OP-ED

The Swing to the Right: The Election and Its Effects On Health Reform

Like Tom Friedman, who lampooned some of this year’s unreasonable campaign rhetoric in a recent column, I too would be in favor of reality-based political campaigns … but that seemed to be too much to ask for this year.  Instead of truth, we now have truthiness.  The joke news shows (and their joke political rallies) seemed to be more popular than the evening news.  (I wish Jon Stewart and his 200,000 fans on the Washington Mall last weekend had stayed home, canvassing for their candidates of choice.)  Fact-checkers told us that many political ads this season were in the “barely true” or “pants on fire” zones according to the Truth-O-Meter.  But in the end, the buzzwords seem to have worked their magic, and many “insiders” are out, and “outsiders” are in.  The angry and the impatient on the campaign trail have, in some cases, adopted the line from the movie Network: “I’m mad as hell, and I’m not going to take this any more,” perhaps forgetting that while that line garnered the Howard Beale character strong ratings, network bosses arranged for his on-air assassination when his ratings fell.

The Utopia tune at the top of this post, “Swing to the Right,” comes to you from the Ronald Reagan era, and perhaps we are seeing the generational swing of the pendulum back to the right.  It does seem to happen every 30 years or so … but don’t blame me — I’m from Massachusetts (home to a Democratic sweep this Election Night).

The last two years have seen a tremendous amount of change in Washington.  The question of the moment, of course, is:  How will the election results affect implementation of health care reform?

The short answer is that even having sustained the losses that they have, the Democrats in Congress will be able to sustain a Presidential veto of any GOP anti-health reform initiative.  The 2012 election may well determine the ultimate course of health reform.  If the GOP gains further ground in two years, then implementation may be that much more difficult to accomplish.

For a cogent analysis of the high stakes for health reform in the midterm elections, see Henry Aaron’s recent piece in the New England Journal of Medicine (hat tip: Jane Sarasohn-Kahn, aka @healthythinker).

(As an aside, the challenges to the health insurance mandate pending in courts around the country, of course, also pose a potential threat to health reform implementation.  Interestingly, GOP opposition to the health insurance mandate coexists with support for the spread of affordable health insurance for individuals, even though combining the two positions makes no actuarial sense: without mandate-driven health insurance purchases by Young Invincibles, there can be no “affordable” health insurance for individuals in a community-rated market.)

Stay tuned for the next bit of political theater as the latest “doc fix” expires December 1, and the lame duck Congress decides what to do about the SGR and the nearly 25% Medicare physician fee schedule cut that will go into effect unless, once again, there is some last-minute Congressional action.

Update 11/5/2010: Here’s a better link to the 2007 MedPAC report, “Assessing Alternatives to the Sustainable Growth Rate System,” and a link to the Congressional testimony given on the MedPAC SGR report by Glenn Hackbarth.  It’s remarkable to consider how many elements of MedPAC’s recommendations made their way into the ACA, while the SGR formula was left alone.  As we move forward into the realm of bundled payments and quality incentives (Massachusetts is getting there first), capping FFS inflation is just not where we ought to be focusing our energies.  Here’s hoping that when Don Berwick and Kathleen Sebelius get hauled in to testify at lots of Congressional committee hearings next year they get to put a bug in the ears of the legislators about this issue so that a long-term solution to the SGR issue may be implemented that will be consonant with the way the rest of the health care market is headed.

David Harlow writes at HealthBlawg:: David Harlow’s Health Care Law Blog, a nationally-recognized health care law and policy blog. He is an attorney and lectures extensively on health law topics to attorneys and to health care providers. Prior to entering private practice, he served as Deputy General Counsel of the Massachusetts Department of Public Health.

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31 replies »

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  2. MD as Hell, we are a dying breed. It makes you wonder what our colleagues were listening to in medical school. It was either “Ka-ching, Ka-ching”, or “you are here to save the world from itself”. You know what I heard? “You are here to learn a craft that a precious few really have the ability to master and provide to the community you will serve, but make no doubt about it, if you let those who are not your equivalent dictate your work, you will fail not only those you treat, but yourself.”
    Yeah, we as a profession continue to fail policing ourselves responsibly, but, letting politicians be the substitute? Here is the painful but appropriate analogy: would you self catherize yourself; this legislation would probably encourage you to do so!
    Hey, harsh to write, but even most harsh to realize true!

  3. “Are you this stupid or not an american citizen? The minority party, specially one with as few seats as the Republicans had, can’t even bring a bill to the floor. How exactly does the minority party pass bills?”
    I was under the impression that the Republicans held both houses of Congress and the Presidency not long ago. Alas, you are clearly a troll and not interested in real discussion.
    Steve

  4. “Paolo what do you want the minority leadership to do?”
    Perhaps, propose reasonable alternatives. Something a few courageous GOP members have done, but the leadership has not. At the very least, don’t poison the well. Some day, the GOP will have full responsibility of governing, and they have made their future life very difficult.
    By ranting against any mandates (while being against pre-ex) and rioting against any cut in Medicare (while being against paying for it), the GOP has put itself in a hole. They have created a problem they cannot solve.

  5. Nate – MG the exit pooling seems to show Seniors are open to reform if they think it will be effective.
    “Voters over 65 favored Republicans last week by a 21-point margin after flirting with Democrats in the 2006 midterm elections and favoring John McCain by a relatively narrow 8-point margin in 2008.”
    Yes because the GOP ran an explicit message of restoring Medicare cuts and that Obamacare was ‘taking money from away from seniors.’ There isn’t a single poll I have seen where seniors support Obamacare but it is almost exclusively because the seniors benefits they paid for as being taken away from them.
    Nevermind that current Medicare beneficaries didn’t pay a nickel for Medicare Part D and receive grossly inflated benefits in return for the actual amount they paid in taxes even if you factor in inflation.
    This rhetoric the GOP is spouting seniors are concerned about ‘leaving their grandchildren with lots of debt’ is a bunch of partisan rhetoric garbage. They are with two huge caveats – as long as you don’t reduce SSI and Medicare benefits. That’s a hell of a caveat.

  6. The administration makes a deal with PhRMA to keep drug prices high, a deal with AMA to keep doctors happy and continue increasing reimbursement and the same with hospitals.
    So cuts are made to Medicare and probably Medicaid shortly while millions more are added each year to both of these entitlement programs. A nice little package except for the fact that we have run out of doctors, nurses and other required health providers, most of whom say they are losing money treating these people and are not going to much longer. Increasing fees won’t solve the burgening problems that not even the doctors recognize; but we can always eat cake if we run out of bread!

  7. MG the exit pooling seems to show Seniors are open to reform if they think it will be effective.
    “Voters over 65 favored Republicans last week by a 21-point margin after flirting with Democrats in the 2006 midterm elections and favoring John McCain by a relatively narrow 8-point margin in 2008.”
    that doesn’t appear to reflect a block of voters with their heels dug in.
    “When in the last two decades have Democrats had that?”
    2008-2010 Peter?
    “It’s called working across the aisle if you want legislation – something the founders seemed to want and Republicans seem to forget.”
    You watch way to much MSM Peter. Anyone that wants to reach across the aisle can shove it, this is how things get worse not better. In Washington reaching across the aisle means taking bad ideas from two parties and passing them both. According to your blathering Peter if they passed a bill that outlawed homosexulaity and gave Amnesty to anyone that wanted it that would be good for the country since both parties worked together? BS, bad ideas are bad ideas and passing them is always bad.
    “When did meaningful healthcare come up between 1995 and 2005,”
    Meaningful to whom? Plenty of bad ideas came up and made things worse during that time. HIPAA for example. COBRA had some changes. Tons of state mandates

  8. “When was it in the last two decades Republicans had that? Oh that’s right they never did.”
    When in the last two decades have Democrats had that? Democrats can’t even get their “Bluedogs” to vote as Democrats. It’s called working across the aisle if you want legislation – something the founders seemed to want and Republicans seem to forget. When did meaningful healthcare come up between 1995 and 2005, unless you mean Medicare Part D, which gave millions to drug companies and added to the deficit. For seniors though that was considered fiscally responsible.
    http://uspolitics.about.com/od/usgovernment/l/bl_party_division_2.htm
    As I said I’m going to sit back with my popcorn and watch how Republicans “fix” what needs to be fixed while keeping everyone happy and wealthy. Since Reagan it’s been 30 years of bubble/bust/bailout/debt – bubble/bust/bailout/debt, while the middle class continue to loose and the wealthy continue to gain. Do you believe Republicans will think any different than they have for 30 years?

  9. “People choose to be poor?”
    Yes sometimes they do Steve, thats not the point. Have you never heard of Medicaid? We have a program that gives families making 18K or 30K free insurance yet 10-15 million of them can’t be bothered to sign up. What about the 10 million or so making over 50K and those making over 75K that can afford it but choose not to?
    “hey have not expended one bit of political capital to try to pass these”
    Are you this stupid or not an american citizen? The minority party, specially one with as few seats as the Republicans had, can’t even bring a bill to the floor. How exactly does the minority party pass bills?
    Are you seriously a doctor? How do you people get out of school?
    “They were willing to resort to reconciliation to pass tax cuts.”
    And who had the majority of votes when they did this? Are you really that clueless on how government works?
    “I think that I have looked at every proposed Republican suggestion for cutting costs. As a practicing doc, most of them make no sense to me.”
    Seeing as how you couldn’t even follow the carton on how laws are made this doesn’t surprise me.
    What part of AHPs don’t you grasp? It’s pretty simple concept. Eliminating State mandates, you can’t figure that one out? Not paying for infertility treatment for example you don’t understand how that lowers cost?
    Paolo what do you want the minority leadership to do? Are you as uninformed as Steve to how laws pass? Now that they are back in power is the time to see if they advance any of those previous plans. As the minority they had no power to push an alternate plan.

  10. Steve is correct. The current GOP leadership is not interested in pushing a plan. They are interested in using health care as a weapon of fear. It works very well in elections, but it doesn’t the help the country, nor does it help conservative positions in the long run.
    In the past, there have been a number of Republican comprehensive plans on how to provide health care to all. Not only did Ryan propose a plan, but Judd Gregg had a plan, Bennett had a plan, and so did McCain(version ’08) and Romney(version ’06). I’m not a fan of most of these (although I like Bennett’s), but at least they were reasonable and could serve as a starting point for intelligent discussion. Instead, we have a yelling match about the evil of socialism vs the evil of insurance companies.

  11. “We have a mandate now, if you don’t buy insurance and get sick you could possibly be denied some care and be financially broke. 40 million people have chosen to ignore this mandate and taken the risk.”
    People choose to be poor? Given the current costs of health insurance, how is the 18k a year, even the 30k a year family supposed to pay for insurance?
    “Republicans have a list of reforms they want to pass that would actually make insurance more affordable, improve care, and resolve the problems in the system, ”
    hey have not expended one bit of political capital to try to pass these. They were willing to resort to reconciliation to pass tax cuts. I think that I have looked at every proposed Republican suggestion for cutting costs. As a practicing doc, most of them make no sense to me. Plans like Ryan’s were ignored by Republican leadership as they knew it was not politically viable.
    Steve

  12. “To hell with your electronic BS. No one needs universal access to your last hemoccult.”
    Yup, the American people have been sold a pig in a poke.
    This scandal will have epic long lasting repercussions. If it wastes half as much money proportionately as in the UK, Obama will give the presidency to anyone who runs against him, including the foreign policy expert Palin.
    He will not have a ghost of a chance of serving a second term.
    Wake up POTUS, you were scammed.

  13. France is raising their retirement age to howls of protest. But when you are broke you’re broke.
    Same here. We are broke. Time to get serious about Medicare cuts and disability cuts and military cuts. It will be bloody.
    If the fees go down December 1st my urgent care stops taking Medicare. Cash will be fine. Maybe I’ll sell subscriptions for access.
    Stop giving away scooters. Stop putting cacaine addicts on disability. Stop putting feeding tubes in nursing home patients. Stop putting noncompliant people on dialysis over and over.
    Once you make some easy choices, the tougher ones get easier.
    To hell with your electronic BS. No one needs universal access to your last hemoccult.

  14. Repub strategy is to make POTUS look like a fool. Whatever it takes. Obama is begging for cooperation in his radio address yesterday. He still does not get it, but neither do the Republicans. What is best for the nation, actually?
    As far as what is best for the patients, take a gander at the HIT debacle in the UK for an example of a serious waste of money.

  15. Although, I agree with your discussion. I still feel that as professionals instead of focusing on the ‘business’ aspect of healthcare, we should direct our efforts in making our clinical skills more sound. Below is a nice website, where you can start.
    Rajesh
    http://www.Rxnotes.net
    1. Central searchable repository of a pharmacists ‘curb-side’ notes.
    2. Transition between hospital and retail settings, your notes can transition with you, not your job!
    3. For access from anywhere, when I do not have direct access to my references/websites.
    4. For the Pharmacist, BY the Pharmacist.

  16. Nate – “MG do you think seniors are open to reform?”
    No. One of the most profound ironies of this election was in PA where Toomey ran a tun of ads about spending and bailouts nailing Sestak yet ran some ads mentioning the Medicare cuts & “taking money from seniors.” No surprise since the No. 1 issue for some exit polls here for the elderly was healthcare (2nd was property taxes which always a rallying cry here in PA was a distant).
    Other GOP members also ran on the issue of Medicare cuts too including Corbett for PA governor. Helped to get the elderly out in large numbers in PA and propel the GOP to control all branches of PA state gov’t since ’95.
    Any politician who try to run on a platform that involves Medicare cuts in any form in PA faces a very uphill climb in one of the grayest states in the US.
    What neither party is willing to talk about is that the greatest transfer of wealth in this country is from the young to the elderly. Millennials though (those born after ’84) will make larger and larger numbers of voters especially by 2016 and it is going to be very interesting to see if this group does every get politically engaged in a consistent way through voting in a way that would be favorable to them & reflect their interests.
    We aren’t there yet but politics in America over the next 10 years are mainly going to be about taking away things from people & not giving them out. This is going to pit various groups against one another depending on the issue and my bet is that one big showdown we will see will be Gen X/Gen Y vs. Boomers/elderly on benefits.

  17. Observation: The Health Care Blog is normally a place of civil discussion. This string is out of character.

  18. without not with
    Stupid doctors spewing slogans they can’t even grasp are vampires, sucking common sense out of the collective universe.
    How do Liberals survive beibg so ignorant?
    “We Repubs in charge, look for more money to go the insurers’ way.”
    Wasn’t it the Democrats that just forced 20-40 million people into the evil insurance companies? Are you that unaware of what is going on quack? How are Repubs in charge when they have 1 of 2 parts of the legislative and don’t have the executive? They have 1/3rd of the power.
    No value? Those claims process them self? Kaiser is a negative on the world? Risk financing is not needed, everyone can pay their own million dollar claim? How did you make it out of grade school?

  19. “sounds great, too bad that republicans were never in power during the last 2 decades and able to fix things.”
    My bad rbar I thought you knew how our goverment works. With control of the house, 60 seats in senate, and the white house you can’t force through bills the other side doesn’t want. When was it in the last two decades Republicans had that? Oh that’s right they never did.
    If you want a quick example to prove my point see AHP, Republicans proposed it for 15 years and could never get it past the Democrats.
    Anything else you would like to add?

  20. Health insurers are parasites. They extract resources from the system without adding any value. As long as they exist, we won’t have an efficient or effective use of resources. Yet, they get the lion’s share of resources in our current system. We Repubs in charge, look for more money to go the insurers’ way.

  21. “Republicans have a list of reforms they want to pass that would actually make insurance more affordable, improve care, and resolve the problems in the system” – sounds great, too bad that republicans were never in power during the last 2 decades and able to fix things.

  22. MG do you think seniors are open to reform? If presented with an opportunity to screw their grandchildren over slightly less then they already are and not take drastic cuts I think they would get behind it. The problem is as seniors they have 45 years experience how government reforms programs.
    I don’t know any seniors that support fraud and waste yet reform made no meaningful efforts to reduce that 50 billion annual bill.
    I think seniors would be open to more efficient and integrated care, 25% of seniors signed up for MA and MA can deliver medicare benefits 3-4% cheaper, how can we replicate that over the remaining 75% without having to bribe them with additional benefits. It’s not going to solve any national problems by itself but 15-20 billion is still 15-20 billion.
    Opening up Medicare to some competition would go over well, specially if it offered better service and responsivness.
    Like republicans seniors aren’t opposed to reform they are opposed to the reform being forced on them so far.

  23. Rally for Sanity was a joke since it really didn’t stand for anything and was symbolic of how pathetic the turnout (estimated to be 18%) was among eligible 18-30 population. They were the only demographic group by age that voted to support the ACA based on various exit polls.
    Contrast this to those 65+ who are about 13% of the population and made up about 28% of the estimated vote. Big surprise that healthcare was the biggest issue for seniors and they came out in large numbers against Obamacare.
    The lesson – Anyone who tries to cross the Boomers and those already retired in terms of any Medicare cuts of risks losing elections. Even Ryan’s bold plans largely leave Medicare in place for the Boomers & current retirees because even he realizes that whatever party tries to radically reform Medicare in terms of benefit cuts will face a really uphill battle at the polls because seniors vote in large numbers in every US election that are much larger than their % of the population.

  24. ” I think the republicans are committed to killing reform”
    killing Obama reform, the same type of failed logic that the last 45 years of reform have been based on. The same failed type of reform that has got us to where we are today.
    Republicans have a list of reforms they want to pass that would actually make insurance more affordable, improve care, and resolve the problems in the system, democrats are only concerned about taking over more of the national economy and having more tax dollars to spend on their pet projects.

  25. Interesting post. Not sure I agree 100% though. I think the republicans are committed to killing reform (if you can believe what Mitch McConnell is saying). The only thing that is really needed is if the economy and jobs picture starts getting better. If that happens a lot of the shrillness will be tempered and cooler heads may prevail.

  26. SPeaking of barely true and pants on fire;
    “Interestingly, GOP opposition to the health insurance mandate coexists with support for the spread of affordable health insurance for individuals, even though combining the two positions makes no actuarial sense: without mandate-driven health insurance purchases by Young Invincibles, there can be no “affordable” health insurance for individuals in a community-rated market.)”
    Your either joking and propogandizing or have no idea how insurance works. Or possibly don’t understand what a mandate is. We have a mandate now, if you don’t buy insurance and get sick you could possibly be denied some care and be financially broke. 40 million people have chosen to ignore this mandate and taken the risk.
    Healthcare reform replaces this inadequate mandate with a worse mandate. We will slightly increase the penalty, instead of no financial penalty for those that stay healthy they might now have to pay a miniscual penalty, still a fraction of the actual cost of insurance though. Millions will continue to ignore the mandate and pay the $700 penalty and avoid $3000+ insurance premiums.
    Where liberals and people such as your self that don’t understand insurance get lost is the reward healthcare reform offers those that ignore the mandate. Even if you break the rules and ignore the mandate you are guarateed the right to buy a policy equal to that of people that did follow the rules. HCR actually makes it less risky for people to not buy insurnace. From a pure profit motive why would anyone buy insurance until you need it?
    Anyone with even basic comprehension of insurance sees how this reform is going to increase the affordability gap not close it. People already game the system at the risk of being locked out of the market becuase of pre-ex, how does eliminating pre-ex risk make it more affordable.
    Liberal hipocracy knows no ends.

  27. “Stay tuned for the next bit of political theater as the latest “doc fix” expires December 1, and the lame duck Congress decides what to do about the SGR and the nearly 25% Medicare physician fee schedule cut that will go into effect unless, once again, there is some last-minute Congressional action.”
    Is this any way to run a business? Only doctors would put up with this chit. The SGR is indeed an inflationary force, even if just by the disruption it causes to medical practices. Then, they want me to spend upwards of $70,000 for an EMR and $660 per month maintenance. Are you kidding me? This gets the c’mon man of the year award.

  28. David, I’ll have to guardedly disagree on your take of the Rally for Sanity. It was not a joke. These people are young, very political (mostly on the center-left) and intent on changing the methodology. From what I see, the rally was just the beginning. Most of them are at the age when you think you can personally change the world for the better and the sky is the limit. I’m not sure where it goes from here and I am of course skeptical of anybody’s ability to change such a massive and well entrenched system, but I have to admire the effort. I wish them well.
    As to health care reform, I certainly hope (against all hope) that the next two years are not a static dog-fight over the edges of ACA, each side trying to tear-down/defend bits and pieces of the perimeter, while the rest of the economy goes down in flames. Perhaps it is about Sanity after all….

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