Health care reform at the precipice: What happens next?

Congress left for summer recess without having passed health care legislation. It has made progress: Three of the four congressional health committees reported versions of the legislation. (Congress never got this far with Bill and Hillary Clinton's health bill.) The one holdout was the Senate Finance Committee, which continues to work on an agreement that will bring some GOP support. Senators Max Baucus (D-MT), the committee chair, and Chuck Grassley (R-IA), its most senior Republican, reported progress but said they wouldn't produce a bill until this month.

By the time Congress returns, its members will have been exposed to excessive advertising and grass-roots lobbying designed to sway voter opinions on health reform. The best that can be said now is that the public is conflicted. Polling before the recess showed that large majorities still support overhauling our health care system. Voters worry about losing health insurance and rising costs, but are anxious that reform will lead to government interference with the doctor-patient relationship, lower quality, fewer choices and higher taxes.

As I have written on my blog, there is a battle under way to win the hearts and minds of physicians. Opinion polls show that the public trusts their doctors. The most powerful message against health reform is that “It will take decisions away from you and your doctor.” If physicians echo this concern, it undermines public support; if they instead say that health reform is good for patients, it increases public support.

Like the public, internists are conflicted. Most continue to support health reform but have concerns about particular elements. They recognize that patients are not well served by a system that leaves millions without insurance and where almost everyone could lose coverage if they develop a chronic illness or lose their job.

But they are deeply divided on whether people should have access to a public plan. Some argue with great passion that a public plan will lead to a government takeover and care rationing. Others believe with equal fervor that patients would benefit from a government-administered plan modeled on Medicare as an alternative to wasteful, inefficient for-profit private insurance.

Internists are also conflicted on whether to raise taxes to fund reform, and if so, on whom? Many express concern about the potential cost and its impact on the deficit, while others say we can't afford not to provide coverage to everyone.

Like other voters, physicians are influenced by personal politics and ideological leanings. Conservatives are likely to oppose almost everything proposed by President Obama and the Democrat-led Congress, especially health reform legislation. Liberals want Obama to succeed, especially on health reform. Many doctors who fall in the middle could be swayed either way.

Conflicts within the medical profession and the public mask the common ground that exists on many issues. ACP supports these common-ground priorities and uses them to evaluate bills:

• prohibiting insurance companies from cherry-picking patients,
• providing sliding-scale subsidies as refundable tax credits to those who cannot get or afford employer coverage,
• allowing individuals and small businesses to buy coverage through a group purchasing pool, similar to that offered to federal employees,
• covering prevention and wellness,
• streamlining health plan administration,
• offering scholarships, loan forgiveness and higher Medicare payments to grow the number of primary care physicians,
• ending the cycle of annual Medicare SGR payment cuts, and
• reducing the costs and inefficiencies of our wasteful and unfair medical liability system.

With the notable exception of liability reform the single biggest blind spot within the Obama administration and Congress pending bills address each of these priorities.

Internists have strong differences of opinion on major elements of health reform. But ACP's priorities are grounded in policies that came directly from ACP membership in most cases, long before the current administration and Congress. They deserve to end up in a final bill.

We have a chance to enact legislation that would make coverage affordable for most Americans, rebuild the primary care physician workforce, and end the cycle of Medicare physician pay cuts. But health reform could also fall from this precipice. If it does, there will be more uninsured, more bankruptcies due to high health care bills, more Medicare cuts, fewer primary care doctors and, quite likely, a Medicare program that runs out of money.