American College of Physicians: Internal Medicine — Doctors for Adults ®

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Three keys to health care reform: change, buy-in and unity

From the July/August ACP Internist, copyright 2009 by the American College of Physicians

By Robert B. Doherty

Congress is engaged in both a marathon and a sprint toward enacting health care reform legislation. Congressional leaders are racing to pass reforms before the August recess but at the same time must clear many hurdles before reaching their destination.

As I write this column in late May, the stars appear to be aligned for health care reform, as President Obama himself has stated. Polls show a large majority of the public wants fundamental reform. A popular president has put the full weight of his office behind it. Congressional leaders have committed to producing a bill, and it appears that a majority in Congress agree. And key stakeholders, including the insurance industry that helped derail health care reform in the early 1990s, say they are on board.

Yet many of the most contentious issues have yet to be resolved. Experienced hands know that betting on health care reform is like picking the Chicago Cubs in a pre-season office pool to win the World Series. No matter how good things look on paper, experience says that something inevitably will go wrong. However, the following considerations should help formulate a reasonable prediction for what the future holds.

Desire for change, fear of it

Although polls consistently show that more than two-thirds of voters support fundamental health care reform, the level of support drops when voters are told that reform “will take decisions away from their doctor.” Critics of the president’s agenda will warn voters that reform will lead to “rationing” of care and “big government getting between you and your doctor,” while supporters will counter with words like “giving you and your doctor more choices” and “health care that can’t be taken away.”

With the cost of universal coverage estimated to be more than $100 billion per year, Congress will need to come up with ways to pay for it. Mr. Obama has proposed raising taxes for people making more than $250,000 per year. Others have proposed putting a dollar limit on the tax exclusion for employer-sponsored health insurance coverage, meaning that anything above the cap will be taxable income for employees. Tax hikes on everything from cigarettes to beer to fructose-sweetened soft drinks might be on the table. The public’s desire for “health care that can’t be taken away” will be pitted against its aversion to higher taxes.

Get doctors on board

Polls show that most physicians are hugely dissatisfied with the status quo. ACP has channeled such frustrations into a powerful call for a better health care system that provides all Americans with access to affordable coverage and to a primary care physician.

Still, I wonder if physicians will be on board when Congress begins producing the details of reform legislation. My sense is that most physicians believe strongly that all Americans should have affordable health coverage but many are concerned that the cure will be worse than the disease.

It would be a huge mistake for Mr. Obama and Congress to take physicians’ support for granted. Democratic and Republican pollsters alike tell us that the public is highly influenced by doctors’ positions and if physicians end up siding with the critics, much of the public may turn against the Obama proposal as well. But if the medical profession stands behind health care reform, it will effectively inoculate the program from the critics’ most effective argument: that it will allow government to take decisions away from doctors.

To keep physicians on board, Mr. Obama and Congress should ensure that health care reform legislation addresses physicians’ major concerns, excessive red tape and hassles associated with health plan interactions, a dysfunctional payment system that undervalues primary care, and Medicare payment cuts.

Keeping the coalition

Mr. Obama has applauded representatives of the insurance industry, medicine, hospitals, and the pharmaceutical and medical device manufacturers for reaching agreement on trimming health care cost increases. Although many of these groups have strong reservations about some of the ideas floating around in Congress, they have for the most part held their fire.

Even if higher taxes become a reality, Congress must find more savings through, for example, payment cuts for “mis-valued” services, drugs and procedures; scrutiny of “excessive” ordering of “unnecessary” tests and procedures; increased regulation of insurance industry practices; and requiring employers to provide coverage or pay higher taxes. All of these options face the threat of high-powered anti-reform campaigns by key stakeholders.

In the end, the fate of heath care reform will likely come down to Mr. Obama’s political skills. So far, he has laid down broad principles but let Congress take the lead on specific details. However, history tells us that the “bully pulpit,” as Teddy Roosevelt famously described it, is the president’s most potent political weapon. When things get stuck in Congress, Mr. Obama may need to step in to broker a deal, and then use his enormous powers of persuasion to sell it to the public.

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