Would I vote for the Senate healthcare bill? Here’s where I stand on reform

Now that the Senate health care bill is nearing its home stretch, some are wondering if I continue to support reform.

As a reminder, I wrote back in July that doctors should support Congress’ health care reform efforts, because, “some reform is better than none, and doctors advocating for a free market-based system shouldn’t hold out, hoping for the perfect package.”

There were deuling columns in last Friday’s New York Times, one from progressive economist Paul Krugman, and the other from moderate conservative David Brooks. Both had strong reservations about what was coming out of the Senate.

In Krugman’s piece, he tells radical progressives opposing the Senate bill, like Howard Dean and Keith Olbermann, to put aside their anger and just pass the damn thing. Sure there’s plenty wrong with it, but 30 million Americans will gain coverage, and if it doesn’t pass, health reform will be dead for another generation.

Brooks also cites the proposal’s many flaws, primarily noting the lack of cost controls and the fact that the health system won’t be fundamentally reformed. He’d vote “no” when pressed. I often agree with Brooks, and his analysis is bang on.

So, who’s right?  Both of them are.

Health care costs are rising because, as Brooks accurately writes, “Consumers are insulated from the costs of their decisions and providers are punished for efficiency.” Simply paying doctors less, which is what expanding Medicare would have done, isn’t the answer as it simply entrenches a broken payment system. That option has since been removed.

We need to completely divorce ourselves from a fee-for-service payment system, which would then provide the necessary incentives for doctors to become more efficient. There is little such language contained in the bill.

And despite Atul Gawande’s assertion that the myriad of pilot programs contained within the bill will help control costs, the required, sweeping change is lacking.

But Krugman is also right in saying the crux of the bill is giving help to those who need it the most: “The result [of passing health reform] would be a huge increase in the availability and affordability of health insurance, with more than 30 million Americans gaining coverage, and premiums for lower-income and lower-middle-income Americans falling dramatically.” That can’t be ignored.

“But what about tort reform?” is a question I often hear.

The lack of any substantive medical malpractice liability reform is why many doctors oppose the progressive approach to health reform. And I agree, much more needs to be done. But keep in mind that, according to the non-partisan CBO, medical liability reform will save only $54 billion over ten years, or 0.5% of the nation’s health spending.

It’s not a huge amount, but certainly not insignificant. Reformers are leaving money on the table here.

And, as I wrote earlier this year in the USA Today, medical malpractice needs to be reformed for the patient’s sake, not the doctors’.

(As an aside, I often wonder why progressive reformers ignore the olive branch that malpractice reform represents to doctors, and choose to antagonize the medical profession by continually harping at how much money physicians make. I firmly believe that more than a few will go as far as support a single payer system – the progressive Holy Grail – if it was explicitly paired with comprehensive medical malpractice reform.)

The question of supporting the current reform efforts, or not, comes down to whether one thinks the status quo is sustainable. I believe the answer is no. The number of uninsured is rising at an unacceptable rate, and, combined with spiraling costs, will lead to the health system’s collapse. Once that happens, more draconian measures will be forced upon us. Measures that assuredly will not be friendly to doctors.

The Senate bill is a flawed, incremental effort, that doesn’t do enough to make primary care the required focus of our health system. Nor does it make any meaningful attempt to reform medical malpractice.

But it brings us closer to universal health insurance coverage, which is a significant achievement. And it does so without significantly expanding government involvement through an expansion of Medicare, or institution of a public plan option, which would have exacerbated the government monopsony on health care.

So, given the choice between seriously flawed reform and none, I’d have to say “yes” to reform.

By the slimmest of margins.

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  • http://curbside.posterous.com Nuclear Fire

    I think you’re wrong, Kevin. I bet costs will increase more rapidly, government involvement will increase and furthur insulating “insurance” as the way to pay for medical expenses will continue to degrade the quality of the healthcare experience. I hope I’m wrong but I doubt it.

  • http://www.getbetterhealth.com Dr. Val

    Ah, but the Devil’s in the details in this bill, Kevin. Did you know it includes language that would expand primary care by certifying homeopaths/naturopaths to practice medicine? That’s just one example of the myriad dangerous “pork” additions to the bill. It’s teeming with redundancy (setting up new agencies that do the same thing as ones we’ve already got, for example) and waste. It will make a bad system worse – and does not align incentives correctly. Dramatically increasing demand without increasing supply will actually drive down quality and access… and costs will rise too. I’m afraid this bill is not a positive step forward. We’ve compromised so much that the result is worse than the current reality. It’s as if we asked a committee to vote on how to fix a sinking ship – and they decided to “plug the hole” with pieces of its own hull.

    We need to scrap this monstrosity and start fresh.

  • Sarahw

    “Some reform is better than none” – is a very poor support for legislation so capable of causing harm.

  • Sarahw

    You wouldn’t stand for such a weak support of any medical test or procedure or protocol that could cause harm.

    But you are perfectly willing to sign on to “anything is better than nothing” when precisely the opposite is true.

  • http://www.twitter.com/matthewbowdish MatthewBowdishMD

    Come on Kevin! “Just pass something and call it reform” has got to be one of the weakest arguments for this bill I have heard yet. Are there not better ways to increase insurance coverage than an antiquated, top-down approach straight out of the 1930s? “Not significantly expanding government’s role in the process?” Have you considered how the IMAC will influence the care you provide? Sure, there may not be a public option or expansion of Medicare, but how is this bill paid for? Through cutting your reimbursement and/or limiting the services that you provide….That means either you stop taking Medicare patients (as our practice may be forced to do) or you increase your patient load. Primary care is already suffering from insurers squeezing doctors’ time with patients. Why argue for a bill that will very likely make this worse without any fix?

    Also, how can we trust that the savings promised by the POTUS in this bill will not adversely affect our ability to deliver high-quality care to patients? Even the CBO alludes to this on page 19 of their letter to Senator Reid,

    “Adjusting for inflation, Medicare spending per beneficiary under the legislation would increase at an average annual rate of less than 2 percent during the next two decades—
    about half of the roughly 4 percent annual growth rate of the past two decades. It is unclear whether such a reduction in the growth rate could be achieved, and if so, whether it would be accomplished through greater efficiencies in the delivery of health care or would reduce access to care or diminish the quality of care.”

    I repeat…
    “…would reduce access to care or diminish the quality of care.”

    This bill is not reform. It will make matters worse for physicians and patients alike. We need real reform, so we should demand that our representatives go back to the drawing board, toss out this “cash for cloture” chicanery and develop a truly bipartisan solution.

  • http://thehappyhospitalist.blogspot.com Happy Hospitalist

    If we can’t control costs with 85% of our population, imagine the disaster we are headed for when we can’t control costs for 100%. We are financially doomed as a nation of debt filled with entitled masses.

    When the time comes where you are paying $$50,000 a year for your family’s health insurance and your company goes bankrupt trying to pay it, or they just stop paying it all together, only then will this nation realize that you can’t get something for nothing.

    Be prepared to be told no or do something about it and keep yourself healthy. Because when the time comes to pay the bills, nobody is going to be there to help you, no matter how much the government wishes to make you believe they will be.

  • http://www.kevinmd.com Kevin

    Thanks all for the comments.

    To those who want to scrap it for something new, there simply won’t be a “next time.” No political party will touch this anytime soon if it fails.

    If reform fails, the next step will be financial collapse from spiraling health care costs, followed by a forced single-payer, likely Medicare for all, system.

    We may be heading that way regardless – the Senate plan may be simply rearranging Titanic deck chairs – but thinking that there will be a future opportunity for bipartisan reform is not politically realistic.

    Kevin

  • Paul MD

    I, for one, am now very excited that Barry Obama will be a one term president and that most of the hooligans of the majority in congress will be given their walking papers next go round.

    I do, however, have significant concerns for what my party will do when the pendulum swings. Physicians have no friends. Dems hate us, GOP hates paying us and the public has no regard for us…until they need us. We suffer from the same syndrom as the legal folks, “all lawyers are scum sucking parasites…except mine”.

    It was either Mea West or Bette Davis that said it best.
    “Hang on…it’s going to be a bumpy ride.” However it plays out, we still have nothing to apologize for.

  • Rezmed09

    It sounds like in 10 years we will still be practicing the same way, with even more forms to fill out, more CYA tests, more patients needing to get in to see us, for more authorization forms to be filled out. And our debt is going to be out of this world.

    The Canandians must be feeling pretty good right now – including the ones who don’t want to wait for their TKR and come to the USA.

  • jsmith

    Kevin, Your analysis is correct. This is not surprising, because it is virtually identical to mine :) . Health care faces several simultaneous but mutually distinguishable crises. First, there is the fact that many Americans face bankruptcy because of medical costs. Not emphasized at this blog, but it is probably the most important issue to most Americans. We all know Americans who have been bankrupted by not have medical insurance. This is a tragedy that this bill at least partially addresses. It is a very significant societal advance.
    Second, costs. Costs must be addressed, and this bill does nothing to address them. You are correct that Gawande’s recent New Yorker article is pollyannaish in the extreme. This bill essentially went after the insurance companies. We’re next in the gunsights. Get used to it. I know it’s hard for some doctors to get their minds around the fact the health care should exist for patients’ benefit and not so we can get rich, but it is true. None of us will starve.
    Third, access. Primary care is in crisis, and of course costs will spiral out of control without robust primary care and quality will suffer. This needs to be addressed, and it is not addressed in this bill.
    This bill must be the beginning of HC reform, not the end. If this is all that we do, HC reform will be a failure.

  • http://insureblog.blogspot.com/ hgstern

    Kevin:

    I tink you’re missing a larger point.

    Three words: Dr. Thomas Hendricks
     

  • The Happy Hospitalist

    Getting 100% of the population into a broken system only accelerates the broken system. The number one priority should not have been access. It should have been cost control. As health care inflation spirals out of control, so will the inability of millions of Americans to afford their insurance. So will the subsidies provided by our governement. We are heading for the bankruptcy of a thousand years. We are screwed. 1005 screwed.

    If you can’t control costs, access does not matter. Putting millions of additional Americans onto Medicaid does nothing but accelerate the bankrupting of our states and federal government, accelerate the bankrupting of hospitals and EDs whiile giving patients a false sense of access (For those without a clue, few doctors accept Medicaid anymore. The cost of providing care is greater than the payment provided. It is in essence, charity care. One can not run an office on charity)

    If you think expenses are high now, wait until more people are abusing it the lack of personal responsibility built into the mandates for access.

    Here is exactly what will happen and why do i know this? Because It’s exactly what I would do as an American operating in a broken health insurance system.

    In a system that forces everyone to buy insurance independent of their underlying risk.

    1) Healthy people will buy the highest deductible, lowest premium plan. Costs will be contained by high deductibles.

    2) Once stricken with illness, the sick people will buy the lowest deductible, highest premium policies and have them subsidized (guaranteed) by their government, knowing that their yearly costs will outstrip their mandated premiums.

    3) The Government goes bankrupt paying for the poor lifestyle choices and lack of personal responsibility resulting in chronic illness.

    4) Nobody can afford health insurance. And the people demand change.

    5) The Government takes over and starts overt rationing of services and prices.

    6) Doctors quit and hospitals close and patients revolt and the tax base is destroyed as ever rising taxes can’t sustain the nanny state.

    7) We go back to bartering chickens for health care. Those that can pay pay. Those that can’t don’t.

    The Eight Stages of American Health Medicine.
    http://thehappyhospitalist.blogspot.com/2009/08/eight-stages-of-american-medicine.html
    7)

  • Tom

    Kill it. A market based reform is the way to go, not a top-down, one-size-fits-all, budget buster. Time to come to our senses and realize that it is not the role of government to be everyone’s mommy, daddy, or fairy godmother. Write this down: IT WILL NOT WORK AS ADVERTISED.

    As it stands, I look for this to morph into a British-style healthcare program. Not good, not the kind of medicine I want to practice. Not the kind of medicine people want, either. Hurting 90% to help the 10% that can’t or won’t help themselves is not good government.

  • http://insureblog.blogspot.com/ hgstern

    And Tom provides the most succinct, accurate and helpful comment thus far:

    “Hurting 90% to help the 10% that can’t or won’t help themselves is not good government.”

    Amen, brother.

  • primary care

    what happens to primary care, it feels like salt on wounds, feels like being kicked in the gut. Are they getting any bit of relief? The burden of job is exploding, who is representing them?

  • Jeff MD

    The bill has become so sanitized that it’s now more of a token gesture of reform that won’t help overall in the long run (and may cause more harm).

    But it’s the American way: I’ll have a diet soda with my double cheeseburger and large fries. At least I’ll feel like I’m doing something positive!

  • Jules

    The bill in it’s current form expands Medicaid and calls it “insuring more people” while cutting Medicare reimbursements to pay for it. That is their definition of Health Care Reform? Passing this bill just for the sake of passing something? Now that is just really lame. Reminds me of the person who can’t make up their mind who to vote for in an election, so they will say they voted for the lesser of two evils. All fine and dandy, but you are still voting for evil. This is just a continuation of the same old insanity.

  • jenga

    Incredible Blogpost and Link Happy.
    I’d like to know how many physicians have google searched “Nonclinical Medical Career” since this has went down. I know my plans are to continue to add rental properties and get out before they physically chain me to an exam room.

  • http://www.familydocs.org/blogs/fp-forum Carla Kakutani MD

    If this effort fails, nobody touches healthcare reform for years to come.
    More medical bankruptcies, more premature death and disabiltiy, wage stagnation as more and more money is diverted to spiraling premiums. More and more employers bailing out of the system all together, leaving more people to the shark infested waters of the individual insurance market and the rest to the growing ranks of the uninsured.
    Doing nothing is doing harm.
    The reason to support this was never about us, the doctors. It was always about protecting patients. Thanks for looking out for them, Kevin.

  • Anonymous

    A market based reform is the way to go

    More transparency and more competition is desirable for the customer / patient, but it is probably politically impossible, since it will be opposed by the well funded insurance lobby for the same reason they opposed any sort of public option — insurance companies do not want to face more competition, whether from a public option or from each other (currently, most insurance companies are monopolies or oligopoly members with respect to the end users / patients (note: not the same as customers — employers are the real customers) — resulting in poor service to the end users / patients).

  • http://insureblog.blogspot.com/ hgstern

    Carla:

    Wonderful talking points, but utter rubbish. First, the whole “medical bankruptcy” kerfluffle was based on specious and incomplete data. Second, there’s no compelling evidence that being uninsured results in a greater likelihood of dying. And finally, being disabled has nothing to do with being insured (otrher than the obvious need for disability insurance coverage, which is a separate issue).

    Other than that, though… :-)

  • http://www.familydocs.org/blogs/fp-forum Carla Kakutani MD

    Hgstern:
    People who have strokes and heart attacks because they were unable to afford care and meds for hypertension and diabetes sometimes end up disabled. Closing in on coverage for all should minimize that kind of preventable loss of productivity.
    I take it you are not a fan of the Institute of Medicine, the Commonwealth Fund, the Kaiser Family Foundation…..

  • http://Curbside.posterous.com Nuclear Fire

    Aspirin $5/year. Lisinopril, HCTZ, metoprolol, simvastatin, metformin $40/year each, $200/year total. 1ppd cigarettes $1800/year. Good lifestyle choices: priceless.

    Primary and secondary prevention are cheap. Do you have any clue what these things cost Kakutani? Sure, many things in medicine are expensive, but not your examples. If we’re going to have a debate, let’s use realistic data.

  • http://insureblog.blogspot.com/ hgstern

    Carla:

    You continue to conflate health care with health insurance. They are not the same, and being uninsured does not mean having to do without health care. And no, I’m not a fan of left-leaning “think tanks” which push their agenda(s) at the expense of facts.

    Anything else?

  • Doc99

    Irony is a bill whose raison d’etre was to cover the uninsured which leaves 30 million uninsured for at least four more years. If Reagan practiced Voodoo Economics, then Reid, Pelosi and Obama have engaged in Magical Thinking. Finally, this is less reform and more a hostile takeover. The Independent Med Fed is a nice touch … nothing like an unelected bureaucracy holding sway over healthcare to instill confidence. (Think IRS) And to whom does this Med Fed report? Why … nobody. Our country’s in the very best of hands.

  • http://www.drmintz.com Dr. Mintz

    Have enjoyed reading all of these comments. The question of whether something (a crticially flawed health care bill) is better than nothing, is a difficult question. I do agree that if a bill doesn’t pass soon, nothing will be done (in Congress) for a decade. I agree with the Happy Hospitalists that “the number one priority should not have been access. It should have been cost control.” But is wasn’t. Starting the arduous process all over again will likely provide neither access nor cost control. However, passing a bill, that other Presidents have failed to do, will at least provide some increased access. There is no question that so much more needs to be done, and that the current bill really does little to reform health care. However, I think of passage of this currently proposed bill as the first of many, many steps necessary to change how health care is delivered in our country.

  • The Happy Hospitalist

    For any suckers out there who actually believes that the government can accurately predict the cost of their bribery, I point you to the truth. You should be afraid. Very afraid about where we are heading.

    http://mjperry.blogspot.com/2009/08/dont-trust-government-estimates-of.html

    Click on the chart and grab some Kleenex.

  • Evinx

    Good intentions do not make for good law.

    Increasing access for some will increase costs for many + result in less healthcare for more patients.

    The 21% SGR fix is not included to make the numbers deficit neutral. Add the 21% fix, + that illusion disappears. Add the assumption that costs will grow at a lower rate than they ever have is another illusion. Add that the actual cost for the first 10 years of operation (most spending kicks in starting in 2014 while taxes etc begin immed) + the illusion becomes more magnfied.

    And stating that if we don’t do something now, we won’t be able to do reform for another 10 or 15 years is flawed logic. What is the something that is SO good that you are willing to lose sight of costs, and harms and loss of freedom?

    Poll after poll show Americans do not want this version of reform. It is not even close. Why the arrogance that a few know what is best for the majority and are willing to use compulsion to attain their beliefs. If this reform was so great, why the rush to get it done with midnight votes? Why not get SOME bipartisan support as was done with Medicare and Medicaid?

    As SarahW said, you would never accept this logic for drugs or procedures; nevertheless, you accept this flawed logic for controlling 16% of our economy. What a shame!

  • BostonDoc

    Barry has blown it and will be a one term president for sure. I confess I was one of those idiots who fell for the “hope, change” nonsense. Maybe it was 8 years of dubya that did it.
    But like the majority of posters here, I will do my best to send the Chicago crowd back where it belongs. Now all the GOP has to do is nominate someone with a slightly higher IQ than Sarah Palin.

  • g

    “Why not get SOME bipartisan support…”

    The Republicans main goal with health care reform is failure. If the Obama administration succeeds with health care reform, the 2010 and 2012 elections will go to the Democrats. The biggest mistake the Obama administration made was trying to include the Republicans in health care reform. At least Nebraska got a good deal.

    And for those of you who wish a truly capitalistic health care system, why are you still accepting insurance payments? Seems kind of hypocritial to blame patients for using a health care system that we pay for in our premiums, taxes and increased prices for products and services. You do have the freedom to go cash only. Are you unwilling to take on the risk of a capitalistic practice? Or do you like the steady stream of patients that the insurance company provides. If you really want to change the system, why are you waiting for the government to bail you out?

    To think that people shouldn’t have to pay into the health care system until they are sick is fatally flawed. How do we all get more out than we put in?

  • Evinx

    G

    thanks for the dailykos or huffpo talking points.
    you may want to check Mankiew’s Intro Econ book + learn what capitalism is – what you describe is simply diatribe.

  • luke54

    “The Republicans main goal with health care reform is failure”.

    g, I beg to disagree. Not that I’m a fan of either party, but the Republicans have introduced healthcare legislation ignored by the Democrats. They, too, want health insurance for all, but not at the expense of further bankrupting this country. Sensible reform must contain costs, and the current legislation does nothing to do that. The CBO estimates that so many are fond of quoting do not include the “doc fix” for Medicare, and the costs will truly add to the deficit. Instead of taxing all of us to death to further promote the nanny state, why not incorporate tort reform (money saver per the CBO), go after the true causes of fraud and abuse (fraudulent DME companies), and seriously look at the amount of money spent and wasted on end of life care foisted upon physicians by families who want “everythiong done”. I’m no economist admittedly, but the cost savings from these three issues alone would save enormous amounts of money, and get many more people insured without taxing the rest of this country into bankruptcy.

    BTW, as you stated, Nebraska got a good deal. Does that imply your support of the corrupt Chicago style purchase of votes?

  • ninguem

    Nebraska was bought off. Special insurance rules for their Blues plans…..and Mutual of Omaha. Special Medicaid rates. Florida’s retirees grandfather in their Medicare Advantage plans. Arizona retirees can’t. They have Republican senators. My state has reliable Democratic votes, no one to buy off. So the red states get nothing except to pay for someone else’s bribe. And the reliable blue states get treated just as badly. Not just whores, but cheap whores. Medicare Advantage was supposed to be terrible, and was supposed to be eliminated. But not for Florida. And not for any FUTURE Florida retirees, just the ones already there.

    I like the reform effort called HSA’s. Now with five years experience, they have been shown to work. So…..Obama taxes it. But he leaves alone the generous insurance plans used by…..Teamsters.

    G’s not worth my time. But Kevin…….do you support the “reform” as it’s being revealed?

    Do you really?

    “…….If reform fails, the next step will be financial collapse from spiraling health care costs, followed by a forced single-payer, likely Medicare for all, system……”

    Sheesh, Kevin, a single-payer system is PRECISELY WHAT OBAMA AND CONGRESS WANT !

    They are on record saying precisely that, for years. If they can’t get from here to there, then craft a bill to completely destroy the private system and leave you no choice but to go single-payer.

  • Ian

    Kevin, any thoughts on the pilot program that will bundle costs rather than charge a fee-for-service? It’s described by Ezra Klein here:
    http://voices.washingtonpost.com/ezra-klein/2009/12/five_cost_controls_in_the_sena.html

  • http://drpullen.com Edward

    I agree that if this goes down to a defeat, meaning no bill passes that provides insurance to many more Americans, nothing will be done for years. I do think that this bill, however it looks at the end will pass, and it will only delay the inevitable single payer universal national health insurance we will end up with. Will whatever the final bill turns out to be help temporarily delaying this eventuality, or speed us toward that end? It will be an interesting decade, but in 2020 I’ll be shocked if we don’t have national health insurance much like the rest of the first world.