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Even with new legislation, health care reform would evolve

From the February ACP Internist, copyright 2010 by the American College of Physicians

By Robert B. Doherty

Health care reform legislation is often characterized as a destination, but it is more like an ongoing journey. Surely, enactment of a law to provide coverage to more than 30 million uninsured Americans would be a singular achievement, but following any such passage, the effort to reform health care will continue.

Medicare illustrates the continuous flow of health care reform. It is not as if Congress enacted Medicare in 1965 and then checked it off the legislative “to do” list. Every Congress since then has made its mark by changing Medicare. Every administration has left its mark through the rule-making process. So it is with the current effort to reform health care.

Changing the changes

Legislation will take years to implement. Federal and state governments will have to create regulatory structures to enforce new rules over the insurance industry, like the rules banning exclusions for preexisting conditions. States will have to expand Medicaid to cover millions more residents. Congress’s appropriations committees will have to decide how much money to put into many of the discretionary programs subject to annual appropriation, such as new grant programs to support training primary care physicians. Most uninsured Americans will not have access to the new coverage options until at least 2013.

A commission to select and fund new models of payment and delivery will have to be organized, appointed and staffed. The selected models will then have to be launched and evaluated. Later, the commission will have to decide which ones should be implemented nationwide.

A mid-term congressional election takes place in 2010, virtually ensuring that the next Congress will exercise oversight of the rule-making process and even try to amend the law before many of its key provisions are implemented, especially if the Republican Party makes big gains in the mid-term elections. Interest groups will lobby Congress and the administration to make the law more to their liking. A presidential election will take place in 2012, and the future of health care reform will be among the issues debated by the contenders.

Meanwhile, the growing national debt will likely result in the Obama administration and Congress designing a process to get more control over spending and revenue, including reforms in the Medicare and Medicaid entitlement programs.

If the current reform effort collapses, it would continue from a very different starting point. Instead of designing and influencing the rules to provide coverage for 30 million Americans, we will be looking at a scenario where the number of uninsured will continue to increase; where health care costs continue to rise at an unaffordable rate for the country, employers and families; where insurance companies could still exclude or overcharge people because they are sick; and where higher spending will cause Medicare to go bankrupt at an earlier date. The need for health care reform will be greater than ever, but the focus will be on enacting policies to ameliorate the worst outcomes, instead of designing a system to cover everyone.

Continued advocacy

The continuous and changing nature of health care reform is a good thing. It allows us to have another bite at the apple if there are parts of the law that we don’t like. It allows for mid-course corrections if the new programs created by Congress have unintended adverse consequences, as any law that attempts to restructure one-fifth of the economy almost certainly will. It allows us to advocate for additional policies if the reforms on the table are not up to the task. For instance, ACP will advocate for stronger policies to reverse a growing shortage of primary care physicians.

The dynamic and continuous nature of health care reform also is unifying. Like other physician membership organizations, the collegiality and unity of ACP’s membership have been tested by the highly partisan political debate over the health care bills. Once we move from the contentious debate over the bills to influencing what happens next, internists can find common ground on the changes they would like ACP to pursue.

The success or failure of the current health reform legislation is enormously important to the country, but will not be the end of the journey. The debate over the government’s role in health care will continue, and ACP will continue to do its part to advocate for policies to make health care affordable and accessible to all Americans.

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