writing powers are regulated by the states and the feds, government regulation of doctors' career choices is minimal.  Some effort will need to be made to either require doctors maintain some primary care patients, shift more care to nurses, physicians assistants, and other staff (although they too are lured to specialists' offices by higher pay), or require doctors serve a number of years as a primary care doctor before moving on entirely.  Such an effort would be more successful if pushed and required by medical associations, rather than the government.

In any case, health care reform will and must face additions and changes as problems are encountered.  The above mentioned problems will need correcting and given the fact that illegals are not covered, immigration reform will become a necessary component of successful long-term reform.

The battle for health care reform is over in Washington for the moment.  Although Senate reconciliation still has to pass, it seems unlikely that Republicans can sink it.  Although they may try, it really is not worth it.  Health care reform has been signed by Obama and will live regardless.  The next battle for health care may be raging right here in Massachusetts.

*Barack Obama, Bart Stupak, and Stephen Lynch photos all from wikipedia.  Menu with calorie count photo from AP via Cleveland Plain Dealer website

1 comment:

Anonymous said...

Though the AMA may have supported this bill, in actuality MOST doctors were against this bill. It did little to address the root of high medical cost: tort. Most independent doctors spend upwards of 30-40% of their revenues to cover their malpractice premiums. (hospitals, which employ up to hundreds of doctors, face similar expenses) This cost is invariably pasted onto patients. Furthermore, many doctors have gotten into the habit of ordering unnecessary tests as a means of "covering their tracks" in event of a malpractice law suit. This further adds to the cost of medical treatment.

The New England Journal of Medicine (one of the most respected Medical Journals) came out with an article that talks about these points in greater detail. As a consequence of this bill, it predicts almost 33% of doctors will now be considering early retirement/ leaving the medical field all together.

Looks like Americans should ready for medical rationing and longer lines at the hospital...but at least Obama and co. can say we finally have "reform"....

(Due to copyright infringement, i can't post a link to the actual article from NE Journal of Medicine...the cbs article provides a synopsis for those interested)..