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What can the audience expect from Congress' second act?

From the February ACP Internist, copyright © 2012 by the American College of Physicians

By Robert B. Doherty

If the 112th Congress was a Broadway play, critical reviews would have shut it down.

“The level of dysfunction that has characterized the 112th Congress may be unparalleled,” wrote Roll Call, Capitol Hill's hometown newspaper.

“[Has] any Congress ever been more dysfunctional, with less cause, than this one?” thundered The Atlantic's Michael Hirsh.

“Congress ends 2011 with record-low 11% approval,” reported the Gallup organization.

The latest example of Congress' dysfunction is the standoff at the end of 2011 over preventing Medicare payment cuts to doctors and extending payroll tax cuts and unemployment benefits.

This was a case where just about everyone—the White House and Congress, both Democrats and Republicans—agreed that no one wanted to see taxes go up, unemployment benefits cut off, and Medicare payments to doctors slashed by more than 27%. Everyone wanted an “extender” bill to prevent such occurrences at least through 2012.

So what did they end up with? A two-month extension, and even that lowest-common-denominator deal was reached only after it looked like Congress would recess without an agreement.

The GOP-controlled House of Representatives passed a bill that would have extended the tax break and unemployment benefits for a full year—and prevented cuts in Medicare payment rates to doctors through 2013—but tied it to restrictions on funding for the health reform law and a rollback of environmental regulations, conditions unacceptable to Senate Democrats and President Obama. Senate Democrats wanted to pay for the full-year extension by raising taxes on millionaires, which was unacceptable to Republicans.

Unable to resolve the differences, the Senate decided to buy time by agreeing to a two-month extension, a compromise supported by an overwhelming majority of its members from both parties. The House of Representatives balked, though, demanding that the Senate negotiate on a longer-team deal. The Senate declined, and with the situation at an irreconcilable impasse, most legislators fled town for the Christmas holiday. It was only after several days of withering criticism—including from Senate Republicans—that the House finally agreed, on Dec. 23, to accept the Senate bill.

March 1 is now the new deadline for Congress to prevent a 24.7% cut in physician payments and to keep unemployment benefits and the payroll tax break from expiring. If past is prelude, Congress will wait until Feb. 29 to reach an agreement. (It likely will need the extra day granted by the leap year!)

Congress' poor performance can also be measured by other lost opportunities. About a year ago, the House Energy and Commerce Committee wrote to ACP and other physician organizations, asking for ideas to reform physician payments and prevent further cuts:

“Unless we begin the process of developing a long-term solution, we will once again be faced with the unwanted choice of extending a fundamentally broken payment system or jeopardizing access to care for Medicare beneficiaries. We cannot let either happen.”

ACP answered the call by offering concrete ideas for stabilizing payments for the next five years and transitioning to a better payment system for patients and their physicians. Yet Congress dropped the ball, and we once again find ourselves, a year later, facing a choice of “extending a broken payment system or jeopardizing access.”

It isn't just with physician payment that Congress ducked its responsibilities. Congress almost allowed the U.S. to default on its obligations to creditors. The ballyhooed “super-committee” couldn't agree on a plan to reduce the federal budget deficit, and because it couldn't, a process called sequestration will impose across-the-board cuts in defense and domestic programs on Jan. 1, 2013. This will reduce funding for medical research, disease control and prevention, the health workforce, and other important health and public safety programs by more than 7%. Some lawmakers are talking about preventing the sequestration cuts, but that would require a bipartisan agreement on equivalent tax increases and spending cuts—the very issues that Congress couldn't agree on for all of 2011.

Regarding health reform, any hope of bipartisan common ground was dashed by the House's insistence on repealing the entire Patient Protection and Affordable Care Act—lock, stock and barrel.

The second act of the 112th Congress, which runs from January through December, isn't likely to be any better. The deep ideological divisions, the unwillingness to compromise, and the looming 2012 election will cause more dysfunction, more brinkmanship, and more unsatisfactory outcomes.

Yet consider this: Before 2012 comes to an end, Congress will probably have to decide on whether it will allow some $4 trillion in tax cuts enacted during President George W. Bush's administration to expire and whether the $1 trillion in sequestration cuts will take place on Jan. 1, 2013. It probably will have to deal with another scheduled physician payment cut of 35% or more. It may fall to a post-election, lame-duck Congress—and possibly a lame-duck administration if President Obama does not win reelection—to try to reach the big agreement on taxes and spending that has remained elusive so far.

As Congress dillies and dallies, the challenges facing the health care system remain: rising costs, uneven quality, and poor and inequitable access. The health reform law will help, but its future will remain uncertain at least through the 2012 election. The good news is that real health reform is already happening, as physicians, hospitals and patients work together to design better and more cost-effective ways of delivering care in their own communities. For now, the best they may be able to hope for from a dysfunctional Washington is that it doesn't get in their way.

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