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History will judge outgoing Congress’ impact on health reform

From the February ACP Internist, copyright 2011 by the American College of Physicians

By Robert B. Doherty

One would have to go back more than 45 years to find a Congress that has had as big an impact on health care as the just-departed 111th Congress. The 89th Congress enacted Medicare and Medicaid, an unprecedented and lasting expansion of government’s role in health care that made affordable coverage available to many millions of elderly, disabled, and poorer Americans, a legacy that has been sustained for almost a half-century. Arguably, the laws passed by the 111th Congress will have an even bigger impact on health care and government, but only if the new 112th Congress doesn’t turn them back.

In February 2009, Congress enacted the $814 billion stimulus law, the American Reinvestment and Economic Recovery Act (ARRA).

ARRA included $149 billion to fund health care, $87 billion of which went to help economically strapped states fund their Medicaid programs through a temporary increase in federal matching funds. Another $25 billion provided temporary federal subsidies to extend COBRA coverage for people who otherwise might have lost it. In addition, $19.2 billion was dedicated to stimulate adoption of health information technology (HIT), $10 billion went to the National Institutes of Health, $2 billion went to community health centers, $1.1 billion went toward comparative effectiveness research, and $500 million went to the National Health Service Corps and other programs created by the Public Health Service Act to expand the primary care workforce.

Although much of the ARRA money already has been spent, 2011 is the first year that physicians will be able to qualify for ARRA’s bonus payments for having a certified electronic health record that meets the government’s “meaningful use” rules.

Also in February 2009, the Children’s Health Insurance Program (CHIP) Reauthorization Act was approved by Congress and signed into law by President Obama. Because of an impasse on a long-term extension of the program between the previous Bush administration and Congress, CHIP had been set to expire on April 1, 2009; the new law ensured its continued funding through 2010.

The American College of Physicians supported the provisions in the ARRA legislation to provide funding for Medicaid and COBRA coverage, primary care, and the HIT incentives programs. The College also was a strong advocate of reauthorization of CHIP.

Although most recent polls show that many voters do not believe the stimulus legislation did much to help the U.S. economy, ARRA funding undoubtedly helped economically strapped states keep their Medicaid programs afloat—especially important because almost 4 million people joined Medicaid in 2009, the biggest enrollment increase in the program’s history. CHIP reauthorization ensured that the states were able to keep and expand coverage for tens of millions of low-income children.

As important as ARRA and the CHIP reauthorization were, they were just a prelude to the 111th Congress’ main act: passage of the Patient Protection and Affordable Care Act, now commonly referred to as the Affordable Care Act (or ObamaCare by its critics). After more than a year of torturous debate, false starts, ugly back-room deals, angry town hall meetings, repeated misrepresentations of its key provisions by political opponents, billions of dollars spent by special interest lobbies, filibusters, and markedly different versions being passed by the House and Senate, Congress was able to overcome what had seemed like insurmountable political obstacles. The Affordable Care Act (ACA) was approved by Congress on March 21, 2010, and signed into law by President Obama two days later. ACP strongly supported enactment of the ACA because it delivered on many of the College’s key priorities relating to coverage, workforce, and payment and delivery system reforms. The College will continue to seek improvements in areas where the ACA falls short.

The 111th Congress’ record on health doesn’t end with the ACA, though. On June 22, 2009, Congress enacted the Family Smoking Prevention and Tobacco Control Act. This legislation was the culmination of a 12-year effort, originally begun by Sen. John McCain and supported by ACP, to give the FDA the authority to regulate tobacco products.

And even after the Democrats took a “shellacking” in the November 2010 mid-term elections, the lame-duck Congress passed bills to reduce foodborne illnesses by increasing federal regulation of food safety and to improve child nutrition, a cause championed by First Lady Michelle Obama. After almost two years of failed attempts to provide stability in Medicare payments to doctors, Congress agreed to a one-year “doc fix” to put off through 2011 any Medicare payment cuts resulting from the flawed Sustainable Growth Rate formula.

On a more ominous note for President Obama’s agenda, because of Republican opposition, the lame-duck Congress was unable to agree on a comprehensive bill to fund federal programs through the end of 2011. Instead, Congress agreed on a temporary measure to continue current funding levels through early March. The temporary measure does not include the funds that the administration requested for implementation of the Affordable Care Act—the first case of the GOP using its increased influence over spending to try to “defund” the ACA, even before the party took control of the House.

The 111th Congress’ remarkable record of achievement on health reform is indisputable, with enactment of the ACA being the capstone. As reporters for Bloomberg News wrote last December, “For the first time since President Theodore Roosevelt began the quest for a national health-care system more than 100 years ago, the Democrat-led House and Senate took the biggest step toward achieving that goal by giving 32 million Americans access to insurance.”

What remains in dispute is whether the 111th Congress’ decisions to greatly expand federal regulation and funding of health care will prove to be a good thing for the country. Also unclear is whether these actions can be sustained. The new House GOP leadership of the 112th Congress has pledged to repeal, replace or at least defund as much of the ACA as it can. Although the Democrats ostensibly remain in control of the Senate, Republican gains give the Minority Leader, Mitch McConnell, even greater ability to obstruct legislation that would fund and implement the law.

History’s judgment of the 111th Congress’ impact on health care will be measured not only by the laws that were passed, but by whether those laws survive in the 112th and future Congresses. Until then, we won’t know if they will have as lasting an impact on the country as the Medicare and Medicaid programs enacted 45 years ago.

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